Reactive Attachment and Fetal Alcohol Spectrum Disorders

Reactive Attachment and Fetal Alcohol Spectrum Disorders Individual, Family, and Community Implications Andrew J. Ballew, Psy.D. Emily Kutner, M.S. James V. Wojcik, Ph.D., LP

Learning Objectives Identify biological and psychosocial influences on attachment Identify methods of psychological assessment used to quantify the biological and psychosocial impact of attachment difficulty Gain insight on empirically based interventions to address this intersection

Beginnings of the Project Canvas Health (formerly HSI) began Fetal Alcohol and Neurodevelopmental Clinic 2010 Training and materials funding by MOFAS Supervised by Jim Wojcik Ph.D. Staffed by fellows Stephanie Varga, Ph.D. Julia Conkel-Ziebell, Ph.D. Andrew Ballew, Psy.D. Doctoral interns also provide some testing

Co-development of CPS and Other Custody Evaluations Canvas staff support Washington Co. CPS staff in assessing children and parents in abuse and other cases Canvas Family Treatment Program and Children s Mental Health Case Management provide treatment and other services to seriously ill children and families Some of these are adoptive families Some of these have substance abuse in parents Many have attachment disorders as part of their context

Co-development of CPS and Other Custody Evaluations Psychological assessment at Canvas continues to evolve to match needs and standards of the field and referral sources Neuropsychological testing for FAS and other neurodevelopmental disorders Diagnostic testing to assess the needs of children, and the capacity of adult caregivers to provide for them Adding scales to objectively measure parenting stress (PSI-4, PRQ, HDI Social Impairment, MACI, BASC, Vineland, ABAS) Integrating the spectrum of issues

Typical FASD Battery IQ Learning Disabilities Executive Functions Memory Adaptive Living Skills Emotional/Behavioral Regulation Visual-Fine Motor Skills Language: Expressive & Receptive Sensory Integration Social Communication

How did we develop the idea? Significant number evaluees in foster or adoptive care The rate of FASD is 10-15 times higher for children in foster care than in the general population (Astley et. al., 2002) Observed pattern of relational and social concerns Examined previous research of co-occurring FASD and RAD Developed first stages of plan to add assessment of attachment and parental impact to the core FASD battery

Literature Review Disruption in mother-child interaction has a profound impact on children with impaired cognitive and emotional development (Lyons-Ruth et al., 2000) Although prenatal alcohol exposure was found to relate to higher levels of insecure attachment, children of mothers who provided them with emotional support were more able to deal with frustration. These children also exhibited higher levels of attachment security.(o Connor, et al., 2001)

Literature Review It is common for children to experience multiple placements prior to age 5 Children with FASD demonstrate poor relational and social connection Adoptive children may have been neglected with little stimulation Alcohol exposure history also tends to be minimalized (Adubato & Cohen, 2011)

Literature Review - Brain becomes hard- wired for chaos, memory problems, inability to regulate states of emoaon, form meaningful relaaonships, or control impulses - Infants born to mothers who drink alcohol (or are depressed) have an increased vulnerability for psychological disorders including aeachment problems o Alcohol abuse impairs maternal organizaaonal and emoaonal regulaaon (Adubato & Cohen, 2011)

Literature Review Alcohol negatively impacts the child s capacity to form attachments Results in stressed attachment Capacity to self-regulate is poor Unpredictable, Unreliable Limbic region of brain is over-activated Survival Fight/Flight (Page, 2002)

Literature Review Sensory integration difficulties are common Poor understanding of verbal communication Heightened awareness of non-verbal Ignore, distort verbal (Page, 2002)

Effects on the brain Diminished growth in the leh hemisphere, which may increase the risk for depression Irritability in the limbic system, seing the stage for the emergence of panic disorder and poseraumaac stress disorder Smaller growth in the hippocampus and limbic abnormaliaes, which can increase the risk for dissociaave disorders and memory impairments Impairment in the connecaon between the two brain hemispheres, which has been linked to symptoms of aeenaon- deficit/hyperacavity disorder (Teicher, 2000)

How does Assessment Help? Identify strengths and areas of growth for the individual Provide effective treatment goals and strategies to facilitate growth and change Provide hope and support to family and community participants What contributes to poor behaviors? Brain damage, environmental factors, disruption in care Gain a understanding of strengths, weaknesses, and significance of difficulty

