Attachment Issues

Running Head: ATTACHMENT ISSUES

Attachment Issues in Maltreated Children John Laing University of Calgary Apsy 693.76

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Introduction The goal of this paper is to review the literature about what are the most effective counselling techniques used to treat abused and neglected North American children under the age of 12 with attachment issues. To answer this question the literature review will also attempt to answer the following questions: 1) how does abuse and neglect affect attachment in North American children under the age of 12? 2) What counselling techniques are available to treat abused and neglected North American children under the age of 12? 3) How are internal working models defined in psychological literature? The literature review will include these areas: (a) discussion of abuse and neglect in children, and (b) counselling techniques for treating abused and neglected children with attachment issues. Definitions of abuse and neglect will be discussed, types of abuse and neglect will be highlighted and the prevalence of abuse and neglect in Canadian children will be discussed. The review will also focus on the importance of counselling in treating abuse and neglect in children, goals of counselling in treating abuse and neglect in children, an overview of counselling techniques and a discussion about internal working models. The literature review will conclude by pointing out some limitations of attachment therapy with maltreated children. In conducting a search of the literature I used several databases including Academic Search Premier, ERIC and PsycINFO. Furthermore, I looked at government websites to locate statistics about abuse and neglect in North American children, as well as to seek information about formal definitions of maltreatment. I ensured I used primary resources whenever possible and excluded literature that was not peer reviewed or in scholarly books. Several of the key words this writer

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used when conducting his research were: attachment; abuse; neglect; internal working models; attachment therapy; and trauma therapy. Body of the Review Abuse and Neglect in Children Under the Age of 18 Defintions of abuse and neglect. Clearly defining child abuse and neglect is a difficult task. Definitions of child abuse and neglect vary across systems. Researchers, members of society, Childrens Protective Services and legislators all have their own criteria for what constitutes child maltreatment. Definitions vary in several ways such as: whether they require harm to the child or include children who have been endangered but not harmed; whether they require an intent to harm the child or the inclusion of unintentional harm; the type of behaviour or damage involved (physical, sexual, or emotional abuse, or neglect); and the frequency and severity of the behaviour (Bensley et al., 2004). Furthermore, differences among cultural groups, the childs age and developmental stage must also be taken into consideration when defining child maltreatment. Although a single, technically sound definition of child maltreatment is difficult to delineate, common consensuses does exist regarding abusive behaviours toward children. Bensley et al. (2004) listed several behaviours that were seen as abusive by participants in their study including: sexual intercourse with a child; making a child touch a parent in the genital area; hitting a child in the face with a closed fist; touching a school-aged child in the genital area; kissing a child in a sexual way; looking at pornography with a child; leaving a baby in the same diaper all day; locking a child in a closet; driving drunk with a child in the car; repeatedly calling a child stupid or other names; spanking a child with a belt or other object; leaving a child with a caregiver who mistreated the child or other children in the past; and feeding a child so poorly that

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it results in physical problems. Although the above list is not exhaustive it demonstrates that there is a high consensus among people regarding what is abusive, regardless of the lack of a unified formal definition. Types of abuse and neglect. Even though definitions of abuse and neglect differ across services several common themes emerge throughout the literature. Most definitions of child maltreatment include: physical abuse; emotional/psychological abuse; sexual abuse; and neglect (Bensley et al., 2004; Brown & Khan, 2003; Dubowitz et al., 2005; Kaplin, Pelcovitz, & Labruna, 1999; The National Clearinghouse on Family Violence, 1997; Trocme & Wolfe, 2001). Physical abuse is defined as the deliberate application of force to any part of a childs body which results or could result in injury (Brown & Khan, 2003; Kaplin et al., 1999; Trocme & Wolfe, 2001). Examples of physical abuse include: hitting a child with a hand; kicking a child; throwing an object at a child; shaking a child; burning or stabbing a child; and chocking a child (Kaplin et al., 1999; Trocme & Wolfe, 2001). Emotional/psychological child abuse occurs when a caregivers behaviours interfere with a childs mental health or social development i.e., yelling, name calling and shaming the child (Brown & Khan, 2003). Also, according to Kaplin et al. (1999), verbal abuse, harsh non-physical punishment and threats of maltreatment constitute emotional/psychological abuse. Trocme and Wolfe (2001) define emotional/psychological abuse as harm against a childs sense of self and involve behaviours by a caregiver toward a child that could lead to the development of behavioural, cognitive, emotional and mental disorders in the child. Examples of these behaviours include verbal threats, put-downs, isolating a child, intimidating, exploiting or constantly placing unrealistic demands on the child (Trcome & Wolfe, 2001).

