BRIEFLIT — July 2020 — Attachment Problems in Young Children

Attachment Problems in Young Children: Effective Interventions for Repairing Young Child Trauma

JULY 2020

Heather Agazzi, Ph.D., MS, IMH-E® University of South Florida hcurtis@usf.edu

Kimberly Renk, Ph.D., IMH-E®

University of Central Florida kimberly.renk@ucf.edu

Research on attachment helps us to understand how security can be created in the caregiver-young child relationship.

This same body of research also can help us uncover how trauma can impact the young child’s attachment system, thereby disrupting later development. Many evidence-based interventions are available for repairing trauma via fostering secure caregiver-young child attachment.

Scope of the Issue Definition. Attachment refers to the emotional connections that develop between young children and their caregivers through a transactional process with a predictable timeline (Boris & Renk, 2017; Zeanah & Boris, 2000). Early animal studies (e.g., Harlow, 1962) suggested that infants are predisposed biologically to attach to caregivers, with caregivers’ interactions serving a regulatory function and shaping young children’s brain development (Landers & Sullivan, 2012). Optimal secure attachment can be observed via noteworthy behaviors (Sroufe, Egeland, Carlson, & Collins, 2015) that allow young children to remain in close proximity to their caregivers and to receive protection from external threats (Bowlby, 1978). Caregivers must serve as young children’s safe haven (i.e., their source of comfort and support) and secure base (i.e., their source of security from which exploration can occur; Powell, Cooper, Hoffman, & Marvin, 2014). Significant deviations in optimal attachment can disrupt development and promote later impairment (Carlson, 1998). Such deviations can occur when caregivers misuse substances, experience mental illness, and/or experience trauma themselves (Boris & Renk, 2017). Parents who have a history of trauma may have difficulty promoting secure attachment for their young children (Khan & Renk, 2018), thereby contributing to an intergenerational cycle of trauma (Khan & Renk, 2019).

Prevalence. Seminal studies (e.g., Ainworth, Blehar, Waters, & Wall, 1978) suggested that approximately 70 percent of young children are attached securely to their caregivers but that approximately 30 percent are attached insecurely. Among young children who have experienced trauma, forming a secure attachment with their primary caregiver is less common. In fact, for children who have experienced abuse and/or neglect, 87 to 95 percent show an insecure attachment (Crittenden, 1988).

Risk Factors. Children who are 7-years of age and younger have higher reported rates of maltreatment (e.g., neglect, physical abuse, sexual abuse). Children with disabilities are especially vulnerable to trauma in the form of child maltreatment, with approximately 31 percent of children with a disability experiencing documented maltreatment relative to 9 percent of children without a disability. Younger children also are at higher risk of trauma through unintentional injury (e.g., motor vehicle accidents, drowning, fire/burns; Child Welfare Information Gateway, 2018). Children living in poverty, especially those from diverse backgrounds, are at additional risk for trauma and have a higher likelihood of life stressors (e.g., single-parent household, dense urban neighborhoods, parental stress; Roy & Raver, 2014).

Consequences. Young children who have experienced early trauma are at risk for speech and language, cognitive, and social-emotional problems (Frederico, Jackson, Black, Cox, & Joffe, 2018). Social-emotional problems include attachment problems, behavior problems, difficulty with emotion regulation, lower self-esteem, and greater posttraumatic stress disorder symptoms (Briggs-Gowan et al., 2010; Levendosky, Huth-Bocks, Shapiro, & Semel, 2003).

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Current Interventions and Best Practices To date, interventions founded in attachment, social-learning, behavioral, and cognitive-behavioral theories have proven most efficacious for young children who have been exposed to trauma. In no particular order, some of these interventions will be overviewed here. These interventions share a number of common features, such as the primary caregiver being a focus of treatment, the utilization of a dyadic focus meant to strengthen the parent-young child relationship, the processing of trauma experiences, and psychoeducation. Readers are encouraged to seek more detailed information.

Parent-Child Interaction Therapy (PCIT). PCIT was developed originally for young children aged 2 to 7 years with disruptive behavior problems. The foundational models of PCIT include attachment theory, social learning theory, and Baumrind’s authoritative parenting style. PCIT aims to promote a warm and nurturing caregiver-young child relationship, increase young children’s positive behaviors, decrease young children’s negative behaviors, improve caregivers’ competence in implementing effective disciplinary strategies, and decrease parenting stress (Timmer, Urquiza, Zebell, & McGrath, 2005). There are two phases (i.e., Child-Directed Interactions and Parent-Directed Interactions) that are implemented across approximately 12 to 18 weeks. Adequate research has supported PCIT as an effective parenting program for families with young children who have been exposed to trauma (Timmer et al., 2006; Timmer et al., 2005). In this use of PCIT, caregivers learn to implement warmth in parenting, to stop the hostile and coercive parenting cycle, and to implement positive discipline strategies meant to address young children’s disruptive behavior problems that commonly coexist with trauma symptoms. Implementation studies have shown increases in positive parenting behaviors, decreases in young children’s externalizing behaviors, decreases in trauma symptoms, reduced parenting stress, and reduced recurrence and risk of abuse. Additionally, improved relationships between young children and their offending caregivers were observed within the first three sessions and sustained over time (Hakman, Chaffin, Funderburk, & Silovsky, 2009).

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT).

