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Attachment and Bonding: Clinical Implications Marolyn Morford, Ph.D. Ph.D. Sarah Kollat, Private Practice Penn State University State College, PA University Park PA CPPA Fall Workshop, September 13, 2014 Main Points Attachment research examines the nature of ties between a very young child and caregiver The term attachment has been overextended by population and age when it is better described as “bonding” Attachment treatment follows a separate path unrelated to research, trying to bridge a gap between what are emerging knowledge and real clinical problems Attachment – Normal Development 'Attachment system' The behaviors and physical features and behaviors of the infant that keep the caretaking adult near and attending Includes response preferences of infant that can begin prior to birth Essential for survival, biologically based Closely related to the 'fear system', activated by threats Critical Nature of Attachment Importance to survival of young and of species Resilience of critical, adaptive functions Attachment & attachment behaviors are such a basic survival skill, only the most extraordinary cases of extreme deprivation result in no attachment behaviors developing A child is not “unattached”: Children vary in whether they are securely or insecurely attached and to whom Young Child Attachment “Strange Situation” Secure – Calm on separation, greets mother on return: 65% Ambivalent/resistant – Distress/unsettled at separation; angry/passive on return: 4050% of children in a low risk sample (Zeanah, 1996) Avoidant - Active exploration, no checking with mother; little response to absence or return of mother: 20% in nonclinical sample Disorganized - Little goal-oriented behavior, Extension from very young children to older children & adults Adult Attachments (Bonding) Self-report, interview, ex., http://www.psychology.sunysb.edu/attachment/measur es/content/aai_interview.pdf Four main, similar styles of attachment have been identified in adults: Secure (~65%) Anxious–Preoccupied (~15%) Dismissive–Avoidant ] Fearful–Avoidant ] (~20%)* Ein-Dor et al. 2004, for summary If the rate of occurrence of an attribute or behavior is this high in a nonclinical (20%) or low risk population (40-50%), can we confidently say we are talking about a disorder? Could these be normal variants in response? Attachment Paradox Could there be some survival advantage to an event that is so prevalent in the population? Is that which is interpreted as dysfunctional for the individual, protective for the group? Benefits to practioners Deprivation Outcomes While there is some research to suggest that neglectful and abusive parenting can be related to externalizing or more impulsive behaviors in a small proportion of children, there is no evidence to suggest that this alone impairs young children’s ability to form bonds. Deprivation Outcomes More importantly, there is absolutely NO evidence that interventions focused on forcing bonds to form will reduce externalizing behaviors. Therefore, difficult children may not be made less difficult by improving a bond or creating attachmentlike behaviors. Attachment Dx Categories Located in DSM 5's Trauma- and Stressor Related Disorders*: Reactive attachment disorder NEW: Disinhibited social engagement disorder *This category also includes Post traumatic stress disorder, Acute stress disorder, Adjustment Disorders. Differential Dx/Co-occuring Developmental delays, esp. language and cognition, stereotypies, other signs of severe neglect (malnutrition) DSM-5 Reactive Attachment D/O 313.89/F94.2 Prevalence: Rarely seen in clinical settings; found in institutions and in severe neglect/abuse before foster placement. Even in populations of severe neglect, less than 2% to 10% of these children (DSM5). Reminder: This indicates resiliency in the majority of children! DSM-5 DIAGNOSTIC CRITERIA FOR REACTIVE ATTACHMENT DISORDER 313.89/F94.1 A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, rarely or minimally seeks comfort or responds to comfort when distressed DSM-5 DIAGNOSTIC CRITERIA FOR REACTIVE ATTACHMENT DISORDER 313.89/F94.1 A persistent social and emotional disturbance characterized by at least 2 of the following: •Minimal social and emotional responsiveness to others •Limited positive affect •Episodes of unexplained irritability, sadness, or fearfulness which are evident during non-threatening interactions with adult caregivers NEW: Disinhibited Social Engagement Disorder DSED 313.89/F94.2 Actively approaches and interacts with unfamiliar adults, exhibiting two or more: reduced reticence approaching and interacting with unfamiliar adults, overly familiar verbal or physical behavior in contrast to age- and culturally appropriate behaviors, diminished checking back with caregivers, or willingness to go off with unfamiliar adult Both Reactive Att Disorder and DSED require Evidence of at least one re: prior care Social neglect or deprivation - persistent lack of having basic emotional needs for comfort, stimulation, and affection met by care-giving adults. Repeated changes of primary caregivers, limiting opportunities to form stable attachments Rearing in unusual settings that severely limit opportunities to form selective Additionally, the child does not meet criteria for Autism Spectrum Disorder, the disturbance is evident before age 5, and the child has a developmental age of at least 9 months Serious social neglect is the only known risk factor for both of these disorders, yet the majority of such children DO NOT develop the disorder; Prognosis depends on quality of caregiving environment following