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Child sexual abuse can be defined as any form of sexual activity with a child in which consent is not or cannot be provided due to age or developmental level of the child (Brown & Khan, 2003). Sexual abuse includes: fondling of a childs genitals; intercourse; incest; rape; sodomy, exhibitionism; and exploiting a child for prostitution or for the production of pornography (Brown & Khan, 2003; Trcome & Wolfe, 2001). Neglect is the most frequently identified form of child maltreatment (Dubowitz et al., 2005; Kaplan et al., 1999). Neglect is difficult to define conceptually and operationally. A definition is difficult to ascertain because of debate over whether a definition of neglect should include potential harm or only actual harm. Furthermore, debate exists over whether or not neglect occurs when a childs basic needs are not met from a childs perspective regardless of contributing factors or should neglect be viewed as occurring based on parent refusal to provide basic needs (Dubowitz et al., 2005). Also, it is difficult to determine at what point a childs basic needs are not being sufficiently met. Neglect can be split into several categories including: physical neglect; emotional neglect; medial neglect; mental health neglect; and educational neglect (Brown & Khan, 2003). However, for the purpose of this paper only physical and emotional neglect will be defined. According to Kaplan et al. (1999), physical neglect occurs when harm or endangerment is inflicted upon a child because of inadequate nutrition, clothing, hygiene and supervision. Emotional neglect happens when a childs parents or caregivers fail to provide for the childs emotional needs including: affection; emotional support; and allowing a child to be continually exposed to domestic violence (Brown & Khan, 2003; Kaplin et al., 1999; Trocme & Wolfe, 2001).

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Prevalence of child abuse and neglect in Canada. According to Brown and Khan (2003) and Trocme and Wolfe (2001), there is little difference between boys and girls for the occurrence of emotional and physical child maltreatment. Trocme and Wolfe (2001) stated that 135, 573 (21.5 per 1000) cases of child maltreatment were investigated by Child Protection Worker in Canada in 1998. Of those, 45% were substantiated by the investigating worker (Trocme & Wolfe, 2001). According to Trocme and Wolfe (2001), the primary reasons for child maltreatment investigations in Canada in 1998 were as follows: child neglect 40%; physical abuse 31%; emotional abuse 19%; and sexual abuse 10%. Child neglect was substantiated for every 2.25 children per 1000; sexual abuse was substantiated 0.86 per 1000 children; neglect was substantiated 3.66 per 1000 children; and emotional abuse was substantiated 2.2 per 1000 children. According to Trocme and Wolfe (2001), 8.97 per 1000 Canadian children suffered from maltreatment in 1998. Prevalence studies conducted in Canada have typically measured rates of victimization during childhood, as opposed to incidence statistics that measure rates of victimization during a specific year (Trocme, 2005). Although Trocme and Wolfe (2001) included all investigations of child maltreatment for persons under the age of 18, Dubowitz et al. (2005) argued that both emotional maltreatment and physical abuse are more likely to occur when a child is between the ages of 4 and 8 years. It is likely then, that incidence rates of child maltreatment during 1998 in Canada were higher for children between the ages of 4 and 8 as well. Counselling Techniques for Treating Abuse and Neglect in Children Importance of intervention in treating abuse and neglect in children. Therapy is critical for improving social adjustment in children and can alter attachment styles in maltreated children (Finzi, Ram, Har-even, Shnit, & Weizman, 2001; Pearce & Pezzot-Pearce, 1994). According to

