Treating Reactive Attachment Disorder in Children
Reactive attachment disorder (RAD) is a fairly new diagnosis of a serious psychological illness that without intervention can lead to detrimental and lifelong effects (Brooks, n.d.). RAD is considered a trauma and stressor-related disorder, as it is psychological distress following exposure to a traumatic or stressful event or the severe and persistent disregard of a child’s basic needs (American Psychological Association, 2013). RAD is characterized by “markedly disturbed and developmentally inappropriate social relatedness” (APA, 2013). Because RAD is under researched, treatment is lacking in both evidenced based approaches and empirically supported treatment (Lin, 2014). There is a strong need for continued research into this area as the consequences for a lack of treatment are tremendous both to the child and the world in which they live.
Overview of Attachment Theory
In order to understand RAD, one must first understand that RAD is an issue of attachment and then have an understanding of what attachment is, how it occurs, and what happens when attachments are broken (Lin, 2014). According to Feldman (2011) attachment is the positive emotional bond that develops between a child and a particular and special individual (p.179). This bond can be between a child and parent or caregiver, as well as between a child and a particular worker in an institutional setting (Smyke et al., 2012).
John Bolby first explored attachment theory in the 1930’s as he studied the effects of maternal loss and a child’s later ability to form relationships (Ainsworth, 1989). Bolby believed that attachment was a biological function that allowed for an infants survival, and provided the means for protection, comfort, and support, as it is vital that children have a secure base from which to explore the unfamiliar world around them (Feldman, 2011). Aside from this, Chapman (2002) describes the benefit of attachment, “Attachment with a parent provides the setting in which emotional responsiveness, behavioral purposefulness, cognitive understanding and language development occur.”
Attachment develops in a cyclical process. During the first few years of life an attachment cycle occurs which builds a child’s level of attachment. The attachment cycle is most commonly presented as occurring between birth and age two (Feldman, 2011). Essentially, an infant will express a need, and the manner in which that need is met determines the cycle of bonding that will occur (Ainsworth, 1989). In healthy bonding cycles, an infant expresses a need and their parent meets the need. In turn, the infant is comforted and learns that the world is a safe place and is able to trust and thus bond with the caregiver (Attachment Disorder Site, 2013).
In the disturbed attachment cycle, an infant expresses a need and that needs is met inadequately, if at all. When the need is left unmet, the infant learns that the world is not a safe place and trust does not develop. Without trust, bonding cannot occur. (Attachment Disorder Site, 2013)
This process is repeated many times over during the first years of a child’s life. In the beginning the needs are primitive but become more complex as the child gets older. In time, “the infant begins to organize these expectations internally into what Bolby has termed working models of the physical environment, attachment figures, and himself or herself” (Ainsworth, 1989).
The attachment cycle produces three types of attachment: secure, resistant, and avoidant (Ainsworth, 1989). Securely attached children have a solid base from which to explore the world around them (Ainsworth, 1989). They are confident because their caregivers have provided loving, consistent, sensitive, and responsive care in response to their needs (Inge, 1992). When a child is unsure if their needs will be met, they display a resistant attachment. This is usually related to having parents who respond inconsistently to their needs (1992). Children suffering from avoidant attachment have learned that their needs will be met with rejection (1992). When they expressed a need, their parent rejected their cry for help or attention (1992). After awhile, the child learns it is hopeless, if not dangerous to continue to express their needs.
Diagnosis of attachment disorder is at times difficult because there are so many comorbid conditions that appear with these children (Hall & Geher, 2003). Children with attachment disorder often end up with a list of other diagnosis that when further examined are encapsulated entirely within the attachment disorder symptom list. This is because the children fluctuate in their behaviors and behave differently depending on whom they are dealing with. One provider may see different symptoms that another provider does not ever notice (Hall & Geher, 2003). Haugaard & Hazan, 2004, also point to the fact that the list of symptoms of attachment disorder is so broad that it may at times be over diagnosed (2004).
