Integrating Attachment Processes with Lifespan Integration Therapy: a Hermeneutic Single Case Efficacy Design with an Adopted Child

Abstract

Purpose

Adopted children are at heightened risk for developing attachment insecurity due to relational disruptions experienced early in life. A newly developed therapy, Lifespan Integration (LI; Pace in Lifespan Integration: Connecting ego states through time (5th ed.), 2012), shows promise in reducing psychopathology and other detrimental outcomes with individuals exhibiting disrupted attachment. In this study, the efficacy of LI for addressing attachment processes with adopted children in middle childhood was investigated.

Methods

A Hermeneutic Single Case Efficacy Design (Elliott in Psychotherapy Research, 12(1), 1-21, 2002 & The handbook of humanistic psychology: Theory, research and practice (2nd ed., pp. 351-360), 2015) was used to gather quantitative and qualitative data from an adoptive parent–child dyad experiencing LI therapy for the first time. The research participant, a 12-year-old male, received 10 sessions of LI therapy with his adoptive mother present to facilitate a more secure attachment.

Results

Client change and the contribution of LI to this change was advocated by expert case developers, and adjudicated by three experts, who concluded that change occurred and that this change was due to LI therapy. Changes in internal attachment processes, and the attachment bond between the parent and child of this dyad, was observed.

Conclusions

This case provides evidence that attachment disruptions can potentially be repaired in middle childhood and ought to be targeted for intervention in early childhood and beyond to prevent later socio-emotional and psychological issues.

Introduction

Of all the factors contributing to a child’s development, none has received greater attention in the literature than the parent–child relationship, as first outlined in Bowlby’s (1969) attachment theory. Attachment, an emotional bond present from birth, is widely recognised as a factor that greatly contributes to emotional, social, and neurological development (Ainsworth et al., 1978; Bowlby, 1969). However, traditional attachment theory has offered the impression that children become “stuck” in their insecure or disorganised pattern of attachment, internalised in early childhood, with little hope of developing secure relationship patterns in adulthood. Due to such a premise, psychological interventions are generally aimed at managing the subsequent social, emotional, and behavioural problems that manifest in middle childhood and beyond (for example, Parent–Child Interaction Therapy; Eyberg & Matarazzo, 1980).

Children with insecure or disorganised patterns of attachment can lack the ability to regulate emotions, manage stress, interact well with others, expect positive responses from others, and maintain a positive view of themselves (Cooke et al., 2019). Not only do these patterns manifest at a conscious level, they can also have deep-seated, embodied consequences in the neural pathways leading to the socioemotional areas of the brain (Cozolino, 2017). A secure attachment relationship, on the other hand, helps to integrate the child’s internal map of self and others across time and space (Siegel, 2012). Although emerging attachment literature has shown evidence that neurobiological change in brain structures is possible for those who have experienced attachment disruptions in early life (Porges, 2011), very few therapeutic interventions, with associated evidence, address these early attachment disruptions. An effective intervention for children with attachment disruptions, such as those who are orphaned or fostered, ought to integrate these neurological processes that represent the different self-states in a warm, supportive, and attuned therapeutic environment.

A Promising Approach: Lifespan Integration (LI)

Lifespan Integration (LI) is a relatively new and promising approach to psychotherapy which addresses attachment mechanisms at an explicit and implicit neurological level using a gentle, body-based approach to trauma recovery (Pace, 2012). When Pace first developed LI therapy, she was influenced by contemporary research findings from attachment theory, interpersonal neurobiology (including neural integration and neuroplasticity), as well as ego-state therapy, body-mind integration, and imagery guidance (Thorpe, 2012). In clinical settings, LI has been observed to promote attachment security, emotion regulation, and more positive representations of self and others. Although the exact mechanisms of how the nervous system integrates new information through psychotherapy is still largely unknown, emerging evidence from recent neuroscience studies shows that psychotherapy may lead to changes in the structure of the brain (Cozolino, 2014, 2017; Malhotra & Sahoo, 2017; Schore, 2005, 2011; Siegel, 1999, 2012). Psychotherapy is thought of as an enriched environment that enhances the growth of neurons and the integration of neural networks (Cozolino, 2017). Neural plasticity, growth, and integration in psychotherapy are enhanced by the establishment of a safe and trusting relationship, mild to moderate levels of stress, activating both emotion and cognition, and the co-construction of new personal narratives (Cozolino, 2017, p. 26). From the perspective of LI, emotional and behavioural changes seem to be anecdotally linked to the integration of self through repetition of timeline cues and, as a result, ego state integration is connected to neural network development. The primary therapeutic mechanism of LI is a timeline with memories of the client’s life. By repeatedly and sequentially going through these memories, the client experiences a coherent whole story of her or his life by integrating different states of mind across time (Thorpe, 2012). LI uses a variety of different protocols which give clinicians the opportunity to address various presenting issues. Most protocols were developed for adult clients, though Thorpe (2012) advocates for flexible adaptations of the protocols for children, including for adopted children and these guidelines were used in the present research.

