Attachment, Trauma, and Healing
Attachment, Trauma, and Healing
Attachment, Trauma, and Healing
of related interest
Attaching in Adoption
Practical Tools for Today’s Parents
Deborah D. Gray
ISBN 978 1 84905 890 2
eISBN 978 0 85700 606 6
Nurturing Adoptions
Creating Resilience after Neglect and Trauma
Deborah D. Gray
ISBN 978 1 84905 891 9
eISBN 978 0 85700 607 3
Nurturing Attachments
Supporting Children who are Fostered or Adopted
Kim S. Golding
ISBN 978 1 84310 614 2
eISBN 978 1 84642 750 3
Second Edition
Foreword. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Acknowledgments. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Confidentiality. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1 Introduction. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
2 Historical Perspective. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3 Roots of Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
4 Personal and Social Competencies: The Attachment Foundation . . . 75
5 Disrupted Attachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
6 Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130
7 Corrective Attachment Therapy: Basic Theoretical and Treatment
Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 164
8 Corrective Attachment Therapy: Methods and Interventions . . . . . 186
9 Corrective Attachment Therapy: The Family System. . . . . . . . . . . . 234
10 Adult and Couple Attachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 256
11 Intensive Outpatient Psychotherapy. . . . . . . . . . . . . . . . . . . . . . . . . 280
12 Corrective Attachment Parenting. . . . . . . . . . . . . . . . . . . . . . . . . . . 315
13 Foster Care, Adoption, and the Child Welfare System. . . . . . . . . . . 348
Appendix A Intake Forms. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 379
Appendix B A Day in the Life… . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 400
Appendix C Sentence Completion Form. . . . . . . . . . . . . . . . . . . . . . . . . . 404
Appendix D Patterns of Attachment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 406
Appendix E Symptom Comparison: ADHD, Biploar Disorder,
Reactive Attachment Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 408
Appendix F The Effective Corrective Attachment Therapist. . . . . . . 413
Appendix G Positive Psychology. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414
Appendix H Life Script. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 421
Appendix I Follow-Up Treatment Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . 425
Bibliography. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 428
About the Authors. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 459
Subject Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 461
Author Index. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 471
List of Tables
Table 3.1 Stages in Early Infant–Caregiver Interaction. . . . . . . . . . . . . . . . . . . . . 61
Table 3.2 Birth to 8 Months . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 63
Table 3.3 Eight to 18 Months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
Table 3.4 Eighteen Months to 3 Years. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Table 3.4 Eighteen Months to 3 Years continued . . . . . . . . . . . . . . . . . . . . . . . . . 68
Table 4.5 Internal Working Models. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77
Table 6.1 Intake Packet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
Table 6.2 Signs of Attachment Disorder in Young Children. . . . . . . . . . . . . . . . 133
Table 6.3 Causes of Attachment Disorder. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134
Table 6.4 Assessment of the Child. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .139
Table 6.5 Parent and Family Assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145
Table 6.6 Continuum of Attachment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 149
Table 7.1 Therapeutic Contracting. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 182
Table 11.1 Adoption Background. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 296
Table 11.2 Placement History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 297
Table 13.1 Minimizing the Trauma of Moves: Developmental Considerations . . 367
List of Figures
Figure 3.1 First-Year Attachment Cycle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Figure 3.2 Second-Year Attachment Cycle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71
Figure 5.1 Vicious Cycle of the Unresponsive Infant . . . . . . . . . . . . . . . . . . . . . . . 97
Figure 8.1 Vicious Cycle of the Acting Out (“Bad”) Child. . . . . . . . . . . . . . . . . . 192
Figure 10.1 Dimensions of Attachment Style. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 257
Figure 12.1 The Autonomy Circle. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 326
Foreword
Sumiko Tanaka Hennessy
It was May, 2004 that I first met Dr. Terry Levy and Mr. Michael Orlans
of the Evergreen Psychotherapy Center/Attachment Treatment and
Training Institute (ATTI), of Evergreen, Colorado. They were teaching a
preconference workshop on Corrective Attachment Therapy at the National
Foster Parent Association Conference in Orlando, Florida. I participated
in their workshop while waiting for the arrival of a group of Japanese foster
parents who were attending this conference. I had just come back to the
United States from my four-year stay in Japan, where I helped to open a
college of social work. During my stay in Japan, I realized the mounting
problems of child abuse and neglect, and made it my mission to get to know
Japanese foster parents who cared for these children. Before going to Japan, I
was the executive director of the Asian mental health clinic in Denver, where
we worked with refugees and immigrants with posttraumatic stress disorder
(PTSD) and Asian adopted children with attachment disorders. Attachment
and healing of trauma had been my lifelong interest.
Although I was very familiar with the attachment therapy offered by
the Attachment Center in Evergreen, Colorado, I had never met Dr. Levy
or Mr. Orlans, who also practiced in Evergreen. I immediately realized that
the work of Dr. Levy and Mr. Orlans was quite different from what I had
observed at the Attachment Center. First, Dr. Levy and Michael Orlans
were family therapists, and based on systems theory, believed that the child
needed to be healed within the family system. The Attachment Center
separated the child from his/her adoptive or foster parents, and placed the
child into a therapeutic foster home. Second, the Attachment Center used
a holding technique which was controlling and coercive. I always felt that
this approach was too severe and worried about damaging the child further.
The therapeutic process used by Dr. Levy and Mr. Orlans, referred to as the
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ATTACHMENT, TRAUMA, AND HEALING
Limbic Activation Process (LAP), was done with the child’s permission, and
was nurturing, supportive, and safe. They stressed the cues of attachment,
including eye contact, gentle touch, and mutual smiles. The DVD they used
to illustrate their therapy process touched me so deeply that I requested there
and then to become a student of their approach.
Immediately after returning to Colorado, I participated in a two-week
training session at their Center, and witnessed how the entire family changed
for the better within the designated 30 hours of therapy (three hours a day
for ten days). Every year since 2005, I have brought a group of Japanese
mental health workers and foster parents to ATTI, where Dr. Levy and Mr.
Orlans gave a week-long workshop on attachment theory, childhood trauma,
and the healing process. These workshop participants always report extremely
positive results of their training.
Another fortuitous event in 2004 was a week spent with Dr. Bessel van
der Kolk at the Cape Cod Institute in Easton, MA. Since our Asian clinic
dealt mainly with refugees from Viet Nam, Cambodia, and Laos, we had
studied the work of Dr. van der Kolk, the president of the International
Society of Traumatic Stress Studies (ISTSS). He is the Chief of Psychiatry
at Boston University, the founder and medical director of the Boston Trauma
Center, and is a leading researcher and clinician regarding psychological
trauma. Dr. van der Kolk presented new approaches to healing trauma based
on recent findings from brain research. He first clarified that psychotropic
medications could not heal trauma, but only reduced the symptoms. The
use of selective serotonin re-uptake inhibitor (SSRI) medication and
counseling might reduce the severity of PTSD symptoms for a while, but
if the patient subsequently experienced a similar occurrence, his/her PTSD
symptoms would reappear. This I knew very well from treating refugees,
as they returned to our clinic for more therapy after they watched refugee
incidents in Europe or Africa on television. The second point Dr. van der
Kolk stressed was that when trauma occurred, the functioning of our new
brain (frontal lobe) diminishes, and the old brain function (limbic system
and brain stem) takes over for survival. Therefore, it is not effective to counsel
a person by targeting the frontal lobe area. Neither our limbic system nor
brain stem is aware of time, therefore flashbacks can occur at any time. As
there is no connection from the frontal lobe area to the limbic system, using
words to heal trauma, which he called “a top-down approach,” does not work.
What we needed to do, he suggested, was to focus our therapy directly on
the overactive, impaired limbic system (symptoms such as arousal, flashbacks,
rage, fearfulness, avoidance). By healing the limbic system and brain stem, we
can then heal the cortex. He called this approach “a bottom-up approach to
10
Foreword
11
Acknowledgments
12
Confidentiality
We have used case vignettes throughout this book to illustrate clinical and
treatment issues. These vignettes are based on actual children, adults and
families, who have participated in our treatment program, although names
and circumstances have been changed to protect confidentiality.
13
1
Introduction
Over 25 years ago, we (Terry M. Levy and Michael Orlans) rarely received a
referral of a child with a diagnosis of attachment-related disorder. The focus
was usually on the symptoms (e.g., anger, aggression, anxiety, depression,
emotionally distant from parents), but the core issue—disrupted attachment
caused by maltreatment and interpersonal trauma—was overlooked. It is now
common knowledge in the mental health and social science fields that lack of
safe, secure, and attuned caregiver–child attachment in the early stages of life
can lead to many problems in childhood and, in fact, throughout life.
Many children are failing to develop secure attachment to loving, protective
caregivers—the most important foundation for healthy development.
They are flooding mental health, child welfare, and school systems with an
overwhelming array of problems (emotional, behavioral, social, cognitive,
developmental, physical, and moral) and growing up to perpetuate the
cycle with their own children. Some social service and mental health
professionals believe that attachment disorder is rare: the evidence indicates
otherwise. Research has shown that up to 80 percent of high-risk families
(poverty, substance abuse, abuse and neglect, domestic violence, history of
maltreatment in parents’ childhood, depression, and other psychological
disorders in parents) create disorganized/disoriented attachment patterns
in their children. Since there are one million substantiated cases of serious
abuse and neglect in the United States each year, the statistics indicate that
there are 800,000 children with severe attachment disorder coming to the
attention of the child welfare system each year (Lyons-Ruth 1996; Pynoos et
al. 2008). This does not include the thousands of children with interpersonal
trauma who are adopted from other countries.
14
Introduction
Attachment
Attachment is the deep and enduring connection established between a
child and caregiver in the first several years of life. It profoundly influences
every aspect of the human condition—mind, body, emotions, relationships,
and morality. Attachment is not something that parents do to their children;
rather, it is something that children and parents create together, in an ongoing,
reciprocal relationship. Attachment to a protective and loving caregiver who
provides security and support is a basic human need, rooted in millions of
years of evolution. We have an instinct to attach: babies instinctively reach
out for the safety of the “secure base” with caregivers; parents instinctively
protect and nurture their offspring. Attachment is a physiological, emotional,
cognitive, and social phenomenon. Instinctual attachment behaviors in the
baby are activated by cues or signals from the caregiver. Thus, the attachment
process is defined as a “mutual regulatory system,” in which the baby and the
caregiver influence one another over time.
The principal developmental task of the first year of life is the
establishment of a secure attachment between infant and primary caregiver.
In order for this bond of emotional communication to develop the caregiver
must be psychologically and biologically attuned to the needs, emotions, and
mental state of the child. Beyond the basic function of secure attachment—
providing safety and protection for the vulnerable young through closeness
to a caregiver—there are several other important functions for children:
• to learn basic trust and reciprocity that serve as a template for all future
emotional relationships
• to explore the environment with feelings of safety and security (“secure
base”), which leads to healthy cognitive and social development
• to develop the ability to self-regulate, which results in effective
management of impulses and emotions
• to create a foundation for the formation of an identity that includes
a sense of competency, self-worth, and a balance between dependence
and autonomy
• to establish a prosocial moral framework that involves empathy,
compassion, and conscience
• to generate a core belief system that comprises cognitive appraisals of
self, caregivers, others, and life in general
• to provide a defense against stress and trauma, which incorporates
resourcefulness and resilience.
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ATTACHMENT, TRAUMA, AND HEALING
16
Introduction
Disrupted Attachment
Children who begin their lives with compromised and disrupted attachment
(associated with prenatal drug and alcohol exposure, neglect of physical and
emotional needs, abuse, violence, multiple caregivers) are at risk of serious
problems as development unfolds, including:
• low self-esteem
• being needy, clingy, or psuedoindependent
• decompensating when faced with stress and adversity
• lacking self-control; being biologically and behaviorally dysregulated
• inability to develop and maintain friendships
• alienation from and opposition to parents, caregivers, and other
authority figures
• antisocial attitudes and behaviors
• aggression and violence
• difficulty with genuine trust, intimacy, and affection
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ATTACHMENT, TRAUMA, AND HEALING
18
Introduction
19
ATTACHMENT, TRAUMA, AND HEALING
at least part of their week in day care (Cohen 2013). Child care services are
well regulated in many countries, but not in the United States. The maternity
and nursing benefits given to working mothers in the United States are
the least generous in the industrialized world. Although there is ongoing
debate regarding the benefits of staying home with your child versus placing
the child in day care, the need for substitute child care is a reality. Research
has revealed the ingredients of quality substitute child care: proper staff
education and training, small staff–child ratios, adequate financial incentives
for staff, consistency of one child care provider who remains with a child
through developmental stages, staff–parent collaboration, cooperation, and
communication. Despite this knowledge, most child care facilities do not
meet these requirements. One survey found that every state in the United
States failed to meet the requirements for quality day care (Young, Marsland,
and Zigler 1997).
Basic Principles
Our treatment program (Corrective Attachment Therapy) and parenting
program (Corrective Attachment Parenting) are grounded in a foundation of
basic theories, principles, and research. The following are the key elements
of our philosophy, which inform our work with children, adults, couples, and
families:
• Family Systems: The child, parents, and other family members must be
understood in the context of the systems that influence their lives. The
focus is on prior and current family systems, and external systems such
as social services, extended family, social networks, and community
resources. The systems model concentrates on the behavior of family
members as they interact in ongoing and reciprocal relationships, and
on the family as it interacts with external social influences.
• Neurobiology: In utero and early attachment experiences significantly
affect the wiring of the brain, because the young child’s brain grows
more than at any other time in life, and relationships shape the
developing brain. Lack of secure attachment and traumatic stress
triggers an alarm reaction, altering the neurobiology of the brain and
central nervous system. Traumatized children and adults often have
impaired wiring in the brain’s limbic system and altered levels of
stress hormones, resulting in anxiety, depression, and self-regulation
problems. Effective treatment and parenting rewires the limbic system
and reduces the biochemistry of stress.
20
Introduction
21
ATTACHMENT, TRAUMA, AND HEALING
changing core beliefs are best achieved via positive experiences with
significant others—therapists, parents, spouses, and siblings. Effective
treatment employs mental, emotional, and interpersonal experiences,
in a safe, sensitive, and supportive manner. Healing parents realize
that the experience of a positive relationship with their children is the
primary vehicle for change.
• Positive psychology: Therapy is competency based. All family members
have resources and strengths that must be identified and encouraged.
It is helpful to focus on “what is right” and build upon that, not only
on “what is wrong.” Therapists and parents must be aware of becoming
frustrated, overwhelmed, and pessimistic. It is crucial to remain calm,
positive, use a language of hope, and communicate an expectation
of success. Positive psychology teaches that resilience, recovery, and
posttraumatic growth following trauma is associated with several
factors: hope, sense of meaning and purpose, positive emotions, social
support, acts of kindness, and internal locus of control (“I can create
change”).
• Theory and research based: Treatment is based on a variety of theories
and research findings. The underpinnings of our model are trauma
theory (PTSD, neurobiology of stress and trauma); family systems
theory (dynamic, structural, strategic approaches); attachment theory
and research (internal working model, developmental research,
disorganized–disoriented attachment, parent–infant bonding);
experiential therapy (affective expression, process orientation);
cognitive–behavioral treatment (cognitive rescripting, developing
coping skills); psychoanalytical theory (object relations); and positive
psychology (signature strengths, resilience). Research findings are
incorporated into the treatment methods to bring about safe and
effective outcomes.
• Solution focused: The primary goal of treatment is positive change—new
choices, perspectives, options, behaviors, coping skills, and relationships.
It is essential to have a conceptual framework that defines the process
of change. Our theoretical framework is revisit, revise, and revitalize.
This framework provides a structure for determining therapeutic goals
and methods during the course of treatment. A four-step model guides
treatment interventions: assess set goals intervene (method) reassess.
• Culturally sensitive: Behavior, as well as the personal meaning of events,
varies depending on cultural background and tradition. The therapist
must be aware of the cultural orientation of the child and family, and
be careful not to project his or her own cultural biases, perceptions, or
22
Introduction
Interpersonal Neurobiology
The study of interpersonal neurobiology focuses on the relationship between
early attachment experiences and the “wiring”of the brain (Siegel 2007; Schore
2012). Understanding neurobiology has resulted in a deeper appreciation of
how the earliest relationships shape child development and have an influence
later in life. Brain development in infancy is “experience dependent”; the
baby’s brain, specifically the limbic system, relies on sensitive and attuned
care from attachment figures for healthy growth and functioning. Early
relationship experiences play an essential role in shaping the architecture of
the brain and building connections between parts of the brain. Chronic stress
associated with lack of safe and secure attachment can impair the formation
of brain circuits and alter levels of stress hormones, resulting in emotional
and biological dysregulation, anxiety, and depression.
Combining our understanding of attachment, trauma, child development,
family systems, and neurobiology enables us to provide a comprehensive
approach to treatment and parent training that links mind, body, and
relationships. Psychotherapy with children and adults who have experienced
interpersonal trauma focuses on changing brain structure and function—
rewiring the limbic brain—in addition to mental, emotional, and social
changes.
Adult Attachment
In recent years there has been significant interest in adult attachment styles
and how these patterns of attachment influence adult intimate and romantic
relationships ( Johnson 2008; Levine and Heller 2010). Attachment styles
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ATTACHMENT, TRAUMA, AND HEALING
learned in childhood tend to endure throughout life. Thus, each of the four
childhood attachment styles has a corresponding adult version. Securely
attached children become autonomous adults, who are comfortable in warm,
loving, and emotionally close relationships. Avoidantly attached children
become dismissive adults, who are distant and rejecting in their intimate
relationships. Anxiously attached children develop into preoccupied adults,
chronically insecure, needy, and worried about abandonment. Children with
disorganized attachment, a result of severe maltreatment, turn into unresolved
adults, who display PTSD symptoms, cannot tolerate emotional closeness,
and have serious psychosocial problems.
The quality of adult attachment relationships affects emotional and
physical health. Just as a secure attachment in childhood is associated with
overall well-being, attachment security in adulthood is a primary factor linked
to a healthy and meaningful life. In addition to a treatment program for
children, parents, and families, we provide therapy for adults and couples who
have a history of maltreatment, unresolved loss, and interpersonal trauma.
