Treating the Lingering Effects of Drug Endangered Children Utah

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Treating the Lingering Effects of Drug Endangered
ChildrenUtahs 2nd Annual Drug Endangered
Children Conference

• Douglas Goldsmith, Ph.D.
• Executive Director
• The Childrens Center

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Drug Abuse and Psychopathology

• Research reports a significant correlation
  between psychopathology and substance abuse
• Individuals with mental health problems have a
  significantly increased likelihood of abusing
  drugs (Kessler et al, 1996)

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Impact of Psychopathology

• Women diagnosed with schizophrenia or affective
  disorder tend to exhibit more negative and less
  positive affect, and are less responsive and
  involved in caregiving

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Impact of Depression

• Depressed mothers show flatter affect and provide
  less stimulation and responsiveness to their
  infants
• Their infants show less attentiveness and are
  more fussy
• Depression Personality Disorder is associated
  with poorest development in offspring

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Addicted Mothers

• Those with higher rates of lifetime psychiatric
  diagnoses, including personality disorders, have
  more maladjusted offspring
• L. Beckwith et al, 1999

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Substance Abusing Mothers

• Show deficits in quality of interactions with
  their infants

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The Attachment Relationship

• Almost every infant will develop an affective
  tie with a caregiver, and will endeavor to use
  that caregiver as a source of comfort and
  reassurance in the face of challenges or threats
  from the environment
• 
  Weinfield, Sroufe, Egeland
  Carlson, 1999

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Individual Differences

• Reflect differences in the childs history of
  care
• Differences cannot be attributed solely to the
  infant or to the caregiver but reflect the
  patterns of interaction across the history of
  care

Weinfield, Sroufe, Egeland Carlson, 1999
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Development of Attachment

• Biological process
• Recognition of the caregiver
• Utilization of the caregiver as
• a haven of safety and a
• secure base in order to
• explore the environment

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Secure Base

• The infant returns to the secure base for
  protection and comfort in the light of any
  threatening or distressing event
• Bowlby and Ainsworth felt that there is a
  delicate balance between exploration and seeking
  proximity

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Attachment Behaviors

• Approach the caregiver
• Crying
• Seeking contact
• Maintaining the contact
• The number of attachment behaviors will vary with
  the degree of the perceived threat in the
  environment
• 
  Weinfield et al (1999)

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Secure vs Insecure Attachment

• The classifications Secure vs Insecure
  Reflect the infants apparent perception of the
  availability of the caregiver if a need for
  comfort or protection should arise, and the
  organization of the infants responses to the
  caregiver in light of those perceptions of
  availability.
• 
  Weinfield et al (1999)

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Secure Attachment

• The caregiver is perceived as a reliable source
  of protection and comfort

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Secure Attachment

• When I am close to my loved one I feel good, when
  I am far away I am anxious, sad or lonely
• Attachment is mediated by looking, hearing, and
  holding
• When Im held I feel warm, safe, and comforted
• Results in a relaxed state so that one can,
  again, begin to explore
  

• Holmes (1993)

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Secure Attachment

• Promote exploration of the environment
• Expand mastery of the environment
• I can explore with confidence because I know my
  caregiver will be available if I become anxious.
• The infant gains confidence in his or her own
  interactions with the world
• 
  
  Weinfield et al (1999)

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Secure Attachment

• Attachment is a reciprocal relationship
• The parent offers caregiving behavior that
  matches the attachment behavior of the child
• The child, using social referencing, checks in
  with the mother looking for cues that sanction
  exploration or withdrawal
• Holmes (1993)

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Anxious Attachment

• Lack experience with consistent availability and
  comfort
• Attachment behaviors are responded to with
• Indifference
• Rebuffs
• Inconsistency

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Anxious Attachment

• Anxious about caregivers availability
• Afraid that the caregiver will be unresponsive or
  ineffective in providing comfort
• Experience anger about caregivers unresponsiveness

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Anxious Attachment

• Shows overt aggression toward the inconsistent
  mother
• Dont you dare do that again! but has to cling
  because he knows from experience that she will.
• 
  Holmes (1993)

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Anxious Attachment

• Maintain constant low levels of anxiety about the
  caregivers availability
• Unable to explore the environment without worry
• Fail to achieve confidence in themselves and
  mastery of their environment
• 
  Weinfield et al (1999)

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Maintaining Proximity

• Secure infants trust in the reliability of the
  caregivers availability
• Anxious infants make frequent bids for attention
  to ensure the availability of the caregiver just
  in case a threat in the environment should occur

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Internal Working Model

• Through a history of responsive care, infants
  will evolve expectations of their caregivers
  likely responses to signs of distress or other
  signals of the desire for contact
• Bowlby believed that, What infants expect is
  what happened before.
• Weinfield et al (1999)

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Impact of the Internal Working Model

• The model governs how children feel toward each
  parent and about themselves, how they expect to
  be treated and how they plan their own behavior
  toward their parent

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Internal Working Model

• Provides foundation for expectations concerning
  the self
• Impacts relationships with caregivers and
  noncaregivers
• The IWM teaches children that Relationships are
  a context in which needs are met.
• 
  Weinfield et al (1999)

