The guiding question for this article was, ‘Can the Integrative Attachment Trauma Protocol for Children (IATP-C) proposed by Wesselman and colleagues (2014, 2018) provide a useful framework for the treatment of children suffering from attachment trauma in Aotearoa New Zealand?’

The integrative approach involves a team treatment approach that integrated family therapy and eye movement desensitization and reprocessing (EMDR) therapy to strengthen attachment relationships in the family and remove obstacles to closeness resulting from trauma in the child’s past. This article explored the guiding question (as noted above) from a clinical practice perspective by reviewing a case example where EMDR therapy was used to address symptoms associated with past trauma, along with components of the integrative approach to reduce challenging behaviour and associated parent-child conflict at home.

Attachment Trauma

Shapiro (2018) made a distinction between ‘big T’ traumatic events (e.g. exposure to injury, sexual harm or death) and ‘small t’ traumatic events (e.g. emotional distress without physical injury). Attachment trauma refers to the experience of big T or small t events in the context of a relationship with a significant attachment figure, usually a parent or caregiver (Wesselman et al., 2018). These events can include any form of child maltreatment or loss of a parent.

Common Challenges in Treatment of Attachment Trauma

Young people who have experienced attachment trauma commonly present with symptoms of posttraumatic stress disorder (PTSD) and severely disrupted behaviour (De Roos et al., 2011; Gomez, 2013; Struik et al., 2017). They are easily mislabelled as ‘undisciplined’ and parents often feel overwhelmed, frustrated and fearful of their own child’s behaviour. Families can also be entrenched in angry patterns of parenting (Wesselman et al., 2014), without realising their child’s behaviour stems from anxiety, fear and a need for control rather than a desire to hurt or disrupt.

Struik et al. (2017) described several barriers to trauma processing, including: clients being avoidant of emotion and unwilling to talk about traumatic events; clients refusing to engage in trauma therapy; and caregivers’ fear that therapy would destabilise their child. The temptation to ‘wait until they are ready’ is great. Unfortunately, symptoms persist and continue to impair functioning, thereby having a cumulative negative effect on development. Ongoing disruptive behaviour often results in multiple care placements, which deprives the young client of opportunities to form secure attachment relationships in the future.

Understanding Challenges in the Treatment of Attachment Trauma

The negative behavioural and mental health consequences of early exposure to adverse events are well documented (Felitti et al., 1998; Hook et al., 2002). Attachment trauma in particular is associated with limited awareness of internal experiences and limited vocabulary for emotion, tendency to avoid feelings, negative beliefs about the self, feelings of shame and guilt, reactivity to triggers and lack of self-regulation skills (De Roos et al., 2011; Gomez, 2013; Struik et al., 2017; Wesselman et al., 2014). The brain of a newborn has limited capacity to organise incoming information and calm the nervous system. In healthy attachment, internal states (e.g. distress, excitement) are initially regulated through the infant’s interaction with a parent. This process of co-regulation can be described as ‘the mutual adaptation between partners in response to one another’s biology and behavior’ (Bornstein & Esposito, 2023, p. 2). Parents can play a vital role in therapy by supporting their child to regulate in sessions. This is crucial because EMDR memory reprocessing requires that the young client remains inside their ‘window of tolerance’, as described by Siegel (2010).

Child EMDR Therapy

There is substantial evidence for the effectiveness of EMDR therapy for the treatment of posttraumatic stress symptoms (PTSS) in children and adolescents (De Beer, 2018). EMDR is also associated with a reduction in symptoms for clients with complex PTSD. A systematic review of randomised controlled trials concluded that EMDR was associated with reductions in PTSD symptoms, depression and anxiety at both post-treatment and follow-up for adults and children (De Beer, 2018). Struik et al. (2017) reported a significant reduction in intrusive and depressive symptoms in a group of chronically traumatised children who were resistant to doing EMDR therapy. A pilot study of the effect of EMDR therapy on attachment security published in 2023 (Barazzone et al., 2023) concluded that EMDR therapy could reduce attachment insecurity in adults with PTSD and complex PTSD. Various specialised protocols have been developed to assist children in EMDR therapy (Struik, 2014; Struik et al., 2017).

