ATTACHMENT DISSOCIATION

ATTACHMENT DISSOCIATION
‘Children who are a ‘TAD’ troubled’ © Lynne Ryan (Trauma, Attachment & Dissociation) The Troubled Triangle: TRAUMA ATTACHMENT DISSOCIATION Trauma almost always results in dissociation in children, particularly young children and trauma interrupts the attachment process. ESTD Norwich 30 & 31 March Lynne Ryan.

ESTD Norwich 30 & 31 March 2017. Lynne Ryan.
TAD – workshop 31 March 2017 Aims of today’s workshop: To explore the interplay of Trauma, Attachment and Dissociation on the child, with particular emphasis on the ‘D’ – dissociation information and strategies to assist the child who is a ‘TAD’ troubled including: a ‘Brainy Guide’, to trauma psycho-education i.e. information about the brain & body's response to trauma An introduction to child theories of dissociation, assessment and treatment ESTD Norwich 30 & 31 March Lynne Ryan.

Why work with children who are a ‘TAD’troubled?
Why bother? They won't remember? They will get over it; They were only little; They / I just want to forget about it; It's time to move on; Why rake up the past? Children are resilient……… ESTD Norwich 30 & 31 March Lynne Ryan.

Why work with children who are a ‘TAD’troubled?
The above are all statements that I've heard from professionals and parents and I believe that these statements represent adult wishful thinking, as an alternative to believing the awful reality that childhood trauma has a devastating impact upon the developing brain; in addition to the fact that it disrupts the attachment relationship and it also creates dissociation - as the only available, adaptive strategy. Child dissociation deserves to be recognised, validated and addressed - which is why this conference – the first of its kind in England – is so important. The cost of not working with dissociation is massive – to the child; their future mental health; their children; services and agencies; the economy etc. Given the knowledge that is now available, It is unethical to dissociate from childhood dissociation. ESTD Norwich 30 & 31 March Lynne Ryan.

The ACE study The ACE Study is one of the largest scientific research studies of its kind, with over 17,000 mostly middle income Americans participating. The focus was to analyse the relationship between childhood trauma and the risk for physical and mental illness in adulthood. Over the course of a decade, the results demonstrated a strong, graded relationship between the level of traumatic stress in childhood and poor physical, mental and behavioural outcomes later in life. What is an Adverse Childhood Experience / ACE? Growing up experiencing any of the following conditions in the household prior to age 18: 1. Recurrent physical abuse 2. Recurrent emotional abuse 3. Contact sexual abuse 4. An alcohol and/or drug abuser in the household 5. An incarcerated household member 6. Family member who is chronically depressed, mentally ill, institutionalized, or suicidal 7. Mother is treated violently 8. One or no parents 9. Physical neglect 10. Emotional neglect ESTD Norwich 30 & 31 March Lynne Ryan.

The ACE study Where can I find more information on the ACE Study? ESTD Norwich 30 & 31 March Lynne Ryan.

What is Trauma? (The T in TAD)
Trauma means INJURY The DSM IV* Defines trauma as: An event which is, or realistically perceived to be, threatening to the life or personal integrity of self and others and The response to the event is one of fear, helplessness or horror *The Diagnostic and statistical manual of Mental Disorders (fourth edition) (DSM IV), published by the American Psychiatric Association, is a diagnostic reference of mental health professionals in the United States. It includes diagnostic criteria for the most common mental disorders, including description, diagnosis, treatment and research findings. ESTD Norwich 30 & 31 March Lynne Ryan.

Trauma The automatic response to trauma, involving the production of toxic amounts of stress hormones which affect: all major body systems brain function * social functioning A bio-psycho-social injury (BAAF Safer Caring: training programme Kate Cairns 2007) CHILD ABUSE – PHYSICAL, SEXUAL & / OR EMOTIONAL, PRODUCES TRAUMA IN THE CHILD ESTD Norwich 30 & 31 March Lynne Ryan.

Complex Trauma The term complex trauma describes both children’s exposure to multiple traumatic events, often of an invasive, interpersonal nature, and the wide-ranging, long-term impact of this exposure. These events are severe and pervasive, such as abuse or profound neglect. They usually begin early in life and can disrupt many aspects of the child’s development and the very formation of a self. Since they often occur in the context of the child’s relationship with a caregiver, they interfere with the child’s ability to form a secure attachment bond. Many aspects of a child’s healthy physical and mental development rely on this primary source of safety and stability. ESTD Norwich 30 & 31 March Lynne Ryan.

