Intervening in Stress, Attachment and Challenging Behaviour

Intervening in Stress, Attachment and Challenging Behaviour Effects in Children with Multiple Disabilities Bartiméus reeks Bartiméus wil kennis en ervaring over de mogelijkheden van mensen met een visuele beperking vastleggen en verspreiden. De Bartiméus reeks is daar een voorbeeld van. Colofon Bartiméus Van Renesselaan 30A 3703 AJ Zeist Nederland Tel. (088) 88 99 888 Email: [email protected] www.bartimeus.nl Auteur: Paula S. Sterkenburg Illustratie: Lida de Zeeuw (www.lidaline.com) Manuscript commission: prof. dr. C. Schuengel (VU University Amsterdam) prof. dr. P. Cuijpers (VU University Amsterdam) dr. P. Fearon (University of Reading, UK) prof. dr. F. Juffer (University Leiden) prof. dr. H. Meininger (VU University Amsterdam) prof dr. J.M.A. Riksen-Walraven (Radboud University Nijmegen) Deze publicatie is mogelijk gemaakt door de Vereniging Bartiméus. ISBN 978-90-71534-57-7 Eerste druk Copyright 2008 Paula Sterkenburg All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanically, by photocopy, by recording, or otherwise, without prior written permission of the author. 2 VRIJE UNIVERSITEIT Intervening in Stress, Attachment and Challenging Behaviour Effects in Children with Multiple Disabilities ACADEMISCH PROEFSCHRIFT ter verkrijging van de graad Doctor aan de Vrije Universiteit Amsterdam, op gezag van de rector magnificus prof.dr. L.M. Bouter, in het openbaar te verdedigen ter overstaan van de promotiecommissie van de faculteit der Psychologie en Pedagogiek op vrijdag 3 oktober 2008 om 10.45 uur in de aula van de universiteit, De Boelelaan 1105 door Paula Sophia Sterkenburg geboren te Boksburg, Zuid Afrika 3 promotor: prof.dr. C. Schuengel copromotor: dr. C.G.C. Janssen 4 Voor mijn vader en moeder 5 6 Contents Chapter I General Introduction 9 Chapter 2 The therapeutic relationship supports affect regulation in children with multiple disabilities: a multiple case design study 21 Chapter 3 Cortisol changes during psychotherapy in adolescents with a visual and intellectual disability and challenging behavior 43 Chapter 4 The effect of an attachment-based behaviour therapy for children with visual and severe intellectual disabilities 61 Chapter 5 Developing a therapeutic relationship with a blind client with a severe intellectual disability and persistent challenging behaviour 81 Chapter 6 General Discussion 101 References 109 Appendix A Protocol for ‘Integrative Therapy for Attachment and Behaviour’ (ITAB) (English and Dutch version) 121 Appendix B Observatie-instrument voor gehechtheidsgedrag (OIG) (Observation Instrument for Attachment Behaviour in Dutch) 141 Appendix C Observatielijsten voor het scoren van gedragsproblemen in de dagelijkse woon / leef situatie (Residential observation lists for challenging behaviour in Dutch) 153 Samenvatting (Summary in Dutch) 161 Dankwoord (Acknowledgement) 171 Curriculum Vitae 175 7 8 Chapter I General Introduction 9 Introduction Attachment is regarded as a pattern of organized behaviour within a relationship (Bowlby, 1973/1998). In times of stress, anxiety or discomfort, a child’s attachment behavioural system generates verbal or non-verbal behaviour in order to attain proximity to an attachment figure. This usually results in safety and care provided by this attachment figure (Bowlby, 1969/1997) and provides children with the opportunity to gradually learn to cope with stressful situations by themselves. If attachment figures react predictably in a sensitive and responsive manner, buffering children’s stress levels, secure attachment relationships are likely to develop. Over time, children develop a mental representation of the relationship between the attachment figure and the self, largely based on these experiences. However, distortions in relationships between children and their caregivers may contribute to atypical patterns of attachment (Bowlby, 1969/1997). These distortions may be the result of unfavourable caregiving (e.g. abuse or neglect) or the absence of one or a small number of caregivers with whom the child can develop a specific relationship (Bowlby, 1969/1997). Although Bowlby found evidence for early parental loss, separation, or complete absence of an early attachment figure amongst children with psychopathology, his theory concerning the link between these experiences and outcomes was not deterministic, but focused on the processes that are set in train by early attachment experiences. He proposed that early experience frames, but also is transformed by, later experience (Bowlby, 1973/1998; Sroufe, Carlson, Levy, & Egeland, 1999). Thus, although children’s experience forms a critical part of the developmental context, change remains possible at numerous points in development (Sroufe