Positive Psychology
Until recently, the field of mental health focused primarily on psychopathology
and mental illness. Positive psychology, conversely, is the study of positive
emotions, psychological strengths, and paths to a meaningful and fulfilling
life. Additionally, lessons learned from research on positive psychology have
shed light on resilience, recovery, and posttraumatic growth following trauma.
The study of posttraumatic growth (PTG) shows that many people increase
personal strength, appreciation of life, positive relationships, and spirituality,
following traumatic experiences. The factors associated with resilience and
PTG are hope, positive emotions, social support, sense of meaning and
purpose, acts of kindness, and internal locus of control (belief in one’s ability
to change).
While our treatment and parenting programs concentrate on alleviating
the psychological, social, behavioral, and biological effects of interpersonal
trauma, there is an equal emphasis on capitalizing on strengths and resources
and fostering resilience—from “victim to survivor.” Individual and family
therapy must facilitate a future-oriented approach, in which the goal is to
help children and adults create meaningful and fulfilling lives.
24
Introduction
25
ATTACHMENT, TRAUMA, AND HEALING
Solutions
What are the solutions to the vast problems of attachment disorder in
families, the child welfare system, and society? The solutions can be found in
four areas: attachment-focused assessment and diagnosis, specialized training
and education for caregivers (Corrective Attachment Parenting), treatment
for children and caregivers that facilitates secure attachment (Corrective
Attachment Therapy), and early intervention and prevention programs for
high-risk families.
• Assessment and diagnosis: Attachment disorder is one of the most easily
diagnosed and yet commonly misunderstood parent–child disorders.
Diagnosis rests on three pillars: 1) developmental history; 2) symptoms
and diagnosis; and 3) attachment history of parents/caregivers. Many
social service and mental health professionals who are adept at assessing
behavioral and emotional disorders are not trained in the use of an
“attachment frame.” Chapter 6 provides a comprehensive overview of
assessment and diagnosis of attachment disorder in children, adults,
and families.
26
Introduction
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ATTACHMENT, TRAUMA, AND HEALING
28
Introduction
29
ATTACHMENT, TRAUMA, AND HEALING
• What high-risk factors in families are most often correlated with the
development of severe attachment disorder?
• Why do some children develop major psychosocial problems as a result
of early compromised attachment, while other children with similar
backgrounds develop normally?
• What are the similarities between the neurobiology of trauma and
attachment disorder?
• What are the family system issues in the understanding and treatment
of attachment disorder?
• Why do many child welfare caseworkers, mental health professionals,
and parents fail to produce positive changes in children with attachment
disorder?
• What are the most effective therapeutic interventions for children,
adults, couples, and families who are dealing with interpersonal trauma?
• What are the effects of day care on attachment patterns in children
and families?
• What are the best out-of-home placements for maltreated children
with attachment disorders?
• When should sibling groups be placed together in foster and adoptive
homes, and when is it best to separate them?
• How does the foster care system exacerbate the problems of children
with attachment disorder, and what are the best solutions for
overwhelmed child welfare systems?
• Do all adopted children have attachment-related challenges and
problems?
• How do you emotionally and intellectually prepare foster parents
and preadoptive parents to address and manage the special needs of
children with attachment disorder?
• What are the changes in public policy that must take place in order to
foster secure attachment and prevent attachment disorder in children
and families in our society?
• What skills and solutions do parents need to be “healing parents?”
• How do you treat adults/couples with early unresolved interpersonal
trauma?
30
2
Historical Perspective
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ATTACHMENT, TRAUMA, AND HEALING
32
Historical Perspective
33
ATTACHMENT, TRAUMA, AND HEALING
34
Historical Perspective
the mother only, then a stranger enters; mother next leaves the room, then
returns; the stranger next leaves the room, and mother then leaves with the
baby now alone; then mother returns. The child’s reactions to separation and
reunion are observed through a one-way mirror and recorded on film for
further analysis. The Strange Situation provokes separation anxiety in the
child, which activates the inborn attachment system. The child’s response to
reunion determines the attachment classification.
Similar to the Uganda findings, the babies explored more with mothers
present (secure base behavior). Three distinct attachment patterns were
discovered, one secure and two insecure/anxious patterns, in 12- to 18-month-
olds. Securely attached babies actively sought out mother when distressed,
maintained contact on reunion, and were easily comforted by mother.
Ambivalently attached babies were extremely distressed by the separation,
but were difficult to soothe on reunion and resisted their mother’s comfort.
Avoidantly attached babies seemed disinterested in their mothers and, in fact,
rejected them on reunion (Ainsworth and Wittig 1969).
Why did these babies respond with different attachment patterns? Did
it have to do with inborn temperament or environmental factors? Ainsworth
was able to answer these questions because she had a team of observers who
made numerous home visits during the infants’ first year of life. Vast differences
in parenting style were found on scales of acceptance, cooperation, sensitivity,
and availability. Mothers of securely attached babies were rated higher on
all four scales; they were more responsive to baby’s needs and signals and
showed more pleasure in their reactions. Mothers of anxiously attached
babies were less likely to respond to their baby’s needs in sensitive, attuned,
and consistent ways, and were inconsistent and unpredictable. Mothers of
avoidant babies were rejecting.
These studies provided concrete evidence about ways in which parenting
style affected individual differences in children. Securely attached babies had
mothers who were affectionate, fed them on demand, and picked them up
quickly when they cried during the early months. These babies cried less
than anxiously attached babies by the end of their first year, indicating
that responsive parenting did not create “spoiled,” dependent children, but
instead, led to healthy autonomy. The mothers of anxiously attached babies
were inconsistent and themselves very anxious and tentative. Avoidantly
attached babies had mothers who were much less affectionate, angry, and
irritable, displayed gruff physical interactions, and often had an aversion to
physical warmth and contact. No wonder these babies rejected their mothers
on reunion—they were doing to their mothers (rejection) what had been
done to them, and showing indifference to disguise their hurt and anger.
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Developmental Studies
Mary Main and colleagues at the University of California at Berkeley began
a longitudinal study of middle-class families in the 1970s. Attachment
patterns were assessed at 12 and 18 months of age, and aspects of psychosocial
development were evaluated. A fourth attachment pattern was discovered—
disorganized/disoriented attachment—where some children displayed both
avoidant and anxious styles, and sought closeness to their mothers in strange
and bizarre ways (Main and Weston 1982). Many of these disorganized
children were found to have been abused (Crittenden 1988) and to have
mothers who had experienced trauma and loss in their own early family
life, which they never successfully resolved or mourned (Main and Solomon
1990). Fear and anxiety were verbally and nonverbally communicated to the
baby (see Chapter 5 for more information on disorganized attachment).
Further studies provided new insights into the emotional, cognitive,
and relationship aspects of attachment. The child’s early attachment pattern
creates an internal working model, a mental and emotional reflection of early
attachment relationships that determines perception of self, others, and the
world (Bowlby 1982). Relationship experiences of the baby and young child
are encoded in the brain’s limbic system. Repeated encoded experiences
become internal working models, or core beliefs, about self, self in relation
to others, and life in general. These core beliefs become the lens through
which children and adults view themselves and others, especially attachment
figures. Core beliefs operate outside of conscious awareness and influence
one’s interpretation of events and social interaction.
The internal working model was found to influence not only behavior
and emotion, but also attention, memory, and language. When 6-year-olds
were asked to react to photographs showing children separated from
parents, the differences were profound. Securely attached children talked
about their feelings associated with separation, had ideas about coping, and
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Historical Perspective
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38
Historical Perspective
Temperament
The previous section focused on the importance of early parenting influences
on the development of attachment patterns. It is also of importance, however,
to emphasize the role of genetics, temperament, and other biological factors.
The nature–nurture debate has been a controversial issue in the social sciences
for many years: to what extent are behavior and personality traits genetic,
biological, or a function of inborn temperament? To what extent do early life
experiences shape and influence the developing individual? Some theorists
and researchers emphasize the biological factor, others point to psychosocial
influences, while another group focuses on the interaction between nature
and nurture as most relevant.
Jerome Kagan (Kagan and Moss 1962; Kagan 1984, 1989, 1994) has
been a leading proponent of the importance of inborn temperament. He
began a longitudinal study of children in 1957 and followed them into
adulthood. Kagan and colleagues found that the children labeled “fearful”
during their first three years of life became adults who were introverted,
cautious, and psychologically dependent on their spouses (Kagan and Moss
1962). They concluded that temperament predicted adult behavior more than
early family influences. Further studies revealed two temperamental types of
children: inhibited and uninhibited. According to Kagan, inhibited children
are more shy with unfamiliar children and adults, smile less with unfamiliar
people, take longer to relax in new situations, have more impaired memory
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ATTACHMENT, TRAUMA, AND HEALING
recall following stress, take fewer risks, have more fears and phobias, and
have higher muscle tension (Kagan 1994). Kagan also notes physiological
differences: “temperamentally inhibited children have a more reactive circuit
from the limbic area to the sympathetic nervous system than do uninhibited
children” (Kagan 1994, p.140).
Karen (1994) reviewed studies that give credence to constitutional and
genetic factors. One study of 120 pairs of identical twins reared apart found
many traits that were genetic in origin (e.g., imagination, leadership, sociability,
stress reactions) (Bouchard et al. 1990). The Colorado Adoption Project
compared adopted children to their biologically unrelated siblings. They
found children temperamentally different despite similar family influences
(Dunn and Plomin 1990). Neubauer and Neubauer (1990) reviewed research
on the genetic origins of personality traits and listed a variety of traits that
appear to have an inherited basis: aggressiveness, alcoholism, depression,
empathy, excitability, temper, shyness, and vulnerability to stress.
The New York Longitudinal Study also focused on inborn temperament
(Chess, Thomas, and Birch 1959; cited in Karen 1994, pp.274–288).
Researchers followed both middle-class and low socioeconomic status
infants into adulthood. They assessed infants’ temperamental characteristics
using nine variables: activity level, rhythmicity, approach or withdrawal,
adaptability, intensity of reaction, threshold of responsiveness, quality of
mood, distractibility, and attention span and persistence. The babies were
found to fit into four different categories:
• Difficult babies (10%) displayed negative mood, were slow to adapt,
withdrew in novel situations, and were irregular in biological
functioning.
• Slow-to-warm-up babies (15%) were similar to the difficult babies, but
reacted with less activity and intensity.
• Easy babies (40%) showed positive mood, regular body functions,
adapted well, and approached rather than withdrew from new
situations.
• The last group, mixed (35%), displayed combinations of these traits.
Evaluations revealed that children born with difficult temperaments
developed the most emotional and behavioral problems over time; 70
percent developed serious symptoms in adulthood. Researchers did not
conclude, however, that temperament alone produced these problems.
Rather, they pointed to an interaction of nature and nurture (temperament
and environment); i.e., children with difficult temperaments were much more
likely to experience negative responses from others as they developed. For
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Historical Perspective
example, these children were more likely to “trigger” their parents, causing
negative parental attitudes and reactions, and provoking old, unfinished issues
to surface (Thomas, Chess, and Birch 1969). Only parents who were patient,
consistent, firm, and emotionally resolved could manage these children well.
Additional evaluations showed that a “poor fit” between child’s and parents’
temperaments often accounted for difficulties (e.g., high-activity child and
low-activity parent) (Chess and Thomas 1987). Again, the conclusion was
that temperament is influential, but that environmental factors play a critical
role. The reaction of parents and others (e.g., teachers) could amplify or
diminish any inborn traits and qualities.
There is no doubt that babies with difficult temperaments are more
challenging to parents and caregivers than those who are easier and more
relaxed. However, family and environmental factors cannot be underestimated,
and many studies validate this notion. Mother’s personality, assessed
prior to the birth of her baby, was found to be a more reliable predictor
of later attachment than temperament. Mothers who were more empathic,
emotionally mature, and stable, were more likely to have securely attached
children (Belsky and Isabella 1988). Another study of 100 infants irritable
after birth found that many more babies (68%) were securely attached at 1
year when their mothers received parenting training to increase sensitivity
than babies without parent training (28%) (van den Boom 1988). Social
support does make a difference in families. Mothers of irritable infants
who received external support (extended kin, social program) were found
to provide parenting that led to secure attachment significantly more than
mothers of irritable infants who lacked such support (Crockenberg 1981).
Thus, it appears that temperament and environment interact in an
ongoing manner over the course of development to determine emotional,
behavioral, and social traits and outcomes. This is hopeful news for children
who are born with difficult temperaments or who receive inadequate or
damaging care in the early phases of life. It indicates that outside forces, such
as effective parenting programs and therapeutic interventions, can go a long
way toward attenuating early difficulties.
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Roots of Attachment
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Roots of Attachment
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ATTACHMENT, TRAUMA, AND HEALING
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ATTACHMENT, TRAUMA, AND HEALING
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Roots of Attachment
forces in the family system affect mother–child attachment and the child’s
process of attachment in general. Attachment occurs in the context of the
family network, including the extended family. The larger social context in
which mother–child attachment occurs exerts more influence on attachment
than the specific characteristics of the mother or child (Donley 1993).
Triune Brain
Paul MacLean (1978), while director of the Laboratory of Brain Evolution
and Behavior, National Institute of Health, developed the triune brain
concept. MacLean described the human brain as actually a hierarchy of
three brains in one, each significantly different in structure, function, and
chemistry. Although the brain has evolved in size and complexity, it still
contains the basic components and functions of its reptilian and mammalian
past. Thus, all human beings carry in their brains this legacy of millions of
years of evolution.
The brain stem (reptilian brain), located at the base of the skull, represents
the first stage of brain evolution and is shared by all vertebrates, from
reptiles to mammals. It controls primitive sexual, territorial, and survival
instincts, such as reproduction, circulation, digestion, and muscle contraction
in reaction to external stimulation. It regulates automatic behaviors like
sleeping, breathing, blood pressure, heart rate, blinking, and swallowing. The
brain stem also governs imitative behavior, tendency toward routine and
ritual, stress-provoked responses, and tropistic behavior (ability to adapt to
environmental changes). Distributed along its length is a network of cells,
called the reticular formation, that governs the state of alertness and serves
as a gateway to channel information to the higher brain structures.
The paleomammalian brain (limbic system), wrapped around the reptilian
brain, developed as evolution proceeded to provide mammals with enhanced
survival skills and the ability to interact with the environment. This second
phase of brain evolution gave humans the capacity to experience and express
emotions and also maintains the immune system, the body’s capacity for
self-healing. The limbic system governs the general adaptation syndrome,
the fight-or-flight response necessary for self-preservation. There are three
subdivisions of the limbic system:
• The amygdala controls emotion and aggression.
• Procreation, affectionate, and sexual behaviors are incorporated into
the sextal area.
• The mammillary portion manages maternal functions, such as nursing
and other attachment-related behaviors.
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ATTACHMENT, TRAUMA, AND HEALING
The limbic system is the seat of all relationship bonds. The brain stem and the
limbic system together are referred to as the “old brain,” primarily concerned
with automatic reactions and self-preservation.
The neomammalian brain (cerebral cortex), the third layer of the brain to
evolve, is most highly developed in humans. It is five times larger than its
two lower neighbors combined, contains more than 8 billion cells (70% of
the nervous system), and is what makes us uniquely human. The prefrontal
cortex allows for planning, creative thinking, capacity to observe internal
emotional states, and to have choice regarding those internal subjective states.
The cerebral cortex, called the “new brain,” governs production of symbolic
language, decision making, and information processing, and is believed to
regulate the “higher emotions” of empathy, compassion, and love (Pearce
1992).
There is an ongoing relationship between the three parts of the brain as
they continually exchange and interpret information. The reticular activating
system (RAS), which begins in the brain stem and is attached to the cerebral
cortex, serves as a switching device between the old and new brain. When
we become threatened or emotionally aroused, the RAS enables the limbic
system to take over and facilitate automatic, instinctual responses (fight or
flight). When we are relaxed, not perceiving threat, the cortex is switched
back on, allowing logic and reasoning to return. The old brain determines our
basic survival reactions, while the new brain allows us to make choices about
those reactions and enables us to consider alternative actions.
The work of MacLean and other researchers demonstrates how much of
the social behavior of animals is controlled by the old brain. An experiment
on rats, for instance, showed they were able to mate, breed, and rear their
young with the removal of their neocortex. MacLean also found that, when
neocortical development was prevented in hamsters, they were still able to
display every behavior pattern found in normal hamsters. Other research
showed that monkeys lost the capacity for typical social behavior when
their neocortex was left intact, but the reptilian and limbic connection
were destroyed (MacLean 1982; cited in Kerr and Bowen 1988, p.36). The
neocortex is crucial for higher-level mental functioning, like speech and
language, but the operation of the old brain governs basic instinctual and
social functions. Much of attachment behavior is governed by the old brain,
and so is rooted in biology and evolution.
Contrary to previous thought, human infants are not born a tabula
rasa (blank slate), but enter the world equipped with a repertoire of basic
survival mechanisms and behaviors. For example, babies are born without
a fear of water (and instinctively hold their breath when submerged), and
with an inborn fear of falling and an ability to reach out for support (the
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Roots of Attachment
Muro reflex); they instinctively orient toward the breast (rooting reflex), and
demonstrate a head-turning reflex to prevent smothering. These reflexes
disappear after three or four months, suggesting that we possess biologically
rooted capabilities until we are able to learn and adapt to our environment.
The triune brain reflects a pattern of evolutionary progression in which
nature builds newer and more complex structures on the foundation
of previous structures. Each component of the triune brain has its own
specialized capabilities and behaviors that emerge sequentially over the course
of development. The successive unfolding and maturation of the triune brain
corresponds to the evolution of human behavior and parallels the stages of
child development. The old brain (brain stem and limbic system) must be
appropriately stimulated and nourished during the early years of life. If this
foundational brain system is understimulated, the higher brain (neocortex)
does not develop to its full potential (Pearce 1992). Sensitive and protective
caregiving stimulates the natural evolution of the old brain during infancy,
the critical phase of prolonged helplessness. When appropriate care is not
provided (e.g., abuse, neglect, multiple separations and losses), intellectual,
emotional, and social maturation does not occur normally and naturally
(MacLean 1978).