Trauma changes beliefs
Through relationships with important attachment figures, children learn to trust others, regulate their emotions, and interact with the world; they develop a sense of the world as safe or unsafe, and come to understand their own value as individuals. When those relationships are unstable or unpredictable, children learn that they cannot rely on others to help them. When primary caregivers exploit and abuse a child, the child learns that he or she is bad and the world is a terrible place. This links into the A in the TAD model - Attachment ESTD Norwich 30 & 31 March Lynne Ryan.

What Is Attachment? (The A in TAD)
Attachment is the capacity to form and maintain healthy emotional relationships. An attachment bond has unique properties. The capacity to create these special relationships begins in early childhood. Unique Features of an Attachment Bond: Enduring form of a bond with a "special" person Involves soothing, comfort, and pleasure Loss or threat of loss of the special person evokes intense distress There is security and safety in context of this relationship Dr. Bruce D. Perry ESTD Norwich 30 & 31 March Lynne Ryan.

Creation of a secure base: 1st Year Cycle:
From Attachment disorder web site - If a child is securely attached, when they are upset, they know that they can approach an adult directly and have their needs met. The need – e.g. hunger, pain etc. leads to crying / rage which is relieved when the need is met by the caregiver through e.g. food eye contact, touch etc. which in turn leads to trust and the belief that the world is safe and adults are ok and the child is ok. ESTD Norwich 30 & 31 March Lynne Ryan.

Disturbed Attachment cycle
From Attachment disorder web site - If the baby’s needs are not met in the first year, this results in a disturbed attachment cycle and the child feels that the world is not safe, they are not ok and adults are untrustworthy. ESTD Norwich 30 & 31 March Lynne Ryan.

What is DISSOCIATION? (The D in TAD)
Definition: “ A disruption in the usually integrated functions of consciousness, memory, identity or perceptions of the environment” DSM, American Psychiatric association 1994. Infants and children who suffer traumatic events – including abuse and neglect, are particularly likely to use dissociation (i.e. psychologically ‘moving away’ from danger) as a survival strategy. (Wieland 2011). Parents and teachers often report excessive ‘spacing out’, ‘daydreaming’ and inconsistent performance. They also often noticed rapid changes of emotional states and incessant lying, even when there was a witness who has observed them doing something wrong. ESTDUK 2011 ESTD Norwich 30 & 31 March Lynne Ryan.

Dissociation “When a child feels very afraid and helpless and cannot physically escape from the situation, he can find a way to ‘escape’ by blocking off (dissociating) the terrifying event/s from his memory; by blocking off (dissociating) feelings of pain, hurt, rage; and by blocking off (dissociating) bad thoughts about himself and those hurting him. He may go into a trance state or ‘space out’ (mild dissociation). He may become unaware of his surroundings (moderate dissociation). He may even separate completely from himself to totally escape from the frightening event/s (severe dissociation). This is a survival technique that can be helpful to the child at the time of the scary event. It is when this separation continues to occur with other threatening events or with reminders – called ‘triggers’ of the traumatic event that it is problematic. This dissociation may keep him from developing normally, forming healthy attachments, and meeting social, academic, and emotional expectations” . (ISSTD website accessed January 2011). ESTD Norwich 30 & 31 March Lynne Ryan.

Dissociation Having dissociation is not a problem while the child is being abused, it's only a problem when the abuse stops ESTD Norwich 30 & 31 March Lynne Ryan.

Dissociation - Symptoms
The child might have ‘imaginary friends/persons’, ‘inside friends that nobody knows about’ or talk about an ‘invisible friend’. The child may hear ‘voices’ There might be a history of self-harming, sexualized or aggressive and violent behaviour. There might be a history of multiple unexplainable physical symptoms that have no somatic source. The child can have amnesia (and may be perceived as lying) The child’s behaviour may rapidly change from calm to aggressive, anxious, regressed or controlling. Inconsistent performance is often reported. The child may struggle to connect to reality while doing tasks at home or at school and prefer to move into fantasy School can report concentration problems, trance like states and learning difficulties The child may have has multiple unexplainable physical symptoms Somatoform dissociation where there is an absence of awareness of body sensations or body experiences leading to for example enuresis and encopresis. ESTD Norwich 30 & 31 March Lynne Ryan.

