Attachment and Bonding: Attachment and Bonding: Clinical ImplicationsClinical Implications

Marolyn Morford, Ph.D. Sarah Kollat, Marolyn Morford, Ph.D. Sarah Kollat, Ph.D.Ph.D.Private PracticePrivate Practice Penn State UniversityPenn State University

State College, PAState College, PA University Park PAUniversity Park PA

CPPA Fall Workshop, September 13, 2014CPPA Fall Workshop, September 13, 2014

Main PointsMain Points Attachment Attachment researchresearch examines the nature of examines the nature of

ties between a very young child and caregiverties between a very young child and caregiver The term attachment has been overextended The term attachment has been overextended

by population and age when it is better by population and age when it is better described as “bonding”described as “bonding”

Attachment Attachment treatmenttreatment follows a separate path follows a separate path unrelated to research, trying to bridge a gap unrelated to research, trying to bridge a gap between what are emerging knowledge and between what are emerging knowledge and real clinical problemsreal clinical problems

Resilience is a neglected factorResilience is a neglected factor

Attachment – Normal Attachment – Normal DevelopmentDevelopment

'Attachment system''Attachment system'

The behaviors and physical features and The behaviors and physical features and behaviors of the infant that keep the behaviors of the infant that keep the caretaking adult near and attendingcaretaking adult near and attending

Includes response preferences of infant that Includes response preferences of infant that can begin prior to birthcan begin prior to birth

Essential for survival, biologically basedEssential for survival, biologically based

Closely related to the 'fear system', activated Closely related to the 'fear system', activated by threatsby threats

Critical Nature of AttachmentCritical Nature of Attachment

Importance to survival of young and of Importance to survival of young and of speciesspecies

Resilience of critical, adaptive functionsResilience of critical, adaptive functions Attachment & attachment Attachment & attachment behaviorsbehaviors are are

such a basic survival skill, only the most such a basic survival skill, only the most extraordinary cases of extreme extraordinary cases of extreme deprivation result in no attachment deprivation result in no attachment behaviors developingbehaviors developing

A child is not “unattached”: Children vary A child is not “unattached”: Children vary in whether they are in whether they are securelysecurely or or insecurelyinsecurely attached and to whom they attached and to whom they are attachedare attached

Young Child Attachment Young Child Attachment “Strange Situation”“Strange Situation”

Secure Secure – Calm on separation, greets mother on – Calm on separation, greets mother on return: 65%return: 65%

Ambivalent/resistantAmbivalent/resistant – Distress/unsettled at – Distress/unsettled at separation; angry/passive on return: 40-50% of separation; angry/passive on return: 40-50% of children in a low risk sample children in a low risk sample (Zeanah, 1996) (Zeanah, 1996)

AvoidantAvoidant - Active exploration, no checking with - Active exploration, no checking with mother; little response to absence or return of mother; little response to absence or return of mother: 20% in nonclinical samplemother: 20% in nonclinical sample

DisorganizedDisorganized - Little goal-oriented behavior, - Little goal-oriented behavior, apprehension of parent: 20% of children in a apprehension of parent: 20% of children in a nonclinical sample, as much as 80% in high risk nonclinical sample, as much as 80% in high risk (Zeanah1996; van Ijzendoorn, 1999)(Zeanah1996; van Ijzendoorn, 1999)

Extension from very young children to older Extension from very young children to older

children & adultschildren & adults

Adult Attachments (Bonding)Adult Attachments (Bonding)

Self-report, interview, ex., Self-report, interview, ex., http://http://www.psychology.sunysb.edu/attachment/measures/cwww.psychology.sunysb.edu/attachment/measures/content/aai_interview.pdfontent/aai_interview.pdf

Four main, similar styles of attachment have Four main, similar styles of attachment have been identified in adults:been identified in adults:

Secure (~65%)Secure (~65%) Anxious–Preoccupied (~15%)Anxious–Preoccupied (~15%) Dismissive–Avoidant ]Dismissive–Avoidant ] Fearful–Avoidant ] (~20%)*Fearful–Avoidant ] (~20%)*

Ein-Dor et al. 2004, for summaryEin-Dor et al. 2004, for summary

If the rate of occurrence of an attribute or If the rate of occurrence of an attribute or behavior is this high in a nonclinical (20%) behavior is this high in a nonclinical (20%) or low risk population (40-50%), can we or low risk population (40-50%), can we confidently say we are talking about a confidently say we are talking about a disorder?disorder?

Could these beCould these be normal variants normal variants in in response?response?

Attachment ParadoxAttachment Paradox

Could there be some survival advantage to Could there be some survival advantage to an event that is so prevalent in the an event that is so prevalent in the population? Is that which is interpreted as population? Is that which is interpreted as dysfunctional for the individual, protective dysfunctional for the individual, protective for the group?for the group?

