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Reactive Attachment Disorder: Yes You Can Or, How to develop parent-child bonds & treat difficult children without fear.

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Presentation on theme: "Reactive Attachment Disorder: Yes You Can Or, How to develop parent-child bonds & treat difficult children without fear."— Presentation transcript:

1 Reactive Attachment Disorder: Yes You Can Or, How to develop parent-child bonds & treat difficult children without fear

2 Marolyn Morford, Ph.D., Center for Child & Adult Development, Marolyn Morford, Ph.D., Center for Child & Adult Development, State College, PA State College, PA 814-861-3300; mmorford@gmail.com 814-861-3300; mmorford@gmail.com v. 2010

3 Main Points Attachment research is a relatively new field; Attachment research is a relatively new field; Attachment treatment appears to be following a separate path only tangentially related to research. In the latters short history, versions of it have been responsible for childrens inappropriate treatment, wasted time & resources and, at worst, emotional & physical maltreatment Attachment treatment appears to be following a separate path only tangentially related to research. In the latters short history, versions of it have been responsible for childrens inappropriate treatment, wasted time & resources and, at worst, emotional & physical maltreatment

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5 While there is some research to suggest that neglectful and abusive parenting can be related to externalizing or more impulsive behaviors, there is no evidence to suggest that this alone impairs young childrens ability to form bonds. While there is some research to suggest that neglectful and abusive parenting can be related to externalizing or more impulsive behaviors, there is no evidence to suggest that this alone impairs young childrens ability to form bonds.

6 More importantly, there is absolutely NO evidence that interventions focused on forcing bonds to form will reduce externalizing behaviors. Therefore, difficult children may not be made less difficult by improving a bond or creating attachment-like behaviors. More importantly, there is absolutely NO evidence that interventions focused on forcing bonds to form will reduce externalizing behaviors. Therefore, difficult children may not be made less difficult by improving a bond or creating attachment-like behaviors.

7 The difficult children we see are treatable. We have to be aware of all diagnostic possibilities. The difficult children we see are treatable. We have to be aware of all diagnostic possibilities. There are a number of child- & adult- friendly well-proven techniques that can change childrens thoughts and behavior for the better as well as those of their caregivers There are a number of child- & adult- friendly well-proven techniques that can change childrens thoughts and behavior for the better as well as those of their caregivers

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9 We can treat these children most effectively if we have the assistance of the caregiver and other adults spending time with the child. We can treat these children most effectively if we have the assistance of the caregiver and other adults spending time with the child. We must recognize and address the emotional and psychoeducational needs of the care giving adult. We must recognize and address the emotional and psychoeducational needs of the care giving adult.

10 Introduction to the problem Diagnosis: Reactive Attachment Disorder, or RAD is a label that has been applied to many children in the past 10 years, esp. adopted and foster children Diagnosis: Reactive Attachment Disorder, or RAD is a label that has been applied to many children in the past 10 years, esp. adopted and foster children Treatment: Specialized treatments and centers have emerged to work specifically with children with this label Treatment: Specialized treatments and centers have emerged to work specifically with children with this label

11 Important Questions… What do we know about diagnosis of Reactive Attachment Disorder? What do we know about diagnosis of Reactive Attachment Disorder? What do we know about the treatment of Reactive Attachment Disorder? What do we know about the treatment of Reactive Attachment Disorder?

12 Larger Problem When our questions exceed our answers When our questions exceed our answers

13 Estimates of mental health problems of children Community samples: 16-22% Community samples: 16-22% Foster care samples: 40-80% Foster care samples: 40-80% Only 11% of CYS children were receiving services in one study Only 11% of CYS children were receiving services in one study 39% of all children who encounter the child welfare system are aged 0 to 5 years. 39% of all children who encounter the child welfare system are aged 0 to 5 years. 1/3 of children under age 3 had cognitive delay; 1/3 under 5 had language delay 1/3 of children under age 3 had cognitive delay; 1/3 under 5 had language delay (US DHHS, 2005)

14 Problem in the clinical field Qualified clinicians become unnecessarily conservative and shy away from challenging child cases, assuming there is a sound basis for the new clinical population and treatments Qualified clinicians become unnecessarily conservative and shy away from challenging child cases, assuming there is a sound basis for the new clinical population and treatments Other clinicians, lacking training (clinical or empirical) try valiantly to meet the need Other clinicians, lacking training (clinical or empirical) try valiantly to meet the need

