Attachment and Complex Trauma: Evaluating Outcomes for Children in Therapeutic Residential Care.

This repeat measures study assessed the progress of 45 children in a therapeutic residential school in terms of attachment, trauma/loss, affect regulation and educational attainment. The aim was to build a profile of complex trauma in severely maltreated children and estimate any changes over a two year period. Attachment, trauma and affect regulation were assessed using the Child Attachment and Play Assessment (CAPA), based on Crittenden's Dynamic Maturational Model of attachment (DMM). Based on a matrix combining attachment risk, unresolved loss or trauma and observed high or low states of physiological arousal, 51% of children improved and 33% showed deterioration. There was a general improvement in education scores but no significant gains made by children whose stories were assessed with unresolved trauma. While insecure attachment can act as a buffer against severe maltreatment, unresolved trauma or loss is pernicious and continues to affect children's development. Specific Adverse Childhood Experiences (ACEs), rather than ACE accumulation, influenced improvement compared with deterioration. In particular perinatal neglect may have had a particularly potent impact on change. DMM Type A+ attachment was more susceptible to loss of regulation than Type C+ and the two attachment patterns require different approaches. The CAPA offers a more finely calibrated analysis than that obtained by the more usual questionnaire assessment of complex trauma and is useful in devising treatment plans for individual children.