serious neglect. (DSM 5) The different editions of DSM consistently have described these disorders as rare and have suggested that they are more often seen in those who have been reared in deprived, institutional settings. DSM-5 (APA, 2013) notes that fewer than 10% of children who have been severely neglected develop RAD, and about 20% develop DSED (also see Gleason et al., 2011). http://www.nasponline.org/publications/cq/42/8/dsm5.aspx Larger Problem When . our questions exceed our answers. . Overextending a concept Diagnosis: Reactive Attachment Disorder, or “RAD” is a label that has been applied to many children in the past 10 years, esp. adopted and foster children Treatment: “Specialized” treatments and “centers” have emerged to work specifically with children with this label Qualified clinicians become unnecessarily conservative and shy away from challenging child cases, assuming there is a sound basis for the ‘new’ clinical population and ‘treatments’ Other clinicians, lacking training (clinical or empirical) try valiantly to meet the need Problem: Diagnosis & Treatment Misapplication of the term occurs often (overextension) DSM-IV or DSM 5 definitions are not widely disseminated Problem: Diagnosis & Treatment Importance of evaluation of validity and effectiveness of proposed treatments Inappropriate or ineffective treatments exist to treat a questionably applied diagnostic label Contributing to the Problem: Misattribution of causality Post hoc reasoning Confirmation bias Single cause assumption (quest for a Unified Theory) Criteria for Diagnostic Category An observable, operational definition that anyone can use and agree with others in its application Distinct from other categories (mutually exclusive) And has predictive utility: We know other things about the person based on the application of this category Overextension of a term Misattribution of causality Post hoc reasoning Confirmatory bias Single cause assumption (Quest for “Unified theory”) “RAD” is an example of a label overextended by some to MANY difficult behaviors Giving the term weak distinguishing or predictive power Examples Oppositional, impulsive, destructive, lies & steals, is aggressive, hyperactive, selfdestructive, cruel to animals, sets fires, as poor hygiene, avoids touch, has toileting problems, is accident prone, high pain tolerance Persistent nonsense questions and incessant chatter Phony, Great theatrical displays Sexually act out at a very young age (seductive clothing, sexual to other children and animals)” RAD label also overextended to caretakers Some groups include caregiver “symptoms” in “diagnosis”: Feel isolated and depressed. Feel frustrated and stressed. Are hypervigilant, agitated, have difficulty concentrating. Are confused, puzzled, obsessed with finding answers. Feel blamed by family, friends, and professionals. Feel helpless, hopeless, and angry. Feel that problems are minimized by the helping profession. (Institute for Attachment, Problems with overextension Those labels do NOT appear in the criteria for Reactive Attachment Disorder, old or new Some of the labels DO appear in other diagnostic categories that are better applied to such children These labels are not clinical and are dangerous in how they make adults think and feel about the children in their care Such labels can apply to many types of individuals with their own histories and problems and do NOT indicate attachment problems Such labels can apply to the parents of many difficult-to-raise children, including those with chronic physical health problems Controversy about RAD Diagnosis Reliability? Not applied consistently by independent clinicians An overfocus on the preconditions (foster care, adoption) instead of symptoms Loss of precision,e.g., when aggression or defiance = aberrant attachment behs Untested alternative therapies are developed and implemented with no or problematic results (AACAP Practice Parameters, JAACAP (2005). What do different types of attachment predict? Insecure attachment creates risk for problems but alone does not cause problems In low risk families, less relation between insecure attachment & later externalizing problems In high risk families, more likely relation between insecure attachment & peer problems, moodiness, depression & aggression (Greenberg, 1999) But… What are we labelling as “attachment”? Couldn’t such a large segment of the population without extreme neglect history be explained by normal variance and temperament, among other possibilities? So…if it’s not RAD, what is it? Or... Reframing (and correctly diagnosing) to reduce fear and encourage competence in child and caregiver OCD Depression Oppositional Defiant Disorder Conduct Disorder Impulse Control Disorder Disruptive Behavior Disorder Generalized Anxiety Disorder Separation Anxiety Disorder Post-traumatic Stress Disorder Pervasive Developmental Disorder Asperger’s Disorder AttentionDeficit/Hyperactive Disorder Adjustment Disorder with Mixed Disturbance of Emotions and Conduct Developmental Delay (especially cognitive and language) Normal Development, Caretaker-child Temperament mismatch Normal Development, Adaptive behavior And… NEW: Disruptive Mood Dysregulation Disorder, DMDD, 296.99/F34.8 (Depressive Disorders): Severe recurrent temper verbal or behavioral outbursts grossly out of proportion in intensity or duration to context, inconsistent w/developmental level, 3+/week. Mood between episodes is persistenly irritable or angry nearly every day and observables by others, not just family, in at least 2 settings What we know about diagnosis The term “Reactive Attachment Disorder” has been applied to a wide