Oct 29, 2009

Nature or Nurture? Which is it? Both!

Most scientists now accept that the nature/nurture debate is not a case of either/or but of genes and environment working together in a complex pattern to influence people's mental health. Researchers from the University of Iowa looked into one example of this examining how genes and attachment work together to influence how good young children are at self-control. They studied 89 children testing them to see whether they had a variation in a gene called 5-HTTLPR, measuring the quality of their relationship with their mothers at 15 months and how good they were at self-control at 25,38 and 52 months. They found that among children who carried a certain variant of the gene insecure attachment to their mothers at 15 months led to poorer ability to control their emotions later. However, those children who had secure attachment to their mothers at 15 months did not have problems with self-control later even if they carried the variation in the 5-HTTLPR gene.

Kochanska, Grazyna, Philibert, Robert A. and Barry, Robin A. - Interplay of genes and early mother-child relationship in the development of self-regulation from toddler to preschool age The Journal of Child Psychology and Psychiatry November 2009, 50(11), 1331-1338

Oct 28, 2009

Child Sexual Abuse causes later problems

An investigation published in the current issue of Psychotherapy and Psychosomatics explores the link between child sexual abuse and inability to express emotions in adulthood.

Alexithymia, a clinical condition typified by a reported inability to identify or describe one’s emotions, is associated with various forms of psychopathology, including depression. Highly alexithymic (HA) outpatients are more likely to be female, less likely to have children and are characterized by more somatic-affective symptoms of depression and interpersonal aloofness.

The Authors of this investigation extended these findings by examining personality traits and childhood sexual abuse history. Participants were 94 depressed patients [57.45% with recurrent major depressive disorder (MDD), 37.23% with single-episode MDD, 5.32% with depressive disorder not otherwise specified] 50 years of age and older recruited from psychiatric treatment facilities in Upstate New York. Individuals completed the Structured Clinical Interview for DSM-IV Axis I disorders. Alexithymia was assessed with the 20-item self-report Toronto Alexithymia Scale. Its 3 subscales measure difficulty identifying feelings and distinguishing them from bodily sensations (DIF), difficulty describing and communicating feelings (DDF) and externally oriented thinking (EOT), the latter being a tendency to focus on concrete details of external events rather than on aspects of inner experience. Depressive symptom severity was assessed with the Beck Depression Inventory-II (BDI-II). Five personality domains, i.e. neuroticism, extraversion, openness to experience, agreeableness and conscientiousness, were assessed with the NEO Personality Inventory. History of childhood sexual abuse was assessed using the Childhood Sexual Abuse subscale of the Childhood Trauma Questionnaire. A latent class cluster analysis (M-Plus 4.20) was performed on the DIF, DDF and EOT subscales. All 3 indicators favored a 3-cluster solution. This solution identified 3 groups, i.e. low alexithymia (LA; n = 11, 63.64% women), moderate alexithymia (MA; n = 40, 60% women) and HA (n = 43, 60.47% women). The distribution of mood diagnoses, single-episode MDD, recurrent MDD and depressive disorder not otherwise specified was not significantly different among the 3 alexithymic clusters (p> 0.05). The Authors conducted 10 separate multivariate generalized logit regressions; odds ratios were calculated for LA versus HA and MA versus HA class membership. Putative predictors were total BDI-II and the 3 subscales, childhood sexual abuse and the 5 personality domains. Covariates were age, gender and education. The 3 BDI-II subscales as well as the total score significantly distinguished LA and MA from HA. Lower levels of depressive symptoms significantly decreased the odds of HA membership. Odds ratios ranged between 0.32 and 0.94 (p< 0.05).

Childhood sexual abuse distinguished MA from HA; lower levels of childhood sexual abuse decreased the odds of HA membership (p< 0.05). Neuroticism, openness and conscientiousness also distinguished the 3 groups. Low neuroticism decreased the odds of HA membership, with odds ratios ranging between 0.95 and 0.97 (p< 0.01). Low openness and conscientiousness increased the odds of HA membership, with odds ratios ranging between 1.02 and 1.07 (p<0.05).

