“The foolish man gets angry, the wise man understands.” Chinese Proverb
Understanding is the key to compassion and the development of compassion in the child for himself, the parents for themselves and the child and parents for each other must be present in every interaction.
Therapists must be guided primarily by compassion and their role in the family is to guide the parents to understanding so they can interact with their children out of a sense of compassion, rather than resentment and frustration. Understanding exactly what the issue is in the family is key. Assessment is key to understanding. Accepting an attachment disorder as first and foremost the result of trauma, seen or unseen, known or unknown, must be incorporated in all therapy sessions and parent coaching.
People with PTSD are not driven by anger or rage as much as they are driven by fear. Maslow’s Hierarchy of Needs states the most important need a person has, after food/water and warmth, is safety, and if that need is not met then nothing else matters. The emotional states and behaviors of children who are traumatized are driven by fear, a sense they are not safe. This sense of safety has nothing to do with the parent’s sense of the safety they are providing. To the traumatized child even the parents who are trying to keep him safe are part of the problem…by their very existence in his life! Rage and anger are the secondary emotions used to cover up this fear as fear is perceived as weak, and rage is perceived as strong. A fearful child needs to project his strongest self in order to keep himself safe because in the past adults had been responsible for his safety and they let him down. He must take care of himself and not trust his survival to anyone else. Helping a traumatized, injured child overcome this mind set is the underpinning of all interactions.
That is not to say that parents will not get angry. Many times if parents are not angry when they begin therapy it is because they no longer care! For the most part the anger felt by the parent's mask the same deep fear for themselves, their home, their family and their future, as the child’s anger and fear does. Their anger must be understood and accepted in the same ways the child’s anger and fear must be understood and accepted. Working with the parents to understand, accept and appreciate their anger and fear as a motivating force to heal themselves and heal the child will go far to help them use their passion for their child and family in positive ways. Helping parents to develop or find their lost compassion is an ongoing piece of the healing.
The negative effects on a family when there is a child with a thought, physical, emotional
and/or behavioral disorder is magnified when the child also suffers from a disordered attachment
and is minimized when the child has a secure attachment.
Childhood disorders and disabilities create a crisis in the parent and child relationship, often affecting the quality of the attachment. When the therapist and family devote time and energy to healing the parent and child relationship then the child and family functioning becomes healthier even when the concurrent mental, emotional, physical and/or behavioral disorder persists. When all time and energy are focused solely on the presenting disability, the child and parent relationship continues to suffer and the family functioning remains poor. Creating and maintaining a secure attachment, therefore, must become the primary task of the therapist and family if the child and the family are to create a healthy, happy, functioning entity…..regardless of the severity of the disability. It is not the presence of a disability in the family that causes negativity. It is rather how the family copes and manages to find a way to enjoy life, despite the presence of a member with a disability. Healthy attachment must undergird all other therapies.
Not all children with disordered attachment can be clinically diagnosed with DSM IV 313.89,
Reactive Attachment Disorder of Infancy and Early Childhood. Families and children with breaks
in the bond still respond well to attachment based treatment.
RAD is a very specific diagnosis that has specific parameters. Disordered attachment is a general term indicating the parent and child relationship pattern is less then optimal. Disordered attachment can be mild, marked by unwelcome but fairly benign negative behaviors of the child such as lack of reciprocal eye contact and touch, sassy, uncooperative, superficially engaging with strangers, argumentative, controlling, impulsive, demanding and /or sneaky. These behaviors demonstrate a lack of closeness with the parents or a low level of anger at the parents that indicate the child and parent do not get as much joy from their relationship as would be optimal. Disordered attachment can also be very severe, marked by extremely negative behaviors on the part of the child such as lying, stealing, destructive, verbally threatening, oppositional, defiant, fire starting, cruel to children and animals, and/or assaultive to the point of being murderous. These behaviors indicate the parent-child relationship is dysfunctional to the point of being potentially dangerous. In order for a diagnosis of Reactive Attachment Disorder to be identified the symptoms must begin before the age of five and it is presumed the negative behaviors are caused by poor care giving patterns such as found in institutions and in families characterized by abuse and neglect. Disordered attachment however, can be found in the presence of caring parents whose children were over indulged, experienced early, unresolved pain or an emotional, mental, behavioral and/or physical disability is present that makes the child difficult to parent. Children whose mothers went through a period of post partum depression, during which they were not emotionally available to baby during a critical period of parent-child attachment development, can also create varying degrees of disordered attachment.