range of behaviors that can be captured more appropriately with other, existing diagnostic categories, including 2 new, more discriminating categories in DSM5 The “problem” behaviors may originate from other causes: The child’s genetic or temperamental tendencies The foster/adoptive parent’s expectations The child’s early experiences and expectations Cultural expectations/mismatch (Rothbaum et al., 2000) Other parenting factors Resilience: Our goal for any child who has encountered risks Defining Resilience Masten's (2001): Good outcomes despite serious threats to adaptation or development Need for demonstrable risk Defining Resilience Can also view it as a diagnosis Examine Risk Level and Competence Level Highly vulnerable Competent Maladaptive Resilience Defining Resilience Risk Level Competence Level Low High Low Highly vulnerable Competent High Maladaptive Resilient Defining Resilience But what are “good outcomes”? What does it mean to “do well”? External Criteria Masten (2001): “Meeting the major expectations of a society for the behavior of children of that age and situation” These are Salient Developmental Tasks Defining Resilience What are salient developmental tasks? Of childhood? Of adolescence? Of adulthood? Defining Resilience Internal Criteria Psychological well-being Low levels of symptoms Which is more important to defining resilience? External Internal Old View of Resilience Only a few children possess remarkable or extraordinary strength to overcome difficulties Superchildren New View of Resilience (based on empirical studies) “Ordinary Magic” Resilience is fairly common Resilience likely to occur if basic systems are in “good working order” Basic Systems What are these BASIC SYSTEMS? Masten (2001) Small set of global factors Connections to caring adults Cognitive and self-regulation skills Positive self-views Motivation Basic Systems Why are these systems so important? What does this imply about interventions for at-risk children? Adoption and Resilience Studying adopted populations presents many challenges Variance in the adoptee’s circumstances (Foster care system, kinship adoption, international adoption, sibling group adoption, etc.) Variance in the age of the child at adoption Variance in the adoptive family’s circumstances (e.g., presence of biological children, singleparent family, etc.) Adoption and Resilience As a result, it is difficult to apply the findings of specific studies to all adopted children What do we seem to know? Early adoption (within first year of life) yields fewer symptoms Deprivation early in life can have lasting impacts on neurological development Many children improve in their symptoms over time after placement Adoption and Resilience BUT. . .The vast majority of adopted children develop within the normal range (Palacios & Brodzinsky, 2010) How can we help to support normal development in these children? Adoption and Resilience Fostering Resilience: A Mother’s Perspective Treat specific symptoms Before that, be certain that these are relevant symptoms “Adopted” as a label Biases that can occur Ignoring of natural variance in human behavior Reducing children to one facet of their history and self Adoption and Resilience Although a child’s history offers context that can aid in understanding their symptoms, we must be careful to not see their history as a symptom itself The mantra still applies: Each client is a study of one! Adoption and Resilience Normalizing remains a strong clinical tool Adoptive parents need healthy and reasonable expectations for their relationship with their children Attachment will not emerge immediately Children will revisit and process their experiences in their birth home/family and/or institution Parents will not be experts of their children immediately. . .and that is okay Adoptive Parents: What to Expect Attachment will not emerge immediately Children will revisit and process their experiences in their birth home/family and/or institution Rose-colored glasses Parents will not be experts of their children immediately. . .and that is okay Children will want to understand their origins This does not mean your relationship with them is lacking! Adoptive Parents: What to Expect Sticks and stones. . . Be aware of normal developmental changes Physical Cognitive Emotional / Social Remember: All families struggle, and all families have reasons to rejoice Struggles offer the opportunity for specific, targeted intervention that are evidencedbased What we know about treatment There is no one treatment (no silver bullet) for the myriad of problems that are described in popular discussions of reactive attachment disorder Treatment focuses on The problem behavior (one at a time) The bond What are the caregiver’s thoughts about the child and expectations about the relationship? The child often has no problems with attachment; the problem is s/he is not attached to the presenting caregiver. … A friend reaching for my 18 mo. old [adopted] daughter asked: “Does she go to strangers?” “Of course,” I answered, “She’s living with strangers.” From L. Melina Raising Adopted Children, Harper Collins, 1998. Treatments should be symptom focused. Known effective interventions for the troubling behaviors are required: behavior therapy cognitive therapy family education parent training as needed, pharmacological approaches Beware of: Damaging, unproven, coercive “therapies” Magical thinking involving regression methods Ineffective treatments that waste limited resources and precious time in a child’s young life American Professional Society on the Abuse of Children (APSAC) Statement Traditional attachment theory holds that