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16 Problem: Diagnosis & Treatment Importance of a clear, valid definition of Reactive Attachment Disorder Importance of a clear, valid definition of Reactive Attachment Disorder Misapplication of the term occurs often Misapplication of the term occurs often Next DSM version may have changes Next DSM version may have changes Importance of evaluation of validity and effectiveness of proposed treatments Importance of evaluation of validity and effectiveness of proposed treatments Inappropriate treatments exist Inappropriate treatments exist

17 RAD label overextended: Is there anything obnoxious that isnt here? Child is oppositional, impulsive, destructive, lies & steals, is aggressive, hyperactive, self-destructive, cruel to animals, sets fires Child is oppositional, impulsive, destructive, lies & steals, is aggressive, hyperactive, self-destructive, cruel to animals, sets fires Child is intensely angry, depressed, moody, anxious, irritable, has inappropriate emotional reactions Child is intensely angry, depressed, moody, anxious, irritable, has inappropriate emotional reactions Child has negative beliefs about self, others, & life, has attn, learning problems Child has negative beliefs about self, others, & life, has attn, learning problems Child lacks trust, is bossy & manipulative, does not give or receive love or is affectionate with strangers, blames others Child lacks trust, is bossy & manipulative, does not give or receive love or is affectionate with strangers, blames others Child has poor hygiene, avoids touch, has toileting problems, is accident prone, high pain tolerance Child has poor hygiene, avoids touch, has toileting problems, is accident prone, high pain tolerance Child lacks empathy, faith, compassion, remorse, identifies with evil and the dark side of life Child lacks empathy, faith, compassion, remorse, identifies with evil and the dark side of life Levy & Orlans (2000) Levy & Orlans (2000)

18 DSM-IV Criteria for Reactive Attachment Disorder: A. Markedly disturbed & developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as shown by either (1) or (2): A. Markedly disturbed & developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as shown by either (1) or (2):

19 DSM-IV Criteria (cont.) (1) Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, shown by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond with a mixture of approach, avoidance, & resistance to comforting, or may exhibit frozen watchfulness. (2) diffuse attachments as shown by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers of lack of selectivity in choice of attachment figures. AND…

20 DSM-IV Criteria (cont.) B. The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder B. The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder

21 DSM-IV Criteria (cont.) C. Pathogenic care as shown by at least one of the following: C. Pathogenic care as shown by at least one of the following: (1) persistent disregard of the childs basic emotional needs for comfort, stimulation, and affection (1) persistent disregard of the childs basic emotional needs for comfort, stimulation, and affection (2) persistent disregard of the childs basic physical needs (2) persistent disregard of the childs basic physical needs (3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care) (3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)AND…

22 DSM-IV Criteria (cont.) D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C). D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C). (Note: grossly pathological care does not always result in the development of Reactive Attachment Disorder, DSM-IV-TR, p. 128 ) (Note: grossly pathological care does not always result in the development of Reactive Attachment Disorder, DSM-IV-TR, p. 128 )

23 DSM-IV Criteria (cont.) Prevalence: Data limited, but true Reactive Attachment Disorder appears to be very uncommon Prevalence: Data limited, but true Reactive Attachment Disorder appears to be very uncommon

24 Foundation of the Problem: Nosology – how we classify pathology Nosology – how we classify pathology Misattribution of causality Misattribution of causality

25 *Criteria for Diagnostic Category An observable, operational definition that anyone can use and agree with others in applying An observable, operational definition that anyone can use and agree with others in applying That is distinct from other categories (mutually exclusive) That is distinct from other categories (mutually exclusive) And has predictive utility: we know other things about the person based on the application of this category And has predictive utility: we know other things about the person based on the application of this category

26 *Misapplication of a diagnosis Overextension: Applying the label to a broader set of criteria and a wider age range than specified by the definition Underextension: Applying the label to a smaller set of criteria or smaller age range than specified by the definition Overextension: Applying the label to a broader set of criteria and a wider age range than specified by the definition Underextension: Applying the label to a smaller set of criteria or smaller age range than specified by the definition

27 *Thinking Errors Misattribution of causality: Misattribution of causality: When two events are observed either at the same time or in sequence (one event preceding another), we have a tendency to conclude that the two events are related in some way. (Correlation=/=Causation) When two events are observed either at the same time or in sequence (one event preceding another), we have a tendency to conclude that the two events are related in some way. (Correlation=/=Causation)

28 Post hoc reasoning Post hoc reasoning For events in sequence, we can (erroneously) conclude that first event caused the second. For events in sequence, we can (erroneously) conclude that first event caused the second. For example, if a child comes from foster care, we cannot predict (a priori) any particular behavior might occur. However, if a therapist hears then that the child is hoarding food or lying to cover-up a bedwetting incident, the therapist may make an assumption that the behavior is due to the earlier experience. For example, if a child comes from foster care, we cannot predict (a priori) any particular behavior might occur. However, if a therapist hears then that the child is hoarding food or lying to cover-up a bedwetting incident, the therapist may make an assumption that the behavior is due to the earlier experience.