Specifically the DSM-IV requires that children diagnosed with RAD have histories of pathogenic care, meaning experiences of parental abuse and neglect or lack of a consistent caregiver (APA, 2013). As previously mentioned, inadequate caregiving leads to a break in a child’s ability to bond later in life (APA, 2013). Since there is not a single, comprehensive tool for diagnosis, clinicians oftentimes utilize a variety of tools that when combined encapsulate most if not all of attachment symptoms. Sheperis et al. (2003) recommend using several reputable assessment tools in addition to parent and child interviews, intelligence tests, and comprehensive psychological histories: Child Behavior Checklist, Behavior Assessment for Children, Eyeberg Child Behavior Inventory, Sutter-Eyeberg Student Behavior Inventory, Randolph Attachment Disorder Questionnaire, and the Reactive Attachment Disorder Questionnaire.
The Child Behavior Checklist (CBCL) is designed to asses for abilities and behaviors in a standard format as well as differentiate between children who have and have not received mental health care in the past (Sherpis et al, 2003). The CBCL is a caregiver report questionnaire that rates a child on emotional problems and assesses for internalizing and externalizing issues as well as symptoms such as: social withdrawal, somatic complaints, anxiety and depression, destructive behavior, social problems, thought problems, attention problems, and aggressive and delinquent behaviors (Inter-University Consortium for Political and Social Research, 2011). The Behavior Assessment System for Children (BASC-2 BESS) The BASC-2 Behavioral and Emotional Screening System (BASC-2 BESS) is a measuring tool for behavioral and emotional strengths and weaknesses of children and adolescents from Preschool-12th grade (Pearson, 2007). Internalizing behaviors are those that are harmful to the child or adolescent while externalizing problems are those that harm others (Kamphaus & Reynolds, 2007). The Eyberg Child Behavior Inventory (ECBI) and the Sutter-Eyberg Student Behavior Inventory are used to determine the severity of conduct related behaviors of children between the ages of 2 and 17 (Hurley, Huscroft-D’Angelo, Trout, Griffith, & Epstein, 2013). The Randolph Attachment Disorder Questionnaire is used to determine the severity of RAD specific symptoms, but it must be noted that it is not specific to the DSM IV criteria for attachment disorder (Wimmer, Vonk & Bordnick, 2009). The Reactive Attachment Disorder Questionnaire does include the DSM-IV criteria and was used as well by Sheperis et al. (2003) in their diagnosis of attachment disorder.
Intervention and treatment
Treatment of RAD is complicated by an almost complete lack of clinical guidelines for treatment as well as a lack of evidence for effective treatment methods (Wimmer, Vonk, & Bordnick, 2009). Despite the lack of formal recognition and official guidelines, there are several treatment methods currently used based on the anecdotal evidence found by social workers, adoption agencies, therapeutic parents, and psychotherapists (Wimmer, Vonk, & Bordnick, 2009).
Treatment of RAD cannot simply focus on the child because the issue lies in their ability to form relationships with others (Brisch, 2012). For this reason, it is very important to support and train those surrounding the child to handle their specific therapeutic needs. Sadly most of those who are tasked with parenting these children have no idea what they are dealing with. What is most disturbing is the knowledge that if they were trained to handle the children in their care with sensitivity, patience, and empathetic understanding, the damage could be prevented or lessoned (Cole, 2005).
Cognitive therapy is based on the concept that “men are not disturbed by things, but by the view they take of those things” (Epitetus, 1916). Children who suffer from RAD have emotions and behaviors that are the byproduct of the perceptions of situations in their lives (Shi, 2014). These children learned that the world was not a safe place and that their needs could not be met by others in early childhood, the way to help them heal it seems would be to help them change those perceptions (Brisch, 2012).
The goal of therapy will be to help the client identify and change their faulty information processing. By correcting false beliefs, there will be an improvement in their mood and negative behaviors (Rubke, S.J., Bleck, D., and Renfrow, M., 2006). Cognitive therapy teaches clients to evaluate their thoughts in a conscious structured way, known as metacognition. By helping clients restructure their thought process, they can be helped to feel better and therefore better cope with their life. (Jones and Butman, 2011: Murdock, 2009)
RAD is caused by cognitive distortions. The distortions come in the form of negative interpretations and predictions of events in a person’s life. These interpretations and predictions are based on the schemas developed in childhood. Schemas are the cognitive structures that organize the information encountered and help to create meaning from them. They are developed through personal experience or vicarious learning. Schemas are based on a person’s core beliefs about the world. (Jones & Buttman, 2011).