et al., 1999). However, change may be more readily accomplished early in life or if there is a foundation of early support in a child’s background (Sroufe et al., 1999). While changes in atypical attachment may be possible in principle, the extent to which they can in fact take place in children without a stable attachment figure, for instance children growing up in orphanages and other institutions characterized by fragmented caregiving, is an open question. The positive outcomes experienced by many children adopted from such circumstances suggest that such a radical intervention may be successful (Rutter et al., 2007; Juffer & Van IJzendoorn, 2007). The limits of the responsiveness of the attachment behavioural system to environmental changes are largely unknown, however. Research has been mostly limited to children adopted from institutions before the age of six years. Research on attachment to foster parents has been conducted in infancy (e.g. Cole, 2005; Stovall-McClough & Dozier, 2004) or in the preschool period (e.g. Oosterman & Schuengel, 2007a, in press; Vorria et al., 2006). In addition, none of these studies have involved children with intellectual disabilities. Attachment may be as important or even more important for children with intellectual disabilities as for children without such disabilities in coping with 10 challenges to mental health (Janssen, Schuengel, & Stolk, 2002; Schuengel & Janssen, 2006). It is not known to what extent it is possible to stimulate attachment behaviour in deprived children of varying ages with intellectual disabilities, or to teach these children to use a specific person as a source of comfort and security during times of stress. This study was guided by these key questions, and explored the psychotherapeutic benefit of stimulating attachment in children with visual and severe intellectual disabilities who show severe challenging behaviours. Disabilities and the development of attachment Fraiberg (1979) suggested that visual disabilities might strongly interfere with the development of an emotional attachment between infants and their parents. Clinically, she observed that in blind children the development of the ability to differentiate between oneself and an object or another person was delayed, as was object and person permanence (Fraiberg, 1977). Parents reported a lack of responsiveness in their infants, since they did not smile at them as much as other children did. In addition, their use of body language differed as the blind children used their hands, instead of facial expression, to express their emotions and reveal their wishes. Ainsworth, Blehar, Waters, & Wall (1978) and Bowlby (1969/1997) included orienting and looking among other behaviours that infants show instinctively at times of fear or distress, such as rooting and sucking, postural adjustment, listening, smiling, vocalizing, crying, and grasping. Thus, visual disabilities may interfere with the development of early attachment relationships. Nevertheless, the limited studies that have been done show little evidence that visual disabilities on their own may be predictive of the development of insecure attachment relationships in infancy (Friedman, 1988; Gerra, 1993). Atkinson et al. (1999) examined the behavioural precursors mentioned by Ainsworth and Bowlby in children with an intellectual disability and found deficits with respect to communicative and attachment behaviours such as looking, eye contact, vocalizations, crying, smiling, turn-taking, social referencing, initiative- taking, approach and language. When affective signals are fewer and harder to interpret, caregivers may also provide less affective feedback, hindering the development of smoothly patterned emotional communication as found in secure attachment relationships. This was the conclusion drawn by Vaughn, Goldberg, Atkinson, Marcovitch, MacGregor, and Seifer (1994) from observations during the Ainsworth Strange Situation Procedure for assessing attachment security in children with Down Syndrome (DS). Children with DS gave only weak signals for contact during reunion episodes. Due to the absence of distress signals (e.g. crying, reaching, holding on) the attachment system of children with DS failed to achieve the proximity needed for arousal reduction. According to Thompson, Cicchetti, Lamb, and Malkin (1985) the children in their study with DS seemed less 11 distressed by the separation from their mothers, took longer to become distressed and less time to settle, and their variety of responses was smaller in comparison with a group of infants without DS. Nevertheless, the children with DS did show attachment-related behaviours. As their attachment behaviours are fewer and harder to interpret it is clear that

Load more