1. Reactive Attachment Disorder: Assessment and Effective Treatments for Foster and Adoptive Children Douglas Goldsmith, Ph.D. Executive Director The Children’s Center

2. What is Attachment? “To say of a child (or older person) that he is attached to, or has an attachment to, someone means that he is strongly disposed to seek proximity to and contact with that individual and to do so especially in certain specified conditions.” Bowlby (1988)

3. Attachment Behaviors Approach the caregiver Crying Seeking contact Maintaining the contact The number of attachment behaviors will vary with the degree of the perceived threat in the environment Weinfield et al (1999)

4. Secure Attachment The caregiver is perceived as a reliable source of protection and comfort

5. Secure Attachment When I am close to my loved one I feel good, when I am far away I am anxious, sad or lonely Attachment is mediated by looking, hearing, and holding When I’m held I feel warm, safe, and comforted Results in a relaxed state so that one can, again, begin to explore Holmes (1993)

6. Secure Attachment Promote exploration of the environment Expand mastery of the environment “I can explore with confidence because I know my caregiver will be available if I become anxious.” The infant gains confidence in his or her own interactions with the world Weinfield et al (1999)

7. Disorganized vs. Attachment Disorder Disorganized Attachment: describes an insecure but selective attachment Attachment Disorder: the failure to show selective attachment –A pervasive disturbance O’Connor & Zeanah (2003)

8. Developmental Perspective “The quality of a young child’s attachment to a caregiver is a risk or protective factor for development of psychopathology.” Zeanah & Smyke (2005)

9. Clinical Perspective “The attachment relationship may be so disturbed as to constitute an already established disorder.” Zeanah & Smyke (2005)

10. Reactive Attachment Disorder DSM-IV The essential feature of Reactive Attachment Disorder is markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 and is associated with grossly pathological care.

11. Core Features There must be evidence of grossly pathogenic care The disturbance must be evident across situations and across relationships O’Connor & Zeanah (2003)

12. Pathogenic Care Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection Persistent disregard of the child’s basic physical needs Repeated changes of primary caregiver that prevent formation of stable attachments

13. Disinhibited Type Predominate disturbance in social relatedness is indiscriminate sociability or a lack of selectivity in the choice of attachment figures.

14. Indiscriminate Behavior “The terms ‘indiscriminately friendly’ and ‘indiscriminate sociability’ … imply more than is actually known about the nature of the child’s behavior” O’Connor & Zeanah (2003)

15. Inhibited Type Persistent failure to initiate and to respond to most social interactions in a developmentally appropriate way.

16. What About Older Children? Defining attachment in older children. Age of onset must be 5 years of age or younger. Multiple caregivers or pathogenic care should be noted on axis IV. Relationship can still be focal point of treatment.

17. Research RAD has been described formally in psychiatric nosology for 25 years Fewer than one dozen studies involving only seven samples of young children Zeanah & Smyke (2005)

18. Assessment “No ‘gold standard’ exists for assessing attachment disorders, and very little information is available on the convergence of information from alternative assessment methods.” O’Connor & Zeanah, 2003

19. Treatment “No treatment has been shown to be effective for children with attachment disorders.” O’Connor & Zeanah 2003

20. Assessment “The key to assessing attachment rests in determining how an infant organizes attachment behaviors to balance the need for protection and comfort with the desire to explore the environment.” Weinfield et al (1999)

21. Assessment Worksheet Helps organize information obtained from observations and interviews Helps determine treatment needs Assists with planning attachment based interventions

22. Secure Base Behaviors Child explores the environment freely while checking in with the parents as necessary –Note child’s affect – Bright and engaged? Anxious? Hypervigilant? –Does child readily explore? –Does child make use of toys? –Does child share positive experiences with the caregivers?

23. Secure Base Child seeks contact with the parents for comfort when anxious, frightened, or hurt –Who initiates the contact? –Is the contact soothing? –How long does it take for the child to soothe? –Is the caregiver sensitive to child’s needs and cues?

24. Secure Base Infants and Toddlers: –Does the child visually check in with the parents to gain reassurance about contact with the examiner? –Does the child demonstrate physical withdrawal at least momentarily when the examiner attempts outreach?

25. Secure Base Do the caregivers demonstrate a sense of pride in the child’s exploration? –Are they responsive to child’s delight in exploration? –Are they facilitating play with an appropriate affect?

26. Insightfulness The parents are able to share examples suggesting insight into the child’s motives, thoughts, and feelings behind a range of behaviors –“ Can you give me an example of a time when your child’s behavior was upsetting to you? What do you think might have been going on in his/her head? –How did these behaviors make you feel?