There are several interventions that could be beneficial to a child with RAD. The first is Questioning. Questioning is utilized to help the client evaluate their thoughts as to accuracy (Murdock, 2009). Chidlren with RAD learned in early childhood that adults could not be trusted to meet their basic needs. In CT the client is asked to provide evidence of their thoughts and beliefs. The ultimate goal is to help the child understand that there are exceptions to their beliefs.
Clients with RAD could be given a Dysfunctional Thought Record (DTR) to take home each week. They should be asked to record times when they experience authomatic thoughts (AT) and during the following therapy session the client and counselor will go through both the DTR and the AT to examine his or her responses. Thoughts are evaluated based on their truthfulness, what the effect of believing the thought has, what the client can do about it, and if a friend were thinking that way how the client would tell them to handle it (Murdock, 2009).
Children with RAD fear sharing their true feelings and emotions as they feel they will not be handled in an appropriate way (Shi, 2012). They support their own distorted thoughts by not sharing their needs with others and then becoming angry when those needs are not met (Murdock, 2009). Role playing is an effective method for helping the client develop the assertiveness necessary to express their feelings in a healthy way about some of their most threatening scenarios, such as letting another person get close to them. The client will be asked to share how they are feeling when they begin to think someone is getting close to them and those feelings will be evaluated as to their accuracy. Once feelings are determined to be faulty, the client and counselor will come up with several assertive ways he or she could express those feelings in an assertive and healthy way. (Murdock, 2009).
Another possible treatment method for RAD is the use of Gestalt Therapy (GT). If one looks that the fact that children with RAD suffer from multiple disconnects, it would appear that a treatment method that is focused on integration of divided parts becoming whole in a way that is healthy and growth oriented would be beneficial (Murdock, 2009). Children with RAD have experienced circumstances where they were not cared for adequately (Brisch, 2012). The maltreatment in early childhood causes a boundary disturbance that prevents the child from connecting to the world around them (Jones & Butman, 2011). Children with RAD are living in survival mode. The focus on survival leads to an unhealthy contact with the environment in which there is an imbalance between them caring for him or herself and “attending to the needs” of those around them (Murdock, 2009, p.212).
The goal of GT is to help the client reconnect with their needs. The cycle of needs broken in early childhood result in unfinished business that interferes with their ability to have a healthy awareness of need and contact. According to Murdock (2009) these clients avoid contact by: introjecting (taking in experiences without experiencing them), projecting (seeing negative qualities in others that are actually present in themself), deflecting (avoiding or interrupting a feeling or interaction with another person), and retroflecting (turning the unacceptable impulses to themselves rather than express negative or painful emotions). Recent studies have shown that therapeutic methods that access emotion “activate a complete associative network making it available for exploration and restructuring,” this allows for re experiencing the emotional events and thus a “change in the trauma memory”(Paivio and Greenberg, 1995). The Gestalt treatment methods are hoped to help the client re experience those events in their life that have lead to a disconnect, create new emotional memories about them, and thus handle the unfinished business of their past (Jones and Buttman, 2011).
Chair Dialogue is utilized to help split off the harsh, judgmental, inner critic into one chair and the person experiencing the self into the other (Murdock, 2009). The goal of chair dialoging is to help the two parts of the self listen to each other with the understanding that this will result in integration. This method may also be used to help the child handle any unfinished business from their past such as addressing neglectful parents or caregivers who did not provide adequate care for them (Jones & Butman, 2011).
Children who have not had their most basic needs met experience a major disconnect between their body and their feelings (Brisch, 2012). Body work is essential to helpin the client become more aware of their physical sensations related to emotional response (Murdock, 2009). The client would be asked to discuss difficult situations and feelings and pay close attention to the way his or her body reacts. Understanding the physical reactions to emotional issues can help the children better handle their responses to emotions previously ignored.
Alternative Treatment Methods
While individual therapy is important, because attachment disorder involves their ability to make and form relationships, the relationships in the child’s life must be created and nurtured (Brisch, 2012). Attachment therapy is based on the premise that a caring, consistent, and responsive caregiver is necessary for the development of normal attachment to others (Wimmer, Vonk & Bordnick, 2009). The goal of attachment therapy is to give the child a “source of emotional security, opportunities for corrective social experiences, and better social skills” (Haugaard & Hazan, 2004).
