What is attachment, learning to attach, attachment disorder, RAD?

[font=Comic Sans MS]There are several models for treating attachment disorders. Some of them have sprung up in response to an increase in numbers of children in foster care and children adopted from institutions in the Eastern European block countries. Children from these backgrounds often present as non-attached to any particular caregiver. Keck and Kupecky (1995) use cradling in their work with poorly attached children and adolescents. Cradling is a technique in which the child is physically held on the lap of parent(s). The cradling is intended to provide physical containment, which can be reassuring if frightening feelings are aroused. Hughes (1997) describes a treatment method for working with nonattached children that encourages the caregiver to treat the child in a manner consistent with the child's developmental age, keeping the child under the constant close supervision of the caregiver. [/font] [font=Comic Sans MS]Dyadic Developmental Psychotherapy has been shown to be an effective treatment method for the treatment of children and teenagers with trauma-attachment disorders. [/font][font=Comic Sans MS]Another treatment method that has been tested and empirically demonstrated to facilitate secure attachment is infant-parent psychotherapy, originally described by Selma Fraiberg and her colleagues (1975). In infant-parent psychotherapy, as it was first conceived, the focus of the treatment was on the parent's emotional conflicts as they affect the infant. Fraiberg believed that a parent's emotional difficulties, originating in conflicted relationship histories, mental illness, family disruption, socio‑economic hardship, or a combination of these factors, could interfere with adequate physical and emotional care giving and lead to a disturbed relationship between mother and baby. More recently, infant‑parent psychotherapy has incorporated the understanding that infant constitutional vulnerabilities, and poorness of fit between the infants' characteristics and needs and the parents' care giving style, may also disrupt the parent‑child relationship. Infant‑parent psychotherapy now focuses on these factors as well as on the parents' emotional liabilities (Lieberman & Pawl, 1988). [/font] [font=Comic Sans MS]In two empirical studies, Lieberman and her colleagues (Fraiberg, Lieberman, Pekarsky & Pawl, 1981; Lieberman, Weston, & Pawl, 1991) have demonstrated that infant-parent psychotherapy can affect changes in the quality of infant-parent attachment, converting insecure attachments to secure ones. This therapy, which combines non‑didactic developmental guidance, help with problems in living, and the psychodynamic exploration of the infant-parent relationship and the parents' relationship history, can help repair anxious relationships and improve the baby's chances for the most favorable developmental outcomes. The case of Lily and her parents illustrates how infant‑parent psychotherapy can facilitate the development of secure attachments in families where there are multiple risk factors in the parents' histories and present lives. [/font][font=Comic Sans MS]Example of infant parent psychotherapy used with a drug-addicted mother [/font][font=Comic Sans MS]Karen was separated from her daughter, Lily, at birth because Karen had sought no prenatal care, she and Lily both tested positive for several substances (including heroin and methadone), and she had no stable home. Lily was placed in a group home where she was cared for by nurses and aides, including one nurse who was assigned to be her particular caregiver. Karen engaged in a day treatment program and visited Lily several times a week. Karen and her frequent comings and goings were confusing to Lily. The staff at the home noted that Lily cried frantically whenever Karen left her, but that when Karen was with her Lily was sometimes clingy and sometimes pushed her away or ignored her overtures. [/font] [font=Comic Sans MS]When Lily was ten months old, Karen was admitted to a clean and sober house for mothers and young children, and Lily was transitioned to her care. The referral for infant‑parent psychotherapy was made to facilitate the transition and to support Karen in undertaking the fulltime care of her daughter. Karen was thrilled to have Lily with her every day, but told the therapist that she could not understand Lily. Lily cried, refused to sleep in her own bed at night, and turned away from Karen when Karen tried to comfort her. Karen was deeply hurt that Lily did not share her joy at their reunion and said, "Lily just doesn't love me. She wants to hurt me to get back at me for leaving her alone. " Over time, the therapist helped Karen to see how difficult the transition from the group home to her care might have been for Lily. Although the group home had been imperfect, it had been Lily's home and filled with familiar figures. The therapist asked Karen about her own responses when she lost people who had been close to her. When Karen began to understand that Lily's behavior might be motivated by grief rather than vengeance, she was able to find ways to comfort Lily. [/font] [font=Comic Sans MS]The therapist observed that in her eagerness to care for Lily, Karen was often intrusive. Rather than responding to Lily's bids for attention, Karen pressed her affection on Lily in ways that made Lily angry. Karen would then feel rejected and pull away. The therapist helped Karen focus on times when Lily turned to . her, and supported her response to Lily at those times. The therapist could then point out the pleasure that Lily took in Karen's attention. The therapist also supported Karen by giving her a place to talk about her hurt and frustration that Lily did not always want her affection when she wanted to give it. With this support, Karen became less intrusive, more aware of Lily's bids, and more consistent