As LI is not a talk therapy, per se, it is especially suitable for children and youth. Children appear to engage easily in the process of the timeline and imagining their life events. LI has been used with several kinds of presenting issues, including children who have anxiety, Attention Deficit Hyperactivity Disorder (ADHD), have experienced birth trauma, early surgeries, sexual abuse, car accidents, adoption issues, and other concerns. For children in middle childhood (approximately six to twelve years), LI offers a therapeutic intervention that can shift their “stuck” patterns of attachment towards more secure representations of self and others, with more optimal emotion regulation and relational capabilities. With a focus on attachment processes, LI can offer late-adopted children – those who have had little opportunity for a consistent early attachment – an integration of their self-states across time and space, allowing them to consolidate and move past their attachment-related challenges. Middle childhood is a particularly important period of development because attachment regulation patterns and relational templates start to become generalized beyond the parent–child environment (Kerns & Richardson, 2008) and it is a time when behavioural, emotional, and social problems become obvious and merit assessment and diagnosis. Children with insecure and disorganized attachment may be particularly vulnerable to relational and socioemotional difficulties during this stage of development (Colle & Del Giudice, 2011). Incorporating the adoptive parents into LI therapy sessions allows for the children to experience this neural integration in the presence of their new attachment figures, who become a resource for continuity of regulation and positive interaction within and beyond therapy. This allows the parent–child emotional bond to grow and become a fulfillment of what was lost in the early years.

Although LI has strong theoretical roots in neurobiology and attachment research, little research has been done on its effectiveness with different populations. Therefore, the current study sought to identify the parent–child attachment processes involved in an attachment-based neural integration intervention (Lifespan Integration), and to understand the flexibility of such attachment processes. A mixed-methods design focused on the parent–child attachment as both a mechanism and a target for change in therapy. The primary research question for the study was: Does Lifespan Integration (LI) improve parent–child attachment and attachment correlates in a family with an adopted child? Attachment correlates include adjustment outcomes, specific parent–child relationship factors, and psychopathology symptom reduction.

Method

Design and Procedure

This study used a mixed-methods Hermeneutic Single Case Efficacy Design (HSCED; Elliott, 2002, 2015). This design is used as an alternative to randomized clinical trials (RCTs) in determining the efficacy of new therapies (or an existing therapy with a new population), and is now honoured as a rigorous and empirically sound process of determining therapy efficacy (Benelli et al., 2015). Quantitative data included weekly, pre-therapy, post-therapy, and one-month follow-up outcome measures. Qualitative measures included an assessment of the child’s and parent’s attributions for change and therapist case notes that give information on therapy process.

An adoptive parent–child dyad was recruited through an LI therapist in the lower mainland of British Columbia, Canada. Inclusion criteria included: child aged 6–12 years with an experience of a disruption of attachment; current demonstration of moderate emotional and/or behavioural concerns; no previous experience with Lifespan Integration, and; willingness to complete all requisite measures for a minimum 4-month period of therapy. Children were excluded from the study if they demonstrated severe emotional or behavioural concerns. Parents who struggled with their own mental health difficulties affecting their parenting skills negatively (determined by both the therapist at intake and the parenting questionnaire) were excluded from the study. The parent and child attended 10 weekly therapy sessions over the course of five months in which LI was the main intervention of each session. The Research Ethics Board (REB) of the university with which the authors were affiliated approved the procedures for this study. The child’s mother provided informed consent for participation in the study, and the child agreed to participate in the study through verbal assent.