Benefits to practioners Benefits to practioners

Deprivation Outcomes Deprivation Outcomes While there is some research to suggest While there is some research to suggest

that neglectful and abusive parenting can that neglectful and abusive parenting can be related to externalizing or more be related to externalizing or more impulsive behaviors in a small proportion impulsive behaviors in a small proportion of children, there is of children, there is nono evidence to suggest evidence to suggest that this alone impairs young children’s that this alone impairs young children’s ability to form bonds. ability to form bonds.

Deprivation Outcomes Deprivation Outcomes More importantly, there is absolutely NO More importantly, there is absolutely NO

evidence that interventions focused on evidence that interventions focused on forcing bonds to form will reduce forcing bonds to form will reduce externalizing behaviors. Therefore, externalizing behaviors. Therefore, difficult children may not be made less difficult children may not be made less difficult by improving a bond or creating difficult by improving a bond or creating attachment-like behaviors.attachment-like behaviors.

Attachment Dx CategoriesAttachment Dx Categories

Located in DSM 5's Trauma- and Stressor Located in DSM 5's Trauma- and Stressor Related Disorders*:Related Disorders*:Reactive attachment disorder Reactive attachment disorder

NEW: NEW: Disinhibited social engagement disorderDisinhibited social engagement disorder

*This category also includes Post traumatic *This category also includes Post traumatic stress disorder, Acute stress disorder, stress disorder, Acute stress disorder, Adjustment Disorders.Adjustment Disorders.

Differential Dx/Co-occuringDifferential Dx/Co-occuring

Developmental delays, esp. language and Developmental delays, esp. language and cognition, stereotypies, other signs of cognition, stereotypies, other signs of severe neglect (malnutrition)severe neglect (malnutrition)

DSM-5 Reactive Attachment D/O DSM-5 Reactive Attachment D/O 313.89/F94.2313.89/F94.2

Prevalence: Prevalence: RarelyRarely seen in clinical settings; seen in clinical settings; found in found in institutionsinstitutions and in and in severe severe neglect/abuseneglect/abuse before foster placement. before foster placement. Even in populations of severe neglect, Even in populations of severe neglect, less than 2% to 10% of these children less than 2% to 10% of these children (DSM5).(DSM5).

Reminder: This indicates resiliency in the Reminder: This indicates resiliency in the majority of children! majority of children!

DSM-5 DIAGNOSTIC CRITERIA FOR DSM-5 DIAGNOSTIC CRITERIA FOR REACTIVE ATTACHMENT DISORDER REACTIVE ATTACHMENT DISORDER

313.89/F94.1313.89/F94.1

A consistent pattern of inhibited, A consistent pattern of inhibited, emotionally withdrawn behavior emotionally withdrawn behavior toward adult caregivers, rarely or toward adult caregivers, rarely or minimally seeks comfort or responds minimally seeks comfort or responds to comfort when distressedto comfort when distressed

DSM-5 DIAGNOSTIC CRITERIA FOR DSM-5 DIAGNOSTIC CRITERIA FOR REACTIVE ATTACHMENT DISORDER REACTIVE ATTACHMENT DISORDER

313.89/F94.1313.89/F94.1 A persistent social and emotional A persistent social and emotional

disturbance characterized by at least 2 of disturbance characterized by at least 2 of the following: the following:

••Minimal social and emotional Minimal social and emotional responsiveness to others responsiveness to others

••Limited positive affect Limited positive affect

••Episodes of unexplained irritability, Episodes of unexplained irritability, sadness, or fearfulness sadness, or fearfulness which are evident which are evident during non-threatening interactions with adult during non-threatening interactions with adult caregivers caregivers

NEW: NEW: Disinhibited Social Engagement Disinhibited Social Engagement Disorder DSED 313.89/F94.2Disorder DSED 313.89/F94.2

Actively approaches and interacts with Actively approaches and interacts with unfamiliar adults, exhibiting two or more: unfamiliar adults, exhibiting two or more: reduced reticence approaching and reduced reticence approaching and interacting with unfamiliar adults, overly interacting with unfamiliar adults, overly familiar verbal or physical behavior in familiar verbal or physical behavior in contrast to age- and culturally appropriate contrast to age- and culturally appropriate behaviors, diminished checking back with behaviors, diminished checking back with caregivers, or willingness to go off with caregivers, or willingness to go off with unfamiliar adultunfamiliar adult

Both Reactive Att Disorder and Both Reactive Att Disorder and DSED requireDSED require

Evidence of at least one re: prior care -Evidence of at least one re: prior care -

Social neglect or deprivation - Social neglect or deprivation - persistentpersistent lack of lack of having basic emotional needs for comfort, having basic emotional needs for comfort, stimulation, and affection met by care-giving stimulation, and affection met by care-giving adults.adults.