The HA group in this study was characterized by higher neuroticism and lower openness to experience and conscientiousness, a profile that reflects a distressed personality type, which has been related to poorer health outcomes and general functioning and more psychological distress. A similar personality profile was observed for the MA group, with the notable exception being their above-average levels of agreeableness and openness to experience. Interestingly, the HA group was characterized by more childhood sexual abuse compared to the MA patients. These findings add to the mounting evidence for a relationship between childhood sexual abuse and alexithymia; individuals with a history of childhood sexual abuse may have a reduced capacity to experience emotion in relation to their trauma, and this phenomenon may generalize to experiencing all emotions. Childhood sexual abuse has been found to interfere with the development of emotion regulation and to be related to attachment disturbance. The combination of childhood sexual abuse and alexithymia must be considered in the design and implementation of treatment studies, as these patients are more resistant to treatment (the attachment disturbance makes it more difficult for these clients to engage in a therapeutic relationship) and have slower recovery rates and poorer outcomes. Identifying a patient as alexithymic may suggest a history of early traumatic events which increases the likelihood and severity of depression. Treatment should be tailored to address the depressive symptoms along with the affective experience (identification, differentiation, labelling and management of feelings).
Source:Psychotherapy and Psychosomatics: Topciu, R.A. ; Zhao, X.; Tang, W; Heisel, M.J.; Talbot, N.L.; Duberstein, P.R. Childhood Sexual Abuse and Personality Differentiating High and Low Alexithymia in a Depressed Population. Psychother Psychosom 2009;78:385-387

Oct 23, 2009

Effects of Trauma (PTSD) on the Brain

Brain scans of people with post-traumatic stress disorder (PTSD) have shown abnormalities in parts of the brain called the anterior cingulate cortex, the amygdala and the hippocampus but it is not known whether these abnormalities have developed because of the PTSD or if they reflect an inherited risk factor for the condition. A team of researchers from Massachusetts and New Hampshire investigated this issue in a study of 66 people. All the participants in the study were identical twins and they were divided into two groups. One group was made up of pairs of twins where one twin had fought in a war and developed PTSD and the other twin had not fought. The other group was made up of one twin who had fought but not developed PTSD and their twins who had not fought. Those veterans who had developed PTSD and their non-combatant twins both showed more activity in their dorsal anterior cingulate cortex and their midcingulate cortex than the group of twins who had not developed PTSD after combat and their twins. The more active the brain regions were in the twins not exposed to combat whose siblings had developed PTSD the worse their siblings' PTSD symptoms were. The study shows that enhanced activity in this part of the brain is a risk factor for PTSD, not a consequence of it.

These findings clearly have implications for people who have experienced Complex Trauma and disorders of attachment.

Shin, Lisa M. ... [et al] - Resting metabolic activity in the cingulate cortex and vulnerability to posttraumatic stress disorder Archives of General Psychiatry October 2009, 66(10), 1099-1107

Oct 18, 2009

Against Coercion

Against Coercion
Arthur Becker-Weidman, Ph.D.
Center For Family Development

The APSAC Report on Attachment Therapy offers ATTACh and all in the field an opportunity to state unequivocally and clearly our opposition to coercive methods in treatment. Another set of excellent standards are the recommendations of the American Academy of Child and Adolescent Psychiatry, “Practice Parameter for the Assessment and Treatment of Children and Adolescents with Reactive Attachment Disorder of Infancy and Early Childhood.”

I think that all clinicians in the field should be very clear and specific about what methods they use and what methods they do not use or condone. At The Center For Family Development we have an informed consent document that clearly spells out our practice and methods and that clearly spells out our opposition to coercion in therapy and parenting. In addition we have statements on our website clearly stating our acceptance of and adherence to the recommendations of the APSAC report and the Academy’s report in addition to our adherence to the Association for the Treatment and Training in the Attachment of Children's White Paper on Coercion and ATTACh's new Professional Practice Manual.. The central component in our treatment and in what we teach parents, is attunement; the ability to develop and maintain an emotionally positive, sensitive, engaged, and responsive relationship. It is based on Attachment Theory and what occurs in the normal parent-child relationship during development. I find nothing in Attachment Theory that would support or condone the use of coercion or intrusive methods in child rearing or treatment. In fact, I defy anyone to find me anything to the contrary in the writings of John Bowlby, Micheal Rutter, Mary Ainsworth et. al., Mary Main, Erik Hesse, Jude Cassidy, Philip Shaver, Thomas O’Conner, Howard Steele, Charles Zeanah, Daniel Siegel, or any of the other well known names in the fields of attachment theory and research, developmental psychology, or infant mental health. It is my opinion and recommendation that all practitioners of attachment-based treatment state their acceptance of and adherence to the APSAC and Academy recommendations.

