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Attachment Disorder The following information is gleaned from a workshop presented by Forrest Lein, MSW, of the Evergreen Attachment Center. It is reprinted from "The Arapahoe County Advocate," November 1998, published by the Arapahoe County Foster Parent Association, Mary Louise Bishop, Editor, 5299 East Hamilton Ave., Castle Rock, CO 80104. Unattached children become full of rage, "a sense of helplessness and hopelessness and anger." The roots of the problem are established as early as the first six months of life. Unattachment impacts the entire family. A high level of commitment is demanded of the foster family and should be considered when deciding to bring an attachment disordered child into the home. A new therapeutic model must be used for an unattached child. Under the traditional model, the therapist establishes a trusting alliance with the child and out of that relationship flows healing. However, unattached children do not trust. They can be charming and give the appearance of health, but they manipulate and control relationships. They do not act out as long as they are in control and are not threatened by close relationships. The importance of attachment During the first two years of life and individual attains his or her full intellectual potential. They develop logical thinking ability, they understand how the world works, and they understand cause and effect. "Because I take action, certain results happen." During this time, they develop coping skills and relational skills. If their physical and affectional needs are unmet, they will find themselves in a hyper-vigilant, survival mode. In that mode, the brain does not develop normally, and attachment does not occur because the child learns to rely only on himself. The emotions associated with this are stored in a primitive part of the brain that is not reached during ordinary talk therapy. During the first year, children usually learn to trust their primary care giver and then others. They learn to trust when their physical needs are met, but also through eye contact, touch, movement, and smiles. When the children have a need, they have a rage reaction. The care givers meet the need, so the children experience gratification; trust develops. During the second year conduct disorders can begin. In normal development the children want something, but their parents limit fulfillment. As children accept the limits, the parents expand them. Unfortunately, the child whose basic trust was not formed in the first year remains in rage. The events of life form attitudes, beliefs, and perceptions--a filter through which the individual interprets the world. This in turn leads to thoughts, feelings, and active responses. If the child is unattached, the filter distorts reality and leads to trouble. Attachment Disorder. What Is It? Attachment disorder is a condition in which individuals have difficulty forming loving, lasting, intimate relationships. Attachment disorders vary in severity, but the term is usually reserved for individuals who show a nearly complete lack of ability to be genuinely affectionate with others. Attachment is the result of the bonding process that occurs between a child and caregiver during the first 2 year's of the child’s life. When the caretaker recognizes and attends to the child's needs innumerable times a year, the child learns the world is a safe place and trust develops. The emotional connection also forms. The child feels empowered in their environment, and develops a secure base from which to explore the world. Attachment is reciprocal, the baby and caretaker create this deep, nurturing connection together. It takes two to connect. It is imperative for optimal brain development and emotional health, and its effects are felt physiologically, emotionally, cognitively, and socially. Children without proper care in the first few years of life have an unusually high level of stress hormones, which adversely effect the crucial aspects of how brain and body develop. Conscience development is dependent upon brain development and follows attachment. Therefore, these children lack prosocial values and morality as well as demonstrating aggressive, disruptive and antisocial behaviors. There are many reasons why the development of this connection and attachment can be disrupted:
These children have learned at a preverbal stage that the world is a scary and distrustful place. This lesson has taken place at a biochemical level in the brain. For this reason, these children do not respond well to traditional therapy or parenting since both rely on the child's ability to form relationships that require trust and respect. These children have Reactive Attachment disorder, and it requires a different type of therapy to address these early attachment difficulties. There is a range of attachment problems resulting in varying degrees of emotional disturbances in the child. Some of these children may have concurrent diagnoses such as Oppositional Defiant Disorder, Conduct Disorder, ADHD, Mood Disorders such as Depression or Bipolar Disorder, and Posttraumatic Stress Disorder. Unfortunately, many children with RAD are often misdiagnosed and receive inadequate therapy for years. Without proper treatment, these children and the societies in which they reside will pay a very high price indeed Symptoms of Attachment Disorder The Child may have some of the following behaviors/symptoms:
The Parents' may exhibit some of the following symptoms:
How to parent and help a child with Attachment Disorder?