Overview of the IATP-C

Wesselman et al. (2018) described a study that used a case series methodology to explore the effectiveness of the IATP-C in addressing the effects of attachment trauma for 22 child participants. They recorded significant improvement in PTSS (as measured with the Trauma Symptom Checklist for Young Children), reduction in disruptive behaviour (as measured with the Child Behavior Checklist) and strengthening of attachment relationships with parents (as measured with the Attachment Disorder Assessment Scale-Revised and an adapted version of Postpartum Bonding Questionnaire). In the IATP-C protocol, clients attend one family therapy and one EMDR therapy session per week, accompanied by at least one parent for all sessions. Treatment ends when outcome measures are at or near subclinical levels and parents report a satisfactory improvement in their child’s behavioural problems. In the 2018 study, treatment lasted between 6 and 24 months.

The main goals of the IATP-C approach are to increase attachment security and emotional support from parents, reduce the child’s challenging behaviour, restructure the child’s belief system and develop new behaviour skills (Wesselman et al., 2014). In the family therapy sessions, the focus is on strengthening the attachment bond and developing an integrative parenting approach (i.e. being responsive rather than reactive). During the EMDR sessions, the therapist follows the standard eight phase EMDR protocol, with specific additions to develop and strengthen internal attachment resources. These specialised protocols include resource development and installation, attachment resource development and self-regulation development and installation. Desensitisation and reprocessing (Phases 3–8 of the EMDR standard protocol) often start with processing present triggers to help reduce reactivity to trauma triggers, reduce reactive behaviours and relieve pressure for families (Wesselman et al., 2018). The transition to standard protocol EMDR is made by first reading the child’s life story (developed by the parents and family therapist) while administering bilateral stimulation (BLS). Clients are usually ready to proceed to the standard protocol after this preparation step.

Case Example

The case described below was referred to a clinical psychology practice to address symptoms of PTSD and parent-child relational problems. The referral was from Oranga Tamariki Ministry for Children and Permanent Caregiver Support Services (PCSS), which is an organisation that supports children in Home for Life care (i.e. permanent placement).

The initial assessment identified significant symptoms of PTSD, a high level of oppositional and defiant behaviour towards parents and frequent aggressive outbursts. The case was de-identified for use in this paper and represents a child EMDR process that incorporated components of the integrative approach to help address severe behaviour challenges. The complete IATP-C was not implemented. Child-specific components of EMDR include the use of drawing, visual rating scales to help clients rate their experience and a variety of BLS modes (e.g. visual, auditory, tactile). Adaptations developed by the EMDR therapist Ana Gomez (2013) were used.

The introduction of IATP-C components resulted from an urgency to reduce clients’ disruptive behaviour and alleviate stress in families. A supervision conversation steered the therapist towards the IATP-C approach. The initial focus on addressing disruptive behaviour meant that components that were not specifically aimed at challenging behaviour (e.g. resourcing protocols) were not used with this client (see the Reflection and Conclusion for more on this). As for outcomes, the client reported a decrease in the level of disturbance associated with traumatic memories during processing as well as an increase in the validity of cognition rating for positive beliefs. The client’s parents described a decrease in disruptive behaviour overall, although disruptive behaviour continued to surface on occasion, but at a lower intensity (i.e. brief, verbal aggression only).

Ben (Aged 14 Years)

Presenting problems. Ben was referred at age 12 years by PCSS because of verbal and physical aggression towards his parents, peers and teachers. He had destroyed property in a fit of rage. His aggression at home had escalated to the point where police had been called several times. Ben had a diagnosis of attention deficit hyperactivity disorder and oppositional defiant disorder and there was a question regarding a foetal alcohol spectrum disorder (FASD) diagnosis. However, the FASD diagnosis was ruled out after a cognitive assessment. Ben’s parents described numerous examples of his meltdowns, with swearing, yelling, throwing objects, breaking things and threatening his parents (once with a knife), following their attempts to direct or redirect his behaviour. Ben’s parents were not exhibiting any significant aggression, so it seemed unlikely that Ben was modelling his behaviour on their example. During his outbursts Ben made comments such as, ‘you are not my parents’.

Attachment and trauma history. Ben is in Home for Life care with a couple in their 60s. He was placed with them for emergency care at age 2 years, and they subsequently became his permanent caregivers. Ben was born into a home of poverty, neglect, substance abuse and family violence, and was uplifted by Child Youth and Family services when he was aged 2 years. Ben’s mother had a transient lifestyle and was abusing alcohol. Ben has several biological siblings and previously had regular contact with them. This was viewed as important by him and his adoptive parents because his biological family were of Māori descent and his adoptive parents were New Zealand European. They wanted him to feel connected to his Māori background. At age 11 years, Ben’s contact with his siblings broke down for various reasons and since then, Ben was essentially growing up as an only child. This was hard for him, and he was always eager to find out how his siblings were doing. During visits with older siblings (before age 11 years), Ben was unfortunately exposed to traumatic events (e.g. a sibling attempting suicide, witnessing violence). Many of his siblings had been in prison, involved in drugs and at times were missing. Ben insisted on being informed of these events, but often showed dysregulated behaviour for several days after hearing bad news about his siblings.

