How to treat children with severe attachment disorders after multiple early experiences of trauma? A model of treatment in an intensive care unit of psychotherapy Brisch, K. H.; Erhardt, I.; Kern, C; Formichella, A; Paesler, U.; Quehenberger, J. International Attachment Conference August 29-Sept 1, 2013 Pavia/Italy Outline • Developmental trauma disorder – a new diagnosis? • Concept of an intensive psychotherapy unit • Study „Moses“ • Treatment of a boy with early traumatisation and later extreme aggressive behavior • Conclusions © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Developmental trauma disorder (Bessel van der Kolk) – a new diagnosis? • • • • • • • Chronic early maltreatment by caregivers Threatening living conditions Changing care systems Loss of caregivers Inadaquate care Physical and emotional deprivation Abuse and violence by caregivers © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Symptoms of Developmental Trauma Disorder • Disorders in – Delay in physical growth – Delay and disorders in neural networking and brain development – Attachment – Affect regulation – Attention – Cognitive functioning – Mentalization and empathy – Interpersonal relationships with aggression – Dissociation © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved What is the basic fault in developmental trauma disorder? • No fromation of secure attachment • Attachment disorder due to early traumatisation by attachment figures © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Window of Tolerance of Stress-Regulation Hyper-Arousal Dissociation Sympathetic Nervous System FREEZE Panic state Fear of death, Activated Attachment System + Hyper-Arousal Dissociation Parasympathetic Nervous System COLLAPSE © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved © zptn-Lutz-Ulrich Besser Attachment traumatization in early childhood – „psychic cancer of the brain“ • Extreme damage to the brain, the body, the psychic and social development – Physical „death“ – Psychic „death“ – Social „death“ • Chronification • Is healing possible with a special „psychotherapeutic intensive care unit“? © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved „Pediatric Intensive Care Unit of Psychotherapy“ for early disorders of attachment and traumatization Components of treatment – Somatic treatment – Social work – Milieu therapy – Individual psychotherapy – Group-psychotherapy – Trauma-therapy (EMDR) – Education © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Milieu-therapy Safty and structure New attachment figures – individual attachment nurse and 2 therapists Psychodynamic and attachment-based understanding Affect and stress regulation Developmental support New group experiences with peers © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Individual Psychotheray • Psychodynamic – attachment based play therapy 4-5x /week • Traumatherapy • ParentCounselling/Education • Familiy-Therapy 1x/week • External individual therapy for mother/father © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Creative Therapy •Art Therapy •Musik Theray •Movement Therapy • Individual sessions (individual frequency) • Group sessions, 3 x /week © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved B.A.S.E.® - Babywatching • 1x a week observation of mother/father – baby – interaction • Promotion of sensitivity, empathy, mentalization • Decrease of aggression • Decrease of anxiety © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Schooling • Mon – Fri 8:30 - 12:00 a.m. • Max. 6 students • Individual teaching • Group teaching • 3 Teachers are team members • Team-supversion • Case-supervsion © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved External supervision and training • Team-Supervision (every 2nd week) • Case-Supervision (3x/week) – Nurses – Therapists – All staff members • Training and supervision in psychotraumatology and attachment © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved CAMPUS INNENSTADT KINDERKLINIK UND KINDERPOLIKLINIK IM DR. V. HAUNERSCHEN KINDERSPITAL Evaluation of a treamtent model Intenvive Care Unit of Psychotherapy for early traumatized children aged 6-13 years „Moses“ Study Sample Children age 6-13 years Intervention group, waiting control group, healthy control group Sample size 3 x N = 24 (total sample size N = 72) Inclusion criteria: Severe early traumatisation with violence, abuse, neglect by primary caregivers Chronification of posttraumatic stress disorder PTSD Attachment disorder Exclusion criteria: Previous inpatient treatment Severe autism, addiction, mental disability (IQ < 85) Treatment of 6 children in a group setting Duration of in-patient treatment: 6 months 16 02.09.2013 Study design 4 points of measurement T0= 6 months before in-patient treatment (only waiting group) T1= Admission to in-patient treatment T2= Discharge T3= Follow-up: 6 months after discharge Methods