29 Confirmatory bias Confirmatory bias Paying attention only to the information that confirms the hypotheses we already have about the childs diagnosis – so that even in the face of contradictory evidence (child adopted at birth, child with natural parents) we will stretch the category to make it fit. Paying attention only to the information that confirms the hypotheses we already have about the childs diagnosis – so that even in the face of contradictory evidence (child adopted at birth, child with natural parents) we will stretch the category to make it fit.

30 Single Cause assumption Single Cause assumption The tendency to try to explain complex phenomena using one explanation: assuming problems with toilet training create an obsessive personality, or that foster placement creates difficulties with forming bonds with people. The tendency to try to explain complex phenomena using one explanation: assuming problems with toilet training create an obsessive personality, or that foster placement creates difficulties with forming bonds with people. Similarly, some clinicians conclude that some one factor in a childs history (such as death of a parent, time in foster care) is the cause for some presenting problem, when other factors might be more important (intelligence, family biological predisposition to certain behaviors, normal developmental variation, etc.). Similarly, some clinicians conclude that some one factor in a childs history (such as death of a parent, time in foster care) is the cause for some presenting problem, when other factors might be more important (intelligence, family biological predisposition to certain behaviors, normal developmental variation, etc.).

31 RAD is example of a label overextended to MANY difficult behaviors RAD is example of a label overextended to MANY difficult behaviors Weak distinguishing or predictive power Weak distinguishing or predictive power

32 Stealing Stealing Very poor impulse control Very poor impulse control Learning lags Learning lags Lack of cause and effect thinking Lack of cause and effect thinking Abnormal eating patterns Abnormal eating patterns Poor peer relations Poor peer relations Sometimes preoccupied with fire Sometimes preoccupied with fire Preoccupation with blood and gore Preoccupation with blood and gore Persistent nonsense questions and incessant chatter Persistent nonsense questions and incessant chatter

33 RAD label misapplied Phony Phony Great theatrical displays Great theatrical displays Chemical self-medication Chemical self-medication Poor self-soothing techniques Poor self-soothing techniques Sexually act out at a very young age (seductive clothing, sexual to other children and animals) Sexually act out at a very young age (seductive clothing, sexual to other children and animals) Passive-aggressive behavior (will say ok if they have to do something, then take 1 ½ hour, or forget, or act confused) Passive-aggressive behavior (will say ok if they have to do something, then take 1 ½ hour, or forget, or act confused)

34 RAD label misapplied Superficially engaging and charming Superficially engaging and charming Lack of eye contact unless theyre lying Lack of eye contact unless theyre lying Indiscriminately affectionate with strangers Indiscriminately affectionate with strangers Non-affectionate on parents terms (they can give a hug when they want but if the parent wants it thats not acceptable) Non-affectionate on parents terms (they can give a hug when they want but if the parent wants it thats not acceptable) Destructive to self, others, and material things, accident prone on purpose Destructive to self, others, and material things, accident prone on purpose Cruel to animals Cruel to animals Lying about the obvious crazy lying Lying about the obvious crazy lying

35 RAD label misapplied They act addicted to their own adrenaline They act addicted to their own adrenaline Refuse to accept responsibility, project blame on others Refuse to accept responsibility, project blame on others Exhibit no remorse Exhibit no remorse Often suggested that they are future serial killers Often suggested that they are future serial killers (L. Eshleman, 2001)

36 RAD label overextended to caretakers Some groups include caregiver symptoms in diagnosis: Some groups include caregiver symptoms in diagnosis: Feel isolated and depressed. Feel isolated and depressed. Feel frustrated and stressed. Feel frustrated and stressed. Are hypervigilant, agitated, have difficulty concentrating. Are hypervigilant, agitated, have difficulty concentrating. Are confused, puzzled, obsessed with finding answers. Are confused, puzzled, obsessed with finding answers. Feel blamed by family, friends, and professionals. Feel blamed by family, friends, and professionals. Feel helpless, hopeless, and angry. Feel helpless, hopeless, and angry. Feel that problems are minimized by the helping profession. (Institute for Attachment, 2003) Feel that problems are minimized by the helping profession. (Institute for Attachment, 2003)

