Attachment and Trauma Therapy

updated May 2014

How Trauma Affects the Brain

To understand how treatment can be effective, it is helpful to understand brain chemistry. The type of sensory deprivation, neglect and other traumatic events that institutionalized children experience affect the brain's development and may cause dysfunctions such as RAD and PTSD (Complex Trauma), primarily by increasing stress hormones such as cortisol and adrenaline. Designed to respond to psychological or physical danger, these hormones prepare the body for fight or flight. By prolonged or repeated exposure to trauma (neglect and/or abuse) the child learns that the world is an unsafe place, and the brain remembers this even after the being placed in a loving, safe home. Research suggests that these experiences can also cause imbalances in the brain chemicals serotonin and noradrenalin in genetically susceptible people.

Noradrenaline, the brain's alarm hormone, acts as an emotional accelerator. Traumatic experiences will reset the brain's chemistry so that the child is in a constant state of readiness to respond to any threat - with a racing heart, high blood pressure, easy startle response and instantaneous explosive behavior. Research indicates that high levels of noradrenaline are the chemical signature of PTSD.

Normal levels of serotonin produce feelings of peace, well-being and clear thinking. It is the brakes to the noradrenaline accelerator. If levels are too low, a child may appear overly aggressive, impulsive or depressed. If levels are too high, the brain can be stopped cold, afraid to do anything - like a deer frozen in automobile headlights. In humans, this is linked to the fearfulness and rigidity seen in obsessive-compulsive behavior. Parents provide a safeguard against low serotonin when they comfort infants, tend to their needs, and control inappropriate behaviors by setting limits.

Brain chemistry which is only 5 to 10 percent off normal can result in a wide variety of mental problems. The idea behind the newest mood stabilizer medications such as serotonin re-uptake inhibitors (SSRIs), is that they seem to restore a normal balance to the brain's chemistry.

Chocolate, cookies, and other foods high in carbohydrates will raise serotonin levels. When depressed people binge on these foods they are basically self-medicating. Brain levels of serotonin can also be increased by eating foods rich in tryptophan such as turkey, chicken, salmon, beef, peanut butter, green peas, brewer's yeast, potatoes, and milk.

Dr. Bruce Perry showed that medication which lowered noradrenaline in children with PTSD dramatically reduced their aggressive behavior. Other therapists are attempting to lower noradrenaline by increasing feelings of security through therapy and increased attachments to parents. Even children born with predispositions for high noradrenaline levels and fearful responses should remain clam in stressful situations if they are with a parent they trust. If the child does not feel secure with his caretaker, noradrenaline and hyperactivity go up. This explains why some adopted children do not remain calm in stressful situations, even when they are with their parents: they do not yet trust their parents.

Today there are a variety of treatments available. Therapies such as EMDR and Neurofeedback, medication, and therapeutic parenting are all designed to do the same thing: increase the level of trust, effect changes in the brain which balance the brain's chemistry, and normalize behavior.

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Treatment Options

Traditional child centered psychotherapies, such as non-directive play therapy, don't work for children with RAD, since they depend on a relationship of trust between the child and therapist. A child with RAD is by definition a child without trust. His or her primary goal needs to be learning to trust his or her parents first, not a therapist. In order for therapy to be successful in repairing the attachment disorder, it is imperative that parents be included in the therapy sessions, and that therapeutic exercises be incorporated which allow children to learn to trust their parents along with processing any trauma.

Dyadic Developmental Psychotherapy

Dyadic Developmental Psychotherapy is an attachment based therapy for children with Complex Trauma and attachment impairment, developed by psychologist Daniel Hughes. Dyadic Developmental Psychotherapy principally involves PLACE - creating a Playful, Loving, Accepting, Curious, and Empathic environment in which the therapist and parent attune to the child's "subjective experiences" (feelings, and thoughts) and help the child make sense of them by reflecting back and validating those experiences to the child by means of eye contact, facial expressions, gestures and movements, tone of voice, timing and touch. This helps children become more regulated, just as babies become regulated to their mothers when they are soothed.

Trauma-Focused Cognitive Behavioral Therapy

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) is a form of cognitive behavioral therapy specifically adapted for children who have experienced trauma. TF-CBT for children with Complex Trauma is similar in many ways to Dyadic Developmental Psychotherapy, and incorporates: enhancing feelings of safety, psycho-education about trauma and its effects, relaxation skills training, clarifying cognitive distortions, parenting skills, and trauma processing using narratives. Family sessions – therapy with the parents present – will enhance attachment and trust in the child as well as address trauma.

