treating the lingering effects of drug endangered children utah’s 2 nd annual drug endangered...

Treating the Lingering Effects of Drug Endangered

Children

Utah’s 2nd Annual Drug Endangered Children Conference

Douglas Goldsmith, Ph.D.Executive Director

The Children’s Center

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)

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

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

Addicted Mothers

• Those with higher rates of lifetime psychiatric diagnoses, including personality disorders, have more maladjusted offspring

L. Beckwith et al, 1999

Substance Abusing Mothers

• Show deficits in quality of interactions with their infants

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

Individual Differences

• Reflect differences in the child’s 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

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

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

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)

Secure vs Insecure Attachment

• The classifications “Secure” vs “Insecure” “Reflect the infant’s apparent perception of the availability of the caregiver if a need for comfort or protection should arise, and the organization of the infant’s responses to the caregiver in light of those perceptions of availability.”


Secure Attachment

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

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 I’m held I feel warm, safe, and comforted• Results in a relaxed state so that one can, again,

begin to explore

•Holmes (1993)

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


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)

Anxious Attachment

• Lack experience with consistent availability and comfort

• Attachment behaviors are responded to with:– Indifference– Rebuffs– Inconsistency

Anxious Attachment

• Anxious about caregiver’s availability

• Afraid that the caregiver will be unresponsive or ineffective in providing comfort

• Experience anger about caregivers unresponsiveness

Anxious Attachment

• Shows overt aggression toward the inconsistent mother

• “Don’t you dare do that again!” but has to cling because he knows from experience that she will.

Holmes (1993)

Anxious Attachment

• Maintain constant low levels of anxiety about the caregiver’s availability

• Unable to explore the environment without worry

• Fail to achieve confidence in themselves and mastery of their environment


Maintaining Proximity

• Secure infants trust in the reliability of the caregiver’s 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

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.”


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


• 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.”



• The infant anticipates the behavior of the caregiver in response to the infant’s signals.

• Learns to view the world as “good and responsive” and the “self as deserving such consideration”.

• Weinfield et al (1999)


• 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



• “When the expectation of being hurt, disappointed, and afraid is carried forward to new relationships, the anxious infant becomes an angry, aggressive child.”


Caregiver Responsiveness

• Anxious dyads– Less sensitive in interactions– Interfere with children’s 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)

Emotion Regulation

• “The caregiver’s responses to the infant’s distress are an external source of emotion regulation before the infant learns to self-regulate”


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

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)

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


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


• 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?


• 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


• Secure Base– May need to address underlying issues

around parental unavailability to the child• Does the parent find parent-child time enjoyable?• Is the child’s 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


• 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


• Secure Base– Help parent learn to give warnings around

transitions and brief separations– Increase predictability of the environment– Increase reliability of parental availability


• Secure Base– Develop nurturing skills– Help the parent learn to be an “ideal

grandparent”• Anticipate the child’s needs• Provide physical comforts• Plan surprises so the child knows s/he is thought

about even when absent

– Increase sensitivity to cues


• 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


• Exploration– Examine the parent’s 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


• Exploration– Teach the child “checking in” behaviors

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

skills


• 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, I’ll help you fix it/ figure it out”• If attacks persist state, “I’ll be in the next room so I

can stay safe but as soon as I hear you calm I’ll be right back”

• Develop deep breathing and self-soothing skills


• 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


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

treating the lingering effects of drug endangered children utah’s 2 nd annual drug endangered...

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