“Seeing the Unseen” Early Attachment Trauma and The Impact on Child’ Development

It is important to broaden our vision on attachment trauma, by pointing out the importance of the quality of parenting as an indicator to develop a secure attachment relationship. This quality mainly depends on the caregivers’ ability to mentalize, regulate, contain, play, and so on. The absence of these features causes traumatic stress in the child and impacts his psychological and neurological development and the possibility to attach. Thus, it is important that we are aware of the relationship between early attachment trauma (EAT) and affect dysregulation and dissociation. The seriousness depends on the early age of the child, the stress level of adverse experiences and the caregiver as the source of trauma.


Introduction
Early childhood trauma has a profound impact on different levels of the child's development and functioning, such as emotional, cognitive, behavioral, social, relational, physical and neurobiological.
The expanded vision on EAT might serve as a basis for a new classification which has implications for recognition and assessment and enables us to incorporate this in clinical practice, early intervention strategies and treatment.
"What is believed to be essential for mental health is that the infant and young child should experience a warm, intimate, and continuous relationship with his mother in which both find satisfaction and enjoyment" [1].
"The essential task of the first year of human life is the creation of a secure attachment bond of emotional communication and interactive regulation between the infant and primary caregiver" [2].
As Bowbly [2] himself stressed the importance of recognizing the impact of early childhood experiences in an attachment relationship as indicators of later psychopathology, the necessity to broaden our vision on early childhood trauma in an attachment relationship, imposes itself. In expanding our view on the existing criteria for traumatic experiences, we have to consider the timing of the experience, the developmental phase of the child in which the experiences take place, and the relationship in which the traumatic experience occurs.
Major advances in brain research show us the effects of early attachment trauma on brain development and enable us to expand our awareness of these adverse experiences. We might consider that the effects of early childhood trauma are more severe because of the developmental periods and the impact on the developing brain. Research on the consequences of early traumatic events helps us to define new criteria for attachment trauma and offers us directions for early identification and enables a more accurate treatment. By raising awareness among both caregivers and clinicians about attachment trauma, prevention strategies and tailor-made treatment might increase and create new therapeutic opportunities.

Secure attachment relationship
It is important to understand the difference between a bond of love and a secure attachment bond.
"All infants need to be cared for. To physically survive, they need to be fed, bathed, and put to sleep. The infant's need for survival and the parent's need to care for their offspring create a bond of love between parent and child. Since the 1960s, many books, articles, and online sources have encouraged parents to bond with their babies by investing more time and energy in taking care of their infant. However, an infant needs something more than love and care giving in order for their brain and nervous system to develop in the best way possible. " In the creation of an attachment bond, the quality of the relationship between the child and his parent is crucial to the child's development. This quality, as Bowbly pointed out, mainly depends on the attachment figure. "The essence is that this attachment figure is functioning as a secure base by which the child can explore the world and retreat in times of distress" [3].
Of great importance is maintaining a continuous relationship between mother and child. In order to achieve this continuity in the attachment relationship, the availability of the caregiver is a key aspect. Any disruption of the attachment bond influences the child's experiences of safety and security and impacts the brain development.
Two important features of the caregiver's availability are the physical and emotional accessibility of the parent. The caregiver is emotionally accessible when she is able to respond in an appropriate way (sensitive responsiveness) to the child's emotions and stress. The ability of the caregiver to respond sensitively to the baby's signals is a core condition to form a secure attachment relationship.
'The appropriateness and promptness of the mother's response are the hallmarks of sensitivity" [4].

