Wednesday, June 22, 2016

Providing Family Friendly Support to Clients with Attachment Disorder

What is Attachment Disorder?
Attachment is defined as the affectional tie between two people. It begins with the bond between the infant and mother. This bond becomes internally representative of how the child will form relationships with the world. Bowlby stated “the initial relationship between self and others serves as blueprints for all future relationships.” (Bowlby, 1975)
Attachment Disorder is defined as the condition in which individuals have difficulty forming lasting relationships. They often show nearly a complete lack of ability to be genuinely affectionate with others. They typically fail to develop a conscience and do not learn to trust. They do not allow people to be in control of them due to this trust issue. This damage is done by being abused or physically or emotionally separated from one primary caregiver during the first 3 years of life. “If a child is not attached–does not form a loving bond with the mother–he does not develop an attachment to the rest of mankind. The unattached child literally does not have a stake in humanity” (Magid & McKelvey 1988). They do not think and feel like a normal person. “At the core of the unattached is a deep-seated rage, far beyond normal anger. This rage is suppressed in their psyche. Now we all have some degree of rage, but the rage of psychopaths is that born of unfulfilled needs as infants. Incomprehensible pain is forever locked in their souls, because of the abandonment they felt as infants.” (Magid & McKelvey 1988) “There is an inability to love or feel guilty. There is no conscience. Their inability to enter into any relationship makes treatment or even education impossible.” (Bowlby 1955). Some infamous people with Attachment Disorder that did not get help in time:  Saddam Hussein, Edgar Allen Poe, Jeffrey Dahmer, and Ted Bundy. One famous person with Attachment Disorder who did get help in time (in 1887!) and became one of the greatest humanitarians the US has ever produced is Helen Keller.
Attachment Disorder Symptoms
      Superficially engaging & charming
      Lack of eye contact on parents’ terms
      Indiscriminately affectionate with strangers
      Not affectionate on parents’ terms (not ‘cuddly’)
      Destructive to self, others and material things (‘accident prone’)
      Cruelty to animals
      Lying about the obvious (‘crazy’ lying)
      No impulse controls (frequently acts hyperactive)
      Learning Lags
      Lack of cause-and-effect thinking
      Lack of conscience
      Abnormal eating patterns
      Poor peer relationships
      Preoccupation with fire
      Preoccupation with blood & gore
      Persistent nonsense questions & chatter
      Inappropriately demanding & clingy
      Abnormal speech patterns
      Triangulation of adults
      False allegations of abuse
      Presumptive entitlement issues
      Parents appear hostile and angry
Any of the following conditions occurring to a child during the first 36 months of life puts them at risk:
      Unwanted pregnancy
      Pre-birth exposure to trauma, drugs or alcohol
      Abuse (physical, emotional, sexual)
      Neglect (not answering the baby’s cries for help)
      Separation from primary caregiver (i.e. illness or death of mother, or severe illness or hospitalization of the baby, or adoption)
      On-going pain such as colic, hernia or many ear infections
      Changing day cares or using providers who don’t do bonding
      Moms with chronic depression
      Several moves or placements (foster care, failed adoptions)
Caring for baby on a timed schedule or other self-centered parenting

Helpful Resources

99 Ways To Drive Your Child Sane – by Brita St. Clair
So You Want to Be a Prince? – by Deborah Hage, MSW
So You Want to Be a Princess? – by Deborah Hage, MSW