Repeated changes of primary caregivers, Repeated changes of primary caregivers, limiting opportunitieslimiting opportunities to form stable to form stable attachmentsattachments

Rearing inRearing in unusual settings unusual settings that that severely limitseverely limit opportunities to form selective attachmentsopportunities to form selective attachments

Additionally, the child does not meet criteria Additionally, the child does not meet criteria for Autism Spectrum Disorder, the for Autism Spectrum Disorder, the disturbance is evident before age 5, and disturbance is evident before age 5, and the child has a developmental age of at the child has a developmental age of at least 9 monthsleast 9 months

Serious social neglect Serious social neglect is the only known risk is the only known risk factor for both of these disorders, yet the factor for both of these disorders, yet the majority of such children DO NOT develop majority of such children DO NOT develop the disorder; Prognosis depends on quality the disorder; Prognosis depends on quality of caregiving environment following of caregiving environment following serious neglect. (DSM 5)serious neglect. (DSM 5)

The different editions of DSM consistently The different editions of DSM consistently have described these disorders as rare and have described these disorders as rare and have suggested that they are more often have suggested that they are more often seen in those who have been reared in seen in those who have been reared in deprived, institutional settings. deprived, institutional settings.

DSM-5 (APA, 2013) notes that fewer than DSM-5 (APA, 2013) notes that fewer than 10% of children who have been severely 10% of children who have been severely neglected develop RAD, and about 20% neglected develop RAD, and about 20% develop DSED (also see Gleason et al., develop DSED (also see Gleason et al., 2011)2011)..

http://www.nasponline.org/publications/cq/42/8/dsm5.aspxhttp://www.nasponline.org/publications/cq/42/8/dsm5.aspx

Larger ProblemLarger Problem

When our questions exceed our answers. . When our questions exceed our answers. . ..

Overextending a conceptOverextending a concept

DiagnosisDiagnosis: Reactive Attachment Disorder, : Reactive Attachment Disorder, or “RAD” is a label that has been applied or “RAD” is a label that has been applied to many children in the past 10 years, esp. to many children in the past 10 years, esp. adopted and foster childrenadopted and foster children

TreatmentTreatment: “Specialized” treatments and : “Specialized” treatments and “centers” have emerged to work “centers” have emerged to work specifically with children with this labelspecifically with children with this label

Qualified clinicians become unnecessarily Qualified clinicians become unnecessarily conservative and shy away from conservative and shy away from challenging child cases, assuming there is challenging child cases, assuming there is a sound basis for the ‘new’ clinical a sound basis for the ‘new’ clinical population and ‘treatments’population and ‘treatments’

Other clinicians, lacking training (clinical or Other clinicians, lacking training (clinical or empirical) try valiantly to meet the needempirical) try valiantly to meet the need

Problem: Diagnosis & Problem: Diagnosis & TreatmentTreatment

Misapplication of the term occurs often Misapplication of the term occurs often (overextension)(overextension)

DSM-IV or DSM 5 definitions are not DSM-IV or DSM 5 definitions are not widely disseminatedwidely disseminated

Problem: Diagnosis & Problem: Diagnosis & TreatmentTreatment

Importance of evaluation of validity and Importance of evaluation of validity and effectiveness of proposed treatmentseffectiveness of proposed treatments

Inappropriate or ineffective treatments exist Inappropriate or ineffective treatments exist to treat a questionably applied diagnostic to treat a questionably applied diagnostic labellabel

Contributing to the Problem:Contributing to the Problem:

Misattribution of causalityMisattribution of causality Post hoc reasoningPost hoc reasoning Confirmation biasConfirmation bias Single cause assumption (quest for a Single cause assumption (quest for a

Unified Theory)Unified Theory)

Criteria for Diagnostic CategoryCriteria for Diagnostic Category

An observable, operational definition that An observable, operational definition that anyone can use and agree with others in anyone can use and agree with others in its applicationits application

Distinct from other categories (mutually Distinct from other categories (mutually exclusive)exclusive)

And has predictive utility: We know other And has predictive utility: We know other things about the person based on the things about the person based on the application of this categoryapplication of this category

Overextension of a termOverextension of a term Misattribution of causalityMisattribution of causality Post hoc reasoningPost hoc reasoning Confirmatory biasConfirmatory bias Single cause assumption (Quest for Single cause assumption (Quest for

“Unified theory”)“Unified theory”)

““RAD” is an example of a label RAD” is an example of a label overextended by some to MANY difficult overextended by some to MANY difficult behaviorsbehaviors

Giving the term weak distinguishing or Giving the term weak distinguishing or predictive powerpredictive power