37 Problems with overextension Those labels do NOT appear in the criteria for Reactive Attachment Disorder Those labels do NOT appear in the criteria for Reactive Attachment Disorder Some of the labels DO appear in other diagnostic categories that are better applied to such children Some of the labels DO appear in other diagnostic categories that are better applied to such children These labels are not clinical and are dangerous in how they make adults think and feel about the children in their care These labels are not clinical and are dangerous in how they make adults think and feel about the children in their care

38 Such labels can apply to many types of individuals with their own histories and problems and do NOT indicate attachment problems Such labels can apply to many types of individuals with their own histories and problems and do NOT indicate attachment problems Such labels can apply to the parents of many difficult to raise children, including those with chronic physical health problems. Such labels can apply to the parents of many difficult to raise children, including those with chronic physical health problems.

39 Controversy about RAD Diagnosis Reliability? Not applied consistently by independent clinicians Reliability? Not applied consistently by independent clinicians Sometimes an overfocus on the preconditions (foster care, adoption) instead of symptoms (correlation is not causation) Sometimes an overfocus on the preconditions (foster care, adoption) instead of symptoms (correlation is not causation) Cultural relevance? Some cultures value inhibition and limited attachments, some value attachments to more than one caretaker. What is definition of indiscriminate sociability? Cultural relevance? Some cultures value inhibition and limited attachments, some value attachments to more than one caretaker. What is definition of indiscriminate sociability?

40 Understanding Attachment Attachment Attachment Attachment is a special, biologically based tie, very hard to eliminate, or damage, given its necessity for survival Attachment is a special, biologically based tie, very hard to eliminate, or damage, given its necessity for survival

41 Critical Nature of Attachment Importance to survival of young and of species Importance to survival of young and of species Resilience of critical, adaptive functions Resilience of critical, adaptive functions Attachment & attachment behaviors are such a basic survival skill, only the most extraordinary cases of extreme deprivation result in no attachment behaviors developing Attachment & attachment behaviors are such a basic survival skill, only the most extraordinary cases of extreme deprivation result in no attachment behaviors developing A child is not unattached: Children vary in whether they are securely or insecurely attached and to whom they are attached A child is not unattached: Children vary in whether they are securely or insecurely attached and to whom they are attached

42 How is Attachment Studied?: Types of Child Behavior Observed Child Subtypes Child Subtypes Secure Secure Ambivalent/resistant (40-50% of children in a low risk sample, Zeanah, 1996) Ambivalent/resistant (40-50% of children in a low risk sample, Zeanah, 1996) Avoidant Avoidant Disorganized (20% of children in a nonclinical sample, Zeanah, 1996) Disorganized (20% of children in a nonclinical sample, Zeanah, 1996) Description Secure base to explore, greets M on return Distress even with M, distress/unsettled at separation, angry or passive on return Active exploration, no checking with M. Little response to absence or return of M Little goal-oriented behavior, stereotypies, apprehension of parent

43 Note: Disorganized (20% of children in a nonclinical sample, Zeanah, 1996) Note: Disorganized (20% of children in a nonclinical sample, Zeanah, 1996) If the rate of occurrence of an attribute or behavior is this high in a nonclinical (20%) or low risk population (40-50%), can we confidently say we are talking about a disorder? If the rate of occurrence of an attribute or behavior is this high in a nonclinical (20%) or low risk population (40-50%), can we confidently say we are talking about a disorder? Could these be normal variants in response? Could these be normal variants in response?

44 How is Attachment Studied?: Types of Maternal Behavior Observed Child Subtypes Child Subtypes Secure Secure Ambivalent Ambivalent Avoidant Avoidant Disorganized, disoriented Disorganized, disoriented Associated Maternal Styles Accepting, cooperative, accessible Inconsistent or unresponsive to child distress Rejecting, less positive physical proximity Less clear but may be associated with highly inconsistent, sometimes frightening parenting

45 What do different types of attachment predict? Insecure attachment creates risk for problems but alone does not cause problems Insecure attachment creates risk for problems but alone does not cause problems In low risk families, less relation between insecure attachment & later externalizing problems In low risk families, less relation between insecure attachment & later externalizing problems In high risk families, more likely relation between insecure attachment & peer problems, moodiness, depression & aggression (Greenberg, 1999) In high risk families, more likely relation between insecure attachment & peer problems, moodiness, depression & aggression (Greenberg, 1999)

46 Correlation does not prove causation Correlation does not prove causation What else might be behind these symptoms or difficult behaviors? What else might be behind these symptoms or difficult behaviors?