caregiver qualities are key, such as Environmental stability Parental sensitivity Responsiveness to children’s physical and emotional needs Consistency and a safe and predictable environment support the development of healthy attachment From this perspective, improving these positive caretaker and environmental qualities is the key to improving attachment and bonds CHILD MALTREATMENT Vol. 11, No. 1, February 2006 76-89 We can treat these children most effectively if we have the assistance of the caregiver and other adults spending time with the child. We must recognize and address the emotional and psychoeducational needs of the caregiving adult as well as the child. Problems with “Attachment Therapy” Lack of informed consent to treatment -where is the advocate for the child? No link between attachment research and current popular treatments Illogical and invalid concepts, e.g., that children must release rage or regress to infancy before they can be loving Unethical targeting of adoptive and foster parent audience Often unlicensed practitioners Creation of adult fear of child & erosion of caregiver confidence Problems, cont. Lack of understanding of child’s developmental needs Lack of understanding of child’s adaptation process Expectation of immediate bonding and interpretation of resistance as “attachment disorder” Physically and emotionally intrusive, thereby retraumatizing an abused or neglected child and delaying development What treatment is recommended? Treat the behavior and the bond (not the same issue) If presented with a child with a history of attachment disruption, do not immediately assume treatment is necessary. Base interventions on symptom presentation: What behaviors are troubling to the child & the caregiver? Do think about the caregiver-child Recommended approaches focus on caregiver behaviors Give the child (a sense of) more control, don’t take control away from the child. Do give control in areas the caregiving adult is comfortable with (give child benign choices). Enhance the sensitivity of the adoptive parent to the child rather than the child to the parent (Dozier et al., 2002) Help the adult articulate what they want out of this relationship and help them Reduce caregiver’s expectation for rapid change and increase their acceptance of the child’s basic temperament and developmental needs (Dozier et al. 2002) Unlink the contingency between the child’s behavior and the permanency of the placement Emphasize positive reinforcement and positive exchanges of affection on the child’s terms, rather than the parents’ (Speltz, 2002, Dozier, et al. 2002). Treat the relationship Teach caregiver how to interact with child, to encourage bonding, cooperation, addressing child’s developmental level & emotional needs, using positive verbal comments, planned ignoring, teaching parent how to implement child directed interactions and parent directed interactions (Dozier, et al., 2002; Eyberg & McNeill, 2003; Webster-Stratton & Hancock, 1998) Treat the relationship Increase the caregiver’s competence and confidence through training: Start small Teach caregiver behavior therapy with child, including behavior substitution, differential reinforcement of incompatible or other behaviors, anxiety reduction techniques, such as gradual exposure, anxiety hierarchy and related treatments Treat the relationship, cont. Cognitive behavior therapy in the family context to assist with parental reframing, negative cognitions, expectations, and problem solving (W-S & H): Examine the thoughts the caregiver is having about the child & doubts about their own parenting ability: “You can parent this child.” Teach parent how to implement positive behavior management in home providing consistent rewards for appropriate behaviors (W-S&H, E&M, Barkley): for ex., giving attention for the positive behaviors the child is able to do, rather than for the failures Provide skill instruction with child for emotional regulation (e.g., anger thermometer) and social skills deficits, including teaching child how to give parent positive feedback Participant clinical examples Summary Attachment research has moved beyond the biological basis of infant and caretaker interactions and extended to older age groups and populations, altering the clarity of the term that bonding might describe Some groups have extended the term to and created interventions for a broad range of behaviors better described by known problems with effective treatments Both researchers and some working professionally with children, especially those children in foster care or adopted, do not address the very strong role resilience plays in growth and development We can Be rigorous and curious in our use of diagnoses and treatments provided to children, especially those who have no other advocates, as well as their families Be confident in providing treatment that is tailored to the specific problem Educate families and professionals to resist the tendency to pathologize or predict a child’s future from her/his current behavior or past Treat the relationship/bond between the parent and child, recognizing the responsibility for the interaction weighs more heavily to the adult caretakers Remember the primary factor as the resilience of children (and adults). Resources for parents & therapists www.help4adhd.org (‘Diagnosis & Trtmt’ link) www.chadd.org www.effectivechildtherapy.com (‘Learning Center’ link) www.promisingpractices.net http://www.apa.org/pi/cyf/cyfnews.html www.bpkids.org www.cachildwelfareclearinghouse.org Parent Training Programs: www.pcit.org www.incredibleyears.com www.triplep-america.com Trauma focused: www.tfcbt.musc.edu