Trauma, attachment & adoption

Emphasing individuals in assessment & treatment

Dr Matt Woolgar Consultant Clinical Psychologist
National Adoption & Fostering Service South London & Maudsley NHS Foundation Trust
Senior Researcher, National Academy for Parenting Research, Kings College London & Lecturer Childrens & Young People's IAPT UCL/KCL

matt.woolgar@kcl.ac.uk
http://www.national.slam.nhs.uk/services/camhs/camhs-adoptionfostering/

Trauma & Attachment

Big constructs, but highly relevant for adopted children But can these big constructs become barriers to specifying what exactly an adopted child & their family need?

Can they obscure the individuality & diversity that the science tells comes from maltreatment?

Trauma - Psychiatric definitions

ICD-10
a stressful event or situation (of either brief or long duration) of an exceptionally threatening or catastrophic nature, which is likely to cause pervasive distress in almost anyone

DSM-IV
both (a) loss of "physical integrity", or risk of serious injury or death, to self or others, and (b) a response to the event that involved intense fear, horror, or helplessness

Trauma vs. Maltreatment/Neglect

Intense, usually single events, do not capture the range of possible early experiences
Low level, chronic negative experience e.g., neglect

Good science re. the biological, psychological & social impact of maltreatment & neglect Consequences quite different for different types of maltreatment & neglect More precision if we state the type, frequency and timing of maltreatment?

Maltreatment & Neglect: Bio-psycho-social impact

Emerging neuroscience demonstrates that early maltreatment increases risks for neurodevelopmental problems
But the science is much more complex than pictures of damaged brains might imply Involves more domains & in complex ways

Service planning for adopted children should be based on a sophisticated understanding of the science and the bio-psycho-social implications of maltreatment

Maltreatment impacts upon bio-psychosocial adaption

Biological Psychological Behavioural

Environment

Maltreatment impacts upon many levels within bio-psycho-social domains

Biological
Genes Brain Immun ology Memory

Psychological
Cognition

Behavioural
Aggression

Attach ment

Crying Avoiding

Physi ology

Motiv ation

Prosocial

Environment

Maltreatment, Neglect, Parenting, School, Peers

Maltreatment impacts upon many levels

Biological
Genes Brain Immun ology Memory

Psychological
Cognition

Behavioural
Aggression

Attach ment

Crying Avoiding

Physi ology

Motiv ation

Prosocial

Environment

Maltreatment, Neglect, Care, Parenting, Peers

Each child is unique

Spaghetti complex and hard to trace or specify each individual link / pathway Each plate is unique Each adopted child also has a unique history & formulation Cannot lump all adopted children together Because she is adopted she is X
Traumatised Brain different Attachment problems Anxious Shameful Without even seeing her, I can tell you she needs Y

Differential Susceptibility
People differ [e.g., genetically] in how much they respond to both positive & negative experiences

Differential Susceptibility
People differ [e.g., genetically] in how much they respond to both positive & negative experiences

Responses are Individual

A bigger dose of stress is worse on average But response to stress varies
Susceptible child may show big problems from only a small dose of maltreatment Resilient child may be resistant to a larger dose

But response to treatment can also vary

Susceptible child may respond well to small intervention if precisely tailored to meet his/her needs Resilient child may show much smaller response

Differential susceptibility in siblings

Boy is older & was exposed to significantly higher level of maltreatment but doing okay now
Great effort expended to address his greater trauma Not bothered either way by treatment so far

Younger girl had less maltreatment, yet struggling in all domains [except some peers]
Challenging to family & system [needy & volatile] Very keen for treatment sensitive, curious & rewarding Great potential, but how to help her?

Dandelions & Orchids

Dandelions do okay in most environments Orchids will do very badly in poor, BUT also in good but not quite right, environments Orchids will flourish in exactly right, tailored or personalised environments A good environment for the brother may still not be precisely right for the sister Puzzling when decent parenting/school good enough for the more maltreated sibling but not enough for the less maltreated one Focusing on the trauma or shared experiences of siblings can obscure these crucial differences

Subtle, complex & unique presentations

(in which common disorders still identifiable)
Learning disability

Attachment Mood

ADHD

???