Genesis of Attachment
Fifty years ago “experts” believed that the human fetus was a blank slate,
devoid of sensitivity, feeling, and any interactional capability. Over the last 30
years, a wealth of knowledge has been acquired about the fetus, its prenatal
environment, and events surrounding the birth experience (perinatal). Pre-
and perinatal psychologists, using such modern clinical tools as electronic
fetal monitors and ultrasound, have proven that the unborn baby has well-
developed senses and reacts to stimuli from mother and the environment.
We now have an increased understanding of the physical, emotional, and
social influences on the unborn baby. Communication, both physiological
and emotional, between parents (particularly the mother) and the fetus can
have a significant impact on future health and development.
Over the past 20 years, the new field of “fetal programming” or “fetal
origins” has been studying how in utero experiences exert lasting effects on
us from infancy into adulthood. A woman’s experiences and lifestyle can
change the development of her unborn baby and beyond. The nutrition in
the womb, the drugs, infections, and pollutants the fetus is exposed to, the
mother’s health, stress level, and state of mind during pregnancy, all affect
the fetus and the person later in life. The experience in the womb has been
linked to physical and mental health problems later in life, including heart
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First Trimester
The first trimester is divided into three separate stages of in utero development:
germinal, embryonic, and fetal (Ornstein 1995). The germinal stage begins at
the moment of conception, when a sperm fertilizes the egg (only one sperm
in a million reaches the egg). It ends two weeks later after the fertilized
egg, repeatedly dividing, implants itself on the uterus wall. A few days after
fertilization, a small cluster of cells forms that is the beginning of the human
heart (Pearce 1992). This is, in essence, the first “attachment” between mother
and offspring.
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ATTACHMENT, TRAUMA, AND HEALING
The embryonic stage lasts from implantation of the fertilized egg in the
uterine cavity until about the eighth week. Embryologists refer to the baby as
an embryo until all of its systems are formed by the end of the second month.
This is the time of greatest differentiation, when organs are undergoing their
most rapid and extensive changes. New organs and systems are created almost
daily. By the end of the third week the embryo is 2 millimeters long and has a
working heart and rapidly developing nervous, skeletal, and digestive systems.
Between the fourth and eighth weeks, the embryo goes from a primitive
shape to one that begins to resemble a human form. By the eighth week,
it has a human face with eyes, ears, nose, lips, tongue, and even milk-teeth
buds. The brain is sending out impulses that coordinate the functioning of
organs; all major organs and structures are beginning to develop. The earliest
sense to develop in the human embryo is touch. As early as six weeks, the
fetus will bend its head away from the site of stimulation when the face is
touched lightly near the mouth (Montagu 1986). The first smooth, circular
movements of the body occur at this time. The life of an embryo is quite
tenuous. Due to the rapid growth and development of organs, this is the time
when teratogens—agents that cause birth defects—are most likely to harm
the embryo (Samuels and Samuels 1986).
The third development period of the first trimester is the fetal stage,
from the ninth week of pregnancy until birth. The ninth week represents a
turning point; only the reproductive system undergoes new formation, while
all other organs simply undergo fine differentiation and rapid cell growth. By
the end of the third month the fetus can kick legs, turn feet, curl toes, make
a fist, move its thumb, turn its head, squint, frown, open mouth, swallow,
and breathe. The vocal cords are completed, digestive glands are working,
and vital functions of breathing, eating, and motion are rehearsed. The baby
shows distinct individuality in behavior, and facial expressions are already
similar to those of the parents.
During the first trimester, as the fetus is physically developing, the “work”
of pregnancy truly begins for the parents. The mother must prepare herself
for the monumental changes that will occur in her anatomy and physiology.
Her uterus grows from 500 to 1000 times its normal size. Her cervix softens,
breasts grow, blood volume increases up to 2½ quarts, and she will experience
significant weight gain. She will store more protein and water, and go
through significant hormonal changes. Psychological and emotional issues,
both conscious and unconscious, begin to emerge as pregnancy unfolds.
As discussed previously, the “old brain” controls biologically rooted
instincts to procreate and attach. The “new brain” (neocortex), however,
is responsible for the complex psychological and social factors involved
in reproducing and caring for the young. A woman’s desire for a baby is
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Second Trimester
The fetus now responds to light, taste, and sound. He or she is capable of
learning, intentional behavior, and has a rudimentary memory. By the fourth
month the fetus can frown, squint, and grimace. The first embryonic cells
are sound sensitive and by four and a half months in utero, the auditory
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Roots of Attachment
Third Trimester
There is a great acceleration in growth toward the end of in utero gestation.
The fetus is showing its greatest weight gain, moving more, and taking on
a “personality” of its own. It is demonstrating preference of activity in day
or night, is more receptive to communication from the outside world, and
is capable of conditioned learning. All the sensory systems are functioning,
i.e., responding to visual, auditory, and kinesthetic stimulation. The unborn
baby is affected by touch, noise, and stress and is particularly vulnerable to
the ingestion of drugs, alcohol, and tobacco. Babies exposed to drugs in utero
are often born with low birth weight, extremely agitated, tactilely defensive,
and may exhibit developmental, emotional, and intellectual impairments.
The effects of fetal alcohol syndrome and fetal alcohol effect have long-
term implications for the child’s ability to learn and integrate experience
(Besharov 1994). Smoking also has serious effects on the fetus. In addition
to injecting the neonate with numerous noxious chemicals (arsenic, cyanide,
formaldehyde, carbon monoxide), smoking decreases the oxygen supply to
the fetus, carried by maternal blood passing through the placenta. Studies
show that an unborn fetus becomes agitated (measured by significantly
increased heart rate) each time mother even thinks about having a cigarette
(Sontag 1970).
During the last few months of pregnancy, the increased activity level of
the fetus falls into certain cycles and patterns. A receptive mother interacts
with her fetus in response to these patterns and knows if it is in deep sleep,
light sleep, or actively awake and alert. Synchrony is developing: the baby
responds to the mother’s rest activity level, and the mother responds to the
baby’s. The fetus and mother are preconditioned to each other’s rhythms,
preparing for the mother to respond to the cries, needs, and other signals
after birth.
Our brains are like pharmacies, compounding a wide range of chemicals
that affect our moods and biological systems. The fetus decodes maternal
feelings through a neurohormonal dialogue (Borysenko and Borysenko
1994). Fear and anxiety, for example, are biochemically induced by a group
of chemicals called catecholamines. When a pregnant woman becomes
frightened, the hypothalamus orders the autonomic nervous system (ANS)
to increase heart rate, pupils dilate, palms sweat, blood pressure rises, and the
endocrine system increases neurohormone production. This floods into the
blood stream, altering both the mother’s and fetus’s body chemistry. When
a mother thinks joyful thoughts, the limbic system releases neuropeptides
into her blood stream, which fit into receptor cells throughout her body (and
fetus). When she feels joy and acceptance, every cell in her body responds
to that emotion. Depression, anxiety, and ambivalence are also broadcast
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throughout her entire body/mind system and to that of the unborn child.
Almost anything that upsets the mother also upsets the fetus. (Infrequent or
isolated incidents will not cause serious harm; it is the ongoing stressors that
produce damaging effects.)
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Prematurity
Premature birth has been found to affect not only the physiology of the infant,
but also early interactions and attachment with caregivers. Preterm infants
show a variety of characteristics: less well-defined sleep cycles; less alertness
and responsiveness at birth; poor motor coordination; greater percentage of
time fussing and crying; and are more difficult to feed and soothe, compared
to full-term infants (Frodi and Thompson 1985). Full-term babies have
an instinctual protective response, “habituation,” that prevents the nervous
system from being overstimulated. Premature babies, however, generally lack
this protective response, and are easily overstimulated.
Prematurity also affects the biological and psychological reactions of
parents. After nine months of pregnancy, parents typically feel a sense of
completion and readiness for the birth of their infant. When this process
is cut short, parents may feel unprepared and anxious. A mother may
blame herself, perceiving the premature birth as her own personal failure.
Disrupting the instinctual and biological schedule increases parental anxiety
and reduces confidence, which can have detrimental effects on the parent–
infant relationship. Some studies have shown that parents of premature
babies initiate less body contact, less face-to-face contact, smile and talk
less, and play less with their infants (Brazelton and Cramer 1990). “On the
whole, interactions with prematures are more taxing for parents, testing their
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capacities to attune to a less responsive, less well put together infant. This
is also true for ‘professional infant handlers ’” (Brazelton and Cramer 1990,
p.199). Other studies of middle-class samples, however, have found mothers
of premature babies to be more sensitive to cues for contact, more responsive
in early face-to-face interactions, and more affectionate and gentle (Field
1987). Parents who become hypervigilant and overprotective toward their
vulnerable infants may inhibit the development of age-appropriate autonomy
and independence.
The premature baby is physically and emotionally isolated at a time when
he or she requires a great deal of contact. The name of the incubator (“isolette”)
aptly describes this predicament. Corrective touching and caressing of the
infant can minimize detrimental effects. Massaging premature babies for
example, has enabled these infants to be more alert, active, responsive, sleep
better, gain weight faster, and leave hospital sooner than untouched babies
(Field 1987). Premature birth alone does not necessarily cause attachment
problems. It does place the infant at risk for anxious attachment, however,
when combined with other risk factors, such as chronic illness and negative
parental responses (Colin 1996).
Birth to 3 Years
Bonding is the biological, genetic, and emotional connection between mother
and baby during pregnancy and at birth. All babies have a bond with their
birth mother. Attachment, however, is learned after birth through interactions
between caregivers and child during the first three years. “Attachment is an
affective bond characterized by a tendency to seek and maintain proximity to
a specific figure, particularly while under stress” (Bowlby 1970, p.12).
Human babies are born earlier in the growth cycle than other mammals.
The fetus must be born when its head has reached the maximum size
compatible with passage through the birth canal. The female pelvis is
relatively small to support an erect posture. The baby must be born after 266
days of gestation in order to pass through the birth canal, due to the rapid
growth of the brain during the last trimester. The baby is born well before
complete maturation. Extrogestation lasts, on average, the same amount of
time as in utero gestation (266 days). Thus, significant brain development
occurs outside the womb, when the baby is exposed to a variety of social and
environmental influences (Verny and Kelly 1981; Montagu 1986).
The infant’s brain, especially the limbic region, is an “open loop system,”
because it relies on attuned and nurturing input from attachment figures
for healthy growth and development. Relationship experiences in the early
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stages of life are most important in shaping the development of brain and
behavior (Lewis, Amini, and Lannon 2000).
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Needs
Development of
Relief Arousal
Trust and
Relaxation Displeasure
Secure Attachment
Gratification:
eye contact
touch
smile
movement
feeding
heart connection
in arms
Crying
One primary function of crying is to communicate discomfort to the caregiver.
Wolff (1969) described four types of infant crying: hunger, pain, danger, and
neurological impairment. Maternal stress level during pregnancy has been
found to correlate highly with infant crying. In one study, almost half of the
mothers whose infant cried extensively reported chronic and severe stress
during pregnancy (Kitzinger 1985; cited in Solter 1995, p.21). Caregivers
who respond promptly, sensitively, and consistently to their infant’s cries have
babies who cry less in frequency and duration as they grow older. Crying is
the baby’s way of signaling to the caregiver that he or she has a need. When
the baby’s need is met, he or she learns that the caregiver is dependable. This
is the basis of trust and secure attachment. Crying also serves the purpose of
releasing stress-related hormones that reduce tension and arousal. Crying is
an inborn stress management and healing mechanism (Solter 1995).
Eye Contact
The caregiver–infant gaze is a primary social releaser and communication
method for the development of attachment. A newborn can focus his or her
eyes 7–12 inches, the exact distance needed to make eye contact in arms. Soon
after birth, the infant can follow a slowly moving light and the movement of
curved objects that have qualities of the mother’s face. Face-to-face proximity
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and eye contact are synonymous with closeness and intimacy. Spitz (1965)
found that infants responded with pleasure when shown a mask of a human
face. When the lower part of the mask was covered, their response did not
change. Covering the upper part, however, (even one eye) caused displeasure
and loss of interest. He concluded that the infant’s response to eye contact
is instinctual. Our autonomic nervous system directs the pupils to expand
slightly when viewing something positive or pleasurable. Conversely, the
pupils shrink when seeing something unpleasant. The pupils cannot lie. The
infant gazes into his or her mother’s eyes and receives potent messages about
her emotional state and level of involvement (Morris 1994).
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Eye contact and observing facial expressions are a main source of information
about others’ feelings. A toddler uses the parent’s facial expressions to guide
behavior. This is called social referencing: “Is it safe to explore? Am I safe with
this stranger? Is my behavior acceptable?” The child visually communicates
with caregivers, which influences his or her actions and emotions.
Touch
All warm-blooded animals are born with an innate need to be touched and
stroked affectionately. Research has confirmed that the handling or gentling
of mammals early in life results in increased weight gain, activity, and
resilience under stress (Simon 1976). The mammalian mother’s behavior of
licking her young serves the purpose of cleaning and also stimulates internal
systems (gastrointestinal, circulatory, immunological).
Touch for the human baby serves both physical and emotional functions.
Somatic stimulation begins in labor when uterine contractions activate
principal organ systems of the fetus. Human babies actually die from lack
of touch. In the nineteenth century, most institutionalized infants in the
United States died of marasmus (“wasting away”). Institutions surveyed in
1915 reported that a majority of infants under the age of 2 had died due to
failure to thrive, related to the lack of touch and affection (Chapin 1915;
cited in Montagu 1986, p.97). Prescott (1971) found that deprivation of
touch and movement contributed to later emotional problems. He also
found that cultures in which physical affection toward infants was high had
low levels of adult aggression, but cultures where affectionate touch was
low had high adult aggression. More recent research on contact comfort
between mother and infant revealed interesting but not surprising findings.
Low socioeconomic-status mothers were given either a soft baby carrier or
a plastic infant seat to use on a daily basis. At 3½ months of age, the soft
carrier infants looked more frequently at their mothers and cried less; these
mothers were more responsive to their babies’ vocalizations. At 13 months,
these infants were more likely to be securely attached (83%) compared with
the infant seat group (30 percent) (Anisfield et al. 1990).
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and leave the hospital sooner. Warm and caring touch lowers stress hormones
(e.g., cortisol), and stimulates the release of oxytocin, the “love hormone,”
which enhances security, trust, and secure attachment (Field 2010).
Humans are prewired to be able to interpret the touch of others. Studies
have shown that people have an innate ability to decode emotions with touch
alone. Hundreds of participants, between the ages of 18 and 36, were able
to communicate eight distinct emotions via touch—anger, fear, happiness,
sadness, disgust, love, gratitude, and sympathy—with accuracy rates as high
as 78 percent (Hertenstein et al. 2009). Touch seems to be a more nuanced
and effective means of communicating emotions than even facial expressions
or tone of voice. Touch definitely promotes more positive interactions and
a deeper sense of connection with others. Recent studies have found that
people buy more if they are gently touched by a store greeter, strangers are
more likely to provide help if touch accompanies the request, and waitresses
receive bigger tips when they briefly touch customers. Most of the people in
these studies did not remember being touched, but when asked they reported
that they liked the person and felt some positive connection (Guerrero et al.
2007). Touch-oriented doctors, teachers, and managers consistently receive
higher ratings. They communicate warmth, caring, and support (Anderson
2008). Of course, context matters; society has rules about whom we can touch,
where, and when. Touch can be appropriate and safe, or inappropriate and
unsafe. Different people as well as cultures have varying comfort levels and
standards regarding touch. There are significant cultural variations in comfort
with touch. Some cultures are more liberal about touching (e.g., Greek,
Puerto Rican), and others less so (e.g., German, British).
Therapeutic touch can be reassuring, comforting, supportive, and
down-regulate anxiety and arousal. We incorporate therapeutic touch in
our treatment and parenting programs. Dyads (e.g., couples, parent–child,
siblings) are encouraged to hold hands at opportune times during Attachment
Communication Training to enhance caring, support, and attachment.
Physical contact from parent to child (e.g., gentle touch of the arm) is
encouraged during the Limbic Activation Process (LAP) to communicate
nurturance, empathy, and love (the LAP will be described in more detail in
Chapters 7,8,9, and 10). Parents are taught to touch their children gently
and sensitively on the hands, arms, or shoulders during conversation to
foster caring and connection. The best way to provide comfort is via touch,
especially when someone needs consoling. The language of touch can deeply
communicate our feelings and inspire connection.
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ATTACHMENT, TRAUMA, AND HEALING
Smile
Smiling is a universal human greeting that signals friendliness and
nonaggression. By the eighth week, the infant begins to smile in response
to seeing the primary attachment figure. The baby’s smile is an instinctive
response that attracts the attention of the caregiver. The smile on the face
of the mother provokes feelings of safety and security in the baby. The
baby’s smile is a powerful signal that rewards and motivates an ongoing
positive parental response. This reciprocal smile promotes secure attachment.
Observing a smile on the caregiver’s face triggers a biochemical reaction in
the baby. Neurotransmitters (e.g., dopamine and endorphins) are released,
which promote brain growth and a relaxed, happy feeling (Schore 1994).
Movement
Movement is another basic instinctual need for healthy development and
attachment. The vestibular–cerebellar system (associated with balance and
movement) is the dominant sensory system during fetal brain development.
Studies on infant monkeys reared in isolation demonstrated that a mother
surrogate that moved (on a swinging device) prevented the development of
social and affectional maladjustment (Mason and Berkson 1975). In humans,
every time the mother moves, the fetus moves, naturally rocking to the rhythms
and motions of the mother’s body. After birth, vestibular stimulation through
activities such as bouncing and rocking plays a crucial role in the infant’s
development. Rocking slows the heart rate, promotes effective respiratory
and gastrointestinal functioning, and decreases congestion. When a baby is
hungry, feeding most effectively terminates crying; at all other times, rocking
is the most effective soothing and calming intervention (Bowlby 1982).
Neal (1968; cited in Montagu 1986, p.161) studied the effects of rocking
on premature infants. He found that when incubators were kept in motion the
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Roots of Attachment
Feeding
In infancy, satisfaction of needs involves food and nourishment. The
psychosocial experiences associated with feeding are part of the infant’s
emotional and relational development. The infant begins to associate food
and feeding with warm skin-to-skin contact, eye contact, and soothing voice
and smile. Breastfeeding can become part of attachment behavior, as it is
another way of clinging to the mother that is both intimate and soothing.