In child and family therapy the “identified patient” is the relationship between the parent and child.
What must heal is the space between them. The ability of the family to withstand the behavioral assaults by the child is not dependent on just the child changing his behavior. Rather, it is also critical that the parents receive support and tools that are more effective then those they are currently using. Working with the families on creating a healing milieu at home frees up the therapist to work with the underlying issues. An important part of the therapist's job is helping the parents become more adept at guiding the child’s behavior thereby, creating and maintaining a secure parent and child attachment.
In order to place the parent-child relationship in the center and make it more reciprocal the therapist
must place the primary caregivers in the lead role as the agents of change.
The parents are acknowledged as central to the healing process and the therapist becomes the parent coach and treatment catalyst. Parents are always present during therapy sessions and they are consulted before each session as to what behaviors are the most difficult to manage. Those behaviors are the ones the therapist addresses first as those are the ones the parents have identified as most likely to damage the relationship and compromise the stability of the home. The therapist must begin with working with the child to discern the underlying psychological processes in the child that are driving the behavior. Two of the goals of attachment therapy are to teach a child to follow the mother’s lead, thereby developing a sense of trust and a diminishing need for control, and to coach the mother in how to be an effective leader. In order for parents to feel totally supported by the therapist the therapist must form an empathetic alliance with the mother. Mom's words and interpretation of events must be listened to closely and not discounted. It is not helpful for the mother to ever feel as if the therapist or other professionals believe her child’s behavioral problems are due to her being a poor mother, even if that is, in rare instances, true. If the mother does have some functioning issues that make her parenting skills questionable, those skills must be brought up to an appropriate level, without inflicting guilt, so mother can be part of the therapeutic process with her child! In order to effectively carry out this philosophy the therapist must not confuse establishing a working relationship with the child as “being the child’s buddy.” The therapist needs to keep in mind the point of therapy is not to bond the child to the therapist, but to bond the child to the parents. When the therapist becomes the child’s best friend and forms a tight relationship with the child the child can use that close relationship to distance himself from his mother. If the child forms a more significant bond with the therapist then the parents the therapist has failed.
The goal of treatment, therefore, is to maintain the relationship so the parents have the opportunity
to provide the nurture and structure over a long enough period of time for the child to heal.
Preserving the child’s ability to live at home becomes paramount. If controlling therapeutic or parenting techniques are required to confront the child with the effects of his behavior then they need to be used. For example, if the child must be kept home to avoid the child’s use of the school staff to triangulate and manipulate then that is done until the school staff is trained well enough to provide for the child’s special needs. If the medication needs to be temporarily raised to the point the child is less reactive that is an acceptable way to give the parents respite until therapy and parenting interventions have time to become effective. If the child needs to spend more time in the bedroom, an in-home-respite setting, while the parents recover from the onslaught of the child’s behaviors then that needs to be prescribed. As drastic of measures as these are they are preferable to placing the child out of the home.
The initial attachment typically is between the child and the mother and generalizes next
to the father, the grandparents and other family members. When this bond is established,
it then generalizes to friends, the community, the school, the therapist and the world.
“Mother” in this instance, refers to the primary caregiver, whether it is the father, nanny, foster parent, adoptive parent or birth parent. The primary caregiver is the individual who spends the most time with the child and the most energy providing for the child’s needs. Typically this is the birth mother as the bond begins at conception and continues to develop during the pregnancy. Mothers, then, are most often the individual the newborn will turn to for comfort and support. After this 9 months of bonding has occurred and the child is born, the child also begins to turn to his father for nurturing. The bond gradually begins to include father as well as mother. In therapy, therefore, mimicking nature’s course of action, the bond is created first with the mother. During these first stages the father’s role is to care for the mother, just as he would during the pregnancy. As the child becomes reciprocal with the mother then the father’s role enlarges. If the child is rejecting of the mother while seeming to embrace the father, teachers, and others, there is a tendency for the child’s vital need for a primary bond with the mother to be discounted. Other people in the child’s constellation of relationships must continually redirect the child’s superficial attempts to establish a relationship with them back to insisting the child first and foremost establish a relationship with the mother.