TF-CBT is recognized as a best practice in trauma-focused intervention (Chadwick Center on Children and Families, 2004) for children and adolescents ages 3 to 18 years who have experienced trauma and who are exhibiting post-traumatic stress symptoms. TF-CBT uses an individual child and conjoint parent format that draws from trauma-sensitive, cognitivebehavioral, stress-management, and parenting approaches. TF-CBT lasts between 12 and 18 sessions and is implemented typically in outpatient settings. The essential components, summarized by the acronym PRACTICE, include: Psychoeducation and parenting skills, Relaxation techniques, Affective expression and regulation, Cognitive coping, Trauma narrative and processing, In vivo exposure, Conjoint parent/child sessions, and Enhancing personal safety and future growth (Cohen, Mannarino, & Deblinger, 2006). The goals of TF-CBT are to decrease children’s negative emotional and behavioral responses to trauma, reframe maladaptive beliefs attributed to trauma, improve children’s adaptive functioning, and provide support and skills so that non-offending parents can cope with their own emotional distress and respond positively to their children.

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Many studies have documented the effectiveness of TF-CBT for children who have experienced sexual abuse and other traumas (Cohen, Mannarino, & Murray, 2011). Others (e.g., Scheeringa, Weems, Cohen, Amaya-Jackson, & Guthrie, 2011) have examined specifically the effectiveness of TF-CBT for young children (who were 3 to 6 years of age). Results included reductions in internalizing and externalizing behavior problems, post-traumatic stress disorders, maladaptive thoughts, and avoidance behaviors. TF-CBT also increased children’s emotional coping skills, social competence, interpersonal trust, and personal safety skills. When compared to other interventions (e.g., nondirective play therapy), gains were observed in fewer clinical sessions with TF-CBT (Deblinger, Stauffer, & Steer, 2001).

Attachment and Biobehavioral Catch-Up (ABC). ABC was developed originally for young children in the child welfare system who are 0 to 2 years of age and who experienced maltreatment, domestic violence, and/or disruption of care (Dozier, Peloso, Lewis, Laurenceau, & Levine, 2008). ABC was founded on the principles of attachment theory and the neurobiological correlates of stress. The goal of ABC is to provide caregivers with skills to help their young children develop more adaptive regulatory strategies. ABC is brief but intensive, using a standard manualized protocol of ten sessions to address key parenting components including following the child’s lead, increasing physical affection and nurturance, reducing parents’ threatening behaviors, and facilitating an environment that allows children to recognize, understand, and express their emotions. Caregivers also learn to recognize the impact of their own issues and past experiences on their current parenting practices. Caregivers receive coaching and immediate feedback to help them re-interpret their young children’s behavioral cues and provide a more responsive and predictable environment. Video recording also is used to examine strengths and weaknesses in parenting behaviors and to monitor progress and changes (Dozier et al., 2008).

Circle of Security (CoS). CoS (Hoffman, Marvin, Cooper, & Powell, 2006; Powell et al., 2009) is an evidence-based, attachment-focused parenting program designed to help caregivers provide a secure base and safe haven for their young children by fostering caregiver resilience and nurturing, helping to facilitate caregiver attachment to young children, and increasing knowledge of how caregivers should interact with young children. CoS is offered in a group format that can help caregivers make social and supportive contact and reduce the isolation that may exacerbate caregivers’ chances of being unsuccessful in reunifying with their young children. Research has suggested that CoS promotes favorable changes in the attachment of young children to their caregivers (Page & Cain, 2009).

For example, high-risk children enrolled in Head Start shifted significantly from a more problematic insecure attachment style (disorganized) to less problematic insecure (anxious-avoidant and anxious-ambivalent) or secure attachment styles following their caregivers’ participation in CoS (Hoffman et al., 2006). Similar findings were noted when pregnant, nonviolent women with a history of substance abuse participated in CoS (Cassidy et al., 2010). Overall, CoS seeks to improve caregivers’ inferences about their young children and their attachment to their young children in order to foster better outcomes for parenting and for young children (Marvin, 2011).

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Child-Parent Psychotherapy (CPP). CPP is a dyadic intervention for young children who are 0- to 5-years of age and who were exposed to child maltreatment and interpersonal violence. CPP integrates the components of psychodynamic, developmental, attachment, trauma, social-learning, and cognitive-behavioral theories. Findings from randomized controlled trials have found that young children who participated in CPP demonstrated fewer post-traumatic stress symptoms, showed better expectations in their relationships, and improved their perception of themselves and their parents relative to those who did not receive CPP (Lieberman, Van Horn, & Ghosh Ippen, 2005). CPP also demonstrated effectiveness in facilitating secure attachment, improving the caregiver-young child relationship, and reducing stress, anxiety, and behavior problems in young children who had experienced maltreatment (Lieberman, Ghosh Ippen, & Van Horn, 2006). The overarching goal of CPP is to provide opportunities for young children to learn trust in relationships and to return to a typical developmental trajectory (Lieberman et al., 2005). CPP involves weekly sessions over the course of a year. In CPP, the caregiver-child relationship is used as a tool to improve the child’s cognitive and social-emotional functioning through a focus on restructuring safety, affect regulation, improving the caregiver-young child relationship, normalization of trauma-related response, and joint construction of a trauma narrative. Play is focused on the caregiver-young child interaction and on the young child’s trauma experience. During CPP, the clinician helps the caregiver to understand the meaning of their young child’s behavior as well their young child’s expression of emotions. The young child’s disruptive behaviors often are reframed as a response to trauma rather than willful defiance.

Summary Young children’s experiences of trauma clearly can be disruptive to the development of secure attachment, particularly when caregiver-young child interactions have involved maltreatment of some kind. Fortunately, there are a number of evidence-based interventions that are designed to foster more secure attachment and improved caregiver-young child interactions in the midst of trauma. Community efforts to build capacity in the providers who are available to deliver these interventions could help to ensure the health of their youngest citizens. Future research should work to identify ways in which infant mental health and other mental health providers can best select interventions to match the needs of their young child clients and their families.

Additional Resources www.nctsn.org www.cebc4cw.org

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