Incorporating Attachment Theory into Clinical Practice in Clinical

Psychology of Intellectual Disability

Development of a Guideline 2015-2017

Faculty For People with Intellectual Disabilities

Need for the guideline

• We now have updated Faculty guidelines for– Psychological therapies– Assessing ID– Challenging Behaviour– Parenting – Dementia

• In development– Forensic work in ID services

• Several of these are produced in partnership (e.g. with Royal College of Psychiatrists)

Attachment theory – the gap

• It is currently possible to work within Faculty guidelines, NICE etc. without consideration of a person’s attachment history

• This would not be acceptable with vulnerable children without ID

• It may ‘distance’ clinicians from painful, intimate features of clinical work (negative reinforcement for avoidance)

• There is little to no account of attachment or emotional trauma in NICE guidance on Challenging Behaviours or Mental Health in persons with ID

Hits for “Attachment” in Key Documents

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3 3

NICE Mental Health &ID 2016

NICE ChallengingBehaviour & ID 2015

BPS & RCP PsychologicalTherapies 2016

RCP & BPSPsychotherapy &

Learning Disability 2004

A Positive and ProactiveWorkforce 2013

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THE CHILDREN’S ATTACHMENT GUIDELINE

Key principles from Children’s Attachment: Attachment in Children and Young People who are adopted from care, in care or at high risk of going into care: NICE,

2016

• Attachment should be assessed and interventions made available in all contexts, at all ages, and wherever the child is in the care system (in care, at risk of going into care, on the edge of care).

• Improving stability of placements, – e.g. by attempting longer term placements as plan A, rather than

temporary

– Retain kinship arrangements where risk allows

– Use comprehensive education and training for potential carers to prepare them for the challenges insecurity & trauma cause

– Provide containing support & advice at all levels

Children’s Attachment cont. …..

• Preparing the person before they enter the care system or change placement

• Improving the likelihood of placement permanence

• Preserving the personal history of children and young people

• Safeguarding during interventions

• Avoiding the treatment of attachment difficulties with pharmacological interventions

• Key workers, personal advisors, social workers, and foster carers should be trained in recognising & assessing attachment difficultiesand associated socio-economic and mental health difficulties, and signs of trauma

• A comprehensive assessment should be carried out before any formal intervention

• Formal assessment tools should be considered (Strange Situation Procedure, Attachment Q-Sort, Manchester Child Attachment Story Task, Child Attachment Interview, Adult Attachment Interview for >15 years)

• Genetic screening should not be offered to predict or identify attachment disorders

• Children need to be referred to services that have specialist knowledge of attachment difficulties and know how to intervene

• Video feedback programmes, and training in parental sensitivity, should be available for foster carers, guardians and adoptive parents for young children.

• Group based training and education should be available for carers of older children

• Sessional work should be available for teenage children and their supporters

• Children whose attachment behaviours do not improve from intervention should have multidisciplinary review

• Intensive support should be available for ongoing difficulties

• Parental sensitivity and behavioural training should be mandatory for professional carers in residential care settings

Key points to pick out• Promoting knowledge of the importance of attachment

and building principles into the fabric of care

• Improving the safety and stability of placements

• De-emphasising genetic explanations and drug treatment for behavioural distress

• Making skilled assessment and intervention widely available, while training carers to think in attachment terms and offering them skilled support and availability

• Video feedback, sensitivity training, and age appropriateness of interventions

• Consideration of trauma, mental health and socioeconomic co-variates and co-morbidities

Outcomes of Attachment Difficulties

• In children & young people:– Less persistence in problem solving at age two

– Poorer theory of mind at ages two-four

– Poorer recall for life events at age 11

– Incompetence with peers

– Low self esteem

– Diagnosis of Reactive Attachment Disorder

– Diagnosis of Disorganised Attachment Disorder

– Diagnosis of Oppositional Defiant Disorder

– Diagnosis of Conduct Disorder

Outcome of Attachment Difficulties

• In adulthood– Proneness to paranoia and diagnosis of schizophrenia– Depressive symptoms – Diagnosis of mood disorder– Diagnosis of obsessive-compulsive disorder– Eating disorder – Diagnosis of avoidant, depressive, paranoid or

schizotypal personality disorder (dismissing attachment)