Therapy to enhance attachment is not a set of techniques or interventions. Therapy to enhance
attachment is a framework that states forming an attachment to parents is the best way
to ensure a child will grow into a healthy, well-functioning adult.
Whatever works to increase the strength of that attachment needs to be considered. That means therapists and parents must “leave no stone unturned” in finding ways to enhance the child’s ability to trust as well as increase the child’s ability to react appropriately to external control while developing age level appropriate internal controls. Theraplay, psychodrama, paradoxical interventions, nutrition, EMDR, confrontation, equine therapy, neurofeedback, medication, proactive and reactive parenting, etc must all be explored for there usefulness in helping a child heal. Teaching a child to do chores “fast and snappy, right the first time” while being “respectful, responsible and fun to be around” contribute to the child’s ability to engage in reciprocal behaviors, but they are not the only tools. Teaching a child strong sitting and jumping jacks are important to teaching a child to follow the mother’s lead and an aid in healing the brain; however, they are not the only tools. An underlying guideline in determining what interventions to use and when to use them is to “Respect the child, not the child’s pathology.” (Foster Cline)
Children behave the way they behave because they think the way they think.
The primary contributors to the development of thinking patterns are the child’s genetics,
the child’s in utero experience and the first two years of life.
Bruce Perry, M.D. states, “It’s not the finger that pulls the trigger of the gun. It’s the brain.” Therefore, taking a detailed history in these three areas of the child’s life is of critical importance to understanding how the child came to the conclusion that the particular behaviors being engaged in are somehow useful and rational, that trust must be avoided and control must be maintained at all costs. The task then becomes not changing the behaviors, but healing the brain so the brain can drive a behavioral change. Effective interventions slowly cause the brain to be rewired from one comfort zone to another. That is why Dr. Foster Cline states, “It takes at least 2 months for every year of life before lasting change can be expected.” Lasting behavior changes are not superficially imposed but come from the inside out. Healing the brain requires the child to experience reciprocal smiles, food, eye contact, touch, and movement in positive ways with the mother. (Since television and electronics does not provide those interacting, brain rewiring experiences it must be avoided.)
As a result of multiple factors leading to the constellation of behaviors and emotional states
there is a high likelihood of multiple, overlapping diagnoses.
Most children with behavioral, emotional and mental disorders have concurrent issues. Generally there will be elements of PTSD, ODD, OCD, Bipolar or other mood disorders, and/or ADD/ADHD as well as disordered attachment. In addition to administering basic functioning tests and obtaining a detailed history multiple other diagnostic surveys may be used to discern mood or thought disorders. It is important for practitioners to avoid the “diagnosis du jour” tendency and to look at the child’s global functioning in order to form effective treatment plans.
Whoever carries the emotion and pain over the child’s behavior is the one
who will make the most lasting change.
If the parents carry the grief/anger/fear then they will change in order to avoid the pain of such deep emotions. When the parent gets overtly angry and upset over the child’s behaviors then the child often says internally, “No point in both of us worrying about this” and will step back. Meanwhile the parent, who hates herself for getting angry and becoming the kind of parent she detests, becomes grief-stricken, guilt-ridden and vows to do better. If, however, the parent does not pick up the emotional burden then the child has the opportunity to take responsibility for his deep emotional pain and pick up the grief/anger/fear resulting from his own actions. When the child chooses to no longer bear the pain of his behavior then he will change. Much like an alcoholic, when the family bears the pain the alcoholic has little reason to change. However, when the alcoholic loses family, job, home, and spouse and must bear the pain of that, he comes to the realization that if life is going to be different he must change. The task of therapy and parenting interventions must be to move the emotional burden for the child’s behaviors from the parents to the child. If anyone is angry or upset about the child’s behavior it must be the child if the child is to change.