Participants

Participants for the case study was one (N = 1) adoptive parent–child dyad where the adopted child was a 12-year-old male, named Jaydee (pseudonym). At the time of research, Jaydee lived with his adoptive mother and father, and biological half-sister, Abigail (pseudonym). Jaydee had a lengthy diagnostic history, receiving diagnoses at age 4.5 years including ADHD; Oppositional Defiant Disorder (ODD); Affective Disorder, Not Otherwise Specified; and Substance-Related Neurodevelopmental Disorder (SRND). Further diagnoses include: High Functioning Autism Spectrum Disorder at age six; Specific Learning Disorder in Math and Specific Learning Disorder in Written Expression at age 10; and Fetal Alcohol Spectrum Disorder (FASD) at age 10. Other problematic symptoms include inflexibility to change, anxiety about the future, extreme emotional reactions to any small variation outside of an expected event, and difficult regulating emotional arousal.

Early developmental trauma for Jaydee began pre-birth, as there was a history of cocaine, alcohol, tobacco, and marijuana use by his biological mother during pregnancy. His birth mother had been engaged in prostitution before and during her pregnancy with him. Jaydee was apprehended from her care at birth. Jaydee was born at 42 weeks’ gestation and weighed nine pounds, spending 12 days following his birth in the Neonatal Intensive Care Unit (NICU) due to breathing and other health difficulties. He was then placed in foster care until age 9.5 months. His adoptive mother described the placement environment as “less than nurturing,” reporting that Jaydee was not held and spent most of his time in a baby seat in a playpen.

Measures

Parenting Styles and Dimensions Questionnaire (PSDQ)

The Parenting Styles and Dimensions Questionnaire (PSDQ; Robinson et al., 1995, 2001) is a 62-item questionnaire assessing one’s parenting style as authoritative, permissive, or authoritarian, following Baumrind’s parenting theory (1967). A five-point Likert scale allowed the parent to rate each item, with 1 = Never and 5 = Always. In the current study, the PSDQ was used as a screening tool, to be sure the parent’s scores fell in the authoritative classification on this measure.

Simplified Personal Questionnaire (PQ)

The PQ was administered weekly to measure the client’s main problems or goals on a seven-point Likert scale (Elliott et al., 1999). This questionnaire was brief and individualised, consisting of approximately ten items of problems the client wished to work on (e.g., mood, school, relationships). Separate PQ’s were generated for the child and parent in the study. The language of each problem on the child’s PQ was modified to be child-friendly and the child was asked to rate each problem using a pictorial “smiley face” scale on a scale from 1 = Not at all to 7 = Max possible (See 31).

Parenting Relationship Questionnaire (PRQ)

The PRQ is a caregiver self-report assessment about the parent–child relationship. In the current study, the 71 items in the 6–18-years version provided information on the caregiver’s parenting style, parenting confidence, stress, and satisfaction with the child’s school (Kamphaus & Reynolds, 2006). Items were rated on a 4-point scale ranging from “never” to “almost always.” This assessment was administered pre-therapy, post-therapy, and at one-month follow-up to both of the client’s parents.

Behavioral Assessment System for Children (BASC-2)

To assess the child’s behaviour systematically, the BASC-2 (Reynolds & Kamphaus, 2004) adolescent version was administered pre-therapy, post-therapy, and at the one-month follow-up. The multidimensional assessment approach taken by the BASC-2 required three categories of information. The parents of the child client were asked to complete the Parent Rating Scale (PRS). Each of these scales was rated on a 4-point scale (“never” to “almost always”); the PRS contained 139 items about the child’s behaviour. The third category of information included the Self Report of Personality scale (SRP), administered to the child regarding his own thoughts and feelings. This scale consisted of 176 true–false and multiple choice items.

Kerns Security Scale

The Kerns Security Scale is a child self-report measure that assessed children’s perceptions of security in parent–child relationships in middle childhood and early adolescence (Kerns et al., 1996). The 15 items on this scale followed a “some kids…other kids” format, such as “some kids find it easy to trust their mom but other kids are not sure if they can trust their mom” (Kerns et al., 2001, p. 73). For each question, the client referred to one type of child as “really true” or “sort of true” for them, choosing one of four response options. The response items were totaled and higher scores (out of 60) indicated greater security on a continuous dimension. This measure was administered pre-therapy, post-therapy, and at the one-month follow-up.

Helpful Aspects of Therapy (HAT)

The HAT is an open-ended questionnaire that assesses patient perceptions of significant therapy events (Llewelyn, 1988). The seven open-ended questions about therapy events were modified for developmental appropriateness for the child client, reducing the number of items to four, while the full seven item questionnaire was kept for the parent to complete (See Appendix B).