Breast milk contains important nutrients and antibodies that nourish the
newborn and strengthen his or her immune system. Colostrum in the
mother’s milk acts as a laxative, effectively cleaning the meconium in the
newborn’s gastrointestinal tract, and is rich in antibodies needed to provide
immunities until the infant acquires his or her own at 6 months. As the
newborn suckles on the mother’s breast, the hormone oxytocin is secreted in
the mother, which helps shrink the uterus, reduces postdelivery bleeding, and
produces pleasurable and loving feelings.
The infant’s brain consumes twice the energy of the adult’s, and must be
provided with nutrients on a regular basis, due to limited storage capacity
of energy (glucose). The regularity and consistency of the feeding ritual, the
quality of the food, and the care with which the food is provided, greatly
influence security, attachment, and later attitudes and behaviors regarding
food. Research showed that children who had pleasurable mealtime
experiences displayed better impulse control, concentration, ability to solve
problems, and greater anticipated pleasure from others (Arnstein 1975).
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ATTACHMENT, TRAUMA, AND HEALING
regulates emotion. ANF also plays a key role in regulating immune system
response, memory, and learning.
Research in the 1940s reported that the mother’s heartbeat affected the
infant in utero (Bernard and Sontag 1947; cited in Pearce 1992, p.103). Years
later, researchers piped an audiotape of a human heartbeat into a newborn
nursery. The babies hearing the heartbeat had increased appetite, weight gain,
sleep and respiration, and cried 50 percent less than the babies not exposed
to the heartbeat (Salk 1960; cited in Verny and Kelly 1981, p.28). Pearce
(1992) notes that if a heart cell is isolated, it loses synchronous rhythm and
fibrillates until it dies. If two heart cells are placed in proximity to one another,
however, they will not only survive, but will also synchronize and beat in
unison. This even occurs across a spatial barrier. Infants who are placed in
close heart-to-heart proximity with a primary caregiver maintain a mutual
heart synchrony.
In Arms
Being held in a caregiver’s loving arms is essential to creating a secure
attachment. All cues of attachment—eye contact, smile, touch, movement,
feeding, and the heart connection—occur within the context of the in arms
position. Babies have thrived close to their mothers in arms throughout
human history. This milieu provides the physical, emotional, and interpersonal
foundation for security, trust, and love. Children who have experienced
neglect, abuse, and multiple moves, have typically lacked the safety and
security of in arms attachment. Healing the negative effects of this early
trauma, for both children and adults, is facilitated by utilizing the in arms
position therapeutically—the Limbic Activation Process (LAP).
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Wants
Child’s response:
accepts limits
tests and defies
limits
learns through
exploration
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Roots of Attachment
memory, the ability to recall specific events, also begins to develop at this
time. The child has an increased ability to organize mental representations;
to form detailed internal working models of attachment relationships,
and to develop emotional and behavioral strategies in response, including
defense. Securely attached children can use information from all three
memory systems (procedural, semantic, and episodic) and can learn that
open and direct communication is most effective. Caregivers are sensitive
to their needs, encourage open communication about thoughts and feelings,
and validate the child’s perceptions. They tolerate negative emotions, while
setting clear and appropriate boundaries regarding dangerous exploration and
negative behavior toward others. These caregivers facilitate a goal-corrected
partnership by encouraging negotiations and constructing cooperative plans.
Avoidantly attached children are extremely defended and have learned
to deny their anger, anxiety, and need for nurturance. Some caregivers are
openly hostile and rejecting, while others are withdrawn and unresponsive.
Either way, the child is rejected. By age 3 or 4, these children openly avoid
and ignore attachment figures and do not give signals that suggest a need
and desire for closeness. Children of withdrawn and depressed caregivers
often become “compulsively caregiving”; the child tries to reassure the parents
and makes few demands (“parentification”). Children of hostile and rejecting
attachment figures become “compulsively compliant”; they are hypervigilant,
monitoring the dangerous social environment, and comply in order to avoid
threat and hostility (Crittenden 1994).
The internal working model of these attachment-compromised children
involves denial of their need for closeness. A “false self ” begins to develop
(Winnicott 1965) as the child buries his or her true feelings and needs.
Children with anxious attachment show inconsistent and unpredictable
behaviors similar to their caregivers. They alternate between anger and
neediness, show limited exploratory competence and self-reliance, and
become selfish and overdependent preschoolers. They often develop a
coercive pattern of behavior in order to keep the attachment figure involved
and controlled. The child and caregiver become enmeshed in a coercive,
angry, and dishonest relationship.
A nonresponsive, neglectful, or abusive environment produces angry,
depressed, and hopeless children. Most young children who are referred for
mental health services have coercive–threatening attachment patterns and
internal working models (Crittenden 1994). These children have frequent and
prolonged temper tantrums and tend to be loud, demanding, and disruptive.
They are accident prone, emotionally and behaviorally impulsive, and want
to be the center of attention, desperately seeking the attentiveness lacking in
their attachment relationships. They are typically restless, irritable, and have
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74
4
Secure attachment in the early years provides the developing child with
a foundation that leads to a variety of healthy psychological and social
outcomes, as discussed in Chapter 2. Securely attached children compared
with those with insecure–anxious–disorganized attachments, demonstrate
advantages with the following:
• self-esteem
• relationships with caregivers
• friendships with peers
• ability to control impulses and emotions
• cooperation and compassion
• independence and autonomy
• positive core beliefs.
This chapter will focus on three additional areas of psychosocial functioning
that are associated with caregiver–child attachment. Observations of child
development and family life, as well as extensive research findings, have
shown that secure attachment results in development of the following:
• a solid and positive sense of self
• prosocial values and morality
• resilience (the ability to handle stress and adversity well).
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Development of Self
The development of an autonomous sense of self is an early stage-salient
task and is unequivocally linked to attachment. Patterns of attachment
that develop as a result of the infant–caregiver relationship directly affect
the child’s emerging sense of self. Maltreated children and children with
attachment disorder typically have extreme disturbances in self-concept,
self-regulation, and the ability to function autonomously.
Children who experience a secure base with an appropriately responsive
and available caregiver are more likely to be autonomous and independent as
they develop. The child is able to explore his or her environment with more
confidence and less anxiety, resulting in enhanced self-esteem, feelings of
mastery, and differentiation of self. Contrary to the belief of some observers,
children who experience consistent and considerable gratification of needs
in the early stages do not become “spoiled” and dependent; they are more
independent, self-assured, and confident. They learn to trust reliable, sensitive,
and attuned caregivers. This secure attachment relationship is a foundation
for a positive sense of self, and a template for future relationships.
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Personal and Social Competencies
1965). As the years pass, their self-esteem diminishes further; they become
less confident and more impulsive, distractible, and unhappy (Erickson,
Egeland, and Pianta 1989).
The internal working model affects how the child interprets events, stores
information in memory, and perceives social situations (Zeanah and Zeanah
1989). Pearce gives an example:
Given different internal working models, one child may interpret
another’s refusal to play as a devastating rejection and evidence of personal
unworthiness. Another child with a more positive internal working
model may perceive and interpret such a refusal as a minor slight. The
subsequent behavior of these two children may well be different (sulking
or an angry outburst by the former versus readily approaching another
potential playmate by the latter. (Pearce and Pezzot-Pearce 1994, p.427)
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Personal and Social Competencies
Modeling
Learning prosocial or antisocial values and behavior is a function of the
nature of the caregiver–child relationship and the modeling provided.
Simply stated, empathic parents rear empathic children. Research has shown
that children show signs of empathy as young as 1 year old, and by age 2,
show concern for a peer in distress (Zahn-Waxler et al. 1992). Children with
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Internalization
The second psychological process that contributes to developing empathy
and morality is internalization. Internalization involves the learning of
standards of conduct, not merely obeying rules, i.e., developing a moral
inner voice. Secure attachment involves internalizing prosocial values and
behaviors, such as caring, compassion, kindness, and fairness. Securely
attached children have an inner voice that guides them in the direction of
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Personal and Social Competencies
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• Stage Five (8–11 years): The child thinks, “I want it, but don’t feel good
about doing things like that.” The child’s internalization is complete;
his or her own moral values have developed based on attachment to
parents and society, and he or she understands not only self-interest,
but also the good of the group.
Sense of Self
The route to caring for others always begins with a solid sense of self. A strong
and positive self-identity, with clear boundaries between self and others, is
the fourth necessary psychological process. During the second year the child
typically becomes increasingly oppositional (“terrible twos”), reflecting his
or her initial efforts to be independent and autonomous. When there is a
solid foundation of secure attachment, this transitional phase is managed
and transcended without major negative or long-lasting consequences. In
Winnicott’s (1965) terms, the parent provides a “holding environment,” a
safe and secure context with healthy boundaries and support for appropriate
forms of self-control and emotional expression. The child with attachment
disorder, conversely, lacks this solid and secure foundation and has a weak
and negative sense of self, with blurred or violated self–other boundaries. The
negativity and defiance characteristic of the second year become pervasive and
chronic, as the child assumes a controlling, fearful, and punitive orientation
toward others. There is no place for empathy, compassion, or kindness, as the
child fights to survive in a world perceived as threatening.
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Personal and Social Competencies
Mirror Neurons
Mirror neurons were discovered in the early 1990s and have revolutionized
our understanding of how people learn from and communicate with one
another (Rizzolatti et al. 1996). Basically, the idea of mirror neurons is
that there are networks in our brains that allow people to feel what others
experience as if it were happening to them. Human brains have an intrinsic
ability for imitation, and are able to share mental processes and emotions.
Brain cells not only fire when a person performs an action, they also fire
when observing someone else’s behavior. For example, a person watches a
race and his or her own heart rate begins to increase with excitement as the
runners cross the finish line. A person sees someone else sniff food and make
a face of disgust, and then the observer’s stomach begins to ache. When a
person smiles, areas of the brain are activated and release neurochemicals that
produce positive feelings. The same brain activity and emotional response
occurs when observing someone else’s smile (Gazzaniga 2008).
Humans begin life with a rudimentary mirror neuron system. Newborns
are able to imitate mouth opening, tongue protrusion, lip pursing, finger
movements, and facial expressions. The anterior insula, a brain region that
receives input from all parts of the autonomic nervous system, responds
in the same way when study participants sniff a foul-smelling substance
and when they observe videos of faces displaying expressions of disgust
(Wicker et al. 2003).
Mirror neurons explain why people seem to “read” others’ minds and have
empathy and heartfelt compassion for another’s pain. Parents can often feel
their child’s pain as if it were their own pain. Spouses can feel their partner’s
distress as if it were their own. Human brains are built with the ability to
understand one another.
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Personal and Social Competencies
Posttraumatic Growth
It is well known that trauma has many negative effects on children and
adults, including PTSD, depression, medical conditions, and substance
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Personal and Social Competencies
side of life, and reduce loneliness and worthlessness. They also connect
people to available resources, such as therapists, physicians, and
community services. New Yorkers with emotional support had fewer
PTSD symptoms and faster recovery following the 9/11 attacks than
others with less social support (Fraley et al. 2006).
• Acts of kindness: Giving support—not only receiving—is tied to
resilience and PTG. Acts of altruism decrease stress and enhance
mental health. Volunteering to help has been found to increase self-
efficacy (“I can make a difference”), enhance self-worth, and heighten
the sense of meaning and purpose (Post 2005).
• Internal locus of control: Individuals with a strong sense of ownership
over their fate are more resilient than those who view themselves as
victims. People with an internal locus of control believe they have a
hand in everything that happens to them, and are more apt to perceive
trauma as something they can overcome. This belief in one’s capability
to produce desired effects by your own actions is also called “self-
efficacy,” which leads to perseverance in the face of obstacles and
challenges (Maddux 2009).
Cultural Variations
The results of numerous studies in the United States show that about one-
third of the children in middle-class families are insecurely and anxiously
attached. The percentage is higher in low-income, multiproblem families.
In all cultures studied (using the same assessment procedure, the Strange
Situation) the results are the same; most infants (65 percent to 70 percent)
show secure attachment patterns, while the remainder show some form of
insecure attachment. These findings must be considered within the realm
of cultural norms and variations. Does the Strange Situation, which was
based on an American population, actually measure attachment security
and insecurity in other cultures? How do the variations in the 1300 human
cultures that exist on our planet influence attachment patterns? Which
aspects of attachment are universal and which are culture specific? Even
with a similar attachment pattern, to what extent do cultural and community
differences result in different implications of this attachment pattern for later
development? For example, the developmental consequences of avoidance for
suburban Anglo American children may be different than the consequences
for inner-city African American children (Colin 1996).
Ainsworth (1973) found many similarities in attachment behavior in
both the United States (Baltimore, MD) and African (Ganda) cultures. Two-
thirds of the babies were found to be securely attached in both populations.
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Also similar were the phases of attachment development and the importance
of the primary caregiver as an attachment figure and a “secure base.” Cultural
differences were also apparent. The Ganda babies were considerably more
distressed by brief separations from their mothers, showed more fear of
strangers, and did not hug or kiss upon reunion. These differences reflect
cultural variations in childrearing practices and resultant differences in infants’
expectations. The Ganda babies were not used to separation (even brief )
from their mothers and seldom interacted with strangers in their village.
American babies were more familiar with brief separations in their home
environment, were used to seeing strangers in public, and were encouraged to
hug and kiss parents after an absence (Karen 1994; Colin 1996). These studies
demonstrated both the universal and culture-specific aspects of attachment.
Grossman and Grossman (1991) replicated Ainsworth’s research with
German families. They found that German children had similar attachment
patterns to American children. Those children who were securely attached
had advantages by age 5 years: they had better social skills and ability to
handle peer conflict and were more likely to seek out their parents when
distressed. A difference was found, however, among the anxiously attached
German children compared to other United States studies; there were fewer
behavioral problems among the anxious German children. Again, cultural
differences seem to be at work, reflecting variations in parenting attitudes
and cultural norms. The avoidantly attached children in the United States
had mothers who were rejecting and showed an aversion to having a warm
and loving relationship with their child. The German mothers were not
rejecting—they cared a lot for their children and were behaving according
to cultural norms that valued self-reliance and independence at an early age.
When the German children were evaluated at age 10, however, those who
were avoidantly attached looked like their counterparts in the United States:
they had more problems getting along with peers and were less confident,
self-reliant, and resilient, as compared to securely attached children. The
Grossmans concluded, “The mere fact that parents are behaving in accordance
with cultural norms does not necessarily spare the children any harm” (cited
in Karen 1994, p.266).
Cultural variations in childrearing practices and patterns of caregiving
have been found around the world. Keefer et al. (1982) found that among the
Gusii, an agricultural culture in Kenya, mothers turn away from their infants
when the infants are most emotional, positive, and excited. Culturally, this
looking-away pattern is normative, and the mothers are merely socializing
the young according to cultural restrictions (i.e., younger individuals do not
look directly at older individuals, especially under emotional conditions). This
pattern is quite different from that of American middle-income mothers,
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Personal and Social Competencies
who tend to make eye contact in response to their babies’ excitement and
arousal. Takahashi (1990; cited in Colin 1996, p.149) studied Japanese
families and found that 12-month-old babies experienced an unusually high
level of stress during separation (in the Strange Situation), and not a single
baby showed avoidant attachment patterns. There were, however, many more
babies in the anxious category than in the United States. These findings
reflect cultural differences. Japanese children are socialized to maintain
harmonious relationships; avoidant behavior is considered rude. Also, in
traditional Japanese society it is rare for babies to be separated from mothers,
and a close mother–child bond is encouraged throughout life.
Children reared on the kibbutzim in Israel had much different child-
rearing experiences than American children. Sagi (1990) found a higher
percentage of anxious children, which is probably a result of “multiple
mothering,” and the inconsistency and unpredictability of caregiving
practices. Infants on the kibbutzim were monitored by hired caregivers
during the day, spent only a few hours with their parents (usually around
dinner time), and were responded to during the night (slowly) by another
caregiver who was responsible for watching over many babies. These findings
are consistent with attachment theory; anxious attachment patterns are often
related to the child’s preoccupation with the unavailable primary caregiver.
Jean Liedloff (1975) wrote about the two and a half years she spent
with the Yeguana, a stone-age tribe living in a South American jungle.
Mothers carried their infants everywhere; the babies shared the “family
bed,” and were showered with love and attention. Despite little training
in obedience, the children were reported to be well-behaved (compliant,
friendly, nonaggressive), and grew to be self-reliant, self-confident, and caring
members of the community. These culture-specific norms are in keeping with
the basic attachment principles and are obvious in American culture today.
For example, it is becoming more common to see parents carry their babies
close to their bodies in soft carriers. This practice has been found to help
promote secure attachment (Anisfeld et al. 1990).
If it is true that attachment is instinctive and adaptive, based on biology
and evolution, then basic aspects of attachment should be universal, found
across cultures, races, and ethnic groups. The evidence suggests that there
are universal attachment behaviors, but that specific behavioral patterns vary
according to culture. In cultures that value distal patterns of caregiving and
early independence (e.g., Northern European), avoidant patterns are more
likely to develop. In cultures that encourage more contact and closeness with
babies and avoid separation (e.g., Japanese), we are more likely to observe
infants and children seeking contact with caregivers when under stress. In
the short term, forming an insecure attachment, regardless of culture, is most
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likely adaptive, i.e., a strategy for the child to cope with an unavailable or
abusive caregiver. The general consensus, however, is that forming secure
attachments early in life (i.e., keeping anger, anxiety, and defensiveness to a
minimum), is probably the best formula for psychosocial well-being in any
culture (Colin 1996).
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5
Disrupted Attachment
1
1 Note: The drawings in this chapter were done by clients at Evergreen Psychotherapy Center as part
of their treatment.
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Disrupted Attachment
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moderate stress, but development is impaired when there are high levels of
stress and interpersonal trauma (Tarullo, Obradovic, and Gunnar 2009).
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Disrupted Attachment
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ATTACHMENT, TRAUMA, AND HEALING
96
Disrupted Attachment
Infant
unresponsive
Caregiver
withdraws,
intrusive
or punitive
Disorganized–Disoriented Attachment
Three organized patterns of behavior toward the caregiver were originally
identified using the Strange Situation, a laboratory-based approach to
studying the infant’s response to separations from and reunions with the
parent. The three attachment patterns were secure, avoidant, and anxious–
ambivalent (Ainsworth et al. 1978).