Attachment therapy interventions are primarily focused on training and preparing the caregiver to better understand and aid the child in forming appropriate attachment. Attachment therapy includes parent education, parent skills training, and intensive family therapy (Wimmer, Vonk & Bordnick). There has been a great amount of controversy surrounding some types of attachment therapy, including holding therapy and rebirthing (Haugaard & Hazan, 2004). These techniques are described as “coercive” and highly criticized because they are used on children who have already experienced physical abuse, as a child who has been physically abused would have trouble distinguishing between holding therapy and the abuse they suffered.
Foster care as Treatment
Therapeutic foster care is fast becoming a treatment method for children suffering from RAD due to the belief that by placing a child in an environment conducive to attachment, the child can heal from previous attachment breaks (Smyke et al., 2012). One of the most notable uses of Therapeutic foster care is in treating children who were institutionalized in early childhood (Smyke et al., 2012). Parental neglect or abuse, abandonment, parental inadequacy, or parental deaths are common reasons why a child ends up in an institutional setting (Wilson & Greenberg, 2010). While institutionalization is less common in America, it is important to note according to the Congressional Coalition on Adoption Institute (2014) US families adopted over 7000 children from international countries that use institutions in 2012.
Therapeutic foster parents who are treating children with RAD are faced with the fact that children with this disorder respond oppositionally to parenting techniques typically found to be beneficial to children (Wimmer, Vonk, & Bordnick, 2009).
Christian counselors see RAD as a much deeper issue (Brooks, n.d.). The way in which a child is able to bond not only affects their earthy relationships, but how they are able to attach to God (Brooks, n.d.). Christian counselors refer to this phenomenon as God attachment (Brooks, n.d.). Children who form inadequate bonds grow with an inability to reach out and rely on God because they have become too independent, in contrast, children who were not allowed to find any self-confidence due to clingy parents, the child is not able to see beyond parental relationships and is not open to the Lord (Brooks, n.d.).
Cognitive therapy has a great deal to offer the Christian counselor. Both Christianity and CT identify and address negative thoughts and beliefs that should be avoided. Cognitive therapy holds people accountable for their beliefs and their behaviors related to those beliefs, much in the same way Christianity does. The concept of reaping and sowing discussed in Christianity is similar to the cognitive therapy idea that negative thoughts lead to negative beliefs and behaviors and vice versa. 2 Corinthians 10:5 tells us to take every thought captive to obey Christ, in the same way cognitive therapist teach clients to take control of their thoughts and align them with rational and constructive thinking. (Jones and Butman, 2011)
The danger with cognitive therapy is that it is more based on the usefulness and provability of a client’s belief than truth. Relativism is a dangerous concept for the Christian therapist; the lines of right and wrong can be easily blurred if a plausible explanation can be given for a thought or behavior. This is why God’s truth is so very important, it serves as an anchor to keep the client and the counselor grounded. It is not the client’s perception, but God’s truth, which should be the ultimate authority. (Jones and Butman, 2011)
Gestalt psychology acknowledges those qualities of human existence that can’t be quantified. This affirms the Christian belief that there are parts of humanity that reach beyond their physical make up, a collection of truths that cannot be explained by science. We are a blend of heart, soul, mind, and strength (Mark 12:30). As a Christian it is important to be fully present and aware of not only one’s self and others, but also of God’s presence, this is a concept that is utilized in Gestalt therapy as well (Jones and Butman, 2011). The focus on relationships with others is another concept that is found in both Christianity and Gestalt theory.
Gestalt theory focuses on the client’s perception of truth, this is dangerous as the human perception of right and wrong is relative, as are their experiences. The Bible warns that the heart is deceiving so a failure to utilize God’s truth in the treatment plan is not only limiting but also dangerous (Jeremiah 17:9). The focus on healing being accomplished simply by bringing the parts of the whole together is deceiving. True healing comes when we are set free from sin through God’s truth. The honest expression of one’s needs is given priority in Gestalt therapy whereas the Christian worldview requires that those needs be balanced with charity.
Children with a history of pathogenic care are at risk of developing Reactive Attachment Disorder. There are few resources available to those caring for children with this disorder, making treatment difficult and often unsuccessful. More research needs to be done to help develop both an adequate method of assessment, but also proper treatment methods that can be empirically supported. A failure to address these issues will leave the most vulnerable clients without the lifeline they need to get well and a society with an entire group of people who are unable to function in a healthy way in it’s midst.
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