ExamplesExamplesOppositional, impulsive, destructive, lies & steals, is Oppositional, impulsive, destructive, lies & steals, is

aggressive, hyperactive, self-destructive, cruel to aggressive, hyperactive, self-destructive, cruel to animals, sets fires, as poor hygiene, avoids touch, has animals, sets fires, as poor hygiene, avoids touch, has toileting problems, is accident prone, high pain tolerancetoileting problems, is accident prone, high pain tolerance

Persistent nonsense questions and incessant chatterPersistent nonsense questions and incessant chatterPhony, Great theatrical displaysPhony, Great theatrical displaysSexually act out at a very young age (seductive clothing, Sexually act out at a very young age (seductive clothing,

sexual to other children and animals)”sexual to other children and animals)”Passive-aggressive behavior (“will say ok if they have to Passive-aggressive behavior (“will say ok if they have to

do something, then take 1 ½ hour, or forget, or act do something, then take 1 ½ hour, or forget, or act confused”)confused”)

RAD label also overextended to RAD label also overextended to caretakerscaretakers

Some groups include caregiver “symptoms” in Some groups include caregiver “symptoms” in “diagnosis”:“diagnosis”: Feel isolated and depressed. Feel isolated and depressed. Feel frustrated and stressed. Feel frustrated and stressed. Are hypervigilant, agitated, have difficulty Are hypervigilant, agitated, have difficulty

concentrating. concentrating. Are confused, puzzled, obsessed with finding Are confused, puzzled, obsessed with finding

answers. answers. Feel blamed by family, friends, and Feel blamed by family, friends, and

professionals. professionals. Feel helpless, hopeless, and angry. Feel helpless, hopeless, and angry. Feel that problems are minimized by the Feel that problems are minimized by the

helping profession. (Institute for Attachment, helping profession. (Institute for Attachment, 2003) 2003)

Problems with overextensionProblems with overextension

Those labels do NOT appear in the criteria Those labels do NOT appear in the criteria for Reactive Attachment Disorder, old or for Reactive Attachment Disorder, old or new new

SomeSome of the labels DO appear in other of the labels DO appear in other diagnostic categories that are better diagnostic categories that are better applied to such childrenapplied to such children

These labels are These labels are notnot clinicalclinical and are and are dangerousdangerous in how they make adults think in how they make adults think and feel about the children in their careand feel about the children in their care

Such labels can apply to many types of Such labels can apply to many types of individuals with their own histories and individuals with their own histories and problems and do NOT indicate attachment problems and do NOT indicate attachment problemsproblems

Such labels can apply to the parents of Such labels can apply to the parents of many difficult-to-raise children, including many difficult-to-raise children, including those with chronic physical health those with chronic physical health problemsproblems

Controversy about RAD Controversy about RAD DiagnosisDiagnosis

Reliability? Not applied consistently by Reliability? Not applied consistently by independent clinicians independent clinicians

An overfocus on the preconditions (foster An overfocus on the preconditions (foster care, adoption) instead of symptoms care, adoption) instead of symptoms

Loss of precision,e.g., when aggression Loss of precision,e.g., when aggression or defiance = aberrant attachment behsor defiance = aberrant attachment behs

Untested alternative therapies are Untested alternative therapies are developed and implemented with no or developed and implemented with no or problematic resultsproblematic results (AACAP Practice Parameters, (AACAP Practice Parameters, JAACAP (2005).JAACAP (2005).

What do different types of What do different types of attachment predict?attachment predict?

Insecure attachment creates Insecure attachment creates riskrisk for for problems but alone does not cause problems but alone does not cause problemsproblems In low risk families, less relationIn low risk families, less relation between between

insecure attachment & later externalizing insecure attachment & later externalizing problemsproblems

In high risk families, more likely In high risk families, more likely relation relation between insecure attachment & peer between insecure attachment & peer problems, moodiness, depression & problems, moodiness, depression & aggression (Greenberg, 1999)aggression (Greenberg, 1999)

But…But…

What are we labelling as “attachment”?What are we labelling as “attachment”?

Couldn’t such a large segment of the Couldn’t such a large segment of the population population withoutwithout extreme neglect history extreme neglect history be explained by normal variance and be explained by normal variance and temperament, among other possibilities?temperament, among other possibilities?

So…if it’s not RAD, what is it? So…if it’s not RAD, what is it?

Or...Or...