47 So…if its not RAD, what is it? Or Reframing to reduce fear and encourage competence

48 OCD OCD Mood Disorder (Mood dysregulation) Mood Disorder (Mood dysregulation) Depression Depression Oppositional Defiant Disorder Oppositional Defiant Disorder Conduct Disorder Conduct Disorder Impulse Control Disorder Impulse Control Disorder Disruptive Behavior Disorder Disruptive Behavior Disorder Generalized Anxiety Disorder Generalized Anxiety Disorder Separation Anxiety Disorder Separation Anxiety Disorder Post-traumatic Stress Disorder Post-traumatic Stress Disorder

49 Pervasive Developmental Disorder Pervasive Developmental Disorder Aspergers Disorder Aspergers Disorder Attention-Deficit/Hyperactive Disorder Attention-Deficit/Hyperactive Disorder Adjustment Disorder with Mixed Disturbance of Emotions and Conduct Adjustment Disorder with Mixed Disturbance of Emotions and Conduct Developmental Delay (especially cognitive and language) Developmental Delay (especially cognitive and language) Normal Development, Caretaker-child Temperament mismatch Normal Development, Caretaker-child Temperament mismatch Normal Development, Adaptive behavior Normal Development, Adaptive behavior

50 What are the advantages of considering other diagnostic categories or any diagnostic category? Importance of considering treatments that are ethical, based on the childs needs, and have been shown to improve difficult behaviors.

51 Conclusion: What we know about diagnosis The term Reactive Attachment Disorder has been applied to a wide range of behaviors that can be captured more appropriately with other, existing diagnostic categories The term Reactive Attachment Disorder has been applied to a wide range of behaviors that can be captured more appropriately with other, existing diagnostic categories

52 The problem behaviors may originate from other causes: The problem behaviors may originate from other causes: The childs genetic or temperament tendencies The childs genetic or temperament tendencies The foster/adoptive parents expectations The foster/adoptive parents expectations The childs early experiences and expectations The childs early experiences and expectations Cultural expectations/mismatch (Rothbaum et al., 2000) Cultural expectations/mismatch (Rothbaum et al., 2000) Other parenting factors Other parenting factors

53 Could RAD (as commonly used) be captured by Parent Child Relational Disorder (a v Code)?

54 What we know about treatment There is no one treatment (no silver bullet) for the myriad of problems that are described in popular discussions of RAD There is no one treatment (no silver bullet) for the myriad of problems that are described in popular discussions of RAD

55 Treatment focuses on The problem behavior (one at a time) The problem behavior (one at a time) The bond The bond What are the caregivers thoughts about the child and expectations about the relationship? What are the caregivers thoughts about the child and expectations about the relationship? The child often has no problems with attachment; the problem is s/he is not attached to the presenting caregiver. The child often has no problems with attachment; the problem is s/he is not attached to the presenting caregiver.

56 [My children, who were adopted at 7 mos.] did not begin to show separation anxiety when I left them until they were perhaps a year old and the attachment process had progressed to the point where I mattered to them more than someone else. A friend reaching for my 18 mo. old daughter asked]: Does she go to strangers? [My children, who were adopted at 7 mos.] did not begin to show separation anxiety when I left them until they were perhaps a year old and the attachment process had progressed to the point where I mattered to them more than someone else. A friend reaching for my 18 mo. old daughter asked]: Does she go to strangers? Of course, I answered, Shes living with strangers. Of course, I answered, Shes living with strangers. From L. Melina Raising Adopted Children, Harper Collins, 1998.

57 Treatments should be symptom focused. Known effective interventions for the troubling behaviors are required, incl. behavior therapy, cognitive therapy, family education, and parent training and, as needed, pharmacological approaches. Treatments should be symptom focused. Known effective interventions for the troubling behaviors are required, incl. behavior therapy, cognitive therapy, family education, and parent training and, as needed, pharmacological approaches.

58 Beware of Beware of damaging, even deadly, effects of invalid, coercive therapies damaging, even deadly, effects of invalid, coercive therapies Ineffective treatments that waste limited resources and precious time in a childs young life Ineffective treatments that waste limited resources and precious time in a childs young life

59 American Professional Society on the Abuse of Childrens (APSAC) Traditional attachment theory holds that caregiver qualities are key, such as Environmental stability Environmental stability Parental sensitivity, Parental sensitivity, Responsiveness to childrens physical and emotional needs Responsiveness to childrens physical and emotional needs Consistency, and a safe and predictable environment support the development of healthy attachment. Consistency, and a safe and predictable environment support the development of healthy attachment.