Case Management to the Rescue~Deborah Hage
For most agencies the central duties for the case manager assigned to the family are somewhat mechanical. The primary goal of case management with a child and family affected by attachment disorders, mood disorders, thought disorders and oppositional defiant disorder is more extensive. The very specific goal is to provide those services that will enable the family to remain a unit. Determining what those elements are and helping the family obtain them is critical.
Since it is the parents who are living with the child and the parents who are the experts on the child, they are the final determiners of what services are needed. The parents decide if therapy is effective. The parents help write the IEP so it is useful to them. The parents decide if medications are effective or not. The parents are pivotal members of the team and final arbiters of what is and what is not helpful to them in parenting the child in their care. The task of the case manager is to create a "circle of support" (Nancy Thomas coined the phrase) for the parents. This circle of support includes the respite providers, schools, therapist and psychiatrist.
When asked, the case manager can provide crucial support and information when the family must deal with others who work with the child. When not asked, it is often because the family believes (often correctly) that the case manager does not have the skills to help appropriately, does not have an understanding of the special needs which the child presents and thus interferes with, rather than contributes to, the provision of services.
In order for the team model to work the parents must have every opportunity for training in ways to gain control of the family environment and effectively discipline (train) child in the reciprocal tasks necessary for a healthy life. They must learn to do this while taking good care of themselves. The child must be able to come when called, stay where he/she is put, do what is expected, follow rules and regulations and go where he is told in order to be able to live independently as an adult. (That is, go to school, maintain a job, drive a car and stay out of jail.) Parent training must consist of appropriate and effective, yet nurturing, interventions, to teach parents how to have backbones of steel and marshmallow hearts. Training in Proactive, Reactive and Intrusive techniques; getting a child to cooperate in chores and engage in reciprocal activities; and when to engage in control battles and when and how to disengage are all essential.
In order to be able to offer appropriate support and advice, the case manager must know as much as the parents about parenting interventions effective with severely behaviorally disturbed children. Attending trainings with the parents, reading, listening to audiocassettes, and being willing to be trained by the parents who, as front line providers, often have more expertise than the worker, are all important.
As members of the circle of support the respite providers' goal is to support parents by giving them a break while enforcing their discipline. They must provide a safe, yet emotionally distant, environment. The goal is not to compete with the child for the parent's affection. The case manager's task is to identify people to provide respite, train them, help them identify and avoid efforts of the child to triangulate and manipulate the adults against each other and to listen to and address the parent's concerns regarding respite. (See Respite Training outline.) The case manager must make sure there is appropriate respite available for the parents as any time the child is in control of the home he will not get well. When the child takes control then the child needs to go to respite until he demonstrates he is willing to allow parents to give him appropriate directives.
The school staff enter the circle of support by teaching the child life skills while not imposing that task on parents already overwhelmed with living with and managing a child whose behavior is extremely challenging. The IEP must be written in such a way that homework is assigned to the child with no expectation of parental involvement. The child's behaviors must be dealt with effectively at school with parental support and advice, but without expecting parents to consequence for behaviors that occur at school. The case manager provides critical support to the parents at staff meetings to ensure the staff understands the pressures which the parents are facing at home and by not allowing the school to assign them unrealistic and inappropriate education related tasks.
The therapist becomes part of the circle of support by providing appropriate and effective therapy that is supportive of primary therapists - the parents. The goal is not to have the child bond with the therapist and thus compete with the parental bond. In order to avoid the child's attempts at triangulation and manipulation it is imperative the parents are present in the room at all therapy sessions. They must be physically present in order to call the child on all lies and misrepresentations of their behavior. Sessions are most useful to the parents when they begin by asking the parents what positive and negative behaviors the child has been exhibiting during the week. Another critical element of the session is brainstorming parenting interventions that address a specific behavior and have the potential to be more effective than what the parents are doing. The paradoxical techniques, that is, telling the child to do what the child is already doing, have great potential to be effective. After spending time with the parents becoming familiar with the current situation, the therapist brings the child in, praises the positive and confronts the negative. While useful, it is not essential that the therapist be trained in holding techniques. Appropriate interventions are experiential, rather than insight or talk based, such as Theraplay, EMDR, Art therapy, Psychodrama, Brain gym, Sensory Integration and other techniques where the therapist is in control. It is often helpful to have the child redo the behaviors exhibited at home. For example, if the child is calling the mom names, then the child comes to therapy and must say the same thing in the same tone of voice at the same volume to the therapist that he/she said to the mom at home. If the child had a tantrum at home then he/she must re-create the tantrum in the therapist's office on the therapist's terms. The point is that often the first step in stopping a behavior is to take control of it away from the child. If the child refuses to cooperate in therapy then the respite provider must step in and keep the child until the child is ready to do what is required for the therapist.
Many of the behaviors and emotions associated with attachment disorder are not alleviated by medication. However, mood, thought, and oppositional defiant disorders have a huge potential to be minimized by the appropriate use of medication. Finding a knowledgeable psychiatrist with experience in the above diagnoses is an important part of the case manager's job in creating a circle of support. The psychiatrist must not be discounting of the parent's experiences with the child's behavior and be able to ask probing questions regarding the child's behavior while listening carefully to the parent's responses. The goal is accurate diagnosis and provision of appropriate medication in effective doses. (Generally, Ritalin is not only ineffective but has the side effect of heightened physical outbursts! Stimulants in children with ODD, RAD and Bipolar is generally counterproductive)
The case manager is crucial in providing the circle of support the parents’ need in order to be successful in maintaining the child's placement in the home. How the case manager develops personal expertise and puts together and trains the treatment team to be supportive of the parents and effective in dealing with the child is key to the child's success and maintenance in the family.
From those who are already entrenched in the RADical World
I asked my fellow Trauma Mama’s what they wish that the people who work with their families knew, here are their responses:

*When you have a child with RAD and someone hands you a sticker chart, it makes you want to shoot yourself in the face. A child who is unconcerned about anyone or anything does not care about your chart. My child would do one of two things, earn all the stickers, get the prize and break it immediately and go right back to the behavior, or pee on the chart, yes I said pee. Secondly, it makes me absolutely furious when a professional shows up to my home and has no idea who my child is or what we are dealing with and pretends. If you don't know, ask, don't act like you know.