Reactive Attachment Disorder Assessment Checklist (Cicchetti, 1989)
Sources: Evergreen Consultants www.attachment therapy.com ©2000-2001 Daniel A. Hughes, Adopting Children with Attachment Problems, Child Welfare League of America © 1999 Compiled by Cathy Bruer-Thompson, Adoption Training Coordinator, Hennepin County, MN 952-541-6251 Many risk factors contribute to development of attachment disorder. Consider how many of the following were present in the life of your foster children in the first two years of life:
SymptomsThe results of attachment disorder have serious implications for family living. These kids are masters of manipulation and will cause significant damage to even the best of family relationships. Crazy lying means they lie about their behavior even though you saw the entire incident, and they know you were watching.
Teenagers with attachment disorder are between a rock and a hard place. Their major developmental hurdle is to "individuate" or distance themselves from care givers, define their own value system, and determine their life goals. Teens who have been blessed with a normal life experience have a basic trust in the world. They find it a good place with adequate help available. Unattached kids lack trust; they must take care of themselves. Parents of unattached teens must hold them accountable for their behavior, even when it is painful for them and the child. They need to involve the police when the teen steps out of line (assault, shoplifting, etc.). Police ordinarily do not like to be called in these incidents. The kids appear to be perfectly nice kids who have simply made a mistake. Keep calling them. At the very least, if something significant goes wrong, you will have established a documented history. The attachment continuum Attachment can be measured on a continuum, with the most attached persons exemplified by Mother Theresa. Members of well-organized families also develop strong attachments. Even persons in dysfunctional families can develop good attachments if their basic needs as an infant were met. Persons who are thrill seekers or risk takers do not feel the responsibility to care for themselves or for those around them. They get an adrenaline high from being in danger. Those who are severely unattached have absolutely no internal conflicts over their behavior or its outcomes. They are likely to become serial killers. The boundary for diagnosis of attachment disorder is between the dysfunctional family where basic needs were met early in life and families where basic needs were not met so members learn to rely on themselves without feeling any obligation to others in the family. New therapy model New technology allows us to see the locus of brain activity. Recent research has shown that if an individual can return to a traumatic experience and resolve the issues with a trained therapist, his or her brain will be physically altered as new neurons develop. This is different for persons with attachment disorder. Coming back to hyper vigilance, when the children allow you to love them, they are no longer in a hyper vigilant state, so their brains can grow. The therapeutic goals of treatment are to help the child resolve early losses, develop trust, establish reciprocal relationships, correct distorted thinking patterns based on new trust, and develop self respect. These tasks require considerable support from other professionals and immediate backup if a dangerous situation arises. Witnesses can be important too. Parenting is possible Parenting is possible with considerable support. All of the parents who bring their children to the Evergreen Attachment Center are suffering at least the secondary symptoms of Post-Traumatic Stress Disorder from repeated rejection, relentless power struggles, and changes in family structure. These kids need homes with high structure and environmental controls. Parents
need to teach proper response to authority and internal controls. Natural and logical
consequences need to be used whenever possible. They are the key to teaching the way of
the world. In addition, they need to build relationships that are nurturing and
reciprocal. Children with Attachment Disorder (AD) are complex. The fundamental factors that organize the way these children function in the world are: 1. On average, there is a developmental delay of three years across all spheres of functioning. This delay, together with their other deficits, makes AD children very prone to episodes of regression. 2. AD children deeply believe that their very survival depends on their being in control of everyone else, in every situation, all of the time. 3. A definition of self as fragmented and bad/evil. Outwardly, AD children present themselves as “victims of life” who are responsible for nothing. Inwardly, these children feel responsible for everything that has happened to them; and the overwhelming shame this generates is more than they can tolerate. Avoiding this pain is the primary reason AD children deny all responsibility, for if they admit responsibility for one thing, it is like lighting a string of firecrackers; they begin to feel the pain for everything they believe they are responsible for. 4. Discipline generally pricks the shame of the AD child, and this is what makes authority figures seem so threatening. Because discipline causes the AD child emotional distress, discipline is held out as proof of adult wishes to hurt the child. If that discipline is given with an air of annoyance or criticism, the adult runs a high risk of provoking a self- protective rage outburst from the child. 5. AD children do not see their own behavior as stemming from decisions or choices that they have made, but as events that just “happened to them”. This belief, combined with their self-image as victims, leaves AD children experiencing themselves as victims of even their own behavior. This, in turn, supports their stance of “no responsibility”. 