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Glaser (2000), there is a strong association between childhood maltreatment and social, emotional, behavioural, and cognitive problems in childhood. Furthermore, psychopathology in later childhood and adulthood is associated with early childhood abuse and neglect (Corbin, 2007; Glaser, 2000; Finzi et al., 2001). Rogosch, Cicchetti, and Aber (1995) argued that there is a relationship between early childhood maltreatment and later peer relationship problems. Erickson and Egeland (1996) argued that children who were emotionally neglected in early childhood were socially withdrawn, inattentive and underachieved in their elementary school years. Different types of childhood maltreatment were found to be associated with adult psychopathology, personal problems and social problems in adults who were abuse and neglected as children (Corbin, 2007; Glaser, 2000; Finzi et al., 2001). Adult eating disorders were more commonly found in those who were emotionally or sexually abused as children (Glaser, 2000). Furthermore, being sexually abused as a child was associated with sexual difficulties in adulthood; emotional abuse as a child was associated with poor self-esteem as an adult; and emotional abuse was associated with marital breakdown as an adult (Glaser, 2000). Also, trauma experienced in early childhood predisposes adults to suffer from PTSD following traumatic events in adulthood (Bremner, Southwick, Johnson, Yehuda, & Charney, 1993; Yehuda et al., 1995). This evidence suggests a poor prognosis for children who have been abused and neglected if they do not receive intervention as children. Overview of intervention techniques. There are several domains of intervention for children with attachment problems. Family interventions aim to improve parental skills and family relations. The goal of family intervention is to help the caregiver understand the emotional and physical needs of the child. It is important for caregivers to be sensitive to the childs negative views of relationships and have an understanding of their role in reshaping the childs view of

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relationships. Behaviourally based attachment interventions seek to improve family sensitivity and the affect-communicating capacity of caregiver-child interactions (Howe, 2006). Behaviourally based attachment interventions guide caregivers while they interact with the child. Affect regulation is a main target of therapy. Maltreated children need help to identify their feelings, consider their impact on self and others, and begin to process them in a more reflective and regulated way (Howe, 2006). Caregivers and therapists must constantly convey what they feel and perceive in the child to ensure as much positive psychological information is being process by the child as possible (Howe, 2006). This is important because maltreated children are not used to receiving so much interest and care. Emphasizing the childs strengths will help them develop a new sense of what role caregivers play and how healthy relationships are established and maintained. It is important for the caregiver and therapist to match their physical expression to their positive language. The caregivers and therapists facial expression, tone of voice and body language have an important impact on if the child perceives the relationship as secure or hostile (Bowlby, 1988; Howe, 2006). Treatments aim to help the caregiver identify, understand and react to the childs signals and needs (Howe, 2006). To achieve this the therapist uses a stop and reflect approach (Howe, 2006). The therapist will ask the caregiver to stop and reflect on their thoughts and feelings that arose during a negative interaction with the child. Through repeated use of this strategy the caregiver is better able to monitor, reappraise and repair their communication with an insecure child (Howe, 2006). Videotaping caregiver-child interactions is another technique of behaviourally based interventions. By recording the interaction between child and caregiver the therapist is able to point out the positive responses of the caregiver and the positive interactions (Howe, 2006). Highlighting the positive interaction builds the caregivers competence and confidence. Through this process the

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caregiver learns to follow the childs lead during interactions and becomes responsive to the child, thereby, improving the childs sense of security (Howe, 2006). The most important intervention is to provide an appropriate, stable, and nurturing environment for a child who has attachment problems. In order to break the cycle of abuse and enhance the childs functioning, interventions must help these children handle their emotional and social dysfunction and change their caregiving environments. Children with attachment problems need calm, consistent and nurturing environments in all areas of their lives. Systemic interventions in the school, community, and foster care should focus on providing professionals and caregivers with education about the need for stability and healthy attachment experiences for children with attachment issues (Corbin, 2007). Educational support and training is an essential part of supporting a childs environment. Caregivers benefit from training and education about normal and abnormal child development (Corbin, 2007; Howe, 2006). Programs that increase the caregivers understanding of how adversity affects childrens psychological and physical develop are paramount in creating nurturing and stable environments for maltreated children with attachment issues. Maltreated children bring their past experiences of abuse and neglect with them to any new environment. The insecure attachment strategies that have helped the child cope with abuse and neglect in the past are often misunderstood by new caregivers (Howe, 2006). A childs previous experience and insecure attachment style affects their behaviour and also affects the caregivers response to the child (Corbin; Howe, 2006; Pearce & Pezzot-Pearce, 1994). Educating caregivers about adaptive strategies, defence mechanisms and attachment behaviours of maltreated children allow the caregiver to understand the child better and respond more appropriately to the childs needs