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EMDR

Eye Movement Desensitization and Reprocessing (EMDR) helps people revisit their trauma, reprocess and desensitize their memories, and resolve their feelings about them. Trauma causes one side of the brain to overcompensate. While the exact mechanism of EMDR's success is not known, Joanne May, PhD. believes that EMDR impacts the information processing center (the connection between the left and right hemispheres), so that both sides of the brain can talk to each other instead of being stuck.

EMDR therapists started using only eye movement, but have found that touch, sound and even vibration work as well. The therapist may use sound, alternating it between the left and right ear or alternate tapping on the client's ankles, arms or shoulders. There are devices which provide a gentle vibration to a small disc which the child can hold, alternating between the left and right hands.

The therapist may do this while the child is expressing the trauma through play or while the mother talks about parts of the trauma or tells a story related to the trauma or adoption. It can even be used to reinforce pleasant feelings such as love and safety or to reinforce concepts that a traumatized child has lost, such as I am worthwhile, or I can ask for help and get it.

When considering this therapy, it is important (and difficult) to find someone who has experience treating young children. This treatment method may not be suitable for the youngest children or those who are severely oppositional, because it does require some cooperation on the part of the child.

Recommended books:

Small Wonders: Healing Childhood Trauma with EMDR, by Joan Lovett, MD

Through the Eyes of a Child: EMDR With Children, by Robert H. Tinker, PhD and Sandra A. Wilson, PhD

Family Narrative Therapy

The Family Attachment and Counseling Center uses narratives (stories) and EMDR to help children process trauma and build attachment. This technique is also appropriate for parents who simply want to address adoption issues with their child.

Joanne May, PhD, founder of The Family Attachment and Counseling Center, says that early neglect/abuse does not necessarily predict the way a traumatized/neglected child will parent as adults. It is rather, the extent to which their life issues are resolved and how they see their own life's story, that determines what kind of parent they will become. Resilience (the ability to overcome misfortune) was the key. In Man's Search for Meaning , Viktor E. Frankl (a concentration camp survivor), defines resilience as the ability to say "I will be different than my beginnings."

The brain in normal people remains plastic (changeable) into old age. Neurons can grow and we can take in new information. But in traumatized individuals, stress releases cortisol which results in the destruction of neurons in the hippocampus, the part of the brain which makes new memories. May postulates that RAD could be a memory disorder, because RAD children can't seem to make or take in new information (like "My new mommy won't leave me, she's not the one who hurt me").

According to May, narratives are as valid as the actual experience because they form new neuro pathways in the brain. RAD kids (especially those who had damage done during first 2 years of life) have formed a conclusion about life: "I'm bad because my birthmother abandoned me". They tend to believe they made it happen. These faulty convictions, also known as “toxic shame” promote a lot of exasperating behaviors. The narratives aim to shift the internal working model and change the behavior and produce calm, even in severely dysregulated individuals.

There are three kinds of narratives:

Claiming Narrative - what it would have been like if you had been with me from the beginning

Trauma Narrative - which talks about and helps process traumatic experiences. It is always done in the third person (referring to "the baby" or a made up name), so that it will be less traumatic for the child to hear. An added benefit is that the child's history doesn't have to be 100% accurate. It enables the parents to go back and fix what went wrong. The structure of the narrative is: a) this is what happened; b) this is not what babies deserve; c) you deserve better.

Successful Child Narrative - use of a story to help a child overcome a specific problem. This is also done in the third person. The narrative gives words and meaning to the child's experience, and provides a hero/heroine for the child to use as a model.

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Theraplay

According to their website, Theraplay® was developed by clinical psychologist Ann M. Jernberg, Ph.D. It is a therapist-directed play therapy for children and their parents. It is designed to enhance attachment, raise self-esteem, improve trust in others and create joyful engagement in family relationships.

Theraplay is based on the natural patterns of healthy interaction between parent and child., and focuses on five essential qualities found in parent-child relationships: Structure, Engagement, Nurture, Challenge and Playfulness. Theraplay sessions attempt to create an empathic connection between the child and the parents. The goal is to change the child's view of the self from bad, shameful and undeserving to worthy and lovable. It attempts to change the child's view of relationships from unreliable to positive, trustworthy and rewarding. Parents are actively involved in the treatment and direct their child in the Theraplay interactions.