6. AD children’s perceptions of daily events are often highly distorted (e.g. caring treatment by adults is seen as the result of the child's effective manipulation of the adult and not as the adult’s choice nor as a reflection of the child’s importance.) These distortions chronically go unrecognized. 7. A simplistic conscience at best; and more likely, none at all. AD children rarely exhibit any interest in developing a conscience, for they see it as being of no use in their daily battle for survival. 8. The emotions of AD children are usually layered, like a thick sandwich. The top layer, which is the emotion most easily triggered, is anxiety. Anxiety is almost immediately translated into self-protective anger in order to push the threat away. Underneath anger is rage which is the final line of defense against the last two, most painful layers of all: shame and finally sadness/grief. 9. Frequently, AD children cannot distinguish one feeling state from another, nor can they reliably connect their feelings to that which triggered them. THE ATTACHMENT DISORDERED CHILD IN RELATIONSHIPS Given their complex and vulnerable make-up, AD children have enormous difficulties negotiating interpersonal relationships. Listed below are some of the many factors that compromise these children's social functioning. 1. A pervasive distrust of others. Anyone who seeks to earn an AD child’s trust is viewed as the most dangerous of all. Efforts to earn trust are usually seen as elaborate “tricks” hiding an intent to hurt the child. 2. Adults in authority roles are viewed as incompetent, unpredictable, rejecting, and easily manipulable. The more an adult gives, the bigger “patsy” he is seen to be. There is no faith in anyone’s control but their own. Their control manifests as affected emotions; as oppositional, passive/ aggressive, or avoidant behavior; and as withdrawal/withholding. They seek to orchestrate not only events, but the very feelings and behaviors of those closest to them. 3. Discipline is viewed as arbitrary and intended to humiliate them. Thus, it only provides further proof that adults cannot be trusted. Discipline is also seen as a failure on the child's part to have effectively manipulated his way out. 4. Love is defined as weakness and used against those who offer it. Sympathy or empathy is understood by AD children as entitling them to whatever they want from that person. Then, if what they want is not forthcoming, the child takes this as further proof of adults’ viciousness. 5. People are seen as entirely interchangeable and are primarily evaluated on the criterion of, “What have you done for me lately?” 6. There is a lack of empathy for others and disinterest in how their behavior affects anyone else. 7. Bizarre, aggressive, oppositional, and withdrawal behaviors are used to mediate interpersonal distance. There are rarely higher level skills, beyond behavioral, for managing closeness or distance. 8. Poor eye contact, except when lying. 9. A near total lack of peer social skills. “Friends” are usually kept for a brief time only. AD children often set peers up to get in trouble with no grasp of the likely future consequences for the friendship. TACTICS 1. AD children frequently use “blackmail” by implying that if an adult does as the child wishes, then the child won’t make trouble for the adult in that situation. 2. Indiscriminate affection is displayed towards strangers if it is seen as an advantageous thing to do. “Charm” is used, not to engage others meaningfully, but as a tool to secure gratification. 3. “Nonsensical or crazy lying”, which refers to lying even when “caught in the act”. Such extreme lying is, in part, about the child maintaining the illusion of having the power to define “reality” itself. So, if she says, “It didn't happen”, it didn't happen. 4. Since it gives away real information and information is power, telling the truth is viewed by AD children as giving adults power over them. Therefore, the truth is to be avoided. 5. It is common for AD children to inquire of authority figures what will happen if rules are broken. The purpose here is to gather information which the child can use to more effectively maneuver that adult in the future. 6. AD children assume that if they have not been directly prohibited from a behavior, then it is all right. If an adult then imposes consequences, the child considers this as betrayal in that he feels set up by the adult. PARENTING THE ATTACHMENT DISORDERED CHILD WHAT DOESN'T WORK 1. “Unconditional Love”. 2. Physical punishments not only not helpful, it is destructive, for it reinforces the AD child's view of adults as abusive. This will, in turn, fuel the child's distrust. 3. Giving the AD child some compensatory slack in the rules and/or lowering behavioral expectations because the child has “so many problems” already. 4. Rescuing the child from the consequences of her behavior and/or attempting to solve the AD child’s problems for her. 5. Emotional reactivity. AD children experience parents’ frustration and anger as proof that the child is effectively controlling his parents’ emotions. This only inflates his grandiose sense of power. 6. Predictable responses on the parents’ part. AD children will learn to navigate around any parental pattern that they can predict. WHAT DOES WORK 1. An unpredictable range of parental responses such that the child is always kept a bit off balance. 