• Secure: The infant is upset when his or her mother leaves the room,
but distress is not excessive; the infant and mother greet one another
actively and warmly upon reunion; the infant quickly relaxes and
returns to play.
• Avoidant: The infant shows little or no distress when his or her mother
leaves, and actively avoids and ignores the mother upon reunion; the
mother also avoids, looking away from her child.
• Anxious–Ambivalent: The infant is extremely distressed by separation,
clinging on to his or her mother and staying near the door crying,
seeks contact upon reunion, but cannot be settled by the mother and
pushes her angrily away.
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These infant responses to separation and reunion reflect the history of the
parent–child relationship, the parenting style, and predict later psychosocial
functioning (Ainsworth et al. 1978; Bretherton 1985).
Further research revealed an additional attachment pattern. Certain
infants did not fit the original three categories: they seemed to lack any
coherent, organized strategies for dealing with separation and reunion. These
infants were classified as disorganized/disoriented, and their behavior was
found to reflect seven types of reactions (Main and Solomon 1986, 1990).
• Sequential display of contradictory behavior patterns: Extremely strong
displays of attachment behavior or angry behavior, followed suddenly
by avoidance, freezing, or dazed behavior. For example, the infant
greets his or her parent with raised arms, but then retreats and freezes.
• Simultaneous display of contradictory behavior: The infant displays
proximity-seeking and avoidant behavior at the same time. For
example, the infant approaches his or her parent with head averted or
by backing toward parent.
• Undirected, misdirected, incomplete, and interrupted movements and
expression: The infant moves away from rather than toward his or
her parent when distressed or frightened. For example, the infant
approaches the parent, but then follows a stranger; the infant appears
frightened of the stranger, but retreats from the parent and leans his or
her head on the wall.
• Stereotypes, asymmetrical movements, mistimed movements, anomalous
postures: The infant shows repeated movement, such as rocking, hair
twisting, or ear pulling; asymmetrical creeping, moving only one side
of body; sudden and unpredictable movements, such as rapid arm and
leg activity after sitting tense and still; uninterpretable postures, such
as head cocked with arms raised for long periods of time.
• Freezing, stilling, slowed movements and expressions: Holding of
positions, such as sitting with arms held out, waist high and to sides;
apathetic or lethargic movements or facial expressions, such as a dazed
expression when greeting the parent.
• Direct indices of apprehension regarding the parent: Display of extreme
fear in response to the parent. For example, looking frightened, flinging
hands over his or her face, running away, a highly vigilant posture,
when the parent returns and approaches.
• Direct indices of disorganization or disorientation: Clear displays of
confusion and disorganization upon reunion. For example, greeting a
stranger with raised arms instead of going to the parent; rapid changes
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Disrupted Attachment
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Disrupted Attachment
avoidant attachment, were more aggressive and impulsive, and had more
conflict with peers and caregivers during their school years (Erickson, Sroufe,
and Egeland 1985; Renken et al. 1989; Sroufe et al. 1990; Egeland, Pianta,
and O’Brien 1993). Among high-risk families, it is clear that early avoidant
attachment patterns place children at high risk for later aggression and other
externalizing problems.
It is the children with histories of disorganized–disoriented attachment
who are most at risk for developing severe problems, including aggression.
Again, disorganized attachment refers to a lack of, or collapse of, a consistent
or organized strategy to respond to the need for comfort and security when
under stress (e.g., separation and reunion). Kindergarten children who were
classified as disorganized in infancy were six times more likely to be hostile
and aggressive toward peers than were those classified as secure (Lyons-Ruth,
Alpern, and Repacholi 1993). Infants of impoverished adolescent mothers are
at risk for developing severe attachment disorder and subsequent aggression.
Sixty-two percent of these infants had disorganized attachment relationships
and were more likely to initiate conflict with their mothers by aggressive and
oppositional behavior by 2 years of age (Hann et al. 1991). These mothers
were less affectionate and more rejecting of their child’s overtures than other
mothers. By the time they became toddlers, these children were aggressive,
avoided and resisted their mothers, and were developing a controlling and
coercive strategy to cope.
The tendency to be controlling toward caregivers and others is a foremost
symptom of disorganized attachment and a constant challenge for those
who care for these children. While infants and toddlers with disorganized
attachment patterns are often helpless, frightened, and confused, as they enter
the preschool and early school years they develop various forms of controlling
behavior. The controlling–caregiver type is characterized by a role reversal,
where the child is overly solicitous, attempting to take care of the parent.
In the second category, controlling–punitive, the child is hostile, coercive,
rejecting, and humiliating toward the parent (Greenberg et al. 1997). Among
clinic-referred preschoolers diagnosed with ODD, a majority were found to
be controlling–disorganized. Mothers were typically classified as “unresolved,”
the adult counterpart of controlling–disorganized attachment (Greenberg et
al. 1991).
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Maltreatment
Childhood exposure to maltreatment and interpersonal trauma is extremely
common. Worldwide, approximately one-third of children experience
physical abuse, and 25 percent of girls and 20 percent of boys experience
sexual victimization (United Nations 2006). Decades of research and clinical
practice confirm the long-term negative consequences maltreatment can
have for children. Studies by the U.S. Department of Health and Human
Services (2011) and the National Child Traumatic Stress Network (Pynoos
2008) show that children who are abused and neglected have an increased
risk of severe mental and physical health problems, including PTSD,
depression, suicide, substance abuse, heart disease, pulmonary disease,
and liver disease. Exposure to traumatic events can alter psychobiological
development and increase risk of low academic performance, engagement in
high-risk behaviors, difficulties in peer and family relationships, and long-
term physical health problems. Children exposed to multiple traumas are
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°° poverty
°° violence in the marital relationship
°° parental unemployment, family stress and disorganization
°° lack of supportive social network, especially among single parents
who lack intimate emotional support.
Not all parents who experienced maltreatment in their families of origin
abuse and/or neglect their own children. What characterizes parents who
transcend their unfortunate histories and provide loving and secure care for
their offspring? There are three major factors (Main and Goldwyn 1984;
Egeland 1988):
• a supportive and loving relationship with an adult during childhood
(e.g., kin foster parent, counselor)
• support partner and/or social supports during parenthood
• a therapeutic intervention that facilitated resolution of early issues,
directing anger and responsibility toward perpetrators rather than self,
and providing a clear account of childhood loss and trauma.
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There is a great deal of support for the belief that in the majority of cases,
children do not lie about abuse allegations. Children with attachment
disorders, however, are at risk of making false allegations of abuse against
parents, teachers, therapists, and others. Often their motivation is control,
revenge, diversion, or even mere amusement. Their ability to appear believable,
adeptness at lying, and lack of concern for others can fool the most experienced
professionals. Therefore, it is crucial to have a thorough understanding of
the child’s background and symptomatology when assessing the validity
of allegations. There are certain “red flags” that can place a child at risk of
making false allegations of abuse. Children who are extremely angry about
prior maltreatment and exploitation are high risk. The risk grows further if
they have a previous history of making false accusations and do not want to
be in their current placement.
Neglect
Child neglect is the most frequently reported and substantiated form of
child maltreatment, accounting for up to 70 percent of all child abuse
reports. Between 1986 and 1993, the number of children physically
neglected increased by 163 percent, while the estimated number of
emotionally neglected children tripled (188 percent increase). Rates of
neglect have remained at these levels into the present time. Birth parents
are the perpetrators of neglect in most cases (91 percent); children are most
often neglected by females (87 percent), because for so many a female is the
only caregiver (NCCAN 1995; U.S. Department of Health and Human
Services 2011).
There is great variability in definitions of neglect. Some focus on the
specific behaviors or omissions of caregivers that endanger the child’s
physical, cognitive, or emotional health (Zuravin 1991). Others argue for
a broader definition that focuses on the conditions of the child, regardless
of the cause (Dubowitz et al. 1993). An even broader view of neglect
is suggested by Hamburg (1992), the past president of the Carnegie
Foundation. He indicts our society for “collective neglect,” failing to provide
adequate health care, child care, and policies that support families in caring
for their young children (Hamburg 1992; cited in Erickson and Egeland
1996, p.6).
Regardless of the definition, several types of neglect have been
identified by health care providers and mental health professionals:
physical, emotional, medical, mental health, and educational (Erickson and
Egeland 1996). Physical neglect is the most commonly identified form and
includes failure to protect from harm or danger and meet basic physical
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Neglect, especially emotional neglect during the first three years, has an
extremely damaging and long-lasting effect on children’s functioning in the
family, with peers and teachers, and in regard to coping skills and learning.
Attachment theory provides a meaningful framework for understanding
the sequelae of neglect (Erickson and Egeland 1996). Children with early
anxious patterns of attachment (emotional neglect) develop negative working
models—negative expectancies and belief systems about self, caregivers, and
the world in general. They expect not to get their needs met, so they shut down
and do not even try to solicit care or affection. They expect to be ineffective
and unsuccessful in tasks, so they give up. Their dependency needs are so
strong they are barely able to become motivated and stay task oriented. The
negative feedback they receive from others perpetuates their low self-esteem
and negative expectations of self and others (vicious cycle).
Violence
The United States is consistently ranked among the industrialized countries
with the highest rates of overall violence. National statistics indicate high
rates of traumatization of children through abuse and through the violence
they witness in homes and communities. Numerous research studies have
documented the adverse effects of violence and maltreatment on children’s
emotional, social, and cognitive functioning, as well as on their physical
health (Osofsky 2011).
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Sexual Abuse
Sexual abuse is common in the histories of children who develop severe
attachment disorder. Sexual abuse involves any sexual activity with a child
where consent is not or cannot be given. This includes sexual contact that is
accomplished by force or threat of force, regardless of where there is deception
or the child understands the nature of the activity (Finkelhor 1979). Sexual
activity includes penetration, sexual touching, or noncontact sexual acts such
as exposure, voyeurism, or displays of explicit materials.
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Child sex abuse is extremely traumatic and occurs more frequently than
often assumed. Estimates of lifetime prevalence are 17 percent for women
and 8 percent for men (Beach et al. 2013). Other surveys have found 27
percent of women and 16 percent of men reported a sexual offense by age 18
(Finkelhor 1990).
Multiple episodes of sexual abuse are common, occurring in more than
half the cases in nonclinical samples and in 75 percent of clinical samples
of abused children (Conte and Schuerman 1987; Elliott and Briere 1994).
Compared to girls, boys are found to be older at the onset of victimization,
and more likely to be abused by nonfamily members, women, and by offenders
who are known to have abused other children (Faller 1989). Girls are at
higher risk for sexual abuse than boys by a ratio of two to one (Everstine
and Everstine 1989). Both males and females are more at risk to be sexually
abused if they live without one of their birth parents, have an unavailable
mother, or perceive their family life as unhappy (Finkelhor and Baron 1986).
The incidence of sexual abuse among disabled children is 1.75 times higher
than nondisabled children (NCCAN 1993). Unlike other forms of child
abuse, sexual abuse does not appear to be related to socioeconomic status
(Berliner and Elliott 1996).
Research indicates that children who have been sexually abused suffer
from a wide range of psychological and interpersonal problems both in the
short term (Beitchman et al. 1991; Berliner 1991; Kendall-Tackett, Williams,
and Finkelhor 1993) and in later adult functioning (Browne and Finkelhor
1986; Finkelhor 1990; Beach et al. 2013). Damage occurs because sexual abuse
is always nonconsensual, developmentally inappropriate, invariably alters the
nature of the relationship within which it occurs, and interferes with normal
developmental processes, leading to an increased risk of maladjustment later
in life (Berliner and Elliott 1996). Finkelhor (1987) synthesized the clinical
issues common to sexually abused children in four “traumagenic dynamics”:
traumatic sexualization, stigmatization, powerlessness, and betrayal. These
four dynamics were shown to be strong indicators of symptom formation in
children (Mannarino and Cohen 1996).
Sexually abused children have more behavior problems than nonabused
children (Cohen and Mannarino 1988; Einbender and Friedrich 1989;
Gomes-Schwartz, Horowitz, and Cardarelli 1990). They tend to lack social
skills, are more aggressive, and are more socially withdrawn than nonabused
children (Friedrich, Beilke, and Urquiza 1987). They commonly suffer from
somatic reactions, sleep and eating disturbances, night terrors and nightmares,
bedwetting, and phobic reactions. The majority of child sexual abuse victims
have been found to suffer from mild to acute posttraumatic symptoms
(DeFrancis 1969; Burgess and Holmstrom 1984). Researchers have found
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abusive act is justifiable punishment for some misdeed, thus “it must be my
fault and I am bad” (Briere 1989). Consequently, these children internalize
a sense of shame, guilt, and self-blame. They feel intrinsically bad, damaged,
worthless, unlovable, or even evil.
Sexually traumatized children often act out sexually with other children,
engage in autoerotic acts, or behave in a seductive way toward adults. This
may be an attempt to gain a sense of mastery over the trauma by repetition
of these events in a symbolic form. They typically engage in sexualized play
that was similar to their victimization and seek to undo their feelings of
helplessness by identifying with the aggressor, doing to other children what
was done to them (Everstine and Everstine 1989).
Incest
Incest is defined as any sexual contact between a child and parent, stepparent,
relative, or anyone who fills the role of parent surrogate. Sexual assaults by
adults in positions of trust are more traumatic than by strangers, due to the
intensity of betrayal and confusion. Research has provided insight into the
family characteristics of incestuously abusing families (Trepper et al. 1996).
The vast majority of these families are socially isolated, enmeshed, quite rigid,
and nonadaptable to change. Communication patterns include secretiveness,
unclear and inconsistent messages, infrequent discussions of feelings, little
attentive listening, and lack of conflict-resolution skills. There is limited or
erratic leadership. Fewer than one-third of families were “father-executive”
type (contrary to the popular notion that there is usually a strong, domineering
father and a weak, ineffectual mother). Lack of family member role clarity is
common, with undefined, shifting, and reversing roles (e.g., “parental child”).
Most offending parents (78%) did not engage in nurturing activities of the
victim when he or she was a baby, reflecting the lack of positive and secure
attachment. More than two-thirds of offending parents used alcohol or drugs
often, and used just prior to an abusive episode. Substance abuse is clearly
a precipitant and a vulnerability factor. Most of the marriages (82%) were
rated in over-all quality as poor and characterized by emotional separateness.
Family members tend to deny aspects of incestuous abuse. Four types of
denial have been identified (Trepper and Barrett 1989):
• Denial of facts: The individual openly challenges the realities of the
abuse.
• Denial of impact: The individual admits incest has occurred, but lessens
the intensity of the meaning of the abuse.
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Ritualistic Abuse
Reports of ritualistic abuse occasionally occur when working with sexually
abused children. Ritualistic abuse is one of the more controversial issues
in the field of child maltreatment; there is much debate over its existence,
prevalence, and the veracity of child victims’ accounts (Kelley 1996).
Ritualistic abuse has been defined as abuse that occurs when some religious,
magical, or supernatural connotations are used in conjunction with the
fear and intimidation of children (Finkelhor, Williams, and Burns 1988).
Lloyd (1991) has defined it as the intentional, repeated, and stylized abuse
of a child by a person responsible for the child’s welfare, typified by such
other acts as cruelty to animals, or threats of harm to the child or others. In
1994, the National Center on Child Abuse and Neglect funded a study on
ritualistic abuse in the United States, and found that 31 percent of mental
health professionals surveyed had encountered a ritualistic abuse case. They
also found that 23 percent of protective service and law enforcement agencies
had encountered at least one case of ritualistic or religion-based child abuse
(Goodman, Bottoms, and Shaver 1994).
Allegations of ritualistic abuse typically involve reports of forced sexual
activity; physical abuse or torture; ingestion of blood, semen, or excrement;
ingestion of drugs; threats of violence or death; threats with supernatural
powers; satanic reference or paraphernalia; witnessing animal mutilations;
and killing of adults and children (Kelley 1996). Research has found that
children who reported ritualistic abuse had greater symptomatology than
children who only experienced sexual abuse (Finkelhor et al. 1988). Reports
of ritualistic abuse are consistently associated with increased impact on and
traumatization of victims (Watermann et al. 1993; Briere 1988; Kelley 1989).
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memory; lack of cause and effect thinking; poor personal boundaries; anger-
management difficulty, poor judgment; and no connection to societal rules
(McCreight 1997).
Psychoactive substances cross the placenta and the blood–brain barrier.
Use of cocaine, alcohol, and narcotics during pregnancy are all associated with
smaller head circumference in the newborn, indicating a potential structural
effect on the brain. Infants exposed to cocaine have a higher risk of premature
birth and low birth weight (Zuckerman 1994; Jaudes and Ekwo 1997).
Cigarette smoking diminishes the blood flow to the placenta and can lead
to prematurity. Methamphetamine is comparable to cocaine in its negative
effects on the fetus, and can cause developmental and behavioral problems
in children. Heroin and other narcotics may lead to over-withdrawal in the
newborn as well as developmental abnormalities (Alexander and Moskal
1997).
Prenatal and postnatal drug exposure affects development and attachment.
For example, an infant or toddler with FAS/E characteristics may not be able
to experience the care and nurturance that may be available from caregivers,
thereby disrupting the attachment process. Children exposed to drugs in
utero were found to have depressed developmental scores at 6 months, which
continued through 24 months of age. The postnatal environment, however,
has an important impact. One hundred percent of children living with drug-
using mothers showed attachment disorders, including avoidance, fear, and
anger toward their mothers. The majority of children (64 percent) of mothers
who stopped using drugs after birth displayed secure attachments (Howard
1994).
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Interpersonal Neurobiology
The relatively new field of interpersonal neurobiology is a developmental
theory that integrates psychology and biology (Siegel 1999; Cozolino 2006;
Arden and Linford 2009; Schore 2012). The focus is on the early stages of
life, which are central to building the brain’s structures and functions. During
the “decade of the brain”—from about 1995 to 2005—new technologies,
such as MRI, enabled researchers to learn about the brain as it processes
internal and external information. The essence of these studies is clear and
now widely accepted in the mental health field: in utero and early postnatal
experiences shape brain development and the children, adults, and parents we
become. The infant’s attachment relationships play a primary role in shaping
the developing brain and the neuronal connections in the brain.