Neurofeedback

Post-Institutionalized (PI) children suffering from psychological, neurological, or learning disorders might benefit from Neurotherapy. Also referred to as EEG biofeedback or neurofeedback (NF), this treatment involves stimulating or suppressing certain types of brainwaves in specific areas of the brain to achieve optimal levels of human functioning.

In adopted children, the causes of brain dysfunction are many: abuse; neglect; deprivation, emotional trauma, head injury; biochemical imbalances; and genetics; to name a few. These dysfunctions may present themselves as various disorders including, but not limited to: PTSD, RAD, Severe Separation Anxiety, Night Terrors, Learning Disabilities, Attention Deficit, Disorder, Obsessive Compulsive Disorder, and Speech/Language pathologies.

A QEEG, or Brain Mapping is performed prior to the NF treatment. This is a process for analyzing electrical activity in the brain. Electrodes are placed at 24 sites on the child's head. They are connected to a computer where the brainwave patterns are recorded. This Brain Map and subsequent report will provide an overall picture of how the child's brain functions and which areas need modulation. The procedure can take up to an hour and half and requires a child to co-operate and sit still.

The QEEG measures brainwaves at sites that allow us to perform specific tasks; e.g., reading, listening, math, logical thinking, auditory processing, sensory processing, impulse control, etc. If frequencies are too high or too low dysfunction occurs. A trained technician will read the QEEG and measure it against a normal population age-appropriate database to determine the treatment protocol.

During treatment, the child is again connected to a computer, this time using one or two electrodes placed in specific locations on their scalp, and one on each ear. The child chooses a computer game where her brainwaves will actually power the game. For example, if she is daydreaming, wiggling and/or not concentrating, a space-ship will not run. When she is focusing well, the ship will fly through space and she will collect rewards such as planets and stars. Meanwhile, her brainwave frequencies will be measured and the therapist can monitor her progress. This "training" will teach her to "suppress" the brainwaves that interfere with higher level thinking or negative behaviors, and "activate" brainwaves that allow for relaxed, calm states, or states of arousal suitable for classroom learning. Eventually the child will recognize newly trained positive states and switch them on automatically when the need arises.

Neurofeedback alone will not cure RAD. It needs to be combined with other therapies. If you train the brain but don't allow the child to process the emotional trauma of her past, the effectiveness of therapy will be limited.

There are no case studies on NF with Post-institutionalized children. Most studies done on children have been in the area of ADD/ADHD.

To find a neurofeedback provider in your area contact EEG Spectrum or Q-metrx. Providers can also be found at Neurology Centers and Pain Clinic Centers in hospitals.

Many, if not most, NF providers will not have experience working with post-institutionalized children. In the case of a typical biological, ADD/ADHD child, a treatment protocol of 15-40 sessions may be adequate. But the parents on Attach-china who have used QEEG brain mapping have found that their children require daily treatment over a period of many months, if not years, since the insult to their brains has been more severe than that of the normal population.

Read about one family's experience with neurofeedback "What Neuro Has Done For Us"

Recommended books:

A Symphony in the Brain by Jim Robbins. Overview of the history/development of Neurofeedback including scientific research and technological breakthroughs including case examples.

Introduction to Quantitative EEG and Neurofeedback by James R. Evans (Editor), Andrew Abarbanel (Editor)

Mindfitness Training: The Process of Enhancing Profound Attention Using Neurofeedback by Adam Crane, Richard Soutar

Change Your Brain, Change Your Life by Daniel Amen of the Amen Clinic. Does not specifically discuss NF, but gives a good understanding of the areas of the brain and behavioral problems associated with them.

Inside the brain: Revolutionary Discoveries of How the Mind Works by R. Kotulak.

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Food Allergies & Sensitivities

When we think of food allergies, we commonly think of anaphylaxis, eczema, hives, and runny noses. However, food allergies and intolerances can be the cause of anxiety, irritability, hyperactivity and even rages in children. Some children exhibit muscular tics, which are commonly mistaken for Tourette’s Syndrome. Others may suffer from headaches - either sinus, migraines, or both.