Reframing (and correctly Reframing (and correctly diagnosing) to reduce fear and diagnosing) to reduce fear and encourage competence in child encourage competence in child and caregiverand caregiver

OCDOCD DepressionDepression Oppositional Defiant Oppositional Defiant

DisorderDisorder Conduct DisorderConduct Disorder Impulse Control Impulse Control

DisorderDisorder Disruptive Behavior Disruptive Behavior

DisorderDisorder Generalized Anxiety Generalized Anxiety

DisorderDisorder Separation Anxiety Separation Anxiety

DisorderDisorder Post-traumatic Stress Post-traumatic Stress

DisorderDisorder Pervasive Pervasive

Developmental DisorderDevelopmental Disorder

Asperger’s DisorderAsperger’s Disorder Attention-Deficit/Attention-Deficit/

Hyperactive DisorderHyperactive Disorder Adjustment Disorder Adjustment Disorder

with Mixed Disturbance with Mixed Disturbance of Emotions and of Emotions and ConductConduct

Developmental Delay Developmental Delay (especially cognitive (especially cognitive and language)and language)

Normal Development, Normal Development, Caretaker-child Caretaker-child Temperament mismatchTemperament mismatch

Normal Development, Normal Development, Adaptive behaviorAdaptive behavior

And…And…

NEW: NEW: Disruptive Mood Dysregulation Disruptive Mood Dysregulation Disorder, DMDD, 296.99/F34.8 Disorder, DMDD, 296.99/F34.8 (Depressive Disorders):(Depressive Disorders):

Severe recurrent temper verbal or Severe recurrent temper verbal or behavioral outbursts grossly out of behavioral outbursts grossly out of proportion in intensity or duration to proportion in intensity or duration to context, inconsistent w/developmental context, inconsistent w/developmental level, 3+/week.level, 3+/week.

Mood between episodes is persistenly Mood between episodes is persistenly irritable or angry nearly every day and irritable or angry nearly every day and observables by others, not just family, in observables by others, not just family, in at least 2 settingsat least 2 settings

What we know about diagnosisWhat we know about diagnosis

The term “Reactive Attachment Disorder” The term “Reactive Attachment Disorder” has been applied to a wide range of has been applied to a wide range of behaviors that can be captured more behaviors that can be captured more appropriately with other, existing appropriately with other, existing diagnostic categories, including 2 new, diagnostic categories, including 2 new, more discriminating categories in DSM5more discriminating categories in DSM5

The “problem” behaviors may originate The “problem” behaviors may originate from other causes:from other causes: The child’s genetic or temperamental The child’s genetic or temperamental

tendenciestendencies The foster/adoptive parent’s expectationsThe foster/adoptive parent’s expectations The child’s early experiences and The child’s early experiences and

expectationsexpectations Cultural expectations/mismatch Cultural expectations/mismatch

(Rothbaum et al., 2000(Rothbaum et al., 2000)) Other parenting factorsOther parenting factors

Resilience: Resilience:

Our goal for any child who has Our goal for any child who has encountered risksencountered risks

Defining ResilienceDefining Resilience

Masten's (2001): Masten's (2001): Good outcomes despite serious threats to Good outcomes despite serious threats to

adaptation or developmentadaptation or development

Need for demonstrable riskNeed for demonstrable risk

Defining ResilienceDefining Resilience

Can also view it as a diagnosisCan also view it as a diagnosis

Examine Risk Level and Competence LevelExamine Risk Level and Competence LevelHighly vulnerableHighly vulnerable

CompetentCompetent

MaladaptiveMaladaptive

ResilienceResilience

Defining ResilienceDefining Resilience

ResilientMaladaptiveHigh

CompetentHighly vulnerable

Low

HighLow

ResilientMaladaptiveHigh

CompetentHighly vulnerable

Low

HighLow

Competence Level

Ris

k L

evel

Defining ResilienceDefining Resilience

But what are “good outcomes”?But what are “good outcomes”?

What does it mean to “do well”?What does it mean to “do well”?

External CriteriaExternal CriteriaMasten (2001): “Meeting the major expectations Masten (2001): “Meeting the major expectations

of a society for the behavior of children of of a society for the behavior of children of that age and situation”that age and situation”

These are Salient Developmental TasksThese are Salient Developmental Tasks

Defining ResilienceDefining Resilience

What are salient developmental tasks?What are salient developmental tasks?

Of childhood?Of childhood?

Of adolescence?Of adolescence?

Of adulthood?Of adulthood?

Defining ResilienceDefining Resilience

Internal CriteriaInternal CriteriaPsychological well-beingPsychological well-being

Low levels of symptomsLow levels of symptoms

Which is more important to defining Which is more important to defining resilience? resilience? External External

InternalInternal

Old View of ResilienceOld View of Resilience

Only a few children possess remarkable or Only a few children possess remarkable or extraordinary strength to overcome extraordinary strength to overcome difficultiesdifficultiesSuperchildrenSuperchildren

New View of Resilience (based New View of Resilience (based on empirical studies)on empirical studies)

““Ordinary Magic”Ordinary Magic”Resilience is fairly commonResilience is fairly common

Resilience likely to occur if Resilience likely to occur if basic systemsbasic systems are are in “good working order”in “good working order”

Basic SystemsBasic Systems

What are these BASIC SYSTEMS? What are these BASIC SYSTEMS? Masten (2001)Masten (2001)

Small set of global factorsSmall set of global factorsConnections to caring adultsConnections to caring adults

Cognitive and self-regulation skillsCognitive and self-regulation skills

Positive self-viewsPositive self-views

MotivationMotivation

Basic SystemsBasic Systems

Why are Why are these systemsthese systems so important? so important?