Journal of Child & Adolescent Behavior
"An appropriate response needs to fulfill the following conditions: The response satisfies the infant's need, is well attuned to the infant, follows immediately the infant's signal, and constitutes a harmonious interaction" [5].
When the mother is rejecting or inappropriate in her response then it may be considered as emotional disruption of the attachment bond and thus attachment trauma.
Although Bowlby [2] emphasized the importance of security and safety in the attachment relationship, we should also take into consideration what A. Schore [2] wrote: "many have accepted and suggested that the attachment relationship is a major organizer of brain development ". This means that more is needed to form a secure attachment bond. Taking this vision into account, "secure attachment depends on the mother's regulation of the infant's internal states of arousal, the energetic dimension of the child's affective state" [6]. The mother serves as an external regulator of the child's internal states. Minimal or unpredictable regulationare hallmarks of caregivers inaccessibility.
Also, high or low stimulation negatively impacts an optimal attachment communication. Low stimulation as appears in emotional neglect is seen by Erickson and Egeland [7] as a form of psychological unavailability. When the mother, who serves as the "emotional regulator" [8], provides no interactive repair, then we might consider her as emotional inaccessible.
Another key factor that forms the basis for a secure attachment relationship is containment. Containment refers to a situation in which "one person receives and understands the emotional communication of another, without being overwhelmed by it and communicates back to the other person" [9].
As Shaver stated: "When the mother is able to reflect upon and thus modulate and integrate her own affective experience, she will not be dysregulated by her infant's (or child's) aggression or other negative effects." Another great deal of importance is a caregiver who is interested in his child like a parent who wonders what the child's thoughts, feelings, desires, needs…are. From this point of view the caregiver can really understand the child and react appropriate. This so called "Mentalization is significant for the child's development of a sense of self.
Another core components of attachment is a well-developed reflective capacity. It is the caregivers' ability to reflect upon their own history, how this history can be triggered by the child. It is also the capability to think and reflect on the child's verbal and non-verbal signals and the possibility to mirror them, so the child can experience and understand their internal state. How an attachment relationship is designed determines the attachment dynamics. As a child internalizes experiences of self and of self in relation to others, the child creates an internal working model that in turn forms a base from which the child interacts with the outer world [10].
This "internal working model of attachment" will establish the template with which a child will construct his future relationships. It creates also an affective cognition about self-worth ("internal working model of self ").
By considering all these conditions, as mentioned above, it is extremely important to achieve a secure attachment. When these conditions are not fulfilled, they form an important basis of early attachment trauma that is so often overlooked and/or considered as unimportant. However, as experienced in our clinical work, it has tremendous effects on a child's development and mental health. We can't reduce our clinical interventions merely based on what is obvious or the presenting symptoms. If we bear in mind the possible existence of early childhood trauma as first adverse experiences, influencing from the very beginning the child's development, then we can offer a complete treatment to our clients.

Classification for attachment trauma
There are many causes of trauma in children and often they are traumatized in the context of a care giving relationship. We can consider attachment trauma as adverse interpersonal experiences, occurring in early childhood, which are repetitive, chronic and between child and caregiver or in a care-giving relationship.
The time and the developmental phase of the child during which these experiences take place are of very great significance. The expanding of our perspective on early childhood adverse experiences imposes itself. This expanded vision might serve as a basis for a new classification which has implications for recognition and assessment and enables us to incorporate this in clinical practice, early intervention strategies and treatment.
Generally, abuse and neglect (sexual, physical, emotional, psychological) are defined as attachment trauma. I want to expand this definition by including different factors which might occur in the care giving relationship and affect the development of the child and the attachment ability. Hence, I consider multiple adverse experiences in a dysfunctional attachment relationship as attachment trauma. Thus, we might then assume that the care giving relationship itself might be the source of trauma.
"Researchers have come to the conclusion that the healthy self organization of the developing neural networks occurs in the context of a relationship with the primary caregiver, mostly the mother" [11].
From the prenatal period, adverse experiences in the mother or in the mother-child relationship, might negatively impact and influence the unborn child. Not only the condition of the mother (physical and emotional) but also her relationship towards her unborn child can be detrimental. Even the quality of the relationship between the mother and the father or certain life events can influence the baby's development in a negative way.
Birth trauma might also have a profound negative effect on the mother and child and interfere with the attachment possibility. We consider as birth trauma: unusually long or short labor, C-section delivery, life threatening experiences concerning as well the mother or the child. According to Bowbly [2], the attachment relationship is a continuous relationship throughout life but the most influential period is the one from the prenatal phase up until the age of four. This period is considered to be crucial in the establishing of a healthy attachment bond.
If in this period any disruptions in the attachment bond occur in the form of physical or psychological inaccessibility, attachment trauma might be caused. A both physical and emotional disruption of the attachment bond influences the infant's development. Separation from, early loss of, changes in primary caregiver are, along with parental illness, divorce, a few examples of physical disruptions. Attempt to commit suicide, marital problems, parental psychopathology, maternal dissociation and more, might cause psychological interruptions.
Another important feature of attachment is the quality of parenting. As stated previously, there are a lot of conditions necessary to form a healthy and secure attachment relationship. When any of these conditions aren't fulfilled, attachment trauma might occur. Another considerable aspect in the creation of a healthy attachment relationship is the parent's attachment style. The caregivers' own history with his parents created "internal working models" which form a kind of blueprint about relationships and sense of self that influences the caregivers' interaction with the child [10]. Crittenden [12] emphasizes that the way how a caregiver processes the infant's information might interfere with the development of an attachment bond. She describes e.g. failures of perception as "Attention-seeking signals such as a child's cry, simply go unheard, at least at the conscious level. Then the child felt powerless to elicit care and protection. This is a frightening experience. " When a caregiver fails to select a response: "They recognize their child's need and distress, but have no idea how to respond. Then children seem socially clueless, cognitively poor and emotionally flat". Apart from a dysfunctional attachment relationship there might also be a lot of stressful events in the life of the child and caregiver that interfere with the attachment ability and cause attachment trauma. Some examples are frequent moves or placements, early medical interventions, a chaotic environment. The awareness of all these possible traumatic experiences has a tremendous implication on the development of prevention strategies and treatment.