Dissociation - Guidelines
Guidelines for the assessment and treatment of children and adolescents with dissociative symptoms and dissociative disorders. Child and Adolescent Committee of the European Society for Trauma and Dissociation (ESTD) Reference: Potgieter-Marks, R., Sabau, A., & Struik, A. (2015). Guidelines for the assessment and treatment of children and adolescents with dissociative symptoms and dissociative disorders. Retrieved from: ESTD Norwich 30 & 31 March Lynne Ryan.

Dissociation - Theories
The most familiar theoretical models for adults at this stage are: The Ego State Model (Watkins, 1978; Watkins & Watkins, 1993,1997), the Behavioral State Model (Putnam, 1997) and the Structural Dissociation Model (Van der Hart, Nijenhuis & Steele, 2006). Struik (2014) describes the use of the Model of Structural Dissociation with children and adolescents, and Wieland (2015) and Gerge et al. (2013) describe the use of the Ego State model as well as the Model of Structural Dissociation with children. The most recent theory in child dissociation, was developed by Silberg (2013) who describes the Affect Avoidance Theory and uses the acronym EDUCATE – to presents her phased model specifically for treating children with dissociative Disorders: E-psycho-Education; D – Dissociation motivation; U – Understanding what is hidden; C – Claim – the dissociated parts of the self; A – Affect regulation; T –Traumatic processing and understanding Triggers; E – Ending stage of therapy. I will now focus upon E - psycho education and A - affect regulation, before briefly looking at how to assess Dissociation and requirements for therapeutic interventions to address Dissociation ESTD Norwich 30 & 31 March Lynne Ryan.

Psycho- Education & Affect Regulation
E – Psycho-Education This involves educating survivors about the brain & body's response to trauma and has been massively helpful in my work with trauma survivors As workers, we need an understanding of how trauma requires a 'brainy' response i.e. a therapeutic response that is informed by neuroscience, by trauma knowledge – including dissociation & by developmental stage (age and stage of the client when trauma happened, since whether working with children or adults, the trauma often occurred at key times in terms of developmental stage / brain development). We are then able to use psycho-ed tools to normalise the reaction to trauma and understand behaviours as creative ways that helped the individual to survive rather than unhealthy beliefs of ' it's all my fault', 'I'm bad' 'I should have done something' 'I'm crazy' etc. ESTD Norwich 30 & 31 March Lynne Ryan.

Trauma and The Brain ESTD Norwich 30 & 31 March Lynne Ryan.

Understanding How the Brain Develops
Our brains are made up of millions of neurons or nerve cells, which send messages to each other across synapses, forming pathways. This allows various areas of the brain to communicate and to work as a ‘whole’. We are born with these millions of brain cells and the brain develops by wiring and re-wiring the connections among the neurons and new synapses between cells are constantly being formed while others are PRUNED away. ESTD Norwich 30 & 31 March Lynne Ryan.

Understanding How The Brain Develops
PRUNING: the way certain brain connections disappear through lack of use – allowing those that are used to become stronger. This pruning, lets the brain keep those pathways that are used i.e. have a purpose and get rid of those pathways that are not being used. So, the brain has a ‘use it or lose it’ principle. HOWEVER, if the baby doesn’t get the experiences it needs, ‘over pruning’ of certain connections may occur, leaving the child struggling to do what would have come naturally otherwise. ESTD Norwich 30 & 31 March Lynne Ryan.

IF you imagine walking through a cornfield, you create a path by treading the crop to make way – the more you tread this path the more established it becomes. This is how pathways in the brain become established. The opposite is also true, imagine a path in a cornfield which is not used – it eventually becomes overgrown and disappears. In theory, the pruning increases the efficiency with which the brain can do what it needs to do. ‘USE IT OR LOSE IT!’ 248 × 72KB J ESTD Norwich 30 & 31 March Lynne Ryan.

Brain Development * The brain develops sequentially: Brain stem: state regulation Before birth – eight months Mid-brain: motor functioning Birth – one year Limbic brain: emotional functioning Six months – two years Cortex: cognitive functioning One year – four years (*Siegal’s hand model) ESTD Norwich 30 & 31 March Lynne Ryan.

Brain Development ESTD Norwich 30 & 31 March Lynne Ryan.

The Triune Brain The reptilian brain - the sensorimotor level is the most primitive part and is responsible for the automatic functions in the body such as breathing and heart beat & in this part of the brain information is processed on a sensorimotor level. The mammalian brain where information is processed on an emotional level is also called the limbic system of the emotional brain. The cognitive level is the neo-cortex this is where the ability for language abstract thinking and reasoning learning and planning deliberate actions reside. ESTD Norwich 30 & 31 March Lynne Ryan.

