Note : Adapted from van der Kolk, B. A. (2014). The body keeps the score. Viking. In all these examples, an awareness and assessment of trauma history can be all that separates an accurate diagnosis from an inaccurate diagnosis. Conversely, because trauma exposure can be a causative or contributing factor to many DSM-5 disorders, individuals who have experienced trauma may also accurately fit other diagnostic criteria. However, many of the disorders provided as “misdiagnoses” in this section are treated with pharmaceutical interventions, which do not directly address the underlying trauma. Because children may hide or deny their own trauma histories, or adapt their behaviors to fit their abusive environments, clinicians need to be able to turn on their “trauma ears” or put on their “trauma lenses” to effectively intervene with children. This diagnostic sensitivity will be discussed in greater detail later in the course in the section on trauma- Jessica brought her eight-year-old son Lee for treatment regarding his ADHD diagnosis. Lee’s school psychologist and his pediatrician both agreed on the diagnosis based on observations reported by Lee’s teacher and Jessica. Lee struggled in the classroom and the teacher was clearly frustrated by Lee’s inability to sit still and his frequent disruptions of the class, as well as his noncompliant response to rules. The teacher was also worried about Lee’s inability to concentrate and its potential effects on his academic achievement. Jessica reported that Lee was also hyperactive at home and that he had difficulty sleeping—observations that also overlapped onto ADHD criteria. Attachment The psychobiological concept of attachment refers to “an emotional bond in which a person seeks proximity to the attachment object and uses them as a safe haven during times of distress and as a secure base from which to explore the world” (Fraley, 2019, p. 404). At a basic evolutionary level, attachment improves the helpless infant’s chances of survival, as human infants are wholly dependent on caregivers. This system is activated in response to danger or fear as well as by separation or threat of separation from the attachment figure. Humans have evolved in such a way that infants and young children will adaptively seek proximity to and maintain contact with a parental figure, even if the caregiver is abusive, hostile, or insensitive (Rincón-Cortés & Sullivan, 2014). The following sections will highlight the characteristics of both healthy and unhealthy attachments and frame the absence of a responsive attachment figure as a traumatic experience that could influence child development and well-being. Healthy Attachment Healthy attachment occurs when caregivers demonstrate sensitivity, an ability to perceive, accurately interpret, and appropriately respond to a child’s signals (Woodhouse, 2018). As children explore their worlds and receive stimulus inputs, they rely on their caregivers to be responsive in helping them to make sense of their environments. When caregivers are emotionally attuned, they provide “subtle physical levels of interaction” that give the child a sense of “being met, understood” and informed care. Case Example feeling safe (van der Kolk, 2014, p. 115). Caregivers may use gaze, touch, language, or other cues to provide reliable, developmentally appropriate, and caring responses. In turn, the child reacts, and a reciprocal process, termed “serve and return,” is enacted (Harvard University, Center on the Developing Child, 2022). These interactions are fundamental to the mind’s development. The caregiver’s consistent, congruent, and engaged interaction and presence enable the child’s healthy psychological and neurobiological development. Securely attached children “get in sync with their environment and the people around them and develop self-awareness, empathy, impulse control, and self-motivation” (van der Kolk, 2014, p. 113).
Within the first few sessions with Lee, the underlying role of his trauma history became apparent. Jessica reported that during the first three years of Lee’s life, she struggled with addiction and was in and out of treatment. She had been sober for the past five years and assumed that Lee could not still be affected by that time in their lives. Eventually, through work with Lee and Jessica together, Lee expressed that he had difficulty sleeping because he had frequent nightmares about his mother using drugs. He also reported that he would often worry about his mother while at school (which further explained to his difficulty concentrating). Although Jessica was sober, she still attended regular meetings, and Lee was aware that her sobriety was an ongoing effort. Jessica also reported that Lee had always been sensitive to yelling and loud noises, which she worked to connect to the days when she was using drugs and frequently hosted parties in her home when Lee was upstairs sleeping. Lee’s loud and active school classroom likely triggered a hyperarousal that then presented as hyperactivity in the room. Linking Lee’s symptoms to his trauma history reframed the function and cause of the symptoms, resulting in treatment targets focused on trauma rather than on ADHD. Lee and Jessica worked together to reconstruct trauma narratives, and Jessica was able to give voice to Lee’s worries while also conveying safety. Lee’s teacher was also informed about Lee’s trauma history and, with trauma psychoeducation, was able to facilitate trauma-informed classroom changes that alleviated the frequent triggering of Lee’s trauma symptoms. Providing all of the healthy attachment ingredients, all the time, is no easy task. Naturally, many caregivers worry that their occasional lapses in attunement or failures to connect mean that they are failing their children (Hubert & Aujoulat, 2018). It is important to reassure parents that healthy attachment relationships require only “good enough” caregiving. In other words, infrequent missteps in attunement are fine, especially when they occur in the context of primarily positive interactions; in fact, children are often comforted in learning that “broken connections can be repaired” (van der Kolk, 2014, p. 119). Recent attention has been brought to the concept of mindful parenting, which can help allow parents to respond nonjudgmentally and supportively to both their child and themselves (Shorey & Ng, 2021). Attachment Failures “Good enough” caregiving implies that attachment relationships do not require perfection; however, continued attachment failures, without repair, can ultimately become traumatic for the child. Commonly, clinicians attend to the “capital T” traumas (e.g., shootings, assaults, or natural disasters) because such traumas are difficult to miss. Yet attachment failures act as “little t” traumas that can be easily overlooked but equally damaging (Tambelli et al., 2015). Humphreys and Zeanah (2015) define traumatic attachment failures as “deviations from expectable environmental inputs” (p. 155), either resulting from lack of necessary, positive inputs (e.g., in cases of neglect or deprivation), or the presence of damaging inputs (e.g., hostile or abusive parenting). Some examples include (van der Kolk, 2014): ● Emotional unavailability and unreliable parenting resulting from a parent’s preoccupation with their own issues ● Distressed, unpredictable parenting ● Intrusive or hostile caregiving actions ● Rejection of the child’s attempts at connection ● The parent’s extreme expression of helplessness or fear to the child ● Generally withdrawn parenting ● An overdependence on the child to meet adult needs
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Book Code: PYFL4024
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