Issues We Treat

Attachment disorder is based on the psychological theories that

1. Normal mother-child attachment forms in the first two years of life; and
2. If a normal attachment is not formed during the first two to three years, attachment can be induced later.

Attachment disorder is a term that is often seen in the research literature (O'Connor & Zeanah) but which is much broader than the clinical diagnosis of Reactive Attachment Disorder, which is described in the Diagnostic & Statistical Manual, 4th Edition, Technical Revision, of the American Psychiatric Association.
This theory (Attachment Theory) is used, for example, to explain the behavioral difficulties of children who have experienced chronic early maltreatment, such as foster and adopted children.
Attachment theory was developed by John Bowlby in the 1940s and 1950s and is the leading theory used in the fields of Infant Mental Health, Child Development, and related fields. It is a well-researched theory that describes how the attachment relationship develops, why it is crucial to later healthy development, and what are the effects of early maltreatment or other disruptions in this process.

When we consider the Attachment Cyle, we think about the baby sleeping, the baby awakens and cries, the caregiver responds to the baby's need, the baby returns to sleep.  When attachment is disrupted, because the caregiver doesn't respond, there is a high potential for the baby to develop attachment disorders.  Below is a YouTube presentation on the Still Face Experiment.  It verifies how quickly the child feels distress with the caregiver becomes unavailable.

CONSENSUS PROPOSED CRITERIA FOR DEVELOPMENTAL TRAUMA DISORDER by Bessel van der Kolk

A. Exposure.  The child or adolescent has experienced or witnessed multiple or prolonged adverse events over a period of at least one year beginning in childhood or early adolescence, including:

A. 1. Direct experience or witnessing of repeated and severe episodes of interpersonal violence;

A. 2. Significant disruptions of protective caregiving as the result of repeated changes in primary caregiver; repeated separation from the primary caregiver; or exposure to severe and persistent emotional abuse

B. Affective and Physiological Dysregulation. The child exhibits impaired normative developmental competencies related to arousal regulation, including at least two of the following:

B. 1. Inability to modulate, tolerate, or recover from extreme affect states (e.g., fear, anger, shame), including prolonged and extreme tantrums, or immobilization

B. 2. Disturbances in regulation in bodily functions (e.g. persistent disturbances in sleeping, eating, and elimination; over-reactivity or under-reactivity to touch and sounds; disorganization during routine transitions)

B. 3. Diminished awareness/dissociation of sensations, emotions and bodily states

B. 4. Impaired capacity to describe emotions or bodily states

C. Attentional and Behavioral Dysregulation: The child exhibits impaired normative developmental competencies related to sustained attention, learning, or coping with stress, including at least three of the following:

C. 1. Preoccupation with threat, or impaired capacity to perceive threat, including misreading of safety and danger cues

C. 2. Impaired capacity for self-protection, including extreme risk-taking or thrill-seeking

C. 3. Maladaptive attempts at self-soothing (e.g., rocking and other rhythmical movements, compulsive masturbation)

C. 4. Habitual (intentional or automatic) or reactive self-harm

C. 5. Inability to initiate or sustain goal-directed behavior

D. Self and Relational Dysregulation. The child exhibits impaired normative developmental competencies in their sense of personal identity and involvement in relationships, including at least three of the following:

D. 1. Intense preoccupation with safety of the caregiver or other loved ones (including precocious caregiving) or difficulty tolerating reunion with them after separation

D. 2. Persistent negative sense of self, including self-loathing, helplessness, worthlessness, ineffectiveness, or defectiveness

D. 3. Extreme and persistent distrust, defiance or lack of reciprocal behavior in close relationships with adults or peers

D. 4. Reactive physical or verbal aggression toward peers, caregivers, or other adults

D. 5. Inappropriate (excessive or promiscuous) attempts to get intimate contact (including but not limited to sexual or physical intimacy) or excessive reliance on peers or adults for safety and reassurance

D. 6. Impaired capacity to regulate empathic arousal as evidenced by lack of empathy for, or intolerance of, expressions of distress of others, or excessive responsiveness to the distress of others

E. Post-traumatic Spectrum Symptoms. The child exhibits at least one symptom in at least two of the three PTSD symptom clusters B, C, & D.

F. Duration of Disturbance (symptoms in DTD Criteria B, C, D, and E) at least 6 months.

G. Functional Impairment. The disturbance causes clinically significant distress or impairment in at two of the following areas of functioning: Scholastic: under-performance, non-attendance, disciplinary problems, drop-out, failure to complete degree/credential(s), conflict with school personnel, learning disabilities or intellectual impairment that cannot be accounted for by neurological or other factors.