Coercion has usually been defined in terms of the therapist’s or parent’s behaviors. This is not a useful approach because it ignores intention, effect, and process. Coercion is the result of interplay among the actor’s behavior and intentions; the recipient’s perceptions and experience; power differentials in the relationship; and the nature and quality of the relationship between the persons involved. For this reason, a better approach may be to focus on the effects of the behavior on the recipient.

Within this context, coercion can be described as behavior that continues to increase the dysregulation of the other. Dysregulation is never a goal in treatment; indeed, it may well undermine progress. Increasing the distress of another without their consent and without actively working to reduce dysregulation when encountered is coercive. Helping the client to explore a trauma for sake of integration is the goal. Some degree of dysregulation may occur along with the processing, but dysregulation is never sought. Any dysregulation occurring needs to be immediately and sensitively addressed to help the child move toward greater regulation. If the goal of therapy is to actively assist the child to move toward greater degrees of regulation, while preventing or limiting experiences of further dysregulation, then there would be no place for the repetitive kicking/screaming and other abusive “techniques” that have caused controversary.

There are three types of coercion:
1. Behavior that continues to increase the dysregulation of the other.
2. Behavior that unintentionally causes dysregulation without then following with efforts to assist the child in re-attaining regulation.
3. Behavior that is likely to cause distress (addressing trauma, shame, or other intense affects/conflicts/losses, etc.) without incorporating interventions that will assist the child in remaining regulated and managing the distress. These interventions include: empathy/comfort from therapist and/or attachment figure, slow pace, frequent breaks, allowing child to stop the exploration, providing information, encouraging child to participate in the control of the process, teaching self-regulation skills.

Distress may be defined as perceived discomfort. Dysregulation is an overwhelming of the client’s ability to function, resulting in dissociation or other extreme defensive manifestations. When the client responds with discomfort and distress, the therapist uses empathy and emotional support to help co-regulate the client’s affect so that it does not move into dysregulation. While experiencing discomfort and distress, the client maintains the ability to be regulated in affect, cognition, and behavior. However, when a client shows terror, rage, or dissociative features, the client requires our help to become regulated. So, for example, in a therapeutic situation a client may willingly discuss an event that is upsetting and increases the client’s discomfort and distress. However, if the client then indicates a desire to stop, yet the therapist or parent ignores this signal, so that the client is forced to continue, this is coercive. It is also coercive to maintain or increase a client’s dysregulated state until the client is exhausted or has a “break through.” In addition, if a client becomes dysregulated and the therapist or parent does not act to decrease the client’s dysregulation that is coercive. Increasing a client’s dysregulation is never acceptable. Whenever a client exhibits such dysregulation, the therapist must act to decrease dysregulation and act to restore the client to a more regulated emotional state.

A therapist or parent may say or do something that unintentionally dysregulates the child, perhaps by not anticipating the power of a conditioned emotional response or missing the child’s cues. What is imperative is that the therapist or parent immediately engages in behaviors or uses words to decrease the child’s dysregulation. In summary, any actions or words that shame, provoke, or sustain interactions that increase a child or other’s dysregulation are coercive and clearly counter-therapeutic.

Another aspect of coercion is using force to require compliance with physically painful commands, such as forced jumping jacks, “power” sitting, prolonged and forced kicking until the child “decides” to answer a question or comply. The key issue in these instances is the use of power and coercion to force compliance for the sake of compliance with a command, which has no basis in safety. Remember, it is about connections not compliance.

ATTACh believes that all attachment-based therapy should be based on sound theory and principle, and that therapists should practice within their competence and training, and with appropriate supervision/consultation.

To review ATTACh's White Paper, Parent Manual, and Professional Practice Manual, go to

Oct 14, 2009

Adverse Childhood Experiences

Having a stressful childhood may slash decades off a person's life, researchers from the Centers for Disease Control and Prevention (CDC) report.

Among people who reported experiencing at least six of eight different bad childhood experiences-from frequent verbal abuse to living with a mentally ill person-average age at death was about 61, compared to 79 for people who didn't have any of these experiences as children, the researchers found.