Brain development begins two weeks after conception and continues
most rapidly during the first three years of life. Our brains are basically
social in nature. Prenatal stress produces increased norepinephrine (arousal
and agitation) and decreased levels of dopamine and serotonin (depression,
anxiety, emotional dysregulation). Brain circuits are being created rapidly in
the early stages, and are largely determined by the quality of the infant–
caregiver relationship and the level of stress. Babies are right-hemisphere
dominant, responding primarily to preverbal and nonverbal emotional
communication—facial expressions, mutual gaze, touch, tone of voice, and in
arms security and safety. The infant’s right brain and the attachment figure’s
right brain are in-synch and attuned during moments of connection. This
“limbic resonance” is the fundamental building block of secure attachment,
and leads to the child’s ability to self-regulate and to the formation of the
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child’s core beliefs (i.e., internal working model). The sensitive caregiver
calms, soothes, and down-regulates the baby’s emotions and physical stress
response, and later the child learns self-regulation. Early experiences of
secure or insecure attachment are encoded into the implicit (preverbal and
unconscious) memory systems in the limbic brain, and become mindsets and
expectations that guide subsequent behavior (e.g., attachment figures are safe
or unsafe, accepting or rejecting). Studies have found that infant attachment
security predicts self-control six years later (Olson, Bates, and Bayles 1990).
Prenatal brain development is influenced by genetics and environment.
Poor nutrition, drugs and alcohol, chronic maternal stress, and other
environmental factors can have adverse effects on the fetus’s brain. Most
postnatal brain development is experience dependent; the brain (especially
the limbic system) is an open-loop system—it relies on attuned and sensitive
caring from attachment figures for healthy growth and functioning (Tierney
and Nelson 2009). Relationship experiences wire the brain circuits, affecting
the structure, chemistry, and genetic expression of the brain.
Neurons are brain cells that play a central role in processing and
communicating information. Communication between neurons occurs via
neurotransmitters that excite or inhibit electrical and chemical messages.
Relationship experiences of the infant and young child develop into neural
networks that determine thoughts, moods, behaviors and attachment style:
what fires together, wires together (Badenoch 2008).
Children deprived of quality relationships have abnormal brain
development, as illustrated by the findings demonstrated by the Bucharest
Early Intervention Project (Zeanah et al. 2003). This research follows
three groups of children: 1) institutionalized group—children living in an
orphanage all their lives; 2) foster care group—children institutionalized at
birth then placed in foster care at a mean age of 22 months; and 3) never
institutionalized group—children living with their biological parents in
the Bucharest, Romania area. The institutionalized children have stunted
and delayed patterns of brain activity, cognitive development, and physical
growth. Children placed in foster care before age 2 show patterns of brain
activity similar to never institutionalized children, indicating the importance
of placing children early to reduce the negative effects of deprivation. This
study confirms that placing babies in institutional settings can have dire
consequences for brain function, and these effects are worse for children
older than 2 years (Marshall et al. 2008).
Limbic System
The limbic system is the social and emotional part of the brain, governing
attachment, nurturing instincts, learning, implicit memory (preverbal,
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Neurochemicals
The brain and nervous system are composed of billions of neurons, which
form connections with many other neurons to create a neural network.
Neurons communicate with one another between gaps, or synapses, via
electrical and chemical messages. Neurons that fire together become wired
together. Over time, the brain circuits and networks that result from these
firings lead to “wiring” of the brain. The social and emotional environment of
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Stress Response
The stress response is critical to the understanding of the neurobiology
of trauma and attachment disorder. Stress is an automatic physiological
response to any situation that is threatening, overwhelming, or requires
adjustment to change. The stress response includes many physical changes,
including increased heart rate and breathing, and inhibited digestion and
immune response, triggered by stress hormones released in response to real
or perceived danger (i.e., fight, flight, freeze). This survival-based alarm
system helped our primitive ancestors deal with their environment. When
they encountered danger they had extra energy and strength to attack or
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escape. When the danger passed the stress response would abate. However,
when the stress response is chronically triggered, such as during childhood
maltreatment and compromised attachment, key biological systems become
altered and dysregulated. Chronic stress is linked not only to many mental
health problems, such as anxiety and depression, but also to numerous
physical health problems, including heart disease, ulcers, and asthma.
There are three interrelated components of the human stress response:
catecholamines, HPA axis, and immune system response. Catecholamines
include epinephrine, norepinephrine, and dopamine, which are released by
the sympathetic nervous system in response to threat. The hypothalamic–
pituitary–adrenal (HPA) axis responds with a cascade of stress biochemicals.
The hypothalamus releases corticotrophin-releasing hormone (CRH), which
triggers the pituitary to release adrenocorticotropic hormone (ACTH), finally
causing the adrenal glands to activate the flow of cortisol, raising the blood
glucose level to respond to threat. The third portion of the stress response
involves the immune system. Elevated levels of stress hormones depress
immune function. Under normal conditions, the immune system releases
proinflammatory cytokines, which increase inflammation to help the body
heal wounds and fight infection. Severe and chronic stress causes inflammation
levels to be abnormally high, resulting in vulnerability to physical problems
and disease. Research on Psychoneuroimmunology (PNI), which focuses on
the mind–body connection, has found that people who suffer trauma have
higher rates of serious illnesses than the general population. The Adverse
Childhood Experiences (ACE) study found that adults who experienced
trauma and disrupted attachment as children—including physical and sexual
abuse, and parental mental illness, substance abuse, and criminal behavior—
had higher rates of cancer, heart disease, bronchitis, diabetes, stroke, and
gastrointestinal disorders, than nontraumatized adults (Felitti et al. 1998).
Similar outcomes have been found in other studies: women maltreated as
children had a ninefold increase in heart disease; 60 percent of women treated
for gastrointestinal illness had an abuse history; significantly higher rates
of chronic pain, chronic fatigue syndrome, and fibromyalgia occurred when
there was a history of trauma and PTSD diagnoses (Kendall-Tackett 2009).
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Two parts of the primitive “old brain” (limbic system), the amygdala and
hippocampus, are particularly involved with the processing of emotion,
memory, and fear responses. The amygdala evaluates the emotional meaning
of incoming stimuli and is the storehouse of emotional memory. The
hippocampus records in memory the spatial and temporal dimensions of
experience and plays an important role in categorizing and storing stimuli into
short-term memory. During times of threat or danger, the amygdala reacts
instantaneously, bypassing the rational brain (neocortex), and triggering an
alarm reaction:
• activating the hypothalamus, which secretes corticotropin-releasing
hormone (CRH)
• stimulating the autonomic nervous system (ANS), which affects
movements
• raising heart rate and blood pressure, and slowing breathing
• signaling the locus ceruleus in the brain stem to release norepinephrine,
which heightens overall brain reactivity, releasing dopamine that
causes the riveting of attention on the source of fear (LeDoux 1992;
Goleman 1995; Arden and Linford 2009).
The amygdala is most fully formed at birth and matures rapidly in the
infant’s brain. Thus, traumatic experiences such as abuse, neglect, and anxious
attachment, are stored in preverbal memory. These memories are intense
perceptual experiences and later in life intrude on awareness in the form of
hypervigilance, nightmares, hyperarousal, and anxiety.
Biochemical and hormonal reactions occur in children during traumatic
stress that produce long-term changes in the mind–body system. In a series
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6
Assessment
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Assessment
Pillars of Assessment
Assessment and diagnosis of attachment disorder and interpersonal trauma
rest on three pillars: 1) developmental history; 2) symptoms and diagnoses
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132
Assessment
The relevant areas of child and family functioning to focus on include the
following:
• presenting symptoms and problems: individual and in social context
• developmental history: biological, psychological, and social background;
attachment history; pre-, peri-, and postnatal factors
• internal working model: child and caregivers (prior and current)
• current parents/caregivers: attachment history, psychosocial func
tioning, marital and other significant relationships
• child–caregiver relationship patterns
• family, community, and cultural systems
• current environmental conditions and stressors.
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Assessment
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Assessment
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Assessment
Presenting Problem
• The symptom checklist is completed by the current caregivers (e.g.,
adoptive parents), teachers, or others familiar with the child. There are
six symptom categories: behavioral, cognitive, affective, social, physical,
and moral/spiritual. (See Assessment of the Child below for a detailed
explanation.)
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Developmental History
• Information about the child’s biological parents and family is
ascertained (when available) by reviewing social service, medical, and
forensic records, and from the verbal reports of the current caregivers.
Relevant information includes issues regarding the biological parents
prior to the pregnancy (e.g. psychosocial functioning, desire for the
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Assessment
Life Script
Our childhood experiences with attachment figures are where our scripts are
written. These experiences develop into core beliefs: the mindsets, attitudes,
and expectations that define who we are, how to relate to others, and what
roles we play. A child’s beliefs about him- or herself are based on how his or
her parents or caregivers act toward that child. For example, messages such as
“You can’t do anything right,” or “Why are you so stupid?” communicate to a
child that he or she is inadequate and incompetent. Unspoken messages can
be even more powerful. For example, a parent who abandons a child conveys
the message, “You are not worthy of love and connection.”
From before birth and well into childhood, our subconscious receives a
tremendous amount of input from which we formulate our beliefs about self,
others, and the world. This is how we are taught to view ourselves as capable
or inept, good or bad, deserving of love or unacceptable. This is how we learn
to expect and anticipate certain behaviors from caregivers and others—safe
or dangerous, kind or mean, available or rejecting. Children also learn how
relationships operate by observing how their parents treat one another; how
they deal with conflict, power, intimacy, and communication. For example,
witnessing his or her father abuse his or her mother teaches a child that
domination and violence are acceptable ways to solve problems and that
females should fear males.
Many adults have some degree of emotional baggage from their pasts—
unhealed pain, losses, resentments, and fears stemming from early life
experiences. As explained, these childhood experiences develop into “working
models,”—the core beliefs, mindsets, and expectations about who we are and
how to relate to others. Without self-awareness, we will be controlled by
these outdated beliefs. Awareness of why we make certain choices frees us
to make healthier choices. The Life Script is an excellent tool for becoming
aware of your early programming, and the associated perceptions, emotions,
and behaviors.
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The Life Script is completed and discussed in detail with the treatment
team. Content (“what”) and process (“how”) are focused on. That is, in
addition to the details of the adult’s prior experiences, significant clinical
information is gathered by observing individual and interactional responses
during the discussion (e.g. how do they deal with emotions; do they provide
empathy and support to one another?). The Life Script questions can be found
in Appendix H).
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Assessment
Family System
• The structure, dynamics, and relationship patterns in the family must
be identified and understood. The family system is both influenced
by, and directly impacts, the emotions and behaviors of the child with
attachment disorder. Assessment focuses on the following:
°° Roles and rules: Family members either create or are assigned specific
roles, which determine behavior and function in the system (e.g.,
scapegoat, rescuer, victim, perpetrator, placator, disciplinarian). Rules
are the “laws” by which the family operates and can be realistic/
unrealistic, appropriate/inappropriate.
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Behavioral
Children with attachment disorder manifest a variety of antisocial and
aggressive acting-out behaviors. They are often self-destructive, including
self-mutilation (e.g., head banging, cutting), and display suicidal gestures
and other self-defeating behaviors. They destroy the property of others,
their own material possessions, or both. Impulsivity and physical aggression
toward other children and adults is common. Aggression can be overt, such
as acts of physical violence, or passive–aggressive, such as manipulative and
surreptitious behaviors. Sadistic cruelty to animals, often secretive, can occur.
Stealing is typical, including theft outside and inside the home. Lying is of
a pathological nature; they remain deceitful regardless of concrete evidence
to the contrary. A preoccupation with fire, gore, and blood sometimes occurs,
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Assessment
as they establish an affiliation with evil and the dark side of life. They can
be ingenious, devious, and “phoney,” giving the appearance of sincerity, but
with ulterior and self-serving motives. For example, helping professionals
may assume the child’s seemingly cooperative responses are sincere, when in
reality this behavior is often manipulative and controlling.
Problems regarding food and eating patterns are common, such as
hoarding and gorging, and may reflect control issues and a need to fill their
emotional emptiness. Children who have been sexually abused manifest
inappropriate sexual behavior, attitudes, and concerns, such as victimizing
others, excessive masturbation, seductive manipulation, and sexualized play.
Sleep disturbances include recurrent nightmares, night terrors, disturbed
sleep patterns, and wandering at night. Enuresis and encopresis are typical
manifestations of anger, aggression, control issues, and physiological
dysregulation.
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she often tries to get out of the car without looking to see if another car
was coming.
Self-Destructive Behaviors
When we brought Tony home from Romania she rocked in her crib, hit
her head against the wall, pulled her hair out, and bit her hands and
arms. When she walks or runs, she runs into things on purpose and falls
down. She is always setting herself up to fail.
Destruction of Property
Billy trashes his room when he is angry. He will pick up the nearest item
and throw it. He has cut up my bedspread and pillow with scissors.
He has put holes in the walls and has carved on our furniture. He has
drawn all over his bed and has picked the wallpaper off the wall. He has
mutilated pictures of himself and has broken all of his toys. He poked
holes in the seats of his chairs and wrote with a marker on the carpet
and sofa. He will break someone else’s most precious toy, then laugh.
Consistently Irresponsible
Sarah tells us her homework is done, but it rarely is. She puts up a big
fuss when she has to do a chore and never gets it done right. All she
wants to do is watch TV. She is consistently irresponsible and forgetful.
She leaves behind lunch pails, backpacks, and her homework.
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Stealing
Ellen steals incessantly. She has gone through my purse many times.
She stole $20 from a friend’s bedroom. She also has stolen two pocket
knives and was caught shoplifting. We had to resort to full body searches
after she took my diamond pin to school hidden in her waistband. She
also stole something off her teacher’s desk. At Easter our daughters
have to lock their Easter baskets in their rooms.
Hoarding
We are constantly finding candy wrappers under Lisa’s bed. We also
find them under the couch and in corners. I recently found a half-eaten
sandwich, old stale cookies, and packets of sugar between her mattress.
We always give her all the food she wants and are puzzled why she has
all these little stashes. Most of the time the food is never even eaten.
Cruelty to Animals
I began to notice that Mary was very nice to the animals as long as she
knew someone was watching her. As soon as she thought she wasn’t
being watched she would kick or hit both the dog and the cat. Then,
anytime she pet them, she would pull a tail or pinch. Now, the cat is
neurotic and fearful around her and the dog avoids her altogether.
Sleep Disturbance
Robert has a very difficult time getting to sleep. He often yells for Dad
or Mom several times a night. He also tosses, turns, and talks in his sleep.
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Hyperactivity
Morning in our house is chaotic. Adam wakes up first and usually makes
a lot of noise to wake us all up. Next, he gets out food and milk, which
he often spills. The counter is left in a mess. He bumps into tables, walls,
and counters, and goes from one room to the next leaving mess after
mess. I give Adam his Ritalin and I have a cup of coffee. I ignore all his
behavior until I’ve had some coffee. Once his medication kicks in he
doesn’t bump into things and he doesn’t argue constantly.
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and evil characters. We recently passed a dead dog on the road. He was
fascinated by it and couldn’t stop talking about how cool it was.
Poor Hygiene
Ken is not concerned at all about personal hygiene. He could really
not care less about having pimples from not washing his face, or not
brushing his teeth, or using deodorant. He hates to take a shower and
wash his hair. Sometimes he will run the water in the shower and pretend
he is washing his hair. He would wear the same socks and underwear
every day if he could.
Cognitive Functioning
A lack of cause-and-effect thinking is evident; failing to recognize and
comprehend the relationship between actions and consequences. Thus,
these children rarely take responsibility for their own choices and actions,
and instead, blame others. Regarding cognitive style (i.e., internal working
models), they perceive themselves as unwanted, worthless, impotent and
“bad,” perceive caretakers as unavailable, untrustworthy, and threatening, and
perceive the world as unsafe and hostile. They define themselves as helpless
victims unable to impact their world, or conversely, as omnipotent, with
a grandiose sense of self-importance as a defense against feeling helpless.
Learning and language disorders can occur as a result of early neurological
damage (e.g., fetal alcohol syndrome, failure to thrive, physical abuse), or in
conjunction with the matrix of psychosocial symptoms mentioned above.
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though! You ask him if he can tell us if he’s done something wrong
and he says yes and tells what it is. Then you ask him if he knows the
consequences. Again, he says yes and tells you. But he still absolutely
refuses to abide by the rules. It’s only a matter of time before he does
the same thing over again. He just does what he wants, not thinking or
caring about what will happen. When playing chess with him, I can use
the same moves to beat him time and time again.
Learning Disorders
Beth is behind in her age level and her educational level. She is in a
special education school, one year behind. They have told us that her
problems are related to early childhood deprivation.
Language Disorders
After leaving Guatemala, Carla’s English was wonderful within six months.
She can understand everything and make herself understandable. She
may, however, act like she can’t speak much English. She does this at
school. They say she has real problems understanding. Carla will try that
ploy with me when she is in trouble. She acts likes she can’t figure out
what you are talking about. She has admitted that she understands you.
After she admits it, then she can have a five-minute conversation with
you about it.
Affectivity
The core emotions these children experience are intense levels of anger,
fear, pain, and shame. They frequently appear disheartened and depressed,
generally in response to unresolved loss and grief. Temper tantrums and
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rage reactions are common. They are emotionally labile with frequent and
unpredictable mood swings. Due to years of avoidance and denial, as well as
a lack of supportive role models, they are not able to identify or express their
emotions in clear and constructive ways. They experience shame regarding
maltreatment as well as their acting out toward others.
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can be in a good mood at school and then see me when I pick her up
and change into a bad mood. I never know what to expect from Lisa.
Each new day is a new challenge.
Social Behavior
Chronic noncompliance is manifested interpersonally as control battles,
defiance of rules and authority, and inability to tolerate external limits. Thus,
these youngsters create frequent conflict with caregivers, teachers, siblings,
and peers. They relate to others in a manipulative, controlling, and exploitative
fashion, lacking the ability to connect with genuine intimacy and affection.
Lacking trust in others (a direct result of unavailable, unreliable, and hurtful
caregivers in the early stages), they overcompensate by pseudoindependence.
They are superficially engaging and charming, indiscriminately affectionate
with strangers, and lack long-term meaningful relationships. Lack of eye
contact is apparent when interaction is perceived as intimate, but they
maintain eye contact for purposes of seduction or control. Typical social
roles developed and maintained include victim (helpless, powerless) and/or
victimizer (perpetrator, bully). Blaming others for their own mistakes and
problems, and taking little or no responsibility for their actions and choices
further alienates and frustrates others.