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(Howe, 2006). Another possible domain of intervention for children with attachment issues is individual therapy. Individual counselling techniques. Another important domain of intervention is individual therapy. Once a child has been placed in a stable and healthy environment it is important they receive individual therapy. Individual therapy must compliment the childs stable (new) environment. Therapy must provide a stable, consistent, safe and reliable place for a child to come (Corbin, 2007; Pearce & Pezzot-Pearce, 1994). Without therapy, children with attachment problems are at an increased risk of further difficulties in social functioning, antisocial behaviour, social withdrawal, social rejection, and low self-efficacy (Finzi et al., 2001). The focus of therapy is to have the child explore their current thoughts about adults and relationships and help them develop new thought patterns that are healthy (Bowlby, 1988; Corbin, 2007; Pearce & Pezzot-Pearce, 1994). New and healthy perspectives about caregivers and relationships would be repeated and learned so that new patterns become ingrained in the childs internal working model (Bowlby, 1988; George, 1996; Johnson, Dweck, & Chen, 2007; Pearce & Pezzot-Pearce, 1994). The therapist must be a stable figure that can develop a long lasting and secure relationship with the child. The therapy itself is about establishing a healthy bond between the child and therapist while simultaneously teaching the chid new perspectives about relationships (Pearce & Pezzot-Pearce, 1994). Therapy changes the brain by creating new neural connections through attachments and new learning. The goal is to provide a counter balance to the childs negative view of relationships in hopes of creating a more positive outlook (Corbin, 2007). One form of individual therapy is sensory intergration.

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Many maltreated children have suffered from sensory deprivation (Corbin, 2007; Howe, 2006). These children often display physical, emotional, and sensory deficits such as: difficulties with balance; poor sight; poor hearing; touch; taste; smell; and understanding the relationship between their emotions and physical sensation (Howe, 2006). Sensory integration techniques help the child understand how their bodies and senses work (Ayers, 1989). Without understanding their bodies, emotions, and sensations it is difficult for the child to move to the next stage of emotional development (Howe, 2006). Animal-Assisted Therapy is a form of nondirective play therapy. The therapist allows the child to choose the activities, materials, toys and themes (Parish-Plass, 2008). The therapist follows the childs lead in an attentive and interactive manner. The therapist reflects the childs behaviours and emotions during therapy to encourage insight and to help the child further develop the themes of therapy. The therapist empowers the child by asking for clarity regarding the childs intentions, emotions, memories and thoughts during play (Parish-Plass, 2008). According to Parish-Plass (2008) this technique is important because it allows the child to work through their issues while simultaneously empowering them. Animal-Assisted Therapy allows the child to explore their feelings and thoughts through both reality and play. If reality becomes too difficult for the child they can take advantage of the opportunity for play (Parish-Plass, 2008). Also, the therapist is able to focus on reality, engage the child in imaginary play or combine the two. Having the ability to go from reality to play is important for maltreated children because they have high levels of anxiety and lowered abilities to use symbolization in play (Parish-Plass, 2008). Animal-Assisted Therapy provides many advantages for therapy. The relationship between the therapist and animal makes the therapist more trustworthy through the childs eyes (Parish-Plass, 2008). Parish-Plass (2008) argued, the

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relationship between therapist and child is more easily established than in other therapies due to the presence of an animal. Other advantages of Animal-Assisted Therapy include: the ability to work on cognition, affect and behaviour; creates an opportunity for change of internal working models of relationships; increases self-esteem; and increases the childs ability to empathize (Parish-Plass, 2008). Child psychotherapy helps the child move beyond the role of victim and enables balanced relationships with others. Therapy serves as a model for healthy adult-child relationships, as well as a safe environment to work through issues of vulnerability, powerlessness and impulse control. Psychotherapy promotes positive peer relationships, new copping skills and provides a support network for the child (Finzi et al., 2001; Pearce & Pezzot-Pearce, 1994). One form of psychotherapy that can be effective for treating children is Narrative therapy. Narrative therapy approaches emphasize problems in families as deriving from negative conversations and interactions (Dallos, 2003). Pathologizing stories come to dominate and restrict peoples behaviours and thoughts (White & Epston, 1990). These narratives are ingrained by the underlying beliefs of the family and child and are reinforced through pathologizing conversations. Narrative therapy seeks to identify the pathological story, externalize the problem from the family or child, and recreate a preferred story that is not pathological in nature. Children how have been maltreated are often labelled as a bad child or become to believe the must have deserved the abuse. Family members often use negative terms to describe the child and place a label on the child that is pathologizing. A child who is constantly labelled as bad may begin to internalize the label and indentify with being bad. Over time the label becomes the childs self-identity. Narrative therapy externalizes the label as a temporary problem and not as an