2. Behavioral rules need to be specific, clear, comprehensive, and phrased in action language. They need to be communicated with the definite expectation that they will be learned and followed. This is best conveyed with a matter-of-fact tone of voice that is free of any emotional edge. 3. Establish the ground rule that the AD child needs to ask, ahead of time, what the rules might be for anything that has never been discussed before. This removes the plea of ignorance from the AD child’s repertoire. 4. Since AD children rarely discriminate between different situations, parents need to actively teach them what behaviors go with what situations. 5. Teaching the AD child, over and over, that behavior is connected to choices on the front end and to consequences on the back end. Thus, if the child is unhappy with the consequences that fall his way, the solution is defined as his learning to make better choices rather than seeking to intensify his efforts to control his parents. 6. Teaching the AD child the language of feelings and helping her connect her feelings to their causes and to the behaviors that she is using to express them. 7. Providing emotional support, when imposing a consequence, for the hardship that the consequence will cause the child. Communicating an understanding of the basis for the child's misbehavior and for resistance to parental interventions. 8. Parents must maintain a balanced stance between providing empathy for factors in the AD child’s history that compromise his current functioning; and expectations, nonetheless, that the child will change his behavior. 9. “Forgetfulness” is never accepted as a valid reason for avoiding responsibilities or consequences. Instead, “forgetfulness” is posed as a choice and the solution is for the AD child to undertake the task of sharpening his memory in the future. 10.Painful feelings are never accepted as a legitimate basis for destructive behavior. If the child wants different consequences, he is given the challenge of developing different methods of emotional expression. 11.Forced choice: With this strategy, parents give the AD child two choices, both of which are agreeable outcomes to the parents. Example: choice one: go to bed on time tonight and you get to stay up until your regular bedtime tomorrow night; choice two: for each minute you are late getting in bed tonight, 5 minutes will be taken off your bedtime tomorrow night. The parents then step back and allow the child's behavior to “tell the tale” of what will happen. The advantage of this approach over simply imposing a consequence is that both outcomes stem directly from the child's behavior, whereas it is easier for the child to frame a consequence as coming from the parents' meanness rather than her behavior. 12. The One Minute Scolding: Parents directly confront their AD child, making direct eye contact, and offering verbal disapproval of behavior. The statement of disapproval is followed by expression of concern for the child’s future welfare if that same behavior continues unabated. This ties the intervention into the child's welfare and helps to mitigate against the child' s tendency to the scolding as reflecting on the parents' wish to be abusive. After one minute, the intervention is over: and there are no further consequences. 13. Overpractice: After a child breaks or “forgets” a rule, she must practice following the rule. Example: Child won’t go to bed when told. Overpractice would begin one hour before bedtime. The child would be told to go to bed (which includes the whole bedtime routine)}. After getting in bed, the child would get up, get redressed, come back downstairs, only to be told to go to bed again. This entire sequence would repeat a third time. 14. Confiscation of items that are misused in any way and return of those items only after the AD child has: 1) behaviorally demonstrated responsible behavior and, 2) given verbal promise to use the item only in the proper fashion in the future. This promise must be restated by the child, word-for- word. Just agreeing with an adult’s rendition of the promise is insufficient. 15. Teaching the child, in specific, clear, behavioral language, how to ask constructively for help. This will require many, many repetitions. 16. Physical touch: AD children are often touch-avoidant. However, parents should not let this intimidate them into never touching their child because touch is a cornerstone of attachment. Therefore, continue with periodic touching during calmer moments, and adjust the length and pressure to make it more manageable for your child. 17. As with therapy, parents should work towards learning how to turn the child’s attempts to disconnect into attachment experiences. 18. Anger and withdrawal should be seen by parents as control efforts by the child rather than true indictments of the parents. 19. Playful, humorous (not mocking) encouragement of the child’s anger and open agreement with the child's critical views of the family (this is termed “the paradoxical approach”). Example: Openly agreeing that the child has gotten a raw deal in having to live with such a stupid and boring family and, the parent is impressed that the child has enough self-control not to be even angrier. 20. Setting aside planned time periods during which the child is allowed to regress to whatever age she would like to be. As part of these “planned regressions”, the parents actually handle the child as if she were the younger age she’s pretending to be. Such planned time for being immature can help AD children pick up missed developmental pieces. Usually, this tactic must be continued for a while to yield any results. IMPACT ON THE FAMILY An attachment disordered child has an enormous impact on a family, be it a biological family, an adoptive family, or a foster family. 