Familial:  conflict, avoidance/passivity, running away, detachment and surrogate replacements, attempts to physically or emotionally hurt family members, non-fulfillment of responsibilities within the family.

Peer Group:  isolation, deviant affiliations, persistent physical or emotional conflict, avoidance/passivity, involvement in violence or unsafe acts, age-inappropriate affiliations or style of interaction.

Legal:  arrests/recidivism, detention, convictions, incarceration, violation of probation or other court orders, increasingly severe offenses, crimes against other persons, disregard or contempt for the law or for conventional moral standards.

Health:  physical illness or problems that cannot be fully accounted for physical injury or degeneration, involving the digestive, neurological (including conversion symptoms and analgesia), sexual, immune, cardiopulmonary, proprioceptive, or sensory systems, or severe headaches (including migraine) or chronic pain or fatigue.

Vocational (for youth involved in, seeking or referred for employment, volunteer work or job training): disinterest in work/vocation, inability to get or keep jobs, persistent conflict with co-workers or supervisors, under-employment in relation to abilities, failure to achieve expectable advancements.

According to The National Center for Biotechnology Information (NCBI), Post-traumatic stress disorder is a type of anxiety disorder. It can occur after you've seen or experienced a traumatic event that involved the threat of injury or death.

Causes, incidence, and risk factors
PTSD can occur at any age. It can follow a natural disaster such as a flood or fire, or events such as:

• Assault
• Domestic abuse
• Prison stay
• Rape
• Terrorism
• War

For example, the terrorist attacks of September 11, 2001 may have caused PTSD in some people who were involved, in people who saw the disaster, and in people who lost relatives and friends.

Veterans returning home from a war often have PTSD.

The cause of PTSD is unknown. Psychological, genetic, physical, and social factors are involved. PTSD changes the body's response to stress. It affects the stress hormones and chemicals that carry information between the nerves (neurotransmitters).
It is not known why traumatic events cause PTSD in some people but not others. Having a history of trauma may increase your risk for getting PTSD after a recent traumatic event.

Symptoms
Symptoms of PTSD fall into three main categories:
1. "Reliving" the event, which disturbs day-to-day activity

• Flashback episodes, where the event seems to be happening again and again
• Repeated upsetting memories of the event
• Repeated nightmares of the event
• Strong, uncomfortable reactions to situations that remind you of the event

2. Avoidance

• Emotional "numbing," or feeling as though you don't care about anything
• Feeling detached
• Being unable to remember important aspects of the trauma
• Having a lack of interest in normal activities
• Showing less of your moods
• Avoiding places, people, or thoughts that remind you of the event
• Feeling like you have no future

3. Arousal

• Difficulty concentrating
• Startling easily
• Having an exaggerated response to things that startle you
• Feeling more aware (hypervigilance)
• Feeling irritable or having outbursts of anger
• Having trouble falling or staying asleep

You might feel guilty about the event (including "survivor guilt"). You might also have some of the following
symptoms, which are typical of anxiety, stress, and tension:

• Agitation or excitability
• Dizziness
• Fainting
• Feeling your heart beat in your chest
• Headache

Signs and tests: There are no tests that can be done to diagnose PTSD. The diagnosis is made based on certain symptoms.
Your health care provider may ask for how long you have had symptoms. This will help your health care provider know if you have PTSD or a similar condition called Acute Stress Disorder (ASD).

• In PTSD, symptoms are present for at least 30 days.
• In ASD, symptoms will be present for a shorter period of time.

Your health care provider may also do mental health exams, physical exams, and blood tests to look for other illnesses that are similar to PTSD.
TreatmentTreatment can help prevent PTSD from developing after a trauma. A good social support system may also help protect against PTSD.
If PTSD does occur, a form of treatment called "desensitization" may be used.

• This treatment helps reduce symptoms by encouraging you to remember the traumatic event and express your feelings about it.
• Over time, memories of the event should become less frightening.