Consequences of attachment trauma
The importance of the deep impact of early childhood trauma on different levels of the child's development and functioning, such as emotional, cognitive, behavioral, social, relational, physical and neurobiological. Early trauma in children can result in psychopathology such as PTSD, depressive and dissociative disorders.
"Disrupted attachment may lead to impairments in three major areas for the developing child: Increased susceptibility to stress, excessive help-seeking and dependency or excessive social isolation, inability to regulate emotions" [13].
"(….) repeated, prolonged, chronic stress is associated with longterm patterns of autonomic reactivity, expressed in "neuronal structural changes, involving atrophy that might lead to permanent damage, including neuronal loss" Schore [14] described the right cortical hemisphere as losing its capacity to integrate sensory processing and thus disrupting the integration of perceptual information. It may result in Sensory Integration Disorder.
Another effect of early childhood trauma as Perry [15] stated: "It can result in a number of biological reactions, including a persistent fear state". Neurochemical systems are affected, which can cause a cascade of changes in attention, impulse control, sleep, and fine motor control". The child can overreact as it is unable to interpret the communication appropriately.
Early childhood trauma impacts the neurophysiology affecting the arousal regulation and might be expressed as hyperarousal and dissociation. When there is a hyperarousal, there might be motor hyperactivity, anxiety, behavioral impulsivity, hypertension, sleep problems.
"Dissociation is basically a mental mechanism by which one withdraws attention from the outside world and focuses on the inner world. In extreme cases, children may withdraw into an elaborate fantasy world where they may assume special powers or strengths" [15]. This shut down has implications for the attachment abilities.
"One of the dilemmas of classification of symptoms of dissociation is that these symptoms assume many and varied forms and expressions. They may be emotional, perceptual, cognitive or functional" [16].
These symptoms should be considered as post-traumatic symptoms, which are often misinterpreted as symptoms of attention-deficithyperactivity disorder, autism, oppositional-defiant disorder, and learning disabilities.
Early neurological damage of the prefrontal cortex, as a consequence of attachment trauma, might cause a failure "to acquire complex social knowledge during the regular developmental period and an enduring impairment of social and moral behavior" [17].
"The development of self-unfolds in the context of attachment and the internalization of important other's perceptions and expectations. How the child is treated early in life is bound to influence his growing self-awareness" [18].

Conclusion
The significance of raising awareness of the core principles of attachment, trauma and neurodevelopment speaks for itself. We need to practice to look beyond the PTSD features and broadening our vision on trauma experiences. If we are able to look beyond what is obvious, we might develop early prevention strategies, improve practice and provide a tailor-made therapy. A proper assessment of the child, the parent and the relationship between the parent and the child might reveal issues we can assimilate in the treatment. The unique experience of the child is determinative for us to understand and honor our children and our clients. Sensitizations of both parents and clinicians about the importance of the early relationship between child and caregiver have to be organized. Increasing knowledge by giving workshops, lecture is an important first step in prevention strategies and enables clinicians to improve their practical skills and therefore their therapeutic potential.