Therapist Session Notes Questionnaire (TSNQ)

The therapist was asked to complete the focused Therapist Session Notes Questionnaire (TSNQ) to document the therapeutic process. The TSNQ, similar to the HAT, also contained questions regarding amount and types of LI protocols used in session. This questionnaire was customised to include attachment-related questions (See Appendix C).

Change Interview

In this qualitative assessment administered at the end of therapy and at 1-month follow-up, the client described and rated their changes that occurred over the course of therapy, following the format of Elliott et al. (2001) Change Interview. The rating of these changes included the expectedness and importance of the changes, and a determination of whether these changes would have likely occurred without the therapy. An adapted, child-friendly version was given to the child, and both parent and child interviews included more specific questions regarding the parent–child relationship both in and out of therapy.

Data Analysis, Case Development, and Adjudication

The HSCED design follows a step by step analytical procedure: compiling and analyzing the rich case record; creating affirmative and skeptic cases based on the data collected; and presenting each case for an adjudication process. Data from the intake process, pre-therapy assessment, weekly therapy notes and measures (including the PQ and the HAT), post-therapy and the one-month follow-up assessment compiled into a rich case record. One team was asked to develop an affirmative case of positive evidence connecting LI therapy to client outcomes, while a second team was asked to develop a skeptic case based on alternative explanations for the observed client change, if any change was observed. The rich case record, affirmative and skeptic cases, and rebuttals were presented to expert adjudicators for an adjudication process regarding the efficacy of therapy. The adjudicators were informed about the HSCED method, and were given a description of each of the measures. They were asked to complete an adjudication form rating their judgments of client change over the course of therapy, whether the change was due to the LI therapy, and how certain they were in making these judgments. These judges were also chosen based on their expertise with LI, the HSCED method, and/or attachment disruptions in adopted children. One judge, [blinded name], was considered a world expert in Lifespan Integration with children; another judge, [blinded name], was a non-LI child therapist with doctoral candidacy who specialized in understanding psychopathology in middle childhood; and the third judge, [blinded name], was a child trauma therapist familiar with LI and the HSCED method.

Results

Rich Case Record

Quantitative outcome data

The mean of Jaydee’s PQ scores was calculated for each week’s session and demonstrated a general decrease in personal problems over the course of therapy (see Fig. 1). Several of Jaydee’s PQ items decreased significantly by two or more points over the course of therapy: difficulty going back to sleep after nightmares decreased by four points; nightmares and fear of the dark decreased by three points, and; daytime worries about nightmares, stress and worry about homework, and troubles starting homework decreased by two points. All other items decreased insignificantly by one point.

Fig. 1.

Tracking of Jaydee’s PQ mean throughout therapy

Jaydee’s mother’s PQ, reflecting her assessment of Jaydee’s problems, also had many items that changed significantly over the course of therapy (see Fig. 2). The items that decreased by two points were: extreme emotional reactions to family members; nightmares; fear of dark; and difficulties with homework. The items that decreased by three points were: provoking conflict or aggression with family members; fear of the unknown, and fear or anxiety for no reason. Stress and worry about homework decreased by four points. All other items decreased insignificantly by one point.

Fig. 2.

Tracking of Parent PQ mean throughout therapy

The standard error of measurement was calculated (including 95% confidence intervals) for Jaydee’s BASC-2 t-scores on the clinical and adaptive scales. Jaydee’s scores on the Interpersonal Relationships scale saw a significant shift from “at-risk” pre and post-therapy (t-scores: 35 and 38, respectively) to “average” at follow-up (t-score = 51). Attitude to school also saw a significant improvement over the course of therapy from “at-risk” pre-therapy (t-score = 60) to “average” at post-therapy (t-score = 48) and follow-up (t-score = 44). Although Jaydee’s self-report scores on all other clinical and adaptive scales of the BASC-2 were in the average range for his age and gender, across the three measurement points, the internalizing problems composite scale saw an improvement from pre-therapy to follow-up in the scales of sense of inadequacy (t-score change = 13 points), locus of control (t-score change = 11 points), social stress (t-score change = 10 points), and anxiety (t-score change = 8 points). Jaydee’s parents reported several positive and significant shifts in scoring categories for Jaydee across the three measurement times in the aggression, anxiety, and adaptability scales.