Support groups, where people who have had similar experiences share their feelings, may also be helpful.
People with PTSD may also have problems with:

• Alcohol or other substance abuse
• Depression
• Related medical conditions

In most cases, these problems should be treated before trying desensitization therapy.
Medicines that act on the nervous system can help reduce anxiety and other symptoms of PTSD. Antidepressants, including selective serotonin reuptake inhibitors (SSRIs), can be effective in treating PTSD. Other anti-anxiety and sleep medicines may also be helpful.
Support GroupsYou can get more information about post-traumatic stress disorder from the American Psychiatric Association -- www.psych.org.
Expectations (prognosis)You can increase the chance of a good outcome with:

• Early diagnosis
• Prompt treatment
• Strong social support

Complications

• Alcohol abuse or other drug abuse
• Depression
• Panic attacks

Calling for an appointment when:
Although traumatic events can cause distress, not all feelings of distress are symptoms of PTSD. Talk about your feelings with friends and relatives. If your symptoms do not improve soon or are making you very upset, contact your health care provider.
Seek help right away if:

• You feel overwhelmed
• You are thinking of hurting yourself or anybody else
• You are unable to control your behavior
• You have other very upsetting symptoms of PTSD

You can also contact your health care provider for help with problems such as repeated upsetting thoughts, irritability, and problems with sleep.

What are Primitive Reflexes?
​
Primitive reflexes are automatic movements that provide essential responses through the birth process and after birth.  When the birth and the early months go right, these primitive reflexes integrate into the system and are replaced with more adult reflexes to assist in maneuvering the world safely.  The brainstem directs the primitive reflexes and require no cortical intervention or thought to show up and later integrate.  These primitive reflexes are vital for survival in the new frontier called life.  As the higher and more sophisticated centers of the brain come online and develop, these early reflexes that don't integrate or show signs of retention become ruptures in the natural development of the child and can carry over into adulthood.

• Moro Reflex: This reflex acts as the baby’s “fight or flight” response to the world. This important reflex usually integrates into the adult startle response by four months. Some signs of retention are emotional immaturity, lack of impulse control, hypersensitivity or hypo-sensitivity, sensory overload, and social immaturity.
• Rooting Reflex: Stroking a baby’s cheek will cause the child to turn and open the mouth. This is the automatic response to turn towards food.  This helps with breastfeeding. Usually disappears by four months. Some signs of retention are thumb sucking, picking eater, speech and articulation problems, and dribbling.
• Palmer Reflex: This is the automatic flexing of the fingers to grab an object if the palm is stimulated. This reflex should integrate by six months. Some signs of retention are messy handwriting, poor manual dexterity, and difficulty with fine motor skills.
• Asymmetrical Tonic Neck Reflex (ATNR): This is intricate for the baby through the birth canal and to develop cross pattern movements.  The ATNR is seen when you lay a baby on its back and turn their head. The arm and leg on the side the child is looking at should extend while the opposite side bends. This response should end by six months. Without integration shows up as poor handwriting, trouble crossing vertical midline, poor hand-eye coordination, and poor visual tracking for reading and writing.
• Spinal Galant: This reflex assists babies with the birth process.  This reflex happens when the skin on the side of an infant’s back is stroked. The child should swing towards that side. The spinal galant should inhibit by nine months. Some signs of retention are poor concentration, unilateral or bilateral postural issues, fidgeting, poor short term memory, and bedwetting.
• Tonic Labyrinthine Reflex (TLR): The TLR helps with head management and prepares the baby for rolling over, sitting up, crawling, standing and walking. This reflex actually integrates slowly while other core systems mature and should disappear by three and a half years old. Signs of not integrating include motion sickness, poor muscle tone, walking on tiptoes, poor balance, and poor short term memory.
• Landau Reflex: Assists with posture development.  This reflex activates at 4-5 months and usually integrates by one year. When the child’s head lifts it causes the entire trunk to flex. When retained appears overall poor motor development.
• Symmetrical Tonic Neck Reflex (STNR): STNR or the crawling reflex divides the body along the midline to prepare and assist with crawling. You can view this reflex by watching the baby’s head drop towards its chest while the arms bend and the legs extend. Interestingly, the STNR appears briefly after birth and the reappears between six to nine months. It should dissolve by 11 months. If retained, there is a tendency to slump while sitting, inability to sit still and concentrate, poor muscle tone, and poor hand-eye coordination.

Movement and Play are common ways to integrate retained reflexes.  We offer a series of exercises for the child or adult to complete between sessions and move through the retention exercise during the regular session.