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Victimized by Others
She sets herself up to be victimized by everyone. Other kids will hurt her
or blame her for things and she says nothing. She has even confessed
to things and then we find out that someone else really did it. She
will purposefully lose a privilege and then feel sorry for herself as the
helpless martyr.
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Physical
Anger, grief, fear, and emotional pain are stored and expressed in the bodies of
children with attachment disorder. They are typically stiff, chronically tense,
and physically defended against closeness and contact. Chest muscles are
particularly rigid as a reaction to the suppression of anxiety and fear, which
results in shallow and restricted breathing. Tension in the throat and facial
area blocks the impulse to cry. They pull back their shoulders, distancing
themselves from others. Some appear robotic in nature, with minimal facial
expression and a vacant stare in their eyes, their bodies expressing emotional
repression and avoidance of others. Problems with personal hygiene are
common. They take little pride in their appearance and living quarters, often
refusing to shower, brush their teeth, and maintain a clean environment.
They are often accident prone, and experience many physical injuries. Minor
injuries are magnified and dramatized in order to receive attention through
manipulation and control. Serious injuries, conversely, are underemphasized
and kept secret, in an effort to avoid vulnerability and helping responses from
caregivers. They are tactilely defensive; rigid body armor is a defense against
human contact and a somatic reaction to prior trauma. Genetically, their
family history is characterized by numerous biologically based problems, such
as clinical depression, substance abuse, aggression, and severe psychological
disturbance.
Poor Hygiene
Sheila swears that she brushed her teeth, but when I check, I find that
her toothbrush is totally dry. When told to wash her hair, she just stands
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in the shower, not even wetting her head. Her hair looks just as greasy as
when she went in. She sometimes sleeps in her clothes, and wears the
same smelly things for days.
Accident Prone
When he walks or runs, he falls down many times. He is always pushing
or bumping into his brother. He always says, “It was an accident.” He
used to turn over furniture and make the pictures on the wall crooked
when he was angry. If there is anything special to any other family
member, you can be sure that he will accidentally break it.
Tactilely Defensive
When Lucy first came to our home I tried to hold her and stroke her
cheek. She screamed and pulled away and said “Don’t touch me, you’re
hurting me.” It took six weeks before I could even approach her. She still
avoids any physical contact or affection.
Genetic Predispositions
Danny’s biological father has been in jail off and on his entire life and his
mother was always depressed. I’m told that he was physically abusive to
his mother, and later to his sister and animals. Danny has never met his
father, but the apple sure doesn’t fall far from the tree. He acts just like
his dad. He has even said, “I’m going to grow up just like my birth dad
because he has power, he hurts people.”
Spiritual/Moral
Spiritual health can be defined in various ways: a state of well-being, not
just the absence of disease; the quality of being at peace with oneself and
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Cruelty to Animals
Cruelty to animals is one of the most disturbing manifestations of severe
attachment disorder. It ranges from annoying family pets (e.g., tail pulling,
rough play, kicking) to severe transgressions (e.g., strangulation, mutilation).
These children lack the capacity to give and receive affection with pets, lack
the motivation and sense of responsibility necessary to provide appropriate
care, and are not able to empathize with the suffering of animals. They often
delight in venting their frustrations and hostilities on helpless creatures to
compensate for feelings of powerlessness and inferiority.
Margaret Mead (1964) suggested that childhood cruelty to animals is a
precursor to adult antisocial violence. Researchers found that the combination
of cruelty to animals, enuresis, and fire setting predicted later violent and
criminal behaviors in adults (Hellman and Blackman 1966). Researchers
at Northeastern University found that children who abuse animals are five
times more likely to commit violent crimes as adults. The FBI’s Behavioral
Science Unit found that a majority of multiple murderers admitted to cruelty
to animals during childhood (Cannon 1997).
Parental abuse of children was the most common etiological factor
found in cruelty to animals (Tapia 1971). Erick Fromm (1973) noted
that children who are sadistic are usually themselves the victims of cruel
treatment. Schowalter (1983) concluded that cruelty to animals represents
a displacement of aggression from the child to a helpless animal. We have
found that animal harassment and abuse is often undetected by the parents.
The child can be remarkably surreptitious in his or her offenses.
Attraction to Fire
Fire provides a particular appeal for some children with attachment disorder.
Its attributes of power and destruction are attractive qualities to the child
who is filled with rage and feels powerless. The child’s fire-setting behaviors
are extremely disconcerting to caregivers. The child senses this fear and
apprehension, and then uses this to his or her advantage in order to gain a
sense of further power and control.
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Fire-setting episodes are rarely impulsive acts, but are more likely to be
carefully considered and planned. Some children establish elaborate alibis
at a moment’s notice, while others show little inclination to “cover up” their
actions. Fire-setting behaviors vary in degree from simple fascination and/
or occasional lighting of matches, to more serious actions, such as setting fire
to a home. The more serious the nature of the premeditated fire, the more
seriously disturbed the child. Society has recognized the magnitude of this
problem. One study found that juveniles accounted for 55 percent of arson
arrests. One-third of those arrested were under 15 years old, and 7 percent
were under 10 (Estrin 1996).
Differential Diagnosis
Attachment disorder shares a particular affinity with ADHD and bipolar
disorder. ADHD is estimated to occur in about 5 percent of school-
age children (American Psychiatric Association 2013). ADHD involves
behavioral and learning difficulties relating to inattention, impulsivity, and
hyperactivity. The exact causes of ADHD are unknown, but research indicates
there is a physiological component. Environmental and social factors, such as
quality of parenting, diet, and toxins affect ADHD, but are not causal factors
(Bain 1991). The correlation of ADHD and reactive attachment disorder has
been placed at between 40 percent and 70 percent of abused, neglected, and
adopted children. ADHD is vastly overdiagnosed in this population.
Children with attachment disorder can also suffer from bipolar disorder.
Bipolar refers to a genetically linked affective disorder characterized by both
manic and depressive mood episodes. These mood swings can range from
overly expansive and irritable, to sad and hopeless, with intervening periods
of normal mood. Symptoms of bipolar disorder were thought to show up in
adolescence or early adulthood. Young children with bipolar disorder often
do not display intense mood shifts, but rather less dramatic variations in
behavior that can easily go undetected. The prevalence of pediatric bipolar
is about 3 percent. For a comprehensive symptom comparison between
ADHD, bipolar disorder, and attachment disorder, see Appendix E.
Key features of autism spectrum disorder can be similar to reactive
attachment disorder. Children with both conditions can show lack of
positive emotions with caregivers, cognitive delays, and impairments in social
reciprocity. However, children with attachment disorder have a history of
severe emotional neglect, while those with autistic spectrum disorder only
rarely have experienced such neglect. The repetitive behaviors and restricted
interests of autism are not found in attachment disorder. Also, children with
autistic spectrum disorder regularly show attachment behavior typical for
their developmental level (American Psychiatric Association 2013).
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Therapy
Basic Theoretical and Treatment Issues
Basic Principles
• Family Systems: The child, parents, and other family members must be
understood in the context of the systems that influence their lives. The
focus is on prior and current family systems, and external systems such
as social services, extended family, social networks, and community
resources. The systems model concentrates on the behavior of family
members as they interact in ongoing and reciprocal relationships,
and on the family as it interacts with external social influences. For
example, family members affect one another—each person’s behavior
serving both as a response and a trigger. A child who enters an adoptive
family with an attitude of hostility may trigger an angry and punitive
response from adoptive parents. This parental response reinforces the
child’s belief that all caregivers are hostile and rejecting. Hostility and
rejection become mutually reinforcing in this child–parent relationship.
Thus, interventions must focus on both the individual and the social
systems in which he or she functions.
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provides the message: “I know what you need in order to feel safe,
and I will meet your needs.” For instance, it is understood that the
child’s hostile and controlling demeanor is actually a defensive strategy
designed to protect him or her from feelings of vulnerability, insecurity,
and fear.
• Empathy: Just as the healthy parent cares deeply about his or her
infant and child, the therapist conveys a heartfelt level of caring and
compassion. The therapist remains proactive, empathic, warm, and
caring, rather than reacting negatively to the child’s overtly hostile or
distancing behavior. The message conveyed is: “How sad that those
horrible things happened to you; I’m sorry that you were treated that
way; I understand what you feel and how much pain you must be in.”
• Positive affect: Parents who foster secure attachments generally
experience and exhibit positive emotional responses as they interact
with their children. They become irritable and impatient on occasion,
but are able to maintain their composure and model healthy coping
styles. The therapist also maintains a positive demeanor, particularly
when the child is acting out (e.g., verbal abuse, distancing, defiant).
This prevents the reenactment of dysfunctional patterns, such as when
the child directly or unconsciously “invites” a caregiver to be rejecting,
angry, or abusive. The message to the child is: “I will not allow you
to control our relationship in unhealthy and destructive ways.” This
provides modeling of positive affect, appropriate boundary setting, and
facilitates change in the child’s internal working model. Traumatized
children are particularly sensitive and reactive to body language: facial
expressions, tone of voice, touch, eye contact.
• Support: Parents of securely attached children provide a scaffold
of support, i.e., a framework that props up or supports the child as
development unfolds: the infant is held in the parent’s arms, the
toddler explores the environment but checks back with the parent
for reassurance, and the preschooler plays independently with friends
while still under the watchful eye of the parent. The therapist also
provides a scaffolding of support tailored to the developmental needs
and capabilities of the child. During the initial phase of treatment, the
therapist emphasizes rules, expectations, and natural consequences. As
therapy progresses, the focus shifts to reinforcing and celebrating the
child’s independent achievements.
• Reciprocity: A positive reciprocal relationship is one in which there is
mutual influence and regulation. The securely attached child achieves a
“goal-corrected partnership” with his or her parents, characterized by a
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sharing of control, ideas, values, feelings, plans, and goals. This parent–
child alliance, achieved by approximately 4 years of age, is based on
the successful completion of earlier stages of attachment. Marvin
(1977) developed the “cookie test” procedure to access a child’s ability
to inhibit his or her own impulses for the benefit of the relationship:
Mother shows the child a cookie, tells her she can have it only after
mother finishes a chore, places the cookie in sight but out of reach,
waits three minutes, then gives the cookie to the child.
Only 19 percent of 2-year-olds could wait (they cry, reach for the
cookie, grab mother’s leg in protest). Most securely attached 3- and
4-year-olds, however, were able to wait the three minutes. They
could inhibit their impulses, taking the mother’s needs and feelings
into consideration. Children with attachment disorder, regardless
of their age, fail the cookie test. They have not achieved the state of
a goal-corrected partnership due to prior insecure and pathological
attachment experiences.
The therapist guides the child toward a reciprocal relationship based
on mutual respect and sensitivity. This begins with the establishment
of a foundation for secure attachment (safety, protection, empathy,
trust). The child begins to learn to balance his or her own needs with
those of others.
• Love: Secure attachment is synonymous with love: the ability to feel
a deep, special, and genuine caring for and commitment to another
human being. Children with attachment disorder often have difficulty
experiencing and demonstrating love toward themselves and others,
because they lack the early attachment relationships necessary to
create the feeling. Corrective Attachment Therapy provides that
relationship context and in doing so, guides the child to a place where
love is suddenly an option. During the course of successful treatment,
a child will commonly say for the first time, “I am feeling love in my
heart.” This open expression of loving feelings occurs with parents eye
to eye, face to face, heart to heart. Children however, will only feel
safe in experiencing and expressing love if the parent(s) are available
to receive that love. Thus, therapy also helps the parents become
emotionally available.
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children and adults. As is the case with most clinical interventions, the LAP
cannot be understood outside of the therapeutic milieu in which it occurs, or
without considering the skillful implementation of the experienced, trained,
and sensitive therapist. The LAP is not a method or technique—it is a relationship
context in which other methods are employed (e.g., cognitive rescripting, inner
child metaphor, psychodramatic reenactment). The therapist must provide
a balance of structure and nurturance, and respect the child’s individual
needs and choices. It is imperative to avoid establishing a complementary
relationship of coercion and compliance, characteristic of prior unhealthy
attachment relationships.
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and rivets attention on the source of the fear. This alarm reaction is designed
to trigger automatically when danger or threat is sensed. Maltreated children,
however, experience a chronic alarm reaction, resulting in symptoms of
PTSD (hyperarousal, intrusive recollections, compulsive avoidance).
The Reticular Activation System (RAS) is a switching device between the
old brain and the new brain. When we are threatened and sense danger, the
RAS shuts down energy to the cerebral cortex, allowing training and instinct
to dominate. When we are calm and relaxed, the limbic system shuts down,
allowing our higher brain center characteristics of creativity and logic to
return. Maltreated children perceive their emotional and physical survival to
be constantly threatened. They are in need of a therapeutic environment that
reduces their biological level of stress and fear. The LAP provides a context
in which the child can be calmed, soothed, and relaxed, thereby reducing
the release of stress-induced hormones. The child is better able to process
information, pay attention, and utilize the neocortex for learning and change.
Promotes Self-Regulation
A primary parental function is to teach the child to self-regulate, i.e. to
modulate and control emotions, impulses, and behavior. Initially, the
attachment figure regulates the infant’s arousal level by providing attuned and
sensitive caregiver responses (e.g., soothes when overstimulated, stimulates
when bored or lethargic). Over time, the securely attached child internalizes
the parent’s lessons and achieves self-regulation. Children with attachment
disorder, however, do not learn this important lesson, and consequently
display such symptoms as aggression, impulsivity, chronic hyperarousal,
difficulty concentrating and staying on task, and inability to control emotions
(e.g., temper tantrums).
The LAP provides a milieu in which the therapist facilitates the
development of the child’s self-control. The therapist can choose to soothe
(down-regulate) or stimulate (up-regulate) the child. Eventually, the child
learns to manage his or her own internal reactions. For example, a child
can be guided through a temper tantrum, learning to talk about anger and
frustration as an effective coping skill. The child begins to learn self-control
and to appreciate a newfound sense of mastery over previously out-of-control
emotions.
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Therapeutic Style
There is a wide variety of styles and demeanors displayed by therapists.
Stylistic differences include intellectual–emotional, distant–engaged,
proactive–reactive, didactic–experiential. Certain therapeutic styles are more
effective with some populations, while different styles are more effective
than others. In working with children with histories of maltreatment and
relationship trauma and their families, we have found that the most effective
therapeutic style is proactive, engaged, and experiential. The components of
effective therapeutic style and structure are listed below.
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Managing Resistance
Children with severe attachment disorder are typically angry, oppositional
and defiant, mistrustful, contemptuous of authority, and lack genuine and
caring relationships. It is not surprising, therefore, that they are extremely
resistant to therapy and therapeutic relationships. Many families that enter
our treatment program have experienced a number of prior treatment failures.
There are two basic patterns of resistance:
• Active resistance: The child overtly opposes, challenges, and avoids
participation. These children can become physically and verbally
aggressive, hostile, punitive, and coercively controlling. These resistive
behaviors and attitudes are direct, transparent, and blatant.
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• Passive resistance: The child’s resistance is covert, often subtle, and more
challenging to manage therapeutically. These children are commonly
superficially compliant and solicitous, self-pitying, “helpless,” and
employ a variety of methods to manipulate and control (e.g., act
“dumb,” forget, leave tasks incomplete, not follow rules, respond slowly
to questions and tasks).
There are a variety of therapeutic responses and strategies that we have found
to be effective in managing and reducing resistance:
• Remain proactive: Therapist sets the tone for the relationship and the
treatment process.
• Neutral emotional response: Therapist avoids negative emotional
responses (e.g., anger, shock, rejection); does not get “triggered” by the
child’s attitudes and behaviors.
• Avoid control battles: Resistance has no power or influence when it “falls
on deaf ears.” The therapist does not engage in most control battles
and power struggles.
• Doing more of the same: Prescribing the symptom or current behavior
“takes the wind out of the sails.” For example, a therapist may encourage
an oppositional child to look into his or her eyes and say, “I don’t want
to do it your way.” The child is now complying with the therapist’s
request, and the therapist can praise the child’s honesty.
• Acknowledging choices and consequences: The child is given the message
that resistance is a choice and has certain consequences. For example, a
child may be told that he or she is free to choose to be noncompliant in
therapy, and a dialogue ensues regarding all the possible consequences
of that choice.
• Convey commitment and perseverance: These children have learned to
“wait the other person out,” i.e., realizing they have succeeded in getting
their way because others become frustrated, confused, or hopeless in
dealing with them. The therapist gives the message, “I will persevere
with you no matter how long it takes.”
• Do not resist the resistance: The therapist allows the child to express
resistance while remaining calm and projecting an air of indifference
regarding behavior (not the child). For example, the therapist may
dialogue with a co-therapist (third-party conversation) about the
child’s resistant behaviors in a nonchalant way, which eliminates the
power of resistance.
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Contracting
Contracting with the child and parents is a basic and crucial component
of the initial stages of treatment and also occurs throughout the treatment
process (recontracting). Therapeutic contracts are verbal agreements
regarding specific desired outcomes. Therapeutic contracts are established
between therapist and child, therapist and parents, and parents and child.
The child contracts with the therapist, for example, to follow the rules
of therapy, learn to express feelings verbally, and to develop trust. Therapists
help the child compile a list of their treatment goals in the initial interview.
This becomes a contract: therapists agree to support the child to achieve
his or her goals; child agrees to work hard to achieve the goals. The parents,
for example, agree to learn effective parenting skills, reduce resentment
toward their child, address their family-of-origin issues, and form a united
team with the therapist. Parent–child agreements focus on expectations and
consequences for the child’s behavior, such as the necessity to learn to trust,
cooperate, and be sensitive to others in the family. There are four benefits to
therapeutic contracts.
• Increases motivation: There is a direct correlation between the strength
of the treatment contract and the desire, commitment, and motivation
to change (Levy and Orlans 1995). Contracting promotes the child’s
and parent’s active involvement and ownership in treatment.
• Provides structure: Contracts are established regarding the goals of
treatment and the general framework of treatment (Hughes 1997).