– Diagnosis of dependent, histrionic, borderline personality disorder (preoccupied attachment)

ATTACHMENT AND INTELLECTUAL DISABILITY

Arriving into a family with an ID

• Adjustment issues following diagnosis (Marvin & Pianta, 1996)

• Sensitivity more difficult to attain for many parents of children with ID (Schuengel & Janssen, 2008)

• Adaptation occurs in families with time, though this happens best where family stress is low and there is good social support (Fletcher, 2016)

Direct cognitive effects

• Parents of children with Down Syndrome often find sensitivity difficult to achieve

• The delay in emotional expression & emotional ‘blunting’ makes it somewhat more difficult to interpret the meaning of the behavioural signals (Cicchetti & Serafica, 1981)

• This has not been replicated with other children who have ID

Direct Care Settings

• Care is:– Discontinuous – Delivered by several individuals– Staff have high workload– Limited opportunity for individual support

• There is more turnover of carers (but lack direct evidence that this is detrimental)

• Carers vary in sensitivity (Clegg & Sheard, 2002)• This variation affects the behaviour of the person

with ID (De Schipper & Schuengel, 2010)

Rates of attachment insecurity in ID

• In Down Syndrome, about 50% achieving secure bonds (Schuengel et al., 2013)

• A study of children with autism suggested about 53% achieve secure bonds (Rutgers et al., 2004) but higher IQ was protective (ID is itself a risk factor)

• Insecure children with ID are disproportionately more disorganised or atypical, at similar rates to children who are maltreated, traumatised, or institutionalised (Schuengel et al., 2013)

• Disorganisation of attachment may be made worse by poor cognitive functioning (difficulty organising incoming information (Schuengel & Janssen, 2006)

Links with challenging behaviour

• Variations in attachment behaviours are linked to variation in caregiver relationships (De Schipper & Schuengel, 2010)

• People with mild-mod ID will refuse medication more readily if they self-identify as dismissing or preoccupied (Larson et al., 2011)

• “Becoming overly fond of support staff” (e.g. following the staff around, crying on separation) is the most common ‘challenging behaviour’ in some studies (Larson et al., 2011)

• Insecure attachment ratings from carers are linked to behaviour problems (Penketh et al., 2014)

• Case series evidence suggests working on attachment before behaviour programmes improves outcomes (Schuengel et al., 2009)

• Psychotherapy cases in routine practice in CLDT settings show higher rates of behaviour disturbance in clients rated as preoccupied or disorganised (Skelly & Reay, 2013; Skelly & Burman, 2015)

• It is expected that avoidant individuals will hide or redirect their feelings because they expect rejection if they do not (Sroufe et al., 2005)

THE GUIDELINE

Structure of the Guideline

ForewordExecutive Summary 1. The need for the guideline2. Overview of Attachment Theory 3. Attachment & ID4. Client and Carer accounts5. Applying Attachment principles to the work of

psychologists in intellectual disability services i. Assessmentii. Formulationiii. Intervention iv. Supervision & Self-carev. Specific additional conditions

Appendices (Inc. self-assessment tool)

Timescale

• Proposal to PSU November 2015

• Draft for Consultation disseminated September 2016

• Consultation closed November 2016

• Response to consultation comments March 2016

• Sent to DCP Professional Standards Unit

PRINCIPLES FOR PRACTICE

5 point model – Conditions for Emotional Security

Removed from first draft after feedback

i. Promote physical safety (safeguarding)

ii. Promote emotional security (stability of placement), minimising hostility, rejection and emotional unavailability

iii. Model emotional warmth and empathy, in an attuned & sensitive way (sensitivity)

iv. Promote mutual engagement and enjoyment of activities

v. Promote new learning together; where difficult, to provide support and ‘scaffolding’

ASSESSMENT

• Include detailed history taking, review of records, interview, observations, formal assessment, and therapeutic sessions.