What does this imply about interventions for What does this imply about interventions for at-risk children? at-risk children?

Adoption and ResilienceAdoption and Resilience

Studying adopted populations presents Studying adopted populations presents many challengesmany challengesVariance in the adoptee’s circumstances (Foster Variance in the adoptee’s circumstances (Foster

care system, kinship adoption, international care system, kinship adoption, international adoption, sibling group adoption, etc.)adoption, sibling group adoption, etc.)

Variance in the age of the child at adoptionVariance in the age of the child at adoption

Variance in the adoptive family’s circumstances Variance in the adoptive family’s circumstances (e.g., presence of biological children, single-(e.g., presence of biological children, single-parent family, etc.)parent family, etc.)

Adoption and ResilienceAdoption and ResilienceAs a result, it is difficult to apply the findings As a result, it is difficult to apply the findings

of specific studies to all adopted childrenof specific studies to all adopted children

What do we seem to know? What do we seem to know? Early adoption (within first year of life) yields Early adoption (within first year of life) yields

fewer symptomsfewer symptoms

Deprivation early in life can have lasting impacts Deprivation early in life can have lasting impacts on neurological developmenton neurological development

Many children improve in their symptoms over Many children improve in their symptoms over time after placementtime after placement

Adoption and ResilienceAdoption and ResilienceBUT. . .The vast majority of adopted children BUT. . .The vast majority of adopted children

develop develop within the normal rangewithin the normal range (Palacios & (Palacios & Brodzinsky, 2010)Brodzinsky, 2010)

How can we help to support normal How can we help to support normal development in these children? development in these children?

Adoption and ResilienceAdoption and ResilienceFostering Resilience: A Mother’s PerspectiveFostering Resilience: A Mother’s Perspective

Treat specific symptomsTreat specific symptoms

Before that, be certain that these are relevant Before that, be certain that these are relevant symptomssymptoms

““Adopted” as a labelAdopted” as a labelBiases that can occurBiases that can occur

Ignoring of natural variance in human behaviorIgnoring of natural variance in human behavior

Reducing children to one facet of their history and Reducing children to one facet of their history and selfself

Adoption and ResilienceAdoption and ResilienceAlthough a child’s history offers context that can Although a child’s history offers context that can

aid in understanding their symptoms, we aid in understanding their symptoms, we must be careful to not see must be careful to not see their history as a their history as a symptom itselfsymptom itself

The mantra still applies: The mantra still applies:

Each client is a study of one!Each client is a study of one!

Adoption and ResilienceAdoption and ResilienceNormalizing remains a strong clinical toolNormalizing remains a strong clinical tool

Adoptive parents need healthy and reasonable Adoptive parents need healthy and reasonable expectations for their relationship with their expectations for their relationship with their childrenchildrenAttachment will not emerge immediatelyAttachment will not emerge immediately

Children will revisit and process their experiences in Children will revisit and process their experiences in their birth home/family and/or institutiontheir birth home/family and/or institution

Parents will not be experts of their children Parents will not be experts of their children immediately. . .and that is okayimmediately. . .and that is okay

Adoptive Parents: What to ExpectAdoptive Parents: What to ExpectAttachment will not emerge immediatelyAttachment will not emerge immediately

Children will revisit and process their Children will revisit and process their experiences in their birth home/family and/or experiences in their birth home/family and/or institutioninstitutionRose-colored glassesRose-colored glasses

Parents will not be experts of their children Parents will not be experts of their children immediately. . .and that is okayimmediately. . .and that is okay

Children will want to understand their originsChildren will want to understand their originsThis does not mean your relationship with them is This does not mean your relationship with them is

lacking!lacking!

Adoptive Parents: What to ExpectAdoptive Parents: What to ExpectSticks and stones. . . Sticks and stones. . .

Be aware of normal developmental changesBe aware of normal developmental changesPhysicalPhysical

CognitiveCognitive

Emotional / SocialEmotional / Social

Remember: All families struggle, and all families Remember: All families struggle, and all families have reasons to rejoicehave reasons to rejoice

Struggles offer the opportunity for specific, Struggles offer the opportunity for specific, targeted intervention that are evidenced-targeted intervention that are evidenced-basedbased

What we know about treatmentWhat we know about treatment

There is no There is no oneone treatment (no silver treatment (no silver bullet) for the myriad of problems that are bullet) for the myriad of problems that are described in popular discussions of described in popular discussions of reactive attachment disorderreactive attachment disorder

Treatment focuses onTreatment focuses on

The problem behavior (one at a time)The problem behavior (one at a time) The bond The bond

What are the caregiver’s What are the caregiver’s thoughtsthoughts about the about the child and expectations about the relationship?child and expectations about the relationship?