Therapy process. Ben and his parents had participated in 40 therapy sessions over a 2-year period. At first Ben was reluctant and engaged superficially. He did acknowledge the importance of his relationship with his parents and recognised that his aggressive behaviour was negatively impacting them. This gave him some motivation to continue in therapy. Rapport was slow to develop, and verbal communication was limited. Following initial information gathering with his parents, Ben joined the sessions but sat listening to his parents and the therapist identifying goals and developing a timeline without much engagement. When invited into the conversation he would provide one-word responses only and frequently challenged his parent’s descriptions without providing his own views. However, occasional corrections from Ben provided some insight into his perception of life events.

Ben completed 20 EMDR processing sessions. Target memories were selected based on his current challenging behaviour and a timeline was developed with substantial input from Ben’s parents. This was essential because some traumatic events (e.g. upliftment from his biological mother) dated back to preverbal stages of development and Ben had no explicit memories. Ben struggled to describe (and possibly to recognise) his responses to traumatic events (memories) and present triggers in any detail. He relied on menus (lists) to identify feelings, cognitions and body sensations.

The EMDR processing sessions were interspersed with parent support sessions, with a focus on addressing Ben’s ongoing challenging behaviour in a trauma-informed manner. The disruptive behaviour did not disappear entirely but decreased in intensity and frequency. Ben’s parents described ongoing agitation, frequent verbal challenges (including swearing) and on occasion outbursts of verbal aggression. A pattern was noticed that involved escalation of aggressive and defiant behaviour when periods of separation from his parents where anticipated. For example, when Ben’s parents went out of the country for 3 weeks to attend to family matters and when Ben transitioned to high school, which involved starting boarding school. When this pattern was noted in therapy, Ben’s parents understood that their absence was likely to increase anxiety for Ben, but he did not openly acknowledge any difficulty (‘it’s fine’).

Stress levels remained high for Ben’s parents. Their relationship was suffering because of disagreements about how to deal with his disruptive behaviour, and both had increasing physical health concerns and were trying to prioritise their own health. There were three occasions during the 2-year period (at 6, 12 and 22 months into therapy) where Ben’s parents were seriously considering giving up and leaving Ben with child welfare services. Once they contacted Oranga Tamariki to alert them of their intention to withdraw as caregivers. This was a heartbreaking moment for them; however, they changed their minds and recommitted to parenting Ben, but with a plan to take turns living away from home to allow each of them some respite from the stress.

IATP-C components. A trauma healing story was developed with Ben’s parents to address the negative consequences of trauma that had occurred in the first 2 years of his life. This approach is generally used for children under the age of 4 years (Struik, 2014; Wesselman et al., 2014); however, it can also be used for activation and reprocessing of memories of early trauma with older children who do not have explicit memories of traumatic events. Auditory BLS and drawing were used while Ben’s parents read the story out loud. Ben did not say much, but he sat drawing while listening and went over to his mum for cuddles when the story was done. He was able to move on to standard protocol for processing of target memories after this.

Ben’s parents benefitted from completing and reviewing the history taking checklist (Wesselman et al., 2014), and commented that they had never considered the specific beliefs and feelings underlying his challenging behaviour. They also benefited from learning the three phases of meltdown approach developed by Ann Potter and described by Wesselman et al. (2014) along with information on emotional attunement. They were able to shift away from correcting Ben’s behaviour while he was upset, opting to listen and reassure instead. This helped Ben to regulate himself and calm down quicker.

Reflections

There is a great urgency for parents to address their traumatised child’s unsettled and disruptive behaviours. They feel they have tried everything they know and are making no progress. In fact, they can often feel targeted and ‘abused’ by their own children. The sense of urgency may also be felt in the therapy room, especially when signs of activation or dissociation are noticed in young clients.