Behavioural

Social skills deficits

Trauma School problems Autism Spectrum Anxiety

The allure of rare disorders in maltreated children (Haugaard, 2004)

Although more common diagnoses, such as ADHD, conduct disorder, PTSD, or adjustment disorder, may be less exciting, they should be considered as first line diagnoses before contemplating any rare condition such as RAD or an unspecified attachment disorder Chaffin et al, 2006 (APSAC) When clinicians become seduced by this allure, they can stop seeing the individual child & family

What are the likely common disorders in adopted children?

Poor mental health data for UK adopted children
A need for well designed research

But UK adopted children largely from Looked After Children (LAC) & have experienced maltreatment / neglect
Excellent epidemiological data for UK LAC
From the Office of National Statistics (ONS) study

Mental Health in UK LAC, Ford et al 2007

Birth family Any disorder Anxiety disorders PTSD Depression Behavioural disorders ADHD Autism [ASD] Neurodevelopmental Learning disability 8.5% 3.6% 0.1% 0.9% 4.3% 1.1% 0.3% 3.3% 1.5% High Risk 14.6% 5.5% 0.5% 1.2% 9.7% 1.3% 0.1% 4.5% 1.5% ONS LAC 46% 11% 2% 3% 39% 9% 2.6% 12.8% 10.7%

Comparing ONS LAC data with Tier 4 Adoption & Fostering Service (AFS)
(Woolgar et al, 2013)

ONS LAC Any disorder Anxiety disorders PTSD Depression Behavioural disorders ADHD ASD Neurodevelopmental Learning disability

AFS

CAMHS Referrals

46%
11% 2% 3% 39% 9% 2.6% 12.8% 10.7%

66%
9% 3% 4% 55% 38% 4% 12% 10%

31%
5% 1% 1% 4% 12% 4% 0% 3%

General CAMHS services for adoption

CAMHS services under-identifying
Behavioural problems Neurodevelopmental problems
ADHD Global learning disability Neurodevelopmental issues (e.g., motor problems etc) Specific learning disability (e.g., dyslexia)

Anxiety, PTSD & depression (to lesser extent)

Summary of what we know

Clear risk for common mental health disorders for UK children adopted from care Complex and pervasive bio-psycho-social presentations can emerge from maltreatment/neglect
So much more than just a damaged brain

Unique and subtle presentations with individual responses to extent [dose] of maltreatment

Biology responds to adversity with diversity in presentation Dandelions & orchids each have a role to play Need a personalised approach to service delivery

Cannot lump together all adopted childrens needs

Complexity in practice:
help with school; they just dont get him Domestic violence in utero & polysubstance misuse; 3 week detox in SCBU; adopted by his first carer History of multiple NHS CAMHS contacts
Series of Tier 3 assessments, discrepant diagnoses each discounting the previous ones
ADHD, no autism Autism, no ADHD ADHD again, but no autism Behavioural problems & poor parenting, but no ADHD or autism

9 year-old adopted boy

Not meeting high CAMHS thresholds so no treatment Family bemused, angry & let down

Tier 4 National & Specialist Adoption Specific Assessment

Few problems at home
Mother very clear & uses visual aids to help understanding

School hate him *evidence of not liking him in their report]

Disagree that he has any mental health issues [he has several] Blame mothers parenting *No, just her committed advocacy+ Low academic expectations [but normal IQ, so school failing]

Outcome
Complex but subtle neurodevelopmental profile Several common disorders, low severity but cumulative high needs Requires substantial school support Liaison with school to explain profile not a horrid child Support School Action/Statementing processes

What is needed for assessment?

Need for expert assessment and differential diagnosis & adoption specific formulations / care plans, based on current evidence
Treatment should be based on a careful assessment conducted by a qualified mental health professional with expertise in differential diagnosis and child development (Chaffin et al, 2006, p87)

National commissioning for adoption assessments?

NHS Tier 4 Specialist Adoption Service model

Multi disciplinary assessment
Personalised bio-psycho-social formulation Prioritise common disorders, even if low threshold

Develop personalised care plan (& revisit) Liaise with network, especially school Primary therapeutic input is the Parents, but various evidence based treatments can support them in this task by addressing complexity.