Assessing Relationship Difficulties From the Typical FASD Battery Adaptive Living Skills: ABAS Socialization, Vineland-II Social Emotional/Behavioral Regulation: BASC-2 Relations with Parents, HDI Relational Impairment, MACI Family Discord

Assessing Relationship Difficulties Parent Relationship Questionnaire (PRQ) and Parent Stress Inventory 4 th Edition (PSI-4) Integrated into core battery Considerations being made for the Parent Child Relationship Inventory (PCRI) Purpose To better identify social and situational aspects that can create challenges to treatment To increase our understanding of biopsychosocial dynamics

Total 160 RAD 14 Non-RAD 92 Social Impairment & RAD 10 RAD & Nonbiological Home 10 All FAS 96 Any FAS & Social Impairment 96 Any FAS, Social Impairment, & RAD 3 FAS (not confirmed) 33 FASD 19 ARND 44 Adopted/Foster Care 76 Biological Family 30 Any FAS & RAD 5 Any FAS, RAD, and Non-biological home 3

Potential for Adaptation and Intervention How does any experience change the functioning of an individual in relationship? Is FASD remediable, manageable, or hopeless? How do attachment disorders and neurodevelopmental disorders interact? How do emotional experiences promote adaptation through neural change?

Dyadic Behaviors Child Categorization Secure Avoidant Anxious/Ambivalent Disorganized Maternal Behavior Emotionally available, perceptive & effective Distant & rejecting Inconsistent availability Conflictual behavior

Continuum of Attachment Anxious Nonattached Secure Disorganized

Insecure Attachment and Executive Function Similar impacts of attachment disorder and FAS Poor emotional control Impulsivity Risk-taking Poor self-care Interpersonal conflicts Misunderstandings Relationship aggression Antisocial behavior

24 Reciprocal Effects of FAS and Attachment Stress Teratological Effects Attachment Comfort Maternal preoccupation with relief from addiction Child demands and development needs

25 Psychotherapeutic Change Elements Building new brain connections through: Relationship quality Sustained moderate levels of arousal Integrating cognition & emotion Mutually constructing a new narrative

DSM V: Reactive Attachment Disorder Divided into two distinguished disorders: Reactive Attachment Disorder Disinhibited Social Engagement Disorder Clinical Implications?

DSM V: Fetal Alcohol Syndrome Disorder Other Specified Neurodevelopmental Disorder Neurodevelopmental Disorder associated with Prenatal Alcohol Exposure Neurobehavioral Disorder associated with Prenatal Alcohol Exposure Conditions for further study

Future Considerations 1. Benefits from diagnosing one over the other or both? Should either the priority? 2. Impact of DSM-5 changes?

Discussion Thoughts? Questions? Reactions?

References Adubato, S.A. & Cohen, D.E. (2011). Prenatal alcohol use and fetal alcohol spectrum disorders: Diagnosis, assessment, and new directions in research and multimodal treatment. UAE: Bentham Science Publishers Astley, S.J., Stachowiak, J., Clarren, Sk.K., & Clausen, C. (2002). Application of the fetal alcohol syndrome facial photographic screening tool in a foster care population. Journal of Pediatrics, 141, 712-717 DeBellis, M.D. & Zisk, A. (2014). The biological effects of childhood trauma. Child and Adolescent Psychiatric Clinics of North America, 23, 185-222. Fraley, R.C. & Speiker, S.J. (2003) Are infant attachment patterns continuously or categorically distributed? A taxometric analysis of strange situation behavior. Developmental Psychology, 39(3), 387-404. Lyons-Ruth, K., Zoll, D., and Grunebaum, H.U. (1986). The depressed mother and her one-year old infant: Environment, interaction, attachment, and infant development. New Directions Child Development, 34, 61-82. National Scientific Council on the Developing Child. (2012). The science of neglect: The persistent absense of resposnive care disrupts the developing brain: Working Paper 12. http://www.developingchild.harvard.edu O Connor MJ, Kogan N, Findlay R. Prenatal alcohol exposure and attachment behavior in children. Alcohol Clin Exp Res 2001; 26(10): 1592-1602. Page, K. (2002). The invisible havoc of prenatal alcohol damage. Journal of the Center for Families, Children and the Courts, 1-24 Teicher, M.D. (2000). Wounds that time won't heal: The neurobiology of child abuse. Cerebrum: The Dana Forum on brain science, 2(4), 50-67.