Dr. David W. Brown and Dr. Robert Anda of the CDC and colleagues from the CDC and Kaiser Permanente have been following 17,337 men and women who visited the health plan between 1995 and 1997 to investigate the relationship between bad childhood experiences and health.

So far, Anda noted in an interview, they have shown links between childhood stressors and heart disease, lung disease, liver disease and other conditions. "The strength of it really surprised me, how powerfully it's related to health," the researcher said.

In the current analysis, the researchers reviewed death records through 2006 to investigate whether these experiences might also relate to mortality. During that time, 1,539 study participants died.

Each person was asked whether they had any of eight different categories of such experiences, including verbal abuse, physical abuse, sexual abuse with physical contact, having a battered mother, having a substance-abusing person in the household, having a mentally ill person in the household, having a household member who was incarcerated, or having one's parents separate or divorce.

Sixty-nine percent of the study participants who were younger than 65 reported at least one of the adverse childhood experiences, while 53 percent of people 65 and older did.

Those who reporting experiencing six or more were 1.5 times more likely to die during follow-up than those who reported none, the researchers found. They were 1.7 times as likely to die at age 75 or younger, and nearly 2.4 times as likely to die at or before age 65.

There are a number of ways that a traumatic childhood could contribute to ill health, Anda noted. For example, childhood stress affects brain development, so individuals who've experienced it may be more likely to suffer from depression and anxiety, and more prone to deal with stress in unhealthy ways, for example by drinking alcohol or smoking cigarettes.

Just a third of the people in the study were completely free of any sort of childhood trauma, Anda added, making it clear that these sorts of harmful experiences are widespread.

"If we want to address a lot of major public health issues we've got to address the kind of stressors children have in our society as a way of primary prevention," he said.

SOURCE: American Journal of Preventive Medicine, November 2009.

Having a stressful childhood can significantly reduce people's life expectancy. Researchers from the U.S. Centers for Disease Control and the Kaiser Permanente Organisation studied 17,337 men and women to investigate the links between bad childhood experiences and health. The researchers defined eight different adverse childhood experiences: verbal abuse, physical abuse, sexual abuse with physical contact, having a battered mother, having a substance-abusing person in the household, having a mentally ill person in the household, having a household member who was incarcerated, or having one's parents separate or divorce. 69% of the study participants under the age of 65 reported at least one of these experiences while 53% of those over 65 did. Those people who reported six or more adverse experiences were 1.7 times more likely to die at 75 or younger and 2.4 times more likely to die at 65 or younger. The authors of the study thought that having a troubled childhood makes people more likely to develop anxiety and depression which they cope with by using tobacco and alcohol.

Oct 9, 2009

Teen maturity

Teenagers are as logical as adults but lack their social and emotional maturity. This might not be a surprise to too many parents but it comes as the result of a study of 935 10-30 year-olds by researchers at Temple University in Philadelphia. Participants in the study were tested on their psychosocial maturity, including tests of impulse control, sensation seeking, resistance to peer influence, future orientation (jam today vs jam tomorrow) and risk perception. They were also tested on their cognitive abilities such as logical thinking. There were no differences in psychosocial maturity throughout the 10-17 year-old age group but there were differences between those who were 16-17 and those 22 and over, and between those who were 18-21 and those above 26. People's cognitive capacities got better from 11-16 but their was no improvement thereafter.

You can find out more about this research at


Oct 6, 2009

Research Cited

My article detailing the developmental lags of children with complex trauma and disorders of attachment was picked up and described on the Evan B. Donaldson Adoption Institute's Research Summary page.

It is a good summary of the article.

Oct 1, 2009

ATTACh Conference in TX

I just came back from the Association for the Treatment and Training in the Attachment of Children's annual conference, this year in San Antonio Texas. It was a wonderful conference for professionals, parents, and researchers. I had the pleasure of hearing Dr. Bruce Perry, a key note speaker, talk about the effects of trauma in childhood on later development. The mediating factor is the effects of trauma on brain development and brain function. This leads to an approach or sequencing of treatment that takes into account which systems of the brain are impaired. This was a very useful talk.

I strongly recommend that people consider the conference next year, in California. More information can be found at www.attach.org