• Particular account of risk factors, e.g. placement breakdown, difficulty with separation or reunion, abuse / neglect, preoccupation with whereabouts of attachment figures, & challenging behaviours with attachment goals.

• Formal tools can be used, e.g. SSQ, Attachment Q-Sort, AAP, SBSHO, MAS-T, QuERRS, Choice-description, DAI.

• Established valid assessments of attachment classification require rigorous training & certification.

FORMULATION

• Incorporate attachment histories in formulations

• If possible specify the attachment strategies used and sensitivity in past and current environments

• Give consideration to developmental level (cognitive / emotional) to give context to attachment strategies used. Consider autism and its influence on attachments.

• Formulation should be shared in a collaborative and non-blaming way.

• Difficulties in attachment may influence the type, intensity and length of interventions.

INTERVENTION

• The quality of attachments can be improved by indirect therapy, direct therapy, and specialised attachment-based approaches like ITAB, CONTACT, etc.

• Good evidence exists for many attachment-focussed interventions, (lack a specific evidence base in people with ID, such as Video Interactive Guidance, Circle of Security, etc.).

• Practitioner psychologists should engage in promoting service design to create maximum stability in care arrangements

• Working with dementia, ASD, profound / multiple ID, parents with ID and Axis II syndromes, all require knowledge of the client group as well as attachment theory.

• Psychologists should consider how their own attachment representations influence their work, and promote working practices that enhance emotional security in the workplace

Companion and core reference

Final thoughts

“Services can be unresponsive, patronising, and avoidant; or they can be helpful and supportive. It’s been way too variable.”

Carol, foster carer for Harry for 36 years, DCP Attachment & ID Guidance, 2017

“They have behaviour, we have relationships”?

Beth Greenhill, Reformulation, 2011

Workshop: Behaviours that Challenge and Attachment in Clinical Practice

• Workshop is to inform authors of the Guidance, and each other, not ‘teach you’

• Who uses attachment already in

– Assessment ?

– Formulation ?

– Intervention?

ASSESSMENT

Group Discussion & Feedback

Assessment – Group Discussion & Feedback

• Thinking about the use of:– detailed history taking, – review of records, – interview, – observations, – formal assessment,– therapeutic sessions.

• Risk factors – placement breakdown, – difficulty with separation or reunion,– preoccupation with whereabouts of attachment figures,– abuse / neglect,– challenging behaviours with attachment goals.

• Formal tools - (SSQ, Attachment Q-Sort, AAP, SBSHO, MAS-T, QuERRS, Choice-description, DAI).

• Established valid assessments of attachment classification.

FORMULATION

Group Discussion & Feedback

Formulation – Group Discussion & Feedback

• Incorporate attachment history

• Attachment strategies used and sensitivity in past and current social environments

• Consideration to developmental level (cognitive & emotional) to give context to attachment strategies used.

• Formulation should be shared in a collaborative and non-blaming way.

• Difficulties in attachment may influence the type, intensity and length of treatment.

INTERVENTION

Group Discussion & Feedback

Intervention – Group Discussion & Feedback

• Current ‘standard’ interventions (PBS, Psychodynamic therapy, CAT, etc.) to incorporate attachment factors.

• Promoting service design to create maximum stability in carearrangements.

• Working with dementia, ASD, profound / multiple ID, parents with ID and Axis II syndromes, all require knowledge of the client group as well as attachment theory.

• Promote working practices that create & maintain security, i.e. reflective clinical supervision.

• Consider own representations and effect on your work.

Future

• Specialised attachment-based approaches like ITAB, CONTACT, etc. (still very new) -enhancing PBS? .

• Attachment-focussed interventions that are evidenced on other groups, (Video Interactive Guidance, Circle of Security)

Wider Group Discussion Questions

1. What is the effect on practice likely to be in your workplace?

2. Would you use the self-assessment tool, and if so, would you join us in researching its usefulness?