Reducing disruptive behaviour was a priority in this case. For Ben, disruptive behaviour was slow to settle, even after he had successfully processed all of the trauma memories on his therapy plan and was working on present triggers. The family’s ongoing struggles motivated the therapist to keep looking for suitable guidelines. A supervision conversation led to identification of the three phases of meltdown as a suitable approach. It was only after information on the three phases of meltdown was shared with Ben’s parents and they were able to adjust their responses (i.e. listening and reassuring rather than correcting or teaching) that significant progress was reported. This observation motivated the therapist to share this information and help parents develop a trauma-informed approach to meltdowns early in therapy with other clients. Completion of the history taking checklist provides useful information for identifying targets for EMDR processing, and it also provides parents an opportunity to review their child’s behaviour in light of their trauma history. They start to see the links between traumatic memories, triggers, negative cognitions and emotions, and the child’s disruptive behaviour. This is a useful step towards emotional attunement and helps motivate parents to change their parenting strategies.

Therapist Assumptions

There was an assumption that processing of relevant, unprocessed traumatic memories is the key to resolving trauma triggers and improving mental health symptoms and disruptive behaviour. In other words, if a therapist could ‘get’ a young client to process the ‘right’ target memories there would be a quick, positive change that brings relief to the client, their family and their social network. Given the complexity of the effects of attachment trauma, that assumption makes no sense, and yet, there it is. Perhaps it comes from hearing the comment ‘children respond very quickly to EMDR’ many times at workshops and conferences or from reading how the ‘sleeping dogs’ method allows successful processing in an average of 7.57 sessions (Struik et al., 2017), forgetting for a moment that this method involves a substantial, customised, preparation phase that involves a sizable social network.

Safety

Parents and therapists can feel they are walking on eggshells, trying not to trigger risky behaviour that can cause harm. It is helpful to consider basic safety precautions such as identifying a separate, safe space for young clients to retreat to and describing their options for getting out. This allows them to control their level of involvement and use physical distance as a rudimentary mechanism for regulating their level of arousal.

Cultural Aspects

Ben’s case illustrates the importance of cultural sensitivity when considering a framework for the treatment of attachment trauma in New Zealand. Non-kin placements often take place across different cultural/ethnic groups, and implications for strengthening of attachment with current caregivers and biological family members should be considered. Clients who can no longer have contact with biological family members are very likely to benefit from a sense of connection to the culture of their birth family.

Conclusion

Treatment of the multilevel negative consequences of attachment trauma is complex. The negative consequences of ruptured caregiver relationships are evident on an individual level (emotional, cognitive, behavioural and neurobiological) as well as an interpersonal level (reactive, oppositional behaviour, need for control and parent-child conflict). Child EMDR therapy offers mechanisms for directly addressing the individual consequences of attachment trauma through resourcing and trauma processing. However, processing of traumatic memories forms one (crucial) piece of a bigger puzzle that needs to address the range of significant challenges associated with the treatment of attachment trauma.

Young clients exposed to attachment trauma can have symptoms of PTSD along with severely disruptive behaviour that often result in risk for injury to themselves or others. They are often avoidant of emotion (positive and negative) and reluctant to talk about past trauma. Central to these challenges is the inability of these young clients to self-regulate, both in their day-to-day lives and in the therapy room. These young clients missed out on early opportunities to develop secure attachment bonds with consistent, sensitive caregivers, which means they also missed out on co-regulation experiences that form a crucial mechanism for the development of self-regulation abilities. IAPT-C provides a comprehensive framework and specialised protocols for the treatment of individual and interpersonal consequences of attachment trauma. It takes into consideration the significant challenges associated with the treatment of attachment trauma and integrates attachment and trauma-specific EMDR protocols and family therapy interventions to address specific needs, educate families on the effects of trauma, and prepare the young person for EMDR processing, while strengthening the parent-child relationship. Parent education, mindfulness skills and attachment resource development create opportunities for co-regulation in parent-child interaction, with coaching and support from therapists. Experiences of co-regulation are expected to enhance self-regulation skills.

The team component of the IATP-C approach makes it possible to address barriers to the current attachment bond between parents and their child by coaching parents towards trauma-informed parenting strategies while reducing reactivity in their child. This combination helps to alleviate stress in the family early in the therapy process. The case example above described use of separate components of the IATP-C approach to guide parents in responding sensitively to challenging behaviour (especially meltdowns) and developing attunement towards their child. These components were initially introduced when the parents reported ongoing frustration with disruptive behaviour and difficulty understanding their child and were subsequently used as soon as it became clear that disruptive behaviour was a major concern. The IATP-C components were effective, but it is likely that implementation of the integrative approach from the start would have been more efficient. The integrative approach can provide a framework and process for addressing the full range of challenges associated with attachment trauma in a systematic manner that could be implemented at a high level of consistency across services and practitioners. This would allow for research and customisation for the New Zealand context.