Understand the Brain Using the Palm of Your Hand –Dan Siegel
If you hold up your hand in a fist with your four fingers curled over your thumb and your fingers facing you, this makes what Siegel calls “a surprisingly accurate general model of the brain.” Your wrist is the brain stem, where your brain connects with your spine. Your thumb represents the limbic system as a whole and, specifically, the amygdala—the fight flight part of your brain. The amygdala is also where you store emotional pain, fears, and decisions (inaccurate) that you are not “good enough.” Your curled fingers and, specifically, your fingernails, represent the prefrontal cortex—the only part of your brain where thinking takes place. ESTD Norwich 30 & 31 March Lynne Ryan.

Trauma impacts the brains wiring and causes emotional dysregulation When we are ‘firing on all cylinders’, our whole brain is working together, we are able to remain calm and think and ‘stay in our window of tolerance’. When we ‘fall out of our windows’, due to trauma or excessive stress, we become emotionally dysregulated and enter FIGHT, FLIGHT or FREEZE mode. The aim of therapy is to assist in rewiring the brain to encourage healthier neural connections and emotional regulation ESTD Norwich 30 & 31 March Lynne Ryan.

Window of Tolerance If the stress stays within the window of tolerance, the three brains can be used together in an integrated fashion. ESTD Norwich 30 & 31 March Lynne Ryan.

Bruce Perry's NMT approach
The Neurosequential Model of Therapeutics is a developmentally sensitive, neurobiologically informed approach to clinical work developed by American psychiatrist –Dr. Bruce Perry. It maps the development of maltreated children to provide a visual brain map of strengths and primary problems so that interventions can target particular areas of the brain ESTD Norwich 30 & 31 March Lynne Ryan.

The 6 R’s (Bruce Perry) Trauma healing, says Perry, requires 6 R’s; it must be: • Relational (safe) • Relevant (developmentally-matched to the individual) • Repetitive (patterned) • Rewarding (pleasurable) • Rhythmic (resonant with neural patterns) • Respectful (of the child, family, and culture) ESTD Norwich 30 & 31 March Lynne Ryan.

Repetition, Repetition, Repetition
“To change any neural network in the brain, we need to provide patterned, repetitive input to reach poorly organized neural networks involved in the stress response. Any neural network that is activated in a repetitive way will change,” development, the more effective… “The first step in therapeutic success is brain stem regulation… Start with the lowest undeveloped/ abnormally functioning set of problems and move sequentially up the brain as improvements are seen… “An example of a repetitive intervention is positive, nurturing interactions with trustworthy peers, teachers, and caregiver… using patterned, repetitive somatosensory activities such as dance, music, movement, yoga, drumming or therapeutic massage… This is true especially for children whose persisting fear state is so overwhelming that they cannot improve via increased positive relationships, or even therapeutic relationships, until their brain stem is regulated by safe, predictable, repetitive sensory input.” Perry (2006). ESTD Norwich 30 & 31 March Lynne Ryan.

How to put all of this brainy stuff into practice
What can we do?? In a safe RELATIONSHIP we: REPAIR – the child’s unhealthy relationships & experiences REGULATE- the child’s emotions REWIRE – the brain – encourage & REPEAT healthy brain connections Re-educate – the child about their dissociation and their brains! ESTD Norwich 30 & 31 March Lynne Ryan.

Back to Dissociation – Assessment
A thorough and holistic assessment of the child is required before beginning therapeutic work which includes: the child's current attachment relationships; traumatic experiences; current symptoms and triggers ad dissociation. I will only briefly explore assessment but want to begin with two questions regarding working with child trauma: 1.in order to work any trauma informed way we need to move away from the question: what's wrong with you? and rather ask: what happened to you? If the child has experienced early childhood trauma, rather than ask if dissociation is present, ask: why wouldn't dissociation be present? ESTD Norwich 30 & 31 March Lynne Ryan.