in responding to them. As Lily grew more confident that her mother would respond when she expressed her need she turned to her mother more frequently and their interaction became more spontaneous and joyful. Within several months, Lily consistently turned to her mother when she needed help, and no longer pushed Karen away when Karen spontaneously offered her affection. her affection on Lily in ways that made Lily angry. Karen would then feel rejected and pull away. The therapist helped Karen focus on times when Lily turned to . her, and supported her response to Lily at those times. The therapist could then point out the pleasure that Lily took in Karen's attention. The therapist also supported Karen by giving her a place to talk about her hurt and frustration that Lily did not always want her affection when she wanted to give it. With this support, Karen became less intrusive, more aware of Lily's bids, and more consistent in responding to them. As Lily grew more confident that her mother would respond when she expressed her need she turned to her mother more frequently and their interaction became more spontaneous and joyful. Within several months, Lily consistently turned to her mother when she needed help, and no longer pushed Karen away when Karen spontaneously offered her affection. [/font] [font=Comic Sans MS]SUMMARY [/font][font=Comic Sans MS]Attachment, an affectional relationship between mother and baby and, later, between other caregivers and baby, is central to the personality development of every infant. Secure attachment can be derailed in many ways. Economic and social stresses, mental illness, substance abuse, and the constitutional vulnerabilities of the child can all act to place difficulties in the path of the relationship between a baby and her mother. These relationships can, however, be healed and the baby returned to a hopeful developmental path.[/font]

[font=Arial]by Arthur Becker-Weidman, Ph.D. [/font][/font][font=Arial][font=Comic Sans MS]A high percentage of the children that I see are foster or adopted children who have lived in one or more foster homes and have suffered from neglect and/or abuse. Often the children come with a diagnosis of Oppositional Defiant Disorder [ODD] or Conduct Disorder [CD]. Many have a secondary diagnosis of Attention-Deficit Hyperactivity Disorder (ADHD). The child's symptoms could also be understood as a Post Traumatic Stress Disorder or depression stemming from a delayed grief reaction in response to one or more significant losses early in childhood. Whatever the diagnosis is, it is important that the developmental history receives the consideration required to provide the appropriate treatment.[/font][/font][font=Comic Sans MS] [/font][font=Arial][font=Comic Sans MS]Because attachment is developed in the first years of life, often times the trauma driving the child's pathology is preverbal. The child needs a solid educational component of treatment for the child to understand what force is driving the feelings and controlling the child's behavior. The parents also need the education and understanding that the child's behavior is not caused from their parenting, but from past traumas. From this base then, new parenting interventions can be designed from a cooperative relationship to fit a child with special needs.[/font][/font][font=Arial][font=Comic Sans MS] [/font][/font][font=Arial][font=Comic Sans MS]Attachment is the base upon which emotional health, social relationships, and one's world view are built. The ability to trust and form reciprocal relationships will affect the emotional health, security and safety of the child, as well as the child's development and future interpersonal relationships. The attachment-disordered child does whatever she feels like, with no regard for others. She is unable to feel remorse for wrongdoing, mainly because she is unable to internalize right and wrong. This child may be savvy enough to speak knowledgeably about standards and values, but cannot truly understand or believe what she is saying. The child may tell you that something is wrong, but that will not stop her from doing it.[/font][/font][font=Arial][font=Comic Sans MS] [/font][font=Arial][font=Comic Sans MS]Children who are adopted after the age of 6 months or so are at risk for attachment problems. Normal attachment develops during the child's first two years of life. Problems with the parent-child relationship during that time, or breaks in the consistent caregiver-child relationship, prevent attachment from developing normally. There is a wide range of attachment problems that result in varying degrees of emotional disturbance in the child. The severity of attachment disorder seems to result from the number of breaks in the bonding cycle and the extent of the child's emotional vulnerability.[/font][/font][font=Comic Sans MS] [/font][font=Arial][font=Comic Sans MS]Emotional vulnerability can be affected by a variety of factors including: genetic factors; prenatal development including maternal drinking and drug abuse; pre-natal nutrition and stress; Fetal Alcohol Syndrome and Fetal Alcohol Effect; temperament; and birth parent history of mental illness (schizophrenia, manic depressive illness, etc.). One thing is certain: if an infant's needs are not met consistently in a loving, nurturing way, attachment will not occur normally.[/font][/font][font=Comic Sans MS] [/font][font=Arial][font=Comic Sans MS]So how can we tell the difference between a child who "looks" attached, and a child who really is making a healthy, secure attachment? This question becomes important for adoptive families, because some adopted children will form an almost immediate dependency bond to their adoptive parents. To mistake this as secure and healthy attachment can lead to many problems down the road. Just because a child calls someone "Mom" or "Dad," snuggles, cuddles, and says "I love you," does not mean that the child is attached, or even attaching. Saying, "I love you," and knowing what that really feels like can be two different things. Attachment is a process. It takes time. The key to its formation is trust, and trust becomes secure only after repeated testing.