Questionnaires and test Attachment interviews und behavioral observations (f)MRi Oxytocin and cortisol in saliva and in blood (1x at T1) 17 02.09.2013 Methods 1 Questionnaires (e.g. PTSD, CBCL 4-18, depression, anxiety) Outcome and process (6-weeks intervall) Tests: e.g. intelligence Attachment Interviews with parents and children: Adult Attachment Interview- AAI (George, C., Kaplan, N. & Main, M., 1985/2001) Adult Attachment Projective Picture System-AAP (George, C., West, M. & Pettem, M., 2012) Child Attachment Interview- CAI (Shmueli-Goetz,Y., Target, M., Fonagy, P., & Datta, A., 2008) Story Stem Completion Task (Gloger-Tippelt & König, 2009) Parent-child play interation (video) Parental Sensitivity (Ainsworth Maternal Sensitivity Scales- AMSS; Ainsworth, 1969) 18 02.09.2013 Methods 2 Structural and und functional fMRI alt all points of measurement Diffusion Tensor Imaging (DTI): micro-myelinisation Functional connectivity Anatomy of hippocampus Paradigm associated (f)MRI sequenz (stimulus: 60 picture of the International Affective Picture Systems IAPS; 20 pictures each pleasure, distress, neutral) fMRI with matched-pair healthy control children 19 02.09.2013 Methods 3 Oxytocin und Cortisol in saliva pre- and post attachment interviews 4 points of measurements: before, after, 15 min. and 30 min. post interview Oxytocin–method: High performance liquid chromatography with mass spectrometry (MSMS). Questions and aims 1 Global aim: Evaluation of the treatment programme of the intensive care unit of psychotheray for early traumatized children with attachment disorders What kind of attachment representation do these children present? Can we change their attachment respresentation to „earned secure“? How does the attachment representation influence the HPA axis and oxytocin secretion? Can we develop and optimize ressources like intelligence, social competence in groups? Questions and aims 2 Can we influence psychopathology (PTSD symptoms, dissociation, anxiety, depression) Can we observe changes in neural structures, function and connectivity of the brain? „Jonas“, 8 years History • Deprivation and extreme phyical maltreatment during 1st and 2nd year of live by his mother • Mother drug and alcohol addiction • With foster parents: 2nd year of live – later adoption by these foster parents • Development of extreme selfharm and aggression against others. • No admission to kindergarten because of aggression • Parents seek ouf for help © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Symptoms • Indifferent attachment disorder • No affect regulation • No stress-tolerance • No schooling • Communiction with mother by picture cards • Many food allergies © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Intensiv-Psychotherapy Unit • Nurse and therapists become new attachment figures • Milieu-therapy: time-intensive instead of time-out • NO – medication • Schooling (from minutes to hours) • Intensive work wiht adoptive parents (both with unresolved trauma in AAI) © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Follow-up • After discharge: – Disorganized attachment – Continuous individual psychotherapy in out-patient department – Schooling: class for children with special needs with school companion • After 1 year: – Ambivalent attachment – normal school with companion – Social integration into family, peers at school • After 2 yerars: – normal school without companion • After 3 years: – Secure attachment © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Conclusion • Treatment should start early • Intensive treatment • In-patient with new intensive positive sensitive attachment experiences • Affect and impuls control • Stress regulation • Social integration • Healthy bio-psycho-social development © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Reference Brisch, Karl Heinz (2012) Treating Attachment Disorders. From Theory to Therapy. 2nd Edition Guilford Press, New York, London Gradiva Award Nomination National Association for the Advancement of Psychoanalysis Japanese, Korean, Italian, Slowakian, Russian, Urkainian translation available! © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Thanks! • Children and their parents! • Team and co-workers • Supervisors • E. Epping, P. Bründl, L. Besser Cooperation: MRI- LMU: Birgit Ertl-Wagner, Daniel Keeser, Ute Coates Endocrinology LMU: Martin Bidlingmaier Psychiatry LMU: Peter Zill; Sylvia de Jonge Oxytocin Lab Olgemöller: Elfriede Schuhmann © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved International Conference October, 11-13, 2013 in Munich/Germany Attachment and Psychosomatics Information and Program www.khbrisch.de © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved Thank you for your attention! • Further information • www.khbrisch.de • www.safe-program.org • www.base-babywatching.de © Copyright K.H. Brisch Munich/Germany 2013. All Rights Reserved