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Trauma, attachment & adoptionEmphasing individuals in assessment & treatmentDr Matt WoolgarConsultant Clinical PsychologistNational Adoption & Fostering ServiceSouth London & Maudsley NHS Foundation TrustSenior 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 & AttachmentBig 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 definitionsICD-10a 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 anyoneDSM-IVboth(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/NeglectIntense, 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 & neglectConsequences quite different for different types of maltreatment & neglectMore 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 problemsBut the science is much more complex than pictures of damaged brains might implyInvolves 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 maltreatmentMaltreatment impacts upon bio-psycho-social adaption

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

Maltreatment, Neglect, Parenting, School, PeersBrainGenesPhysiologyImmunologyEnvironmentBiologicalPsychologicalBehaviouralCognitionAttachmentMemoryMotivationAggressionCryingProsocialAvoidingMaltreatment impacts upon many levels

Maltreatment, Neglect, Care, Parenting, PeersBrainGenesPhysiologyImmunologyEnvironmentBiologicalPsychologicalBehaviouralCognitionAttachmentMemoryMotivationAggressionCryingProsocialAvoiding

Each child is uniqueSpaghetti complex and hard to trace or specify each individual link / pathway Each plate is uniqueEach adopted child also has a unique history & formulationCannot lump all adopted children togetherBecause she is adopted she is XTraumatisedBrain differentAttachment problemsAnxiousShamefulWithout even seeing her, I can tell you she needs Y

[cf. RM services]10Differential SusceptibilityPeople differ [e.g., genetically] in how much they respond to both positive & negative experiences

11Differential SusceptibilityPeople differ [e.g., genetically] in how much they respond to both positive & negative experiences

12Responses are IndividualA bigger dose of stress is worse on average

But response to stress variesSusceptible child may show big problems from only a small dose of maltreatmentResilient child may be resistant to a larger doseBut response to treatment can also varySusceptible child may respond well to small intervention if precisely tailored to meet his/her needsResilient child may show much smaller response13Differential susceptibility in siblingsBoy is older & was exposed to significantly higher level of maltreatment but doing okay nowGreat effort expended to address his greater traumaNot 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 & rewardingGreat potential, but how to help her?Dandelions & OrchidsDandelions do okay in most environmentsOrchids will do very badly in poor, BUT also in good but not quite right, environmentsOrchids will flourish in exactly right, tailored or personalised environmentsA good environment for the brother may still not be precisely right for the sisterPuzzling when decent parenting/school good enough for the more maltreated sibling but not enough for the less maltreated oneFocusing on the trauma or shared experiences of siblings can obscure these crucial differencesSubtle, complex & unique presentations(in which common disorders still identifiable)???MoodTraumaLearning disabilitySchoolproblemsSocial skills deficitsAnxiety1616The 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

17What are the likely common disorders in adopted children?Poor mental health data for UK adopted childrenA need for well designed research

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

18Mental Health in UK LAC, Ford et al 2007Birth familyHigh RiskONS LACAny disorder8.5%14.6%46%Anxiety disorders3.6%5.5%11%PTSD0.1%0.5%2%Depression0.9%1.2%3%Behavioural disorders4.3%9.7%39%ADHD1.1%1.3%9%Autism [ASD]0.3%0.1%2.6%Neurodevelopmental3.3%4.5%12.8%Learning disability1.5%1.5%10.7%Comparing ONS LAC data with Tier 4 Adoption & Fostering Service (AFS)(Woolgar et al, 2013)ONS LACAFSCAMHS ReferralsAny disorder46%66%31%Anxiety disorders11%9%5%PTSD2%3%1%Depression3%4%1%Behavioural disorders39%55%4%ADHD9%38%12%ASD2.6%4%4%Neurodevelopmental12.8%12%0%Learning disability10.7%10%3%General CAMHS services for adoptionCAMHS services under-identifyingBehavioural problemsNeurodevelopmental problemsADHDGlobal learning disabilityNeurodevelopmental issues (e.g., motor problems etc)Specific learning disability (e.g., dyslexia)

Anxiety, PTSD & depression (to lesser extent)

Summary of what we knowClear risk for common mental health disorders for UK children adopted from care