60 From this perspective, improving these positive caretaker and environmental qualities is the key to improving attachment. From this perspective, improving these positive caretaker and environmental qualities is the key to improving attachment. CHILD MALTREATMENT, Vol. 11, No. 1, February 2006 76-89

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62 Problems with Attachment Therapy Lack of informed consent to treatment -- where is the advocate for the child? Lack of informed consent to treatment -- where is the advocate for the child? No link between attachment research and current popular treatments No link between attachment research and current popular treatments Illogical and invalid concept that children must release rage before they can be loving Illogical and invalid concept that children must release rage before they can be loving Unethical targeting of adoptive and foster parent audience Unethical targeting of adoptive and foster parent audience Often unlicensed practitioners Often unlicensed practitioners Creation of adult fear of child & erosion of caregiver confidence Creation of adult fear of child & erosion of caregiver confidence

63 Problems, cont. Corrective attachment therapy is coercive and resembles psychological methods to destabilize an individual to force adherence to a particular ideology or point of view Corrective attachment therapy is coercive and resembles psychological methods to destabilize an individual to force adherence to a particular ideology or point of view 1) damaging of individuals defenses through an intensive devaluing interpersonal process; 1) damaging of individuals defenses through an intensive devaluing interpersonal process; 2) offering an opportunity to escape the process by accepting and stating required beliefs, refuting previously held beliefs, and confessing to prior behaviors. 2) offering an opportunity to escape the process by accepting and stating required beliefs, refuting previously held beliefs, and confessing to prior behaviors. 3) providing social group approval of the individuals compliance and rejection of competing ideas. (Borgattoa and Borgatta, 2000) 3) providing social group approval of the individuals compliance and rejection of competing ideas. (Borgattoa and Borgatta, 2000)

64 Problems, cont. Lack of understanding of childs developmental needs Lack of understanding of childs developmental needs Lack of understanding of childs adaptation process Lack of understanding of childs adaptation process Expectation of immediate bonding and interpretation of resistance as attachment disorder Expectation of immediate bonding and interpretation of resistance as attachment disorder Physically and emotionally intrusive, thereby retraumatizing an abused or neglected child and delaying development of trust & security Physically and emotionally intrusive, thereby retraumatizing an abused or neglected child and delaying development of trust & security

65 What treatment is recommended? Treat the behavior and the bond (not the same issue) Treat the behavior and the bond (not the same issue) If presented with a child with a history of attachment disruption, do not immediately assume treatment is necessary. Base interventions on symptom presentation: what behaviors are troubling to the child & the caregiver? If presented with a child with a history of attachment disruption, do not immediately assume treatment is necessary. Base interventions on symptom presentation: what behaviors are troubling to the child & the caregiver? But do think about the caregiver-child relationship But do think about the caregiver-child relationship

66 Recommended Approaches for Suspected Attachment Disorders Give the child (a sense of) more control, dont take control away from the child. Do give control in areas the care giving adult is comfortable with (give child benign choices). Why? Give the child (a sense of) more control, dont take control away from the child. Do give control in areas the care giving adult is comfortable with (give child benign choices). Why? Enhance the sensitivity of the adoptive parent to the child rather than the child to the parent (Dozier et al., 2002) Enhance the sensitivity of the adoptive parent to the child rather than the child to the parent (Dozier et al., 2002) Help the adult articulate what they want out of this relationship Help the adult articulate what they want out of this relationship

67 Reduce caregivers expectation for rapid change and increase their acceptance of the childs basic temperament and developmental needs (Dozier et al. 2002) Reduce caregivers expectation for rapid change and increase their acceptance of the childs basic temperament and developmental needs (Dozier et al. 2002) Unlink the contingency between the childs behavior and the permanency of the placement Unlink the contingency between the childs behavior and the permanency of the placement Emphasize positive reinforcement and positive exchanges of affection on the childs terms, rather than the parents (Speltz, 2002, Dozier, et al. 2002). Emphasize positive reinforcement and positive exchanges of affection on the childs terms, rather than the parents (Speltz, 2002, Dozier, et al. 2002).