Many children with have shown dramatic improvement when the following were integrated into trauma & attachment therapy:

Examination for food allergies. Blood tests may be done to determine whether a there is an IgE allergy or IgG allergy. An IgE allergy is best described as a typical food allergy, which shows an immediate reaction, and at its most severe can cause anaphylaxis. An IgG allergy can best be described as a delayed reaction allergy or food sensitivity/intolerance. This delay in reaction can be as much as 24 to 48 hours, making it difficult to identify.

Since both IgE and IgG allergies or sensitivities can cause emotional and behavioral symptoms in children, it is well worth the effort to identify any offending foods. Blood tests for allergies may help to distinguish which foods are causing problems, especially when there is an overlap. However, as testing is not 100% reliable, the best method to determine whether there is a food intolerance is to remove the suspect food from one’s diet for 3-6 weeks, and then do a “food challenge”. After 3-6 weeks without any of the food, the body will become quite sensitive to it, and symptoms will become clear after eating the food. If one suspects that a severe or anaphylactic reaction will occur, this should only be done under a doctor’s supervision.

In particular, families have found that maintaining a gluten free and casein free diet have shown improvement in some children.

Artificial dyes and preservatives: The American Academy of Pediatrics has finally joined the British government in officially linking artificial coloring in food to hyperactivity and ADHD in children. In fact, the UK banned the use of artifical colors in food in 2007. Many children’s hyperactivity is demonstrably reduced by eliminating artifical colors and preservatives from their food.

Heavy metal toxicity and other metabolic imbalances have been linked to:

• Depression.
• Attention deficit hyperactivity disorder.
• Learning & language disorders
• Developmental delays
• Autism or pervasive developmental disorder.
• Behavioral disturbances.

DAN! (Defeat Autism Now!) doctors and naturopaths routinely test for metal toxicity and metabolic imbalances. Eliminating these, and use of dietary supplements, can help dysregulated children become calmer and therefore begin to integrate attachment and trauma therapy into their brains and bodies.

Therapies Which DON'T WORK for Children with RAD

The reason these therapies don't work for children with RAD is that they all depend on a relationship of trust between the child and therapist and/or child and parent. A child with RAD is by definition a child without trust. His or her primary goal needs to be learning to trust his or her parents first, not a therapist. It is imperative that parents be included in the therapy sessions, which is not usually the case in the below mentioned therapies.

Non-Directive Play Therapy involves the child and therapist using puppets, drawing, games, and play-acting to resolve problems. However, this type of play therapy allows children to stay stuck in the trauma and manipulate the therapist with the play, rather than learning to safely follow and trust dependable adults. Since parents are not involved in the session, there is no work being done to strengthen and repair the attachment between parent and child.

Sand Tray Therapy is a method used to assess the psychological well-being of children and adults by analyzing how they express themselves through the manipulation of objects in small, tabletop sandboxes (or trays). Sand Tray participants are invited to create a miniature world by arranging toy people, animals, and other items in the sandtray. It relies on the child to work out the trauma herself. But a child who has never had a view of the world which included safety, trust and adults meeting her needs will not know how to achieve that goal on her own.

Talk Therapy involves helping the child to face the memory, and talk through the various upsetting parts. This is used more with older children and teen-agers. However, children with RAD are experts at manipulating therapists by "giving them what they want" and becoming the ideal patient. Cognitive-Behavioral Therapy uses small rewards or successes as motivators to replace negative thoughts, feelings, and behaviors with more useful ones, in a systematic, stepwise manner. RAD children tend to see these rewards as another way to trick their parents and prove how stupid adults are.

Disclaimer

This Attach-China/International Parenting Network was founded by a parent for parents of children adopted from China who have Complex Trauma/PTSD or other attachment issues as a resource for these issues. The content selected for the website is intended to share information about various therapies, and although certain articles speak to the success some families have had with those therapies, the website is not intended as an endorsement of any particular therapeutic course of treatment.

Families with children with possible Complex Trauma/PTSD and attachment issues are urged to seek medical advice. If a family begins a therapy without medical advice, they do so at their own risk. Children may have unusual or unique reactions to various types of therapies and "one-size-does-not-fit-all" when dealing with these issues. This website is not intended to take the place of professional therapy and Attach-China/International can assume no responsibility for a family's therapeutic choices for their child.

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