A large decrease in the Relational Frustration scale on the PRQ was observed in Jaydee’s mother’s score from pre-therapy (t = 78; upper extreme) to post-therapy (t = 57; average) and follow-up (t = 59; average). Minimal changes were reflected in both parents’ scores on other scales of the PRQ. Jaydee’s total score on the Kerns Security Scale increased by 6-points from pre- to post-therapy and another 6-points from post-therapy to follow-up. These numbers are used to observe descriptive change rather than significant psychometric change in Jaydee’s felt security over the course of therapy as there are no norms available for this scale.

Qualitative Outcome Data

Jaydee reported helpful or important events in his HAT questionnaires including talking about his fears, his baby-self, his dreams/nightmares. Jaydee reported no hindering events. His mother described helpful events and experiences from sessions including the therapist’s encouragement of Jaydee throughout therapy and the LI memory cues. Hindering events reported by his mother included the inability to include other family members in therapy as she believed these relationships would benefit from LI intervention.

Change and helpful experiences were discussed in the change interviews with Jaydee and his mother, administered at post-therapy and follow-up. Jaydee reported that he no longer had nightmares, he did not worry about his nightmares, he could control his emotions better, and he rarely fought with his sister (see Tables 1 and 2 in Appendix D). Although the baby-self parts of therapy were difficult for him, including his mother holding the doll, he acknowledged that this experience was helpful.

In Jaydee’s mother’s change interview at post-therapy and follow-up, she described Jaydee as being happy most of the time, having a better relationship with his father, and instigating less conflict with his sister (see Tables 3 and 4 in Appendix D). She reported seeing him become less volatile and less blaming since therapy started, and less concerned about school, although she attributed this to changes in the school environment. At follow up, she said that all her goals for therapy were met and she attributed the changes observed to therapy as well as several extra-therapy changes (school environment and extracurricular activities).

The TSNQ revealed several interesting trends regarding the therapist’s interpretation of what the client was experiencing in LI therapy. From the first session, the therapist identified the most helpful or important events to be how the client understood and represented his baby-self. An important part of therapy occurred with the introduction of the baby doll in the relevant LI protocol, as the client demonstrated discomfort, dislike, and rage towards the doll representing his younger self. The therapist interpreted this as activating early attachment trauma. Inviting Jaydee’s mother to hold the doll was considered especially helpful for attachment repair. The therapist highlighted several attachment-based themes, including: the client seeking proximity and contact with his mother during timeline repetitions; initiating and maintaining communication with his mother throughout joint sessions; separating from his mother without anxiety or avoidance in individual sessions, and; demonstrating increased emotion regulation throughout the course of therapy.

Case Development and Adjudication

Affirmative Brief

Key areas of change in stable client problems included support from the client and parent’s PQs and Change Interviews, as well as the therapist session notes. These demonstrated an increase in positive mood, confidence, empathy and relationship with parents, and a decrease in anxiety, including specific fears. Outcome-to-process mapping evidence included the client choosing to be without his mother in some sessions as a demonstration of ego development, as well as session summaries demonstrating insight and trauma resolution. A particularly poignant demonstration of integration occurred in the final session, when the client said “I think [my baby-self] has turned 12 and a half, right now.” Behavioural markers (e.g. infant-like actions to paraverbal voice changes, a closeness with his mother, and a new ability to fight back during nightmares) were listed as a demonstration of event-shift sequence evidence. Specific processes (e.g. the baby doll attunement activities, repetitions of the timeline, and the use of the nesting cup)—were named as helpful for change and exemplified evidence of process-outcome correlation.

Skeptic Brief

Non-improvement was observed in some scales of the PRQ (father and mother). Relational artifact was discussed as a possibility because the therapist and researcher roles were observed to be blurred for the client. Change was thought to be more pronounced in the qualitative measures in light of the quantitative measures. Expectancy artifacts were suggested alongside the client’s motivation to “help science”, which may have influenced his willingness to report change. Extra-therapy events were reported as helpful by Jaydee and his mother. The reactive effects of research, according to the HSCED design, were related to change in the client, since he seemed to flourish under the extra attention from his mother and two professionals.