68 How to Treat Difficult Children Examples of specific valid interventions for these children Examples of specific valid interventions for these children Comprehensive medical diagnosis and care of child Comprehensive medical diagnosis and care of child Developmental assessment of child and childs needs at that particular age Developmental assessment of child and childs needs at that particular age Respond to the caregivers distress, focus on developing an alliance, identify the major concerns the adult has with the childs behavior Respond to the caregivers distress, focus on developing an alliance, identify the major concerns the adult has with the childs behavior Respond to the childs distress, focus on alliance and on identifying the childs concerns and goals, if age appropriate Respond to the childs distress, focus on alliance and on identifying the childs concerns and goals, if age appropriate

69 Treat the relationship Teach caregiver how to interact with child, to encourage bonding, cooperation, addressing childs developmental level & emotional needs, using positive verbal comments, planned ignoring, teaching parent how to implement child directed interactions and parent directed interactions (Dozier, et al., 2002; Eyberg & McNeill, 2003; Webster-Stratton & Hancock, 1998) Teach caregiver how to interact with child, to encourage bonding, cooperation, addressing childs developmental level & emotional needs, using positive verbal comments, planned ignoring, teaching parent how to implement child directed interactions and parent directed interactions (Dozier, et al., 2002; Eyberg & McNeill, 2003; Webster-Stratton & Hancock, 1998)

70 Treat the relationship Increase the caregivers competence and confidence through training: start small Increase the caregivers competence and confidence through training: start small Teach caregiver behavior therapy with child, including behavior substitution, differential reinforcement of incompatible or other behaviors, anxiety reduction techniques, such as gradual exposure, anxiety hierarchy and related treatments Teach caregiver behavior therapy with child, including behavior substitution, differential reinforcement of incompatible or other behaviors, anxiety reduction techniques, such as gradual exposure, anxiety hierarchy and related treatments

71 Treat the relationship, cont. Cognitive therapy in the family context to assist with parental reframing, negative cognitions, expectations, and problem solving (W-S & H): Examine the thoughts the caregiver is having about the child & doubts about their own parenting ability: You can parent this child. Cognitive therapy in the family context to assist with parental reframing, negative cognitions, expectations, and problem solving (W-S & H): Examine the thoughts the caregiver is having about the child & doubts about their own parenting ability: You can parent this child.

72 Teach parent how to implement positive behavior management in home providing consistent rewards for appropriate behaviors (W-S&H, E&M, Barkley): for ex., giving attention for the positive behaviors the child is able to do, rather than for the failures Teach parent how to implement positive behavior management in home providing consistent rewards for appropriate behaviors (W-S&H, E&M, Barkley): for ex., giving attention for the positive behaviors the child is able to do, rather than for the failures Provide skill instruction with child for emotional regulation (e.g., anger thermometer) and social skills deficits, including teaching child how to give parent positive feedback Provide skill instruction with child for emotional regulation (e.g., anger thermometer) and social skills deficits, including teaching child how to give parent positive feedback

73 Clinical examples

74 Reactive Attachment Disorder: Fact and Fiction Fiction Fiction Children with behavior problems who have a history of foster care or residential placement can be assumed to have Reactive Attachment Disorder T/F Children with behavior problems who have a history of foster care or residential placement can be assumed to have Reactive Attachment Disorder T/F Children who do not show affection to their adoptive or foster parents have problems with attachment T/F Children who do not show affection to their adoptive or foster parents have problems with attachment T/F Special treatment programs for Reactive Attachment Disorder are effective and valid T/F Special treatment programs for Reactive Attachment Disorder are effective and valid T/F Children labeled with Reactive Attachment Disorder must, in many cases, be forced to bond with their parents T/F Children labeled with Reactive Attachment Disorder must, in many cases, be forced to bond with their parents T/F Forcing bonding and attachment treats a myriad of problem behaviors T/F Forcing bonding and attachment treats a myriad of problem behaviors T/F

75 Reactive Attachment Disorder: Fact and Fiction, cont. Fact - Definition Fact - Definition Attachment and attachment behaviors are a most basic activity of human beings & all mammals; only in extraordinary circumstances does attachment fail to occur T/F Attachment and attachment behaviors are a most basic activity of human beings & all mammals; only in extraordinary circumstances does attachment fail to occur T/F Infants can show attachment to more than one caregiver, in fact, this is common. T/F Infants can show attachment to more than one caregiver, in fact, this is common. T/F Reactive Attachment Disorder refers to a narrow range of disturbance T/F Reactive Attachment Disorder refers to a narrow range of disturbance T/F Disruptions of attachment can create stress responses in the organism T/F Disruptions of attachment can create stress responses in the organism T/F