Complex and pervasive bio-psycho-social presentations can emerge from maltreatment/neglectSo much more than just a damaged brain

Unique and subtle presentations with individual responses to extent [dose] of maltreatmentBiology responds to adversity with diversity in presentationDandelions & orchids each have a role to play

Cannot lump together all adopted childrens needsNeed a personalised approach to service delivery22Complexity in practice: 9 year-old adopted boyhelp with school; they just dont get himDomestic violence in utero & polysubstance misuse; 3 week detox in SCBU; adopted by his first carerHistory of multiple NHS CAMHS contactsSeries of Tier 3 assessments, discrepant diagnoses each discounting the previous onesADHD, no autismAutism, no ADHDADHD again, but no autismBehavioural problems & poor parenting, but no ADHD or autismNot meeting high CAMHS thresholds so no treatmentFamily bemused, angry & let down2323Tier 4 National & Specialist Adoption Specific AssessmentFew problems at homeMother 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]

OutcomeComplex but subtle neurodevelopmental profileSeveral common disorders, low severity but cumulative high needsRequires substantial school support Liaison with school to explain profile not a horrid childSupport School Action/Statementing processesWhat is needed for assessment?Need for expert assessment and differential diagnosis & adoption specific formulations / care plans, based on current evidenceTreatment 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 modelMulti disciplinary assessmentPersonalised bio-psycho-social formulationPrioritise common disorders, even if low thresholdDevelop personalised care plan (& revisit)Liaise with network, especially schoolPrimary therapeutic input is the Parents, but various evidence based treatments can support them in this task by addressing complexity.

Development & recovery4 yr old boy in pre-adoptive placement

4yrs: Reactive Attachment Disorder (RAD)Oppositional Defiant Disorder (ODD)9yrsSpecific, but not secure, attachments to parents evident, so no longer DAD or RADAutism Spectrum DisorderADHDNormal IQ, but severe deficits in adaptive functioning & literacyBreakdown Attachment Disorderwhats love got to do with it..? A lot.Attachment disorder - RADASDADHDODDSubtle neuro-psychologicalproblemsRADSocial &AdaptivefunctioningRecovered[stability& love]SpecialistassessmentParentingInterventionSchoolliaison MedicationSocial skillsIf left undiagnosed & untreated? 17 year-old adopted girlPresented with Severe mood swingsSelf-harmTheft, aggression; running away; threatening behaviourAssociating with risky & inappropriate adultsEarly & persistent school [& work] failure

Existing diagnosisAttachment disorder only (not a recognised diagnosis)Previous treatmentNone, as no local CAMHS provision for attachment disorder family left without any supportAssessmentHistoryConduct problemsODD then CDADHDDepressed moodSelf-harmAssessmentLow mood Low self-esteemLearning disabilityReading disorderCharming & easily engaged

No attachment disorder now or ever any evidence for itMissed opportunities for evidence-based interventionsODD/CD from 4 yearsADHDDepressed moodEducational support for reading / low IQ

Complex presentation & developmental course, with accumulating risksAll 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 parentingOutcomeCelebrated 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 diagnosisSummaryBig concepts such as Trauma and Attachment are important for adoption formulationsBut the science tells us thatAdversity breeds diversity not similarity, so dont let big concepts obscure individual needsCommon, treatable disorders are very common & treatable in looked after and adopted childrenAdopted families require comprehensive assessments and personalised treatment plans including evidence-based interventions

ResourcesI have included some further rather technical references nextThe 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 MaltreatmentReport of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems, Child Maltreatment, 2006AssessmentUse expert clinicians Prioritise common disorders Assess neurodevelopmental factorsFamily context not just the childConsider cultural issues; situations & contexts; multiple time pointsAvoid extreme prognosis (e.g., psychopathy); pejorative terms (e.g., manipulative); distress as mechanism of change; broad checklists

TreatmentUse evidence based approaches for 1st line common disordersBrief, goal-directed interventions for increasing parental sensitivity for children with attachment problemsUse parent training techniques, e.g., Time Out etc. for behaviourInclude the family & not just the child.Avoid attachment parenting techniques using: holding, coercion; regression etc., as unproven & harmfulReadingsChaffin, 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, 1079-1095.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).