Adjudication

Table 1 presents a summary table of the adjudicators’ determinations present, each adjudicators’ scores, and the median for each question. Adjudicator A found four key areas of change (i.e. decreases in anxiety and problematic nightmares; increases in insight about baby-self emotion regulation) that were substantiated by quantitative or qualitative measures, or both. Adjudicator B found that the most compelling evidence for change came from the client and parent self-reports, the therapist’s observations and session summaries, and the demonstration of a positive relationship with his mother from multiple reports. For this adjudicator, skeptic arguments about extra-therapeutic factors of extracurricular activities and the increased attention received due to therapy were compelling. Adjudicators A and B noted that the skeptic case’s argument about lack of quantitative change was not relevant to the goals of this client’s therapy. Adjudicator C based the decision for change on observations of Jaydee’s mood, his comments on his baby-self becoming older, his interest in his birth mother, his increased developmental appropriateness, and his fighting back in nightmares. This adjudicator expressed appreciation for the skeptic team’s argument for non-improvement in the father-child relationship, the dual researcher-therapist role for the therapist, and the influence of extra-therapeutic factors.

Table. 1.

Adjudicators’ Scores for Change

	Adj. A	Adj. B	Adj. C	Median
1. To what extent did the client change over the course of therapy?	80%	80%	80%	80%
1.b. How certain are you?	80%	80%	80%	80%
2. To what extent is this change due to therapy?	80%	60%	80%	80%
2.b. How certain are you?	100%	80%	80%	80%

Change Due to Therapy

Adjudicator A stated that the change outcomes for this client are commonly observed in many LI clients. Adjudicator B described the client’s demonstration of ego development and increased insight as influential in attributing change to therapy, as well as the increased and maintained connectedness with his mother. Adjudicator C listed affirmative case evidence including the mother’s change interview attributions and Jaydee’s perception of his baby-self changing. This adjudicator also found the emphasis of LI timelines being connected to change important.

Mediating and Moderating Factors

The adjudicators listed helpful therapy processes, including: the presence of an experienced, warm, and coherent therapist; support from the mother in therapy; LI timeline repetitions; the baby doll; cognitive interventions (e.g. psycho-education) combined with LI concepts; reenactment of nightmares; respect and cooperation with Jaydee’s desires for being with his mother or apart; self-soothing activities and objects (e.g. sand tray), and; encouragement and reward for tolerating distress in therapy.

The adjudicators listed several of Jaydee’s personal resources that enabled him to make the best use of therapy, including his capacity to engage with the therapeutic processes as an individual agent (e.g. self-reflection, empathy) while also emotionally connecting with his mother. His ability to engage with the LI therapy timeline repetitions and to move between ego and emotional states was also useful, as these are considered difficult tasks for young people to complete. They noted that the client’s mother was a major personal resource for the client, including her support within and outside of therapy. Other resources included a decrease in the demand of school work and an increase in extracurricular social support.

In summary, all adjudicators agreed that change occurred, and that most of this change could be attributed to LI therapy. These conclusions are “significant” under the HSCED method, as an 80% median across judges is sufficient as a reasonable standard of proof in providing clear and convincing evidence for client change and client change due to therapy (Stephen & Elliott, 2011). Adjudicators’ decisions were based on an analysis of qualitative and quantitative evidence, as presented and argued by the affirmative and skeptic teams.

Discussion

In this HSCED study, Lifespan Integration was judged to be helpful and effective in addressing Jaydee’s presenting concerns considering his adoptive and attachment trauma. After consulting the rich case record, as well as the affirmative and skeptic teams’ cases and rebuttals, a majority agreement was reached that Jaydee experienced substantial change (80% median) with 80% certainty. The extent to which this change was attributed to therapy was also substantial (80% median) at 80% certainty. Using the median is appropriate for representing the majority decision in the HSCED method (Stephen et al., 2011); 80% is an acceptable standard of proof that represents “clear and convincing evidence” (Stephen & Elliott, 2011, p. 238).

The HSCED method also allowed for an examination of the change experienced in LI therapy and the various parts of LI therapy that were useful. Lifespan Integration processes were considered to be causal influences of Jaydee’s change. The LI timelines helped integrate the different ego states that were triggered for Jaydee when his prenatal development, birth, foster and adoption experiences were discussed and imagined. Repair in the form of the baby doll representing of his infant self and experiencing his mother demonstration of love and safety towards the doll were also considered pivotal moments for the client.

Implications For Counselling Practice

Adopted children are seen in therapy with a variety of presenting issues, including multiple diagnoses, and middle childhood is often the age when early attachment traumas start manifesting as internalizing and/or externalizing symptoms. The changes observed in Jaydee over the course of therapy indicate that Lifespan Integration is a good fit for children who have experienced attachment trauma and whose caregivers are looking for a therapy that builds upon core attachment processes as well as resolving current anxieties or behavioural problems. It is an example of how internalised attachment patterns from early childhood trauma are flexible enough to change in middle childhood.