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intrinsic trait of the child. During narrative therapy exceptions to the problem are identified along with instances when the child resisted the problem (Dallos, 2003; White & Epston, 1990). The child is encouraged to develop ways he or she can stand up to the problem, thereby creating a new preferred life narrative. For example, a child with attachment issues who is aggressive is not the problem. However, acting aggressively toward their peers is a problem. The act of aggression is the temporary problem that can be overcome and is not an intrinsic trait of the child. The therapist will then help the child develop strategies to resist aggression when it tries to take control over the child. As the child learns to control his or her anger they will begin to elicit more favourable responses from their environment. These more desirable responses from the environment will begin to be ingrained in the childs internal working model, thereby, replacing their existing pessimistic representation of the world. Internal working models. Children hold working models of self and others. Internal working models hold information, expectations and feelings about other people and produce the way relationships are represented in a childs mind (Bowlby, 1988; Pearce & Pezzot-Pearce, 2007). Internal working models help a child predict how their primary caregiver and other people in their environment will behave (Goldsmith, 2007). Derived from their experiences with caregivers, internal working models guide children as they interpret situations and create plans for how to respond and behave in new environments and relationships. Relationships in the first few years of the childs life create a map for the child to navigate new relationships and environments (Bowlby, 1988; Goldsmith, 2007; Pearce & Pearce-Pezzot, 2007). Maltreated children who have not experienced available and reliable caregiving perceive their environment as unreliable; therefore, they fear exploration and engage others with aggressive and negative behaviours (Goldsmith, 2007). Children who have been maltreated often have internal working models that

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hold negative information about caregivers and relationships. Maltreated children often have internal working models that view people as unresponsive to their needs, untrustworthy and uncaring. Specifically, internal working models derive from the childs beliefs about how acceptable they are in the eyes of their caregivers (Pietromonaco & Barret, 2000). This is achieved when the child measures and interprets the level of responsiveness of the caregiver to their needs. Children who have not suffered maltreatment and have secure attachments develop a representation (internal working model) of themselves as acceptable and worthwhile. Conversely, children with insecure attachments, due to maltreatment, develop internal working models of being unacceptable and unworthy (Pietromonaco & Barret, 2000). Internal working models of others include expectations about who will serve as attachment figures, how available attachment figures are and how they will respond when need (Bowlby, 1979; Goldsmith, 2007; Pearce & Pezzot-Pearce, 1994; Pietromonaco & Barret, 2000). Through repeated use internal working models become automatic and subconscious. Internal working models automatically guide a childs attention, interpretation of situations and memory (Pietromonaco & Barret, 2000). This process generates expectations of relationships and develops strategies for how a child will deal with those relationships (Bowlby, 1979; Bowlby, 1988). Effectiveness of counselling. Attachment problems develop within relationships, therefore, correcting attachment problems requires interventions that improve stability and increase quality of the caregiver-child relationship. According to Chaffin et al. (2006), a review of more than 70 studies of interventions designed to improve early childhood attachment showed that interventions that improved caregiver sensitivity were the most effective in improving childrens attachment