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Internal Working Model

• The infant anticipates the behavior of the
  caregiver in response to the infants signals.
• Learns to view the world as good and responsive
  and the self as deserving such consideration.
• Weinfield et al (1999)

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Internal Working Model

• Anxious infants learn to see the world as
• Unpredictable
• Insensitive
• The self does not deserve better treatment
• These beliefs are carried forward to new
  relationships and new experiences

Weinfield et al (1999)
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Internal Working Model

• When the expectation of being hurt,
  disappointed, and afraid is carried forward to
  new relationships, the anxious infant becomes an
  angry, aggressive child.
• 
  Weinfield et al (1999)

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Caregiver Responsiveness

• Anxious dyads
• Less sensitive in interactions
• Interfere with childrens behaviors
• Less accessible to bids for contact
• Avoidant dyads
• Averse to physical contact
• Express little emotion during interactions
• Insensitive to timing cues Weinfield
  et al (1999)

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Emotion Regulation

• The caregivers responses to the infants
  distress are an external source of emotion
  regulation before the infant learns to
  self-regulate

Weinfield et al (1999)
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Emotion Regulation

• Through observing and interacting with an
  attachment figure the infant learns what it is
  like to behave in a relationship
• Secure children develop
• Self-control
• Behavioral reciprocity
• More skilled interactions than anxious
  counterparts

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Emotion Regulation

• Consistently providing for infants needs does
  not condemn them to perpetual dependency, but in
  fact serves as the springboard for self-reliance
  because it instills a sense of efficacy
  concerning the environment. Being consistently
  nurtured and responded to empathically leads not
  to a spoiled, self-indulged child, but rather to
  an empathic child. Weinfield et al
  (1999)

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Attachment Based Interventions

• Secure Base
• Take a careful look at the stressors the family
  is experiencing e.g. illness, divorce, deaths,
  moves, financial stressors
• Major stressors may need to be carefully
• addressed before the family
• is emotionally ready to work
• on relationship strategies

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Attachment Based Interventions

• The parent must have a secure base in order to
  provide a secure base!

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Attachment Based Interventions

• Secure Base
• Does the family have an extended support system
  available? Who is the parent turning to for
  support when emotionally drained/ overwhelmed?
• Does the primary caregiver need their own
  psychotherapy to address personal issues around
  psychiatric problems?

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Attachment Based Interventions

• Secure Base
• Prioritize issues around safety such as exposure
  to domestic violence, transitions for
  parent-time, extreme hostility/ safety concerns
  between caregivers who are separating

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Attachment Based Interventions

• Secure Base
• May need to address underlying issues around
  parental unavailability to the child
• Does the parent find parent-child time enjoyable?
• Is the childs behavior so out-of-control that
  the parent is unable to find enjoyable one-on-one
  moments?
• Plan behavioral interventions to increase
  cooperation to parental requests

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Attachment Based Interventions

• Secure Base
• Decrease oppositional battles around
• Toileting
• Assist with toilet training or encourage the
  parent to relax anxiety around toileting
  accidents
• Eating
• Stop discussions about quantity of food or
  insisting that the child increase their food
  repertoire
• Sleeping
• Encourage the parent to help the child regulate
  anxiety around sleep. Develop a bedtime routine

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Attachment Based Interventions

• Secure Base
• Help parent learn to give warnings around
  transitions and brief separations
• Increase predictability of the environment
• Increase reliability of parental availability

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Attachment Based Interventions

• Secure Base
• Develop nurturing skills
• Help the parent learn to be an ideal
  grandparent
• Anticipate the childs needs
• Provide physical comforts
• Plan surprises so the child knows s/he is thought
  about even when absent
• Increase sensitivity to cues

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Attachment Based Interventions

• Exploration
• Help the parent develop age appropriate
  expectations
• Carefully evaluate and develop appropriate
  parental supervision
• Assess joint pleasurable activities and develop a
  list of pleasant activities

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Attachment Based Interventions

• Exploration
• Examine the parents ability to let go
• Develop plans and support the parent in managing
  conflict free separations by waiting until the
  child is comfortable in a new environment

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Attachment Based Interventions

• Exploration
• Teach the child checking in behaviors
• Always keep the caregiver in view
• Use a timer to help the child develop checking-in
  skills

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Attachment Based Interventions

• Emotional Regulation
• Teach the parent to use Time-in
• Remain available during emotional outbursts
• Only move away if child attempts physical attacks
• Constantly reassure child that, As soon as you
  calm down, Ill help you fix it/ figure it out
• If attacks persist state, Ill be in the next
  room so I can stay safe but as soon as I hear you
  calm Ill be right back
• Develop deep breathing and self-soothing skills

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Attachment Based Interventions

• Emotional Regulation
• Work on acceptance of physical contact
• Help child make self-contact rather than
  other-contact to soothe self
• Avoid direct no and instead fantasize what it
  would be like if the child could get all of
  his/her needs met
• Write down and post the desire to be satisfied at
  a later date/ time
• Model self-soothing cognitive strategies
• Teach empathic listening skills
• Use transitional objects

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Attachment Based Interventions

• Utilize therapy sessions to model the safety,
  empathy, and security of a holding environment.