27. Insightfulness The parents are able to appropriately reflect the child’s feelings: –Watch for cues during your observation –Ask how the caregivers responded the last time the child felt frightened, worried, or anxious

28. Insightfulness The parents show sensitivity to the child’s needs for affection and respond both to the child’s needs for comfort as well as to the child’s desire to terminate physical contact

29. Frightening Behavior The parents have protected the child from exposure to domestic violence or other environmental variables that would create fear or anxiety for the child –Protection from violence and excessive arguing –Protection from frightening movies

30. Frightening Behavior The parents avoid engaging in frightening behavior e.g. purposely scaring the child, physically harassing the child despite the child’s pleas to stop the behavior –Parents avoid threatening to leave or abandon the child

31. Protection The parents establish appropriate boundaries with extended family members and strangers regarding contact with the child –Supervision issues –Parents exhibit an awareness of need for vigilance around unfamiliar people and situations

32. Protection The parents provide a sense of safety in the home by not allowing persistent physical or verbal attacks from siblings, peers, or other people present in the home –Caregivers establish and adhere to limits on sibling rivalry behaviors –Caregivers process verbal attacks between siblings

33. Protection Separations from the child for more than several days have been kept to a minimum –Have the parent describe the child’s behavior upon their return home

34. Structure and Developmental Guidance The parents are aware of, and are responding to, the child’s current developmental needs

35. Structure and Developmental Guidance The parents expectations of the child are neither overwhelming or too restrictive –Be particularly sensitive to children who appear older than their years –Be aware of parental expectations of the oldest child

36. Structure and Developmental Guidance The parents are able to set and maintain appropriate limits during the session and report appropriate limits in the home –Are the parents willing to assert their authority? –Are caregiving decisions abdicated to the child?

37. Summarizing Your Findings Strengths of the parent-child interaction Concerns about the parent-child interaction

38. Summarizing Your Findings What are the attachment/ relationship needs of this particular child? What skills do the parents need to develop?

41. Attachment Based Interventions Secure Base –May need to address underlying issues around parental unavailability to the child  Is the child’s behavior so out-of-control that the parent is unable to find enjoyable one-on-one moments? –Plan behavioral interventions to increase cooperation to parental requests  Does the parent find parent-child time enjoyable?

42. Attachment Based Interventions Secure Base –Use precision commands to help the parent develop positive behavioral control  Stop the coercive cycle  Use time-limited time-outs to gain compliance  Reinforce all compliant behaviors  Positive practice  Encourage the parent not to give up positive reinforcers prematurely

43. Attachment Based Interventions Secure Base –Decrease oppositional battles around:  Toileting –Assist with toilet training or encourage the parent to relax anxiety around toileting accidents  Eating –Stop discussions about quantity of food or insisting that the child increase their food repertoire  Sleeping –Encourage the parent to help the child regulate anxiety around sleep. Develop a bedtime routine

44. Attachment Based Interventions Secure Base –Help parent learn to give warnings around transitions and brief separations –Increase predictability of the environment –Increase reliability of parental availability  This is important particularly for the non- custodial parent  Evaluate the possibility of telephonic or electronic communication

45. Attachment Based Interventions Secure Base –Develop nurturing skills –Help the parent learn to be an “ideal grandparent”  Anticipate the child’s needs  Provide physical comforts  Plan surprises so the child knows s/he is thought about even when absent  Increase sensitivity to cues

46. Attachment Based Interventions Exploration –Help the parent develop age appropriate expectations –Carefully evaluate and develop appropriate parental supervision –Assess joint pleasurable activities and develop a list of pleasant activities

47. Attachment Based Interventions Exploration –Examine the parent’s ability to “let go” –Develop plans and support the parent in managing “conflict free” separations by waiting until the child is comfortable in a new environment

48. Attachment Based Interventions Exploration –Teach the child “checking in” behaviors  Always keep the caregiver in view  Use a timer to help the child develop checking-in skills

49. Attachment Based Interventions Emotional Regulation –Teach the parent to use “Time-in”  Remain available during emotional outbursts  Only move away if child attempts physical attacks  Constantly reassure child that, “As soon as you calm down, I’ll help you fix it/ figure it out”  If attacks persist state, “I’ll be in the next room so I can stay safe but as soon as I hear you calm I’ll be right back”  Develop deep breathing and self-soothing skills

50. Attachment Based Interventions Emotional Regulation –Work on acceptance of physical contact  Help child make self-contact rather than other- contact to soothe self –Avoid direct “no” and instead fantasize what it would be like if the child could get all of his/her needs met –Write down and post the desire to be satisfied at a later date/ time –Model self-soothing cognitive strategies –Teach empathic listening skills –Use transitional objects

51. Attachment Based Interventions Safe Harbor –Assess use of negative projections –Assess parent’s past trauma’s that may be interfering with an “objective” view of the child –Assess parent’s ability to benefit from an insight-oriented approach

52. Attachment Based Interventions Safe Harbor –Help parent utilize respite services to be more emotionally available –Help parent utilize support system more effectively

53. Attachment Based Interventions Safe Harbor –Use insightfulness strategies to help the parent look at negative projections and learn to reframe the child’s behaviors  “ What do you think was going on in your child’s head when that happened?”  Listen empathically to gain an understanding of what it is like to walk in this parent’s shoes  Agitation toward the parent indicates that the therapist is not understanding the parent’s stress

54. Attachment Based Interventions Safe Harbor –Conflicts don’t need to be addressed right away! Encourage the parent to wait until both are feeling calmer to process. –Help parents focus on providing the child with new coping strategies and ideas for solving conflicts –Practice positive solutions!