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security. This was supported by Bakermans-Kranenburg, Van Ijzendoorn, and Juffer (2003) when they identified common characteristics among more successful approaches. Shorter term interventions with better focus, that were goal-directed produced better results than broad focused and longer term interventions. Also, focused, goal-directed, behavioural approaches targeted at increasing the caregivers sensitivity to the childs needs produced better outcomes as well (Bakermans-Kranenburg et al., 2003). Dyadic Developmental Psychotherapy is an effective method for treating children with attachment disorders. Becker-Weidman (2006) studied the effectiveness of Dyadic Developmental Psychotherapy with children who have attachment disorders. According to Becker-Weidman (2006) Dyadic Developmental Psychotherapy produced better outcomes for children with attachment disorders compared to the control group that received usual care. Usual care included: individual therapy; play therapy; family therapy; residential treatment; and intensive outpatient treatment. According to Becker-Weidman (2006) Dyadic Developmental Psychotherapy is effective because of its focus on affective attunement between therapist and child, caregiver and child, and therapist and caregiver. Maintaining affective attunement creates dyadic regulation of affect between child and therapist creating a sense of safety and security for the child to explore their affect associated with past trauma (Becker-Weidman (2006). Affectively attuned relationships are described as both people experiencing the same affect and their affects co-vary (Becker-Weidman, 2006). The attuned relationship between therapist and child allows for the child to work through the shame of past maltreatment and current misbehaviours are explored, experienced and integrated (Becker-Weidman, 2006; Chaffin et al., 2006). According to Becker-Weidman (2006) Dyadic Developmental Psychotherapy significantly decreased symptoms of attachment disorder,

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withdrawn behaviours, anxiety and depression, social problems, thought problems, attention problems, rule breaking behaviours and aggression. Critical evaluation of counselling techniques. Some studies have found that clients with resistant or avoidant attachments do not benefit from relational interventions (Corbin, 2007; Chaffin, et al., 2006; Howe, 2006; Pearce & Pezzot-Pearce, 2007). Children with attachment issues often have a stable attachment style that is difficult to influence and is insensitive to replacement experiences such as therapy (Corbin, 2007). The Pessimistic Model of counselling children with attachment problems posits that increasingly stable characteristics account for consistency in behaviour across time, therefore, interventions are not effective later in life (Chaffin et al., 2006; Pearce & Peaaot-Pearce, 2007). Early intervention such as infant-parent psychotherapy is derived from this model. According to the Pessimistic Model only early intervention can produce positive changes in a childs internal working model. Compensatory interventions also fall under the Pessimistic Model. Compensatory interventions focus on strengthening emotion regulation strategies that could raise the threshold for internal working model activation. For example, the therapist would help the child identify emotional arousal at low levels and engage in self-regulating strategies to prevent activation (Pearce & Pezzot-Pearce, 2007). The goal is to prevent activation through arousal as opposed to changing the internal working model. Conversely, the Optimistic Model maintains the maladaptive internal working models can be transformed (Pearce & Pezzot-Pearce, 2007). The change process occurs inside the therapeutic relationship. The therapeutic relationship introduces an element of discontinuity into the child internal working model (Pearce & Pezzot-Pearce, 2007). The relationship provides an opportunity for the child to see positive responses to their needs which will begin to construct new expectations

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about how others can be expected to respond (Chaffin et al., 2006; Pearce & Pezzot-Pearce, 2007). There are several problems with this model. First, the Optimistic Model presupposes that children will engage in therapy aimed at changing their internal working model. Secondly, isolated experiences in therapy are not powerful enough in themselves to promote change to a childs internal working model. The primary caregiver and school personal also play vital roles in changing a childs view of the world. Thirdly, often times the child directs their anger at the therapist. Children with attachment issues are sceptical about the potential for a relationship with the therapist. This creates difficulty for the therapist in establishing a secure base for treatment to occur (Pearce & Pezzot-Pearce, 1994). Lastly, according to Pearce and Pezzot-Pearce (2007), the Optimistic Model lacks sufficient research supporting its utility. Summary and Conclusion This paper provided an overview of counselling techniques used to treat maltreated children. The literature reviewed can be conceptualized under the attachment framework. Children who have been maltreated often display behavioural, emotional and psychological deficits. Under the theoretical framework of attachment, maltreated children often form maladaptive representations of self, relationships and their environment. These representations of the world are known as internal working models in the attachment literature. Several counselling techniques may be used to treat maltreated children with attachment issues. Appropriate interventions are crucial in helping maltreated children. It is important that the child is placed in a safe and nurturing environment; caregivers receive education about the childs needs and attachment issues; and the child receives individual therapy or family therapy. Some scepticism exists in the literature about the effectiveness of psychotherapy with young children. The child may target the therapist making it hard to establish the secure bond

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needed to begin working through the childs attachment issues. Further research is needed to identify best practice for treating children with attachment issues, as well as to determine if internal working models can be changed over time.

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