*What I have loved most is working with people who understand the chaos that comes with parenting a child like mine and who adjust accordingly, who I can text late or early and they will get to me when they can, who will say, "wow, I don't know, let me work on it" The best professionals are not the ones who know everything, but the ones who know to ask when they don't.

* I have also loved working with people who listened empathetically, asked what she could do to help, and even took all the kids back and sent me out for coffee on a couple of occasions when she saw how tired I was. She didn't treat me or my children like a case number, she treated us like humans and I love her for it.

* Don't be judgmental upon arrival. Assess the situation with an open mind (especially if they read a chart stating the child's special needs). Be aware that not all children are truthful. Notice to new or newer therapist: when a parent is disclosing child's history, please be aware they are sharing this for HELP. I had a therapist come in and started working with our family a couple years ago. She had never met our children. I gave her a history on J and she seemed very eager to help. Next thing I know I received a call from CPS over an event that happened while they were still in DCS custody. Needless to say that has made our family very skeptical of any new therapist coming in now. Another thought, don't be sympathetic all the time to my child all the time. She thrives on that attention and causes her to regress. For instance if we go to the park and Ms J didn't get to go for cussing our entire family out, don't show her you are sympathetic and acting as if their was a better consequence. Be supportive of the parent at all times and never show the child you disagree with parent. If you do disagree with parent in something they have did take it up with them personally in a confidential setting not in front of child.

* I hate it when a professional tries to "put themselves in our situation" or acts as if something they have gone through is similar. I'm sorry unless you have experienced a child IN YOUR HOME with this condition at this severity, I don't need your stories because our family needs HELP.

* Honestly, I've become so jaded that I automatically assume that they won't understand or be educated or be helpful. I just assume that there will be no help. I assume that they are people who mean well, but are incapable of helping. I'm not sure if that helps you at all, but that is where I am. People don't understand the stress, the pain, the frustration, and the damage being done.

* I have been fortunate in this area. When Tori was in kindergarten I had a brand new (her first case) TSS. I trained her on RAD with Nancy T. stuff. I was thankful that she was willing to learn and not set in her ways. I have tried to get professionals who understand the diagnosis. It goes much easier when they do. When sticker charts have been suggested to me, I usually say "They are ineffective with RAD kids, but go ahead and try if you want." Some have taken my advice, and some have learned through experience.  A few weeks ago, my daughter's new behavioral specialist gave her a journal. I just smiled, knowing that she would use it for anything but journaling. She did. Lesson learned for the BSC. Most of the professional wrap around support people have loved working with us. Our home is clean enough to be healthy, not infected with fleas and lice , and they are not afraid to sit down or take me up on an offered drink. They notice that I have parenting skills and am doing the right things. They appreciate that they do not have to spend time trying to teach me basic parenting skills. Most of what they try doesn't work any better than what I am already doing. What I love about them working with Tori is that I get a break when they are with her. Hubby and I often have a lunch date when Tori's TSS takes her to the library for a few hours. It is like a mini respite for me, and Tori gets another adult reinforcing what Mom and Dad are doing at home.

* Education of law enforcement for when they need to be called out. Do NOT separate parent & child. Do NOT assume the child is being abused. Do NOT tell the parent they need to spank (discipline) the child more. Assume the child COULD be playing the victim role VERY well if the parent TELLS you they are RAD and tries to explain the problem. If a child is hiding with a knife in hand when the police arrive, don't assume that knife wasn't a threat. Don't come down on the parent for calling 911. These things only empower a RAD child. Our RAD therapist told us we had no choice but to put our child in a home because of the inadequacy of our emergency services (including the mental health in our area).

*I must say I'm I'm agreement with the sticker charts because with mine it just doesn't matter how many charts or rewards...I also agree with the pitiful act when all they really need is to be held accountable for the hell they've been subjecting everyone around them to....I think journals are pointless as you have to want to make them worthwhile.....writing down coping skills to use next time....yea never happens....I am not sure how to make things work more effectively, but I wish we could figure something out. The things that don't work time and time again are just frustrating.

*NEVER say things like, "That's typical teenage boy behavior," or "my niece/ child/ neighbor's second cousin did that once" - you have NO IDEA of the difference in intensity and frequency unless you've lived it. Please don't assume that just because you've worked with my child for 50 minutes that you "get it," especially if I'm saying you aren't seeing something - my child can honeymoon for 6 weeks or more, and one would LITERALLY rather die than let anyone see her issues. Believe me, support me and validate me. Do NOT refuse to read the documents and questions the parent provides because you want to "form your own opinions and develop a relationship" with my child - my child has RAD - and I have learned a LOT about my child's needs that needs to be respected so we're not wasting time - especially attempting to develop a relationship with MY child - that's MY job. Just because my child is your client, please respect that I have to take care of my WHOLE family, including myself - that doesn't make me a bad parent to this ONE child. Here's some more things I wish I knew -

Feel free to contact me anytime, if I don’t know, I will help find it.

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