Dissociation – Assessment
Child Dissociative Checklist (CDC) (Putnam, Helmers, &Trickett, 1993). A questionnaire for children from 4-14 years old, filled in by the carer with excellent validity and reliability The Child Dissociative Experience Scale and Post Trauma Inventory (CDES.PTSI) (Stolbach, 1997, adapted from Bernstein & Putnam, 1986). The CDES assesses PTSD and dissociative symptoms and is a self-report questionnaire for children 7-12 years old, but can be used for children years old as well. The Adolescent Experience Scale (A-DES) (Armstrong, Putnam, Carlson, Libero, & Smith, 1997; Farrington, Waller, Smerden, &Faupel, 2001; Smith & Carlson, 1996). The A-DES is a self-report questionnaire for adolescents to assess dissociative symptoms and experiences. The Somatoform Dissociation Questionnaire (SDQ-20). The SDQ-20 is a self report self report questionnaire for adolescents from the age of 16 to evaluate the severity of somatoform dissociation. In addition to questionnaires on dissociative symptoms, standardized screening instruments can be used to screen PTSD symptoms, such as the Trauma Symptom Checklist for Children (TSCC; Briere, 1996), The Trauma Symptom Checklist for Young Children (TSC(Y)C Briere et al., 2001), The Child Behaviour Checklist (CBCL) for children 1-5 and 6–18, the Teachers Report Form (TRF) for children 6–18 and the Youth Self Report for children (YSR) (Achenbach & Roscorla. 2007). (ESTD guidelines 2015) ESTD Norwich 30 & 31 March Lynne Ryan.

Dissociation – Goals for treatment
To establish safety for the child to the fullest extent possible, to recognize and prevent trauma and reenactments (Ford &Courtois, 2013; Silberg, 2013) To promote stabilization and emotional regulation (Arvidson, Kinniburgh, Howard, Spinazzola, Strothers, Evans, Andres, Cohen, Blaustein, 2011; Silberg, 2013; Struik, 2014). To provide ways for the child to process traumatic experiences (Silberg, 2013; Struik, 2014; Wieland, 2015). To establish integration of the dissociative states and enable the child to develop an integrated sense of self. (Silberg, 2013; Wieland, 2015) To re-integrate the child back in age appropriate levels of functioning across all domains: cognitive, emotional, social and relational. In this way children can develop a sense of agency, competency and mastery over their minds, bodies and lives again (Arvidson et al, 2011; Silberg, 2013). ESTD Norwich 30 & 31 March Lynne Ryan.

The goals are achieved via a Staged approach to Therapy
1. Safety, Stabilisation & Symptom Reduction – safety; psycho education; attachment; emotional regulation, internal co-consciousness and co-operation (Fraser Table); 2.Trauma Processing and working with dissociation - ; externalising the child’s internal world; EMDR and creative techniques to process trauma 3. Integration – of parts; keeping safe; improving social skills; expanding support systems; positive self image; strengthening attachments; building positive experiences NB the stages do not progress in a neat sequential fashion, e.g. stabilisation occurs throughout therapy - see slide below ESTD Norwich 30 & 31 March Lynne Ryan.

3 Phases of Therapy ESTD Norwich 30 & 31 March Lynne Ryan.

SAFETY IS KEY WHEN WORKING WITH TRAUMA
ESTD Norwich 30 & 31 March Lynne Ryan.

SAFETY Safety is the first priority when treating traumatized children (AACAP, 2005; ISSTD, 2003). It makes sense that trauma processing cannot be effective if the child continues to experience new traumatic experiences. In addition to being safe, the child must also feel safe. A threatened child will automatically focus on the world around him to protect himself, which may elicit fight/flight/freeze responses or the need to dissociate. In order to process traumatic memories the child must focus on the inside, which puts him in a vulnerable position. A child can only do that when there is no perceived threat from outside. There are four elements in regards to safety: physical safety, behavioural control, emotional safety and therapeutic safety. (ESTD guidelines 2015) ESTD Norwich 30 & 31 March Lynne Ryan.

LEARN; READ; ASK; TRAIN; NETWORK
In summary Dissociation is an amazing adaptive strategy that served a vital purpose for the child in enabling them to survive traumatic experiences. It becomes maladaptive when a child is safe and the dissociative symptoms have a negative effect on the child's life and functioning Working with the child’s trauma and attachment difficulties is not enough for them to heal after abuse and neglect– the child’s dissociation must also be addressed Safety first – the pre requisite to a child engaging in therapy is safety. If a child is unsafe, they may well need to keep their dissociative defences in order to survive. Self care - because of the strong positive and negative (counter-) transference when working with dissociative children and parents, clinicians should have access to regular (peer) supervision or consultation to reflect on these phenomena and prevent vicarious traumatization. Skill up! Dissociative children need therapists (and adults around them) to be trauma informed and to have an understanding of dissociation – LEARN; READ; ASK; TRAIN; NETWORK ESTD Norwich 30 & 31 March Lynne Ryan.

Go Change The World!! ESTD Norwich 30 & 31 March Lynne Ryan.

ATTACHMENT DISSOCIATION

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