In the process of Lifespan Integration therapy, Jaydee demonstrated the ability to access parts of his self that were “stuck” in his earliest traumatic moments and then integrate these parts into his present self with the help of his caregiver and therapist, using the LI timeline. The accessibility of these earlier ego states supports the argument that Jaydee’s presenting problems of age-inappropriate fears and aggression/dysregulation were most likely influenced by these earlier parts. That these presenting problems decreased or were eliminated completely over the course of therapy leads to the conclusion that his earlier insecurely attached parts were integrated back into the security of his present life situation. Integration is a key function of attachment, as a sign of healthy attachment processes at work.

Therapists working with children in middle childhood with a history of attachment disruption can follow the example set of Jaydee’s case in numerous ways. The inclusion of a secure adoptive parent helped Jaydee regulate in session and facilitated repair work with the baby doll. Using metaphors such as nesting cups and the tree rings allowed the LI ego states conceptualization and timeline process to be better explained. Therapists should be aware that the introduction of the physical baby doll may be very triggering for the child client, and tools for grounding are necessary to supplement this part of LI therapy. Although LI is considered a gentle approach that does not re-traumatise the client, expressions of extreme resistance from child clients can demonstrate the severity of earlier attachment disruptions.

Limitations and Future Directions

The PRQ and Kern’s Security Scale were used in this study, but did not fully reflect attachment processes observed and inferred from Jaydee’s case. The PRQ, from the parent’s perspective, was very behaviorally-based. This measure did not draw conclusions about Jaydee’s internal experiences, the changes in the parent–child bond observed in this case, and the socioemotional changes associated with this bond. The Kern’s Security Scale, while allowing for Jaydee to give some report about how he feels about his parents, was also based on Jaydee’s cognitive understanding of how he compares to other kids in relating to his parents. This report did not reflect his early attachment experiences related to emotional dysregulation, traumatic body-based memories, and other relational and psychopathological difficulties. A better measurement for encapsulating what we know about attachment (e.g., emotion regulation, neural correlates, attachment trauma) is needed, particularly for children. As systematic case-study research grows to better represent practice-informed research, attachment assessment must follow to allow for an in-depth examination of attachment processes in a single-case. Such an assessment must include a focus on healing rather than classification. Healing of attachment processes, as represented by interpersonal neurobiology literature (e.g., Schore, 2003; Siegel, 2012) and Jaydee’s specific case, is done through the integration of attachment experiences in the presence of a secure attachment figure. New assessments should include a focus on integration and the involvement of an attachment figure in integration.

Future directions for LI therapy with children should continue the use of concrete objects in the room as both visual representations of LI concepts as well as for regulation throughout the powerful therapeutic moments of LI. Close attention should be given to the way a child reacts to each protocol, using baseline when necessary to calm the child down, and introducing attunement protocol only when the therapist believes the child to be ready, after baseline and birth-to-present have been introduced.

Conclusion

The case of Jaydee demonstrates that early attachment trauma resulting in complex presentations in middle childhood can be addressed, cleared, and repaired in therapy. For Jaydee, such a focus on integrating his early experiences into his current timeline and understanding of self was facilitated by the presence and attunement of his primary attachment figure, his adoptive mother. The positive change in Jaydee due to this therapy, rated as substantial by adjudicators in the HSCED method, is evidence that an attachment-based trauma intervention can be effective for older children who have early attachment disruptions. Lifespan Integration provides a tangible intervention that can help children integrate these early experiences into their present developmental stage, using the warm, caring, and attuned support of both therapist and parent. Presenting a therapy that fits well with the adoption population is beneficial to many families who are trying to give abused, neglected, and abandoned children a “second chance” at a thriving life. These children can integrate their experiences in a way that addresses their history while promoting relational and emotional well-being in their current contexts which can bring hope and relief to the families and communities who support them, and the therapists who work with them towards healing.

Appendices

Appendix A: Simplified Personal Questionnaire Forms

Appendix B: Helpful Aspects of Therapy Form

Appendix C: TSNQ Form

Appendix D: Tables

Declarations

Conflict of Interest

The authors have no conflicts of interest to declare.