The child often has no problems with The child often has no problems with attachment; the problem is s/he is not attachment; the problem is s/he is not attached to the presenting caregiver. attached to the presenting caregiver.

… … A friend reaching for my 18 mo. old A friend reaching for my 18 mo. old [adopted] daughter asked: “Does she go to [adopted] daughter asked: “Does she go to strangers?”strangers?”

““Of course,” I answered, “She’s Of course,” I answered, “She’s livingliving with with

strangers.” strangers.” From L. Melina From L. Melina Raising Adopted ChildrenRaising Adopted Children, Harper Collins, 1998., Harper Collins, 1998.

Treatments should be symptom focused.Treatments should be symptom focused. Known effective interventions for the Known effective interventions for the

troubling behaviors are required:troubling behaviors are required: behavior therapybehavior therapy cognitive therapycognitive therapy family educationfamily education parent training parent training as needed, pharmacological approaches as needed, pharmacological approaches

Beware of: Beware of: Damaging, unproven, coercive “therapies”Damaging, unproven, coercive “therapies” Magical thinking involving regression Magical thinking involving regression

methodsmethods Ineffective treatments that waste limited Ineffective treatments that waste limited

resources and precious time in a child’s young resources and precious time in a child’s young lifelife

AmericanAmericanProfessional Society on the Abuse of Professional Society on the Abuse of

Children (APSAC) StatementChildren (APSAC) Statement

Traditional attachment theory holds that Traditional attachment theory holds that caregiver qualitiescaregiver qualities are key, such as are key, such as

Environmental stabilityEnvironmental stability Parental sensitivityParental sensitivity Responsiveness to children’s physical and Responsiveness to children’s physical and

emotional needs emotional needs Consistency and a safe and predictable Consistency and a safe and predictable

environment support the development of environment support the development of healthy attachmenthealthy attachment

From this perspective, improving these From this perspective, improving these positive caretaker and environmental positive caretaker and environmental qualities is the key to improving qualities is the key to improving attachment and bondsattachment and bonds

CHILD MALTREATMENT CHILD MALTREATMENT

Vol. 11, No. 1, February 2006 76-89Vol. 11, No. 1, February 2006 76-89

We can treat these children most We can treat these children most effectively if we have the assistance of the effectively if we have the assistance of the caregiver and other adults spending time caregiver and other adults spending time with the child.with the child.

We must recognize and address the We must recognize and address the emotional and psychoeducational needs of emotional and psychoeducational needs of the caregiving adult as well as the child.the caregiving adult as well as the child.

Problems with Problems with “Attachment Therapy”“Attachment Therapy”

Lack of informed consent to treatment -- where is Lack of informed consent to treatment -- where is the advocate for the child?the advocate for the child?

No link between attachment research and current No link between attachment research and current popular treatmentspopular treatments

Illogical and invalid concepts, e.g., that children Illogical and invalid concepts, e.g., that children must release rage or regress to infancy before they must release rage or regress to infancy before they can be lovingcan be loving

Unethical targeting of adoptive and foster parent Unethical targeting of adoptive and foster parent audienceaudience

Often unlicensed practitionersOften unlicensed practitioners Creation of adult fear of child & erosion of Creation of adult fear of child & erosion of

caregiver confidencecaregiver confidence

Problems, cont.Problems, cont.

Lack of understanding of child’s developmental Lack of understanding of child’s developmental needsneeds

Lack of understanding of child’s adaptation Lack of understanding of child’s adaptation processprocess

Expectation of immediate bonding and Expectation of immediate bonding and interpretation of resistance as “attachment interpretation of resistance as “attachment disorder”disorder”

Physically and emotionally intrusive, thereby Physically and emotionally intrusive, thereby retraumatizing an abused or neglected child retraumatizing an abused or neglected child and delaying development of trust & securityand delaying development of trust & security

What treatment is recommended? What treatment is recommended?

Treat the behavior and the bond (not the Treat the behavior and the bond (not the same issue)same issue)

If presented with a child with a history of If presented with a child with a history of attachment disruption, do not immediately attachment disruption, do not immediately assume treatment is necessary. Base assume treatment is necessary. Base interventions on symptom presentation: interventions on symptom presentation: What behaviors are troubling to the child & What behaviors are troubling to the child & the caregiver?the caregiver?