Often, it is mom who is in the most pain. Mom is typically the one to identify something is wrong with the relationship and seek help to change it. Mom then is the one most open to change. Supporting mom first, so she can help heal her child, is often the best approach since the child does not recognize that he is in pain and will be blaming mom for his unhappiness while rejecting therapeutic help.
Healing the parent-child relationship and enabling the creation of a functional,
mutually enjoyable attachment takes teamwork.
The parents, caseworker, therapist, psychiatrist, respite provider, school staff, community, church members, etc must all form a single minded team to reinforce the parents’ skills and support them in their efforts. Consequences for specific behaviors of the child need to be discussed by the team as any intervention or technique can be abusive when misused. Parents must have access to team members who can discuss with them what the child is doing to destroy the parent-child relationship and push the parents away. It is the responsibility of the team members to find ways to brainstorm parenting techniques and evaluate their effectiveness. The team must also be available to minimize the negative impact of those who do not understand the situation with the family and ill informed but well meaning community members who judge the parents harshly. The team must be there to offer support, tools, and advocacy while honoring the parent’s effort to save their child.
Traditional talk and insight based therapies often fail to help children
with attachment disorders and a brain affected by early childhood trauma.
Traditional therapies are based on establishing a relationship with the child and using that relationship as a trust base to deal with issues. Many children with attachment based disorders cannot form the necessary trust of adults to use that relationship as a basis for change. The ability to form relationships is the problem and cannot be used to heal the problem. Interventions known by experience to be ineffective in the treatment of children with disordered attachments or RAD are those which depend on talking to generate insight, building an alliance with the child at the expense of the parents, and giving the child control of the therapy, such as non-directive play therapy. Non-directive play therapy is counter indicated with attachment disorders. There is research documenting the use of Eye Movement Desensitization and Reprogramming (EMDR) for the treatment of PTSD and neurofeedback for the treatment of ADD/ADHD and attachment disorders (VanBloem). Bessel van der Kolk, M.D., of Harvard University found that language and logic are not accessible to the brain when the brain is experiencing the enlarged emotional states associated with PTSD. Talking to a client with the PTSD symptoms associated with 90% of children with disordered attachment is counterproductive. He also stated, “Traditional therapy is useless for severely traumatized people, but especially children because it does not reach the parts of the brain that were most impacted by trauma.” Treatment must be experiential and behavior based, not talking, to achieve insight. The most profound damage to the child’s development most often occurred during preverbal stages of development. They did not talk themselves into being behaviorally and emotionally problematic and they cannot talk themselves out of it. Discerning “tells” or “reveals” is a critical skill. The therapist and the parents cannot depend on a child telling the truth verbally so they must develop the ability to read the child’s physical cues -facial expressions, body language, size of pupils, clenching of hands, covering their mouth/eyes/ears during therapy, etc. A child will involuntarily, though subtly, reveal when the therapist has touched on a statement the child believes is true. Being able to read the child’s “tells” is best accomplished by having the child laying across the therapist’s lap. As children heal they are are more apt to behave their way into a new way of thinking, non-verbally responding to therapy and parental interactions, then to think their way into a new way of behaving.
Becoming an attachment oriented child and family therapist requires training
and expertise that goes above and beyond traditional fields of study.
Becoming an attachment based child and family therapist requires first and foremost having empathy for parents whose children are emotionally and behaviorally problematic. It is essential that empathy be followed up with a rigorous course of study, training, and internship in the specific practices and techniques required. Using ineffective techniques can be extremely damaging, often more damaging then doing nothing. Ineffective therapy reinforces the child’s sense of helplessness and hopelessness as they learn to believe that even professionals cannot help. They become hardened to therapy and more determined to not cooperate. Children affected by emotional and behavioral disorders do not grow out of their pathology, they grow into them. Children get more ingrained in pathological behaviors the longer they are allowed to continue. Every year that passes makes it more difficult for the child to recover healthy functioning. If at the end of 2 months of weekly intervention there is no positive sign of change in the child or family functioning, the therapist needs to admit he or she is not helping the family and refer them to another therapist. It is unethical to continue draining the family’s time and energy and resources while driving the child’s pathology deeper.