1. The mother generally receives the brunt of the child’s acting out as she is usually crafted into a symbol for all of the adult failures in the child’s life. Behavior is typically better when father is home. This creates parental conflict, wherein the mother viewed the father as minimizing things and the father sees the mother as overreacting. The child will nourish this split and take full advantage of it to exercise control over the parents. 2. AD children are extremely skilled at attacking parents’ (and other adults) weaknesses. The children's years of hypervigilance have given them a keen understanding of how adults operate and where their vulnerabilities lie. 3. Because these children give so little back in return for parenting efforts, parents often go through a progression of feeling selfish for wanting a return on their investment, then guilty, then worthless, and finally enraged. This eventually leads to intense parental ambivalence that includes strong wishes to eject the child out of the family. 4. Because AD children are so skilled at charming others, and because the parents are struggling so hard, extended family and friends offer little support and may move to blaming the parents themselves for the child’s extreme behavioral problems at home. Worse still, professionals all too often fall into this same trap. 5. AD children have a knack for ruining most planned pleasurable activities, and they do so to protect themselves from the intimacy these activities imply. They are also terrified of handing their parents the power to give them happiness. 6. These children can stir up great amounts of confusion within the family as to who is responsible for their behavior. 7. Siblings eventually become extremely jealous and angry about the amount of familial resources that their attachment disordered sibling is using up. Special thank you for this article to Lawrence B. Smith LCSW-C, LICSW Randolf Attachment Disorder Questionnaire The Randolf Attachment Questionnaire+ADQ) is a tool for diagnosis based upon parent/care giver responses. It has a 98% correlation with the truth. Based on its results, a therapist can diagnose mild, moderate, or severe attachment disorder. He or she can also diagnose conduct disorder. Kids who are diagnosed with moderate to severe attachment disorder may not succeed in a family or residential treatment setting because they can manipulate staff and family members and appear "cured" without addressing the underlying issues. Teens Teenagers with attachment disorder are between a rock and a hard place. Their major developmental hurdle is to "individuate" or distance themselves from care givers, define their own value system, and determine their life goals. Teens who have been blessed with a normal life experience have a basic trust in the world. They find it a good place with adequate help available. Unattached kids lack trust; they must take care of themselves. Parents of unattached teens must hold them accountable for their behavior, even when it is painful for them and the child. They need to involve the police when the teen steps out of line (assault, shoplifting, etc.). Police ordinarily do not like to be called in these incidents. The kids appear to be perfectly nice kids who have simply made a mistake. Keep calling them. At the very least, if something significant goes wrong, you will have established a documented history. The attachment continuum Attachment can be measured on a continuum, with the most attached persons exemplified by Mother Theresa. Members of well-organized families also develop strong attachments. Even persons in dysfunctional families can develop good attachments if their basic needs as an infant were met. Persons who are thrill seekers or risk takers do not feel the responsibility to care for themselves or for those around them. They get an adrenaline high from being in danger. Those who are severely unattached have absolutely no internal conflicts over their behavior or its outcomes. They are likely to become serial killers. The boundary for diagnosis of attachment disorder is between the dysfunctional family where basic needs were met early in life and families where basic needs were not met so members learn to rely on themselves without feeling any obligation to others in the family. New therapy model New technology allows us to see the locus of brain activity. Recent research has shown that if an individual can return to a traumatic experience and resolve the issues with a trained therapist, his or her brain will be physically altered as new neurons develop. This is different for persons with attachment disorder. Coming back to hyper vigilance, when the children allow you to love them, they are no longer in a hyper vigilant state, so their brains can grow. The therapeutic goals of treatment are to help the child resolve early losses, develop trust, establish reciprocal relationships, correct distorted thinking patterns based on new trust, and develop self respect. These tasks require considerable support from other professionals and immediate backup if a dangerous situation arises. Witnesses can be important too. Parenting is possible Parenting is possible with considerable support. All of the parents who bring their children to the Evergreen Attachment Center are suffering at least the secondary symptoms of Post-Traumatic Stress Disorder from repeated rejection, relentless power struggles, and changes in family structure. These kids need homes with high structure and environmental controls. Parents need to teach proper response to authority and internal controls. Natural and logical consequences need to be used whenever possible. They are the key to teaching the way of the world. In addition, they need to build relationships that are nurturing and reciprocal. |
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Foster and Adoptive Care Association
of Minnesota |
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