76 Reactive Attachment Disorder: Fact and Fiction, cont. Fact – Definition, cont. Fact – Definition, cont. Observations of disorganized attachment have been associated with later externalizing behaviors, not necessarily with ability to form affectionate bonds T/F Observations of disorganized attachment have been associated with later externalizing behaviors, not necessarily with ability to form affectionate bonds T/F Disorganized attachment alone has not yet been proven to cause later problems. Both are possibly caused by other factors, such as a family predisposition to impulsivity or mood dysregulation. T/F Disorganized attachment alone has not yet been proven to cause later problems. Both are possibly caused by other factors, such as a family predisposition to impulsivity or mood dysregulation. T/F

77 Reactive Attachment Disorder: Fact and Fiction, cont. Fact – Treatment Fact – Treatment There is no direct relationship established between foster care, adoptive placement, and maladaptive behaviors or ability to form bonds with others. Many of these children never require treatment; many children from adequate homes do require treatment. T/F There is no direct relationship established between foster care, adoptive placement, and maladaptive behaviors or ability to form bonds with others. Many of these children never require treatment; many children from adequate homes do require treatment. T/F There is no one proven treatment for the entire broad range of behaviors popularly referred to as Reactive Attachment Disorder, in fact, this term is misused very frequently. T/F There is no one proven treatment for the entire broad range of behaviors popularly referred to as Reactive Attachment Disorder, in fact, this term is misused very frequently. T/F

78 Fact and Fiction Fact – Treatment, cont. Fact – Treatment, cont. Attachment therapy can carry a high risk of psychological injury to the child, can be coercive and reminiscent to the child of previous miscues and even abuse by an adult T/F Attachment therapy can carry a high risk of psychological injury to the child, can be coercive and reminiscent to the child of previous miscues and even abuse by an adult T/F Attachment therapy meets none of the criteria required for validation at any level. Current support is only in testimonial form. T/F Attachment therapy meets none of the criteria required for validation at any level. Current support is only in testimonial form. T/F Specific behavior problems can be addressed individually by validated treatments T/F Specific behavior problems can be addressed individually by validated treatments T/F If attachment disorder is suspected, it is the relationship, not the child, that needs treatment T/F If attachment disorder is suspected, it is the relationship, not the child, that needs treatment T/F

79 Conclusion We have an obligation to We have an obligation to Provide treatment that is better than no treatment and so will not waste the limited resources available to children Provide treatment that is better than no treatment and so will not waste the limited resources available to children Be rigorous and conservative in our evaluation of diagnoses and treatments provided to children, especially those who have no other advocates Be rigorous and conservative in our evaluation of diagnoses and treatments provided to children, especially those who have no other advocates Teach caregivers what we know Teach caregivers what we know

80

81 Postscript

82 Consider the resilience of human nature

83 What is resilience? Capacity to resist the potential negative consequences of risk and develop adequately Capacity to resist the potential negative consequences of risk and develop adequately Reduced vulnerability to stressors Reduced vulnerability to stressors Ability to thrive, mature, and increase competence in the face of adverse circumstances (Gordon, Kimberly A. 1996 Infant and Toddler Resilience: Knowledge, Predictions, Policy, and Practice. Head Start Conference) Ability to thrive, mature, and increase competence in the face of adverse circumstances (Gordon, Kimberly A. 1996 Infant and Toddler Resilience: Knowledge, Predictions, Policy, and Practice. Head Start Conference)

84 Resources for parents & therapists www.help4adhd.org (Diagnosis & Trtmt link) www.help4adhd.org (Diagnosis & Trtmt link) www.help4adhd.org www.chadd.org www.chadd.org www.chadd.org www.effectivechildtherapy.com www.effectivechildtherapy.com www.bpkids.org (Learning Center link) www.bpkids.org (Learning Center link) www.bpkids.org www.promisingpractices.net www.promisingpractices.net www.promisingpractices.net http://www.apa.org/pi/cyf/cyfnews.html http://www.apa.org/pi/cyf/cyfnews.html http://www.apa.org/pi/cyf/cyfnews.html

85 www.cachildwelfareclearinghouse.org www.cachildwelfareclearinghouse.org www.cachildwelfareclearinghouse.org Parent Training Programs: www.pcit.org www.pcit.org www.pcit.org www.incredibleyears.com www.incredibleyears.com www.incredibleyears.com www.triplep-america.com www.triplep-america.com www.triplep-america.com Trauma focused: www.tfcbt.musc.edu Trauma focused: www.tfcbt.musc.eduwww.tfcbt.musc.edu

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