Development & recovery

4 yr old boy in pre-adoptive placement 4yrs:
Reactive Attachment Disorder (RAD) Oppositional Defiant Disorder (ODD)

9yrs
Specific, but not secure, attachments to parents evident, so no longer DAD or RAD Autism Spectrum Disorder ADHD Normal IQ, but severe deficits in adaptive functioning & literacy

Breakdown Attachment Disorder

whats love got to do with it..? A lot.
Attachment disorder - RAD

Subtle neuropsychological problems

Social & Adaptive functioning

ASD

ADHD

ODD

RAD

Specialist assessment

Social skills

School liaison

Medication

Parenting Intervention

Recovered [stability & love]

If left undiagnosed & untreated?

17 year-old adopted girl

Presented with
Severe mood swings Self-harm Theft, aggression; running away; threatening behaviour Associating with risky & inappropriate adults Early & persistent school [& work] failure

Existing diagnosis
Attachment disorder only (not a recognised diagnosis)

Previous treatment
None, as no local CAMHS provision for attachment disorder family left without any support

Assessment
History
Conduct problems
ODD then CD

Assessment
Low mood Low self-esteem Learning disability Reading disorder Charming & easily engaged No attachment disorder now or ever any evidence for it

ADHD Depressed mood Self-harm

Missed opportunities for evidencebased interventions

ODD/CD from 4 years ADHD Depressed mood Educational support for reading / low IQ

Complex presentation & developmental course, with accumulating risks All obscured by general, impersonal & incorrect diagnosis of attachment disorder which also allowed services to avoid helping the family Failure to see the individual child Brother done well & at university differentially susceptible siblings same good adoptive parenting

Outcome
Celebrated 18th birthday by running away Found 3 days later by police investigating another matter, bleeding & agitated Taken to A&E, admitted and assessed by adult services - in the here and now Went out as a child with attachment disorder, sent home as an adult with a personality disorder diagnosis

Summary
Big concepts such as Trauma and Attachment are important for adoption formulations But the science tells us that
Adversity breeds diversity not similarity, so dont let big concepts obscure individual needs Common, treatable disorders are very common & treatable in looked after and adopted children Adopted families require comprehensive assessments and personalised treatment plans including evidencebased interventions

Resources
I have included some further rather technical references next The excellent Chaffin et al article brings together world leading attachment and maltreatment researchers and clinicians to make recommendations about how to assess and treat maltreated/ neglected children with attachment issues.

Chaffin et al, 2006 Child Maltreatment

Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems, Child Maltreatment, 2006

Assessment Use expert clinicians Prioritise common disorders Assess neurodevelopmental factors Family context not just the child Consider cultural issues; situations & contexts; multiple time points Avoid extreme prognosis (e.g., psychopathy); pejorative terms (e.g., manipulative); distress as mechanism of change; broad checklists Treatment Use evidence based approaches for 1st line common disorders Brief, goal-directed interventions for increasing parental sensitivity for children with attachment problems Use parent training techniques, e.g., Time Out etc. for behaviour Include the family & not just the child. Avoid attachment parenting techniques using: holding, coercion; regression etc., as unproven & harmful

Readings
Chaffin, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., Zeanah, C., et al. (2006). Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems. Child Maltreatment, 11, 76-89. Ford, T., Vostanis, P., Meltzer, H., & Goodman, R. (2007). Psychiatric disorder among British children looked after by local authorities: Comparison with children living in private households. British Journal of Psychiatry, 190, 319-325.

McCrory, E., De Brito, S., & Viding, E. (2010). Research Review: The neurobiology and genetics of maltreatment and adversity. Journal of Child Psychology & Psychiatry, 15, 10791095. Belsky, J. & Pluess, M. (2009). Beyond diathesis stress: differential susceptibility to environmental influences. Psychological Bulletin, 135, 885-908. Bakermans-Kranenburg, M. J. & van IJzendoorn, M. H. (2007). Research Review: genetic vulnerability or differential susceptibility in child development: the case of attachment. Journal of Child Psychology & Psychiatry, 48, 1160-1173. Woolgar, M. & Scott, S. (2013). The negative consequences of over-diagnosing attachment disorders in adopted children: the importance of comprehensive formulations. Clinical Child Psychology & Psychiatry doi:10.1177/1359104513478545 (April 2013 Online First).