Reactive attachment disorder (RAD) is a rare but serious condition in which infants and young children don't establish healthy bonds of attachment with parents or caregivers.
A child with reactive attachment disorder is typically neglected, abused or orphaned. We see RAD in both domestic and foreign adoptions and birth children.  RAD develops because the child's basic needs for comfort, affection and nurturing aren't met and loving and caring attachments with others are never established. This may permanently change the child's growing brain, hurting the ability to establish future relationships. What is most important is to realize that it is never too late.  For years, it was the belief of the Psychology community that if the window of opportunity had closed early on, that there was little to no hope in changing a person's destiny.  Today, we believe at AAaCC concur with the theory that the brain is more plastic and that there can be improvement and healing, including with adults who frequently have personality disorders.  With treatment, children can develop more stable and healthy relationships with caregivers and others. Safe and proven treatments for reactive attachment disorder include psychological counseling and parent or caregiver education.
Signs and symptoms in babies may include:

• Withdrawn, sad and listless appearance
• Failure to smile
• Lack of the normal tendency to follow others in the room with the eyes
• Failure to reach out when picked up
• No interest in playing peekaboo or other interactive games
• No interest in playing with toys
• Engaging in self-soothing behavior, such as rocking or self-stroking
• Calm when left alone

Signs and symptoms in toddlers, older children and adolescents may include:

• Withdrawing from others
• Avoiding or dismissing comforting comments or gestures
• Acting aggressively toward peers
• Watching others closely but not engaging in social interaction
• Failing to ask for support or assistance
• Obvious and consistent awkwardness or discomfort
• Masking feelings of anger or distress
• Alcohol or drug abuse in adolescents

As children with reactive attachment disorder grow older, they may develop either inhibited or disinhibited behavior patterns. While some children have signs and symptoms of just one type of behavior, many exhibit both types.

• Inhibited behavior. Children with inhibited behavior shun relationships and attachments to virtually everyone. This may happen when a baby never has the chance to develop an attachment to any caregiver.
• Disinhibited behavior. Children with disinhibited behavior seek attention from virtually everyone, including strangers. This may happen when a baby has multiple caregivers or frequent changes in caregivers. Children with this type of reactive attachment disorder may frequently ask for help doing tasks, have inappropriately childish behavior or appear anxious.

There's little research on signs and symptoms of reactive attachment disorder beyond early childhood. It may lead to controlling, aggressive or delinquent behaviors, trouble relating to peers, and other problems. While treatment can help children and adults cope with reactive attachment disorder, the changes that occur during early childhood are permanent and the disorder is a lifelong challenge.

When to see a doctor
If you think your child may have reactive attachment disorder, see a doctor. You may start by visiting your family doctor. However, if your child likely has reactive attachment disorder or another mental health problem, you'll need to see a doctor who specializes in the diagnosis and treatment of mental illness (psychiatrist) for a complete evaluation.
Consider getting an evaluation if your baby or child:

• Prefers not to be held
• Usually likes to play alone
• Doesn't seek out physical contact
• Avoids you
• Will readily go to strangers
• Seems uninterested in you

Causes 

To feel safe and develop trust, infants and young children need a stable, caring environment. Their basic emotional and physical needs must be consistently met. For instance, when a baby cries, his or her need for a meal or a diaper must be met with a shared emotional exchange that may include eye contact, smiling and caressing.
A child whose needs are ignored or met with emotionally or physically abusive responses from caregivers comes to expect rejection or hostility. The child then becomes distrustful and learns to avoid social contact. Emotional interactions between babies and caregivers may affect development in the brain, leading to attachment problems and affecting personality and relationships throughout life.
Most children are naturally resilient, and even those who've been neglected lived in orphanages or had multiple caregivers can develop healthy relationships and strong bonds. It's not clear why some babies and children develop reactive attachment disorder and others don't.

Risk factors

Reactive attachment disorder is rare. However, there are no accurate statistics on how many babies and children have the condition. Reactive attachment disorder begins before age 5, usually starting in infancy.
Factors that may increase the chance of developing reactive attachment disorder include:

• Living in an orphanage
• Institutional care
• Frequent changes in foster care or caregivers
• Inexperienced parents
• Extreme neglect
• Prolonged hospitalization
• Extreme poverty
• Physical, sexual or emotional abuse
• Forced removal from a neglectful or abusive home
• Postpartum depression in the baby's mother
• Parents who have a mental illness, anger management problems, or drug or alcohol abuse

Complications

If untreated in childhood, complications can develop into adulthood:

• Delayed learning or physical growth
• Poor self-esteem
• Delinquent or antisocial behavior
• Relationship problems
• Temper or anger problems
• Eating problems, which can lead to malnutrition in severe cases
• Depression
• Anxiety
• Academic problems
• Drug and alcohol addiction
• Unemployment or frequent job changes
• Inappropriate sexual behavior

(Some information taken from MayoClinic.com)

Trauma is an emotional response to a terrible event like an accident, rape or natural disaster. Immediately after the event, shock and denial are typical. Longer term reactions include unpredictable emotions, flashbacks, strained relationships and even physical symptoms like headaches or nausea. While these feelings are normal, some people have difficulty moving on with their lives. Psychologists can help these individuals find constructive ways of managing their emotions.