[/font][/font][/font] [font=Arial][font=Comic Sans MS]Normal attachment takes a couple of years of cycling through mutually positive interactions. The child learns that he is loved, and can love in return. The parents give love, and learn that the child loves them. The child learns to trust that his needs will be met in a consistent and nurturing manner, and that the he "belongs" to his family, and they to him. Positive interaction. Trust. Claiming. Reciprocity (the mutual meeting of needs, give and take). These must be consistently present for an extended period of time for healthy, secure attachment to take place. It is through these elements that a child learns how to love and how to accept love.[/font][/font][font=Comic Sans MS] [/font][font=Arial][font=Comic Sans MS]Older adopted children need time to make adjustments to their new surroundings. They need to become familiar with their caregivers, friends, relatives, neighbors, teachers and others with whom they will have repeated contact. They need to learn the ins and outs of their new household routines and adapt to living in a new physical environment. Some children have cultural or language hurdles to overcome. Until most of these tasks have been accomplished, they may not be able to relax enough to allow the work of attachment to begin. In the meantime, behavioral problems related to insecurity and lack of attachment, as well as to other events in the child's past, may start to surface. Some start to get labels like, "manipulative," "superficial," or "sneaky." Sooner or later the family may decide that this kid is all "take" and no "give." The child "gives" only when it is to his own benefit. The child can seem to be very selfish and controlling. On the inside, she is filled with anxiety. She has not developed the self-esteem that comes with feeling she's a valued, contributing member of a family. The child cares little about pleasing others, since her relationship with them is quite superficial.[/font][/font] [/font][font=Arial][font=Comic Sans MS]FIRST YEAR OF LIFE CYCLE[/font][/font][font=Comic Sans MS]

[/font][font=Arial][font=Comic Sans MS]by Arthur Becker-Weidman, Ph.D. [/font][/font][font=Comic Sans MS][/font][font=Arial][font=Comic Sans MS]The first year is a year of needs. When the infant has a need, it initiates attachment behavior in order to summon a nurturing response from the attachment figure. The need-gratifying response usually includes touch, eye contact, movement, smiles and lactose. When gratification occurs, trust is built. This cycle occurs hundreds of times a week and thousands of times in the first year. From this relationship, a synchronicity develops between parent and child. The caregiver develops a greater awareness of the child and learns just how to respond. The child develops good cause-and-effect thinking, feels powerful, trusts others, shows exploratory behavior and develops empathy and a conscience.[/font][/font][font=Comic Sans MS] [/font][font=Arial][font=Comic Sans MS]Parenting children with attachment difficulties is a job that requires a great deal of patience, understanding, courage, solid support systems and personal fortitude. Children with attachment difficulties rarely and only superficially return love. Therapists, teachers, child protective services and even spouses often do not understand the challenge and deception an attachment-disordered child displays toward an adoptive or foster parent in charge of primary care. Often times the child will project the greatest amount of pathology towards the mother figure in an attempt to make the world believe that if the mother was not so harsh and controlling, the child would be as lovable as he superficially displays.[/font][/font][font=Arial][font=Comic Sans MS] [/font][/font][font=Arial][font=Comic Sans MS]Therapists often times are introduced to attachment disorder cases by witnessing a burned-out parent in their office who is angry, resentful and full of blame toward their child. The child, however, is engaging, full of energy, innocent and displaying confusion at the parent's anger. Unfortunately, the therapist reacts by thinking (and sometimes saying), "If this mom would just lighten up on this kid, she would not have so many problems." This can lead the therapist to scolding the parent much in the same way the parent scolds the child. Many well-intentioned but naive healthcare workers believe that, "All this kid needs is love," and end up creating an alliance with the child against the parents that further prevents the family getting the help they desperately need. [/font][/font][font=Arial][font=Comic Sans MS] [/font][font=Arial][font=Comic Sans MS]TREATMENT[/font][/font][/font] [font=Comic Sans MS]The basic purpose of attachment therapy is to help the child resolve a dysfunctional attachment. The goal is to help the child bond to the parents and to resolve the fear of loving and being loved.[/font][font=Comic Sans MS] [/font][font=Arial][font=Comic Sans MS]A major dynamic in the treatment is the affective regressive work needed to heal the emotional wounds that drive these children's behavior. Therapeutic holding allows the child to access deep, genuine, and intense emotions needed to work through the feelings, not simply get over them. A corrective emotional experience is orchestrated when allowing the child to express these feelings, recognize and recall them, and identify the events and the people involved. In essence, the child going through this experience with their parents allows for resolution of old pathological emotions while simultaneously creating powerful new bonds.[/font][/font]