DoDo think about the caregiver-child think about the caregiver-child relationship relationship

Recommended approaches focus Recommended approaches focus on caregiver behaviorson caregiver behaviors

Give the child (a sense of) more control, don’t Give the child (a sense of) more control, don’t take control away from the child. Do give take control away from the child. Do give control in areas the caregiving adult is control in areas the caregiving adult is comfortable with (give child comfortable with (give child benignbenign choices). choices).

Enhance the sensitivity of the adoptive parent Enhance the sensitivity of the adoptive parent to the child rather than the child to the parent to the child rather than the child to the parent (Dozier et al., 2002)(Dozier et al., 2002)

Help the adult articulate what they want out of Help the adult articulate what they want out of this relationship and help them evaluate their this relationship and help them evaluate their expectationsexpectations

Reduce caregiver’s expectation for rapid Reduce caregiver’s expectation for rapid change and increase their acceptance of change and increase their acceptance of the child’s basic temperament and the child’s basic temperament and developmental needs developmental needs (Dozier et al. 2002)(Dozier et al. 2002)

Unlink the contingency between the child’s Unlink the contingency between the child’s behavior and the permanency of the behavior and the permanency of the placementplacement

Emphasize positive reinforcement and Emphasize positive reinforcement and positive exchanges of affection positive exchanges of affection on the on the child’s termschild’s terms, rather than the parents’ , rather than the parents’ (Speltz, (Speltz, 2002, Dozier, et al. 2002).2002, Dozier, et al. 2002).

Treat the relationshipTreat the relationship

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

Treat the relationshipTreat the relationship

Increase the caregiver’s competence Increase the caregiver’s competence and confidence through training: Start and confidence through training: Start smallsmall Teach caregiver behavior therapy with Teach caregiver behavior therapy with

child, including behavior substitution, child, including behavior substitution, differential reinforcement of incompatible or differential reinforcement of incompatible or other behaviors, anxiety reduction other behaviors, anxiety reduction techniques, such as gradual exposure, techniques, such as gradual exposure, anxiety hierarchy and related treatments anxiety hierarchy and related treatments

Treat the relationship, cont.Treat the relationship, cont.

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

Teach parent how to implement positive Teach parent how to implement positive behavior management in home providing behavior management in home providing consistent rewards for appropriate behaviors consistent rewards for appropriate behaviors (W-S&H, E&M, Barkley): for ex., giving (W-S&H, E&M, Barkley): for ex., giving attention for the positive behaviors the child is attention for the positive behaviors the child is able to do, rather than for the failuresable to do, rather than for the failures

Provide skill instruction with child for Provide skill instruction with child for emotional regulation (e.g., anger emotional regulation (e.g., anger thermometer) and social skills deficits, thermometer) and social skills deficits, including teaching child how to give parent including teaching child how to give parent positive feedbackpositive feedback

Participant clinical examplesParticipant clinical examples

SummarySummary

Attachment research has moved beyond the Attachment research has moved beyond the biological basis of infant and caretaker biological basis of infant and caretaker interactions and extended to older age interactions and extended to older age groups and populations, altering the clarity groups and populations, altering the clarity of the term that bonding might describeof the term that bonding might describe

Some groups have extended the term to Some groups have extended the term to and created interventions for a broad and created interventions for a broad range of behaviors better described by range of behaviors better described by known problems with effective treatmentsknown problems with effective treatments

Both researchers and some working Both researchers and some working professionally with children, especially professionally with children, especially those children in foster care or adopted, those children in foster care or adopted, do not address the very strong role do not address the very strong role resilience plays in growth and resilience plays in growth and developmentdevelopment

We can We can Be rigorous and curious in our use of Be rigorous and curious in our use of

diagnoses and treatments provided to diagnoses and treatments provided to children, children, especiallyespecially those who have no those who have no other advocates, as well as their familiother advocates, as well as their familieses

Be confident in providing treatment that Be confident in providing treatment that is tailored to the specific problemis tailored to the specific problem

Educate families and professionals to Educate families and professionals to resist the tendency to pathologize or resist the tendency to pathologize or predict a child’s future from her/his predict a child’s future from her/his current behavior or pastcurrent behavior or past

Treat the relationship/bond between the Treat the relationship/bond between the parent and child, recognizing the parent and child, recognizing the responsibility for the interaction weighs responsibility for the interaction weighs more heavily to the adult caretakers more heavily to the adult caretakers

Remember the primary factor as the Remember the primary factor as the resilience of children (and adults). resilience of children (and adults).

ResourcesResources for parents & therapists for parents & therapists

www.help4adhd.org (‘Diagnosis & Trtmt’ (‘Diagnosis & Trtmt’ link)link)

www.chadd.org www.effectivechildtherapy.comwww.effectivechildtherapy.com

www.bpkids.org (‘Learning Center’ link) (‘Learning Center’ link) www.promisingpractices.net http://www.apa.org/pi/cyf/cyfnews.html

www.cachildwelfareclearinghouse.org

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