Specific goals regarding the child, parents, and family system are
identified and agreed upon. Aspects of the therapeutic framework,
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Therapeutic Goals
Effective therapy is contingent on the establishment of clear and concrete
goals. Goals must be framed positively (“desired outcomes”), stated in specific
behavioral terms, and be realistic and achievable. A sense of ownership
regarding goals increases motivation for children and parents. Therapeutic
goals for children, parents, and Corrective Attachment Therapy are listed
below.
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Methods and Interventions
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Methods and Interventions
figures. For children, attachment figures provide a secure base so that they can
explore, learn, and develop in healthy ways (Ainsworth 1967; Bowlby 1988a).
Similarly, therapists serve as a reliable and trustworthy figure—a secure base.
Clients use the safety of the therapeutic relationship to acknowledge and
discuss feelings and experiences that were denied and avoided, and to try out
new behaviors, mindsets, and relational patterns. The therapist’s support and
acceptance helps reduce anxiety and distress, so clients can learn about prior
and current relationships and begin the process of change (Farber, Lippert,
and Nevas 1995).
There are many therapist characteristics that engender a secure base.
Therapists are emotionally available, sensitive, and responsive in predictable
and consistent ways. They are attuned to client’s needs and emotions,
both verbally and nonverbally. Therapists provide empathy, understanding,
support, encouragement, and positive mentoring. They mitigate anxiety,
stress, and emotional pain, and facilitate new solutions and experiences. The
therapist and client establish a positive working alliance, a psychologically
protective holding environment (Winnicott 1985). Research supports the
idea that therapists function as a secure base. Studies show that therapists
are perceived as providing the same secure base as spouse and family, are
considered a safe haven to turn to for comfort during distress, provoke
separation protest when absent, and produce feelings of safety, acceptance,
and support in clients (Farber and Metzger 2009).
Clients will naturally reenact behavioral patterns and expectations in the
therapeutic relationship (“transference”). Employing an attachment-focused
model, the therapist can assess how they cope with stress and respond to the
therapeutic relationship, including deactivating (avoidant), hyperactivating
(anxious), or secure attachment strategies. Avoidantly attached adults are
reluctant to come to therapy because they are self-reliant and avoid depending
on others. However, when in therapy, they typically intellectualize, brag about
their own accomplishments, do not take responsibility for their own part in
issues, and criticize others. They let it be known they do not need help. The
therapeutic relationship is emotionally distant. Anxiously attached adults are
prone to self-disclosure and intense emotions, but are limited in their ability
to explore new ways of behaving, thinking, and relating. They find it hard to
accept support, and react to the therapist based on their expectation that he
or she will be inconsistently available. Adults with a history of severe trauma
(unresolved) do not feel safe enough to use the therapist as a secure base. As a
result of severe maltreatment and relationship trauma, they view themselves
as bad and unlovable, and others as dangerous and unreliable. Thus, therapy is
a slow process; it takes a long time to develop a trusting relationship, if ever.
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Hope
A positive therapeutic relationship also instills hope in clients. Research
on hope has magnified in the last 30 years. Regardless of the therapeutic
approach, hope has been found to be a critical component of positive
change. Hope is linked to better physical and psychological health, academic
performance, and recovery from trauma (Gilman, Shumm, and Chard 2012).
Hope develops within the context of early attachment relationships.
When children feel safe and have their needs gratified they learn to trust,
which gives them the opportunity to experience hope. Traumatic experiences
shatter one’s belief in a safe world and in trustworthy and dependable
relationships. This leads to a sense of a foreshortened future and the loss of
hope, and the symptoms common to PTSD, depression, and complicated
grief.
Building hope is a key aspect of healing with traumatized children and
adults. Hope empowers and motivates traumatized individuals to believe in
the possibility of a brighter future. Connectedness to others plays an important
part in engendering hope; the therapeutic relationship serves as a vehicle
to combat hopelessness. Increasing hope with trauma survivors involves: 1)
creating trusting and close relationships; 2) teaching coping strategies that
bring about positive change (e.g., anger management and relaxation skills);
and 3) identifying and working toward goals.
Using the therapeutic relationship as a secure base (i.e., safe, supportive,
encouraging), clients are encouraged to think about specific goals (agency
thinking; “I want to be close to my parents”), and learn methods to achieve
those goals (pathway thinking; “I am learning communication skills”). For
instance, in our initial interview, we assist children and adults to write a list of
their treatment goals and discuss how to reach those goals. They often report
that this exercise makes them feel more “hopeful.”
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cognitive abilities. The beliefs the teachers had in the students’ abilities
and potential were subtly communicated to the students—a self-fulfilling
prophecy (Rosenthal and Jacobson 1968).
The placebo response is also explained as favorable response to receiving
care and positive attention from others (e.g., physicians, therapists) who
patients believe can help relieve their discomfort and distress. The doctor’s
behavior—“bedside manner”—plays an essential role. Instilling hope, being
empathic, and building trust enhance the placebo effect and lead to positive
change. Researchers found that patients suffering from irritable bowel
syndrome reported more symptom relief when their physicians showed
empathy, listened actively, and touched the patient, compared to not providing
these caring behaviors (Kaptchuk et al. 2008). The placebo effect may also
have an element of psychological conditioning. Once a person benefits from
an intervention, that person associates the intervention with a benefit. For
example, learning that the act of swallowing a capsule precedes relief, taking
a sugar pill may bring on the physiological changes real drugs can yield.
Researchers have used brain scans to show that there is a physiological
explanation for the placebo effect, including objective changes in brain
chemistry. When people believe they will get better, the brain releases
endorphins, a natural pain-relieving substance. Measurable changes in
brain chemistry may explain the large placebo effect seen in the treatment
of depression. Parkinson’s disease is associated with a shortage of the
neurotransmitter dopamine. Placebos have triggered dopamine production;
expecting relief caused patients to have a biochemical response (Kirsch 2010).
Understanding the placebo effect provides valuable insight into
psychotherapy and therapeutic parenting. It is critical to appreciate the power
of ritual, imagination, hope, trust, compassion, empathic witnessing, and the
therapeutic relationship in the healing process. The psychological, social, and
neurobiological aspects of the placebo response activate the mind–body self-
healing processes and contribute to symptom reduction and overall well-
being.
The next section of this chapter will describe the three phases or stages
of the treatment process—revisit, revise, revitalize. The rationale, goals, and
methods of each stage will be explained.
Revisit
The first stage of the therapeutic process involves revisiting prior significant
attachment and trauma experiences (e.g., separation, abandonment, abuse,
neglect, multiple placements, and violence in the home). Many theorists and
clinicians who deal with maltreated children and adults acknowledge the need
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to revisit early life events in order to identify emotional, cognitive, social, and
physical sequelae (Friedrich 1990; Terr 1990; Crittenden 1992b; James 1994;
Gil 1996; Pearce and Pezzot-Pearce 1997). Through the process of revisiting,
the therapist gains valuable diagnostic information and understanding of the
internal working model, emotional responses, and interpersonal patterns.
“You have to go back to the trauma; you have to do exposure therapy, you
have to bear witness; the person has to come to terms with the meaning”
(Herman 2012, p.19). The basic question is: “What was this child’s unique
response to prior life events, and how does this affect current and future
attachments?” This stage focuses on four elements:
• personal meaning and interpretation
• a detailed review
• acknowledging and expressing affect
• managing defenses.
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Attachment Disorder:
“I was treated bad”
Abuse and neglect
Multiple disruptions
Negative Responses
Negative Working Model
“Others treat me bad”—parents,
“I am bad, unlovable”
teachers, peers and others.
“Caregivers are unsafe,
Punishment and rejection
unreliable”
reinforces NWM
Conduct Disorder:
“I will act badly”
Aggressive
Oppositional
Dishonest
Uncaring
A Detailed Review
The child is guided through a verbal accounting of events, the context in
which events occurred, personal meaning, affective and somatic responses,
and imagery. Honesty is encouraged to reduce denial, distortion, and
dissociation. The child acknowledges and shares thoughts and feelings about
painful events with the therapist. Timing, however, is crucial. This sharing
must occur in the context of a safe and secure therapeutic relationship. This
detailed account includes the following components:
• child’s perception of events
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Managing Defenses
Defense mechanisms such as idealization, projection, displacement,
dissociation, denial, and splitting are designed to protect the child from
overwhelming and intolerable feelings and memories of traumatic experiences.
Although these defenses are adaptive for survival, they have damaging long-
term psychological consequences. For example, overidealizing an abusive
or neglectful mother allows the child to avoid and deny the painful reality
that she provided insufficient nurturance, love, and protection. Denial saves
the child from having to experience the grief and anger that accompanies
facing the truth. Dissociation is an automatic response that protects the child
during trauma; the child splits off from the experience, no longer having to
feel the pain, fear, or humiliation of the moment. Displacement enables the
child to project onto foster or adoptive parents the feelings and perceptions
that he or she actually has toward maltreating biological parents or others.
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Revise
The second stage in the therapeutic process is revision. The focus now becomes
both developing and revising: developing secure attachment patterns that were
never previously established, and revisiting disturbed attachment patterns
that were created early in life. All previous interventions have provided a
foundation for assisting the child and parents to achieve the following goals:
• construct new interpretations
• deal effectively with emotions
• develop secure attachments
• learn prosocial coping skills
• create mastery over prior trauma and loss
• develop a positive sense of self
• enhance self-regulation
• address family systems issues (family-of-origin work with parents,
marital issues, parenting skills, mobilizing community resources).
There are several basic issues to consider during this phase of treatment.
First, during therapy it is difficult to separate cognitive, emotional, and social
change. There is an ongoing process of weaving interventions that focus on
various components of change. Second, cognitive rescripting (i.e., challenging
the child’s negative working model) is only effective when combined with
positive emotional change. The emphasis must be on changing both thoughts
and feelings, since one affects the other, in an ongoing and reciprocal manner.
Third, the climate and context in which these changes occur is crucial.
The therapist functions as a “secure base” for the child, providing safety,
predictability, empathy, guidance, and support. It is common knowledge
among mental health professionals working with maltreated and traumatized
children that a major goal is always empowerment of the “victim.” The
therapeutic environment must provide a safe context for appropriate risk
taking, honest disclosure, and emotional release, which leads the child from
helplessness to empowerment and from inadequacy to mastery.
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Emotional Processing
It is common for children and adults with histories of maltreatment, trauma,
and compromised attachment to avoid painful memories and reminders
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Catharsis
Cathartic release of emotions has been found to be helpful for grieving
losses (Scheff 1979), treating PTSD and sexual abuse (Allen and Borgen
1994), and in reducing and managing anger (Chandler 1993). However,
catharsis is useful in the treatment process only when integrated with other
therapeutic techniques, when occurring within the context of a safe and
healing relationship, and when combined with a cognitive component (e.g.,
cognitive rescripting).
Traumatic memories of infants and young children are organized on a
nonverbal, sensory-based level (visual images; olfactory, auditory, or kinesthetic
sensations; intense waves of feelings) (van der Kolk 1996). Emotional
experiences and strong, affectively charged memories are disconnected from
language and rational thought. Though many of these incidents occurred
before conscious memory, the feelings provoked are not forgotten. Cathartic
methods provide access to these sensory-based memories.
The child with attachment disorder is a hostage to powerful emotions.
Anger, fear, and unresolved emotional pain dictate his or her choices and
actions. These children spend a great deal of time and energy in service to
these emotions rather than the emotions being in service to them. Prior
traumatic experiences have taught them to deny, avoid, repress, or dissociate
from emotions. They must be taught to experience, process, and express
emotions in a constructive way. A crucial part of this process involves
emotional release, which is effective under the following conditions:
• The child expresses affect within the context of a corrective relational
experience, i.e., the child internalizes acceptance, empathy, and support
from the therapist.
• Shame is reduced as the child releases intense emotions, eye to eye,
face to face, in an accepting environment.
• The therapist models constructive expressions of his or her own affect,
i.e., does not react to the child’s emotions with anger, anxiety, or shock.
Important messages are conveyed: “You are safe with me because I
can handle your intense feelings. I will teach you how to handle your
emotions, and also show you by my example.”
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Mourning Losses
It is difficult but essential to confront losses of significant attachment figures
in the child’s life. Children with attachment disorder experience a variety of
losses.
• The loss of a primary attachment figure: The child is removed from abusive
or neglectful parents by social services, or placed in an orphanage.
• The loss of a subsequent attachment figure: The child must leave foster
parents or caregivers in an orphanage.
• The experience of multiple losses: The child moves through a variety of
foster homes or other out-of-home placements.
• The loss of never having a biological attachment figure after birth: The
child is born drug exposed and immediately placed in foster care, or
the child is adopted at birth.
Children with attachment disorder typically avoid or deny their grief about
losses by being chronically angry, controlling, or aggressive. Also, fantasies or
revenge or false “forgiveness” are designed to avoid grief, sadness, and shame.
Through the use of various therapeutic vehicles (inner-child metaphor, first-
year cycle, psychodramatic reenactment) the child can express his or her grief
directly and honestly.
Trust
A hallmark of attachment disorder is lack of trust in caregivers and self. The
child’s core belief (negative working model) about caregivers is “I cannot
trust that caregivers will keep me safe, fulfill my needs, or love and value me.”
The child’s core belief about self is: “I cannot trust that I will ever be safe; my
needs are not valid; I do not trust that I am capable, lovable, or worthwhile.”
Children with attachment disorder begin therapy not trusting the therapist,
their current caregivers, or their ability to improve.
A salient developmental task of the first year of life is to develop basic trust
in the context of a secure attachment relationship. Infants who are securely
attached learn that helplessness and vulnerability are tolerable physical and
emotional states. They trust their caregivers to provide safety, protection,
and need fulfillment. The infant and toddler with insecure or disorganized
attachment learn that helplessness and vulnerability are not tolerable states.
Insufficient or nonexistent parental care results in a lack of trust and high
levels of anxiety associated with helplessness. As development unfolds, the
child becomes increasingly more angry, controlling, and oppositional, to
defend against feelings of intense helplessness and vulnerability.
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°° Be honest with yourself and partner about what you are thinking,
perceiving, and feeling, even if you are worried about “making waves.”
°° Share both thoughts and feelings; “The way I see the situation is
____, and this makes me feel ____.”
°° Make “I” statements. You are taking responsibility for your own
perceptions and emotions. No questions, blaming, or criticizing.
°° Be brief. Say one or two things, and say it once. Lengthy speech is
annoying and difficult to follow.
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°° Tune into both content and process. The content is the words, ideas,
and topic. The process is the deeper meaning, the meta-message—
the “message behind the message.” What is your partner’s emotional
message?
• Restating: When your partner is done expressing his or her thoughts
and feelings, you now restate what you heard: “I heard you say ____.”
This is called “reflective listening,” as you are reflecting back the
messages you received.
• Feedback: Your partner will now tell you how well you did as a listener.
“Yes, you heard me accurately; you got my message, thank you.” If
you did not think your partner heard all your messages accurately, or
misinterpreted your message, you can say, “No, I did not say what you
heard; let me try again.” It is OK to clarify your thoughts and feelings,
giving your partner another chance to listen. The goal is: message sent;
message received. No distortions or misinterpretations.
• Reverse Roles: The speaker becomes the listener, and the listener now
takes a turn at sharing. Follow the same rules and guidelines previously
described. You and your partner have several chances to practice
sharing and listening skills.
• Discuss Results: After you and your partner have had several turns
sharing and listening, talk with one another about how it was to use
the ACT method. Share your thoughts and feelings considering the
following:
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°° What are some of the issues you want to discuss in the future using
ACT?
Examples of ACT with children, parents, and siblings, and adult partners
will be presented in subsequent pages in the context of case examples.
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1. What did he or she teach you about anger and handling anger?
______________________
2. Describe a memory about this person’s anger. ____________________
3. What messages and values do you want to keep or reject?
______________________
Recognize Self-Talk
Self-talk is what you tell yourself about yourself, others, and situations. These
preconceived ideas and beliefs have a major influence on how you deal with
conflict and anger because feelings follow thoughts. Self-talk can be positive
(“I can do this”) or negative (“I’ll never succeed”). Increasing your positive
“scripts” will lead to more positive attitude and behaviors.
Task: Describe a situation in which you got very angry. Now describe your
self-talk before, during, and after the situation. Include self-talk about
yourself, the person you were angry with, and other self-talk (e.g., others, the
world in general).
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Problem-solving
Children with attachment disorder are unable to manage conflict (internal or
interpersonal) and solve problems because of chronic emotional turmoil and
their refusal to reach out for help. Thus, learning to solve problems effectively
involves both the ability to utilize internal resources and turn to others
for guidance and support. Children learn these skills and practice them in
various settings:
• identify a specific problem
• brainstorm possible options and solutions
• communicate with a “trusted” significant other about alternatives
• make a list of pros and cons, choices, and consequences
• evaluate the results of the particular solution chosen.
Therapeutic Methods
A number of therapeutic methods, described in detail (with case examples)
below, provide the structure to achieve treatment goals:
• first-year-of-life attachment cycle
• child’s self-report and list
• rules of therapy
• review of historical information
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does not gratify the baby’s basic needs (or there is no consistent caregiver
available), insecure attachment occurs, i.e., the infant does not learn to trust
him- or herself or caregivers.
The child is told about the consequences of insecure attachment: anger;
inability to trust and be emotionally close; discomfort with touch; perceives
him- or herself as defective and caregivers as unsafe; inordinate need to
control others (“bossy,” manipulative); and lacks self-control. The child is
asked to evaluate him- or herself in reference to these prior traits: “What
happened in your early family life? Were your needs met? Did you learn to
trust caregivers?”
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Therapist: I’ll draw a circle. Here it is. Not perfect, a little crooked.
Annie: No one’s perfect, except the Lord!
Therapist: OK. There’s the four parts of this circle. [Draws four lines
on the circle.] It begins when a baby is born. What can a baby do?
Annie: They can’t do nothing.
Therapist: That’s right, babies are very helpless. But they do have
needs. What do little babies need?
Annie: Food.
Therapist: That’s right, food. What else?
Annie: Love.
Therapist: Yes, love; what else does the baby need?
Annie: A home.
Annie, previously resistant and agitated, is now calm, engaged in the
task, and even enjoying herself (laughter). She seems interested in the
first-year-of-life story. The therapist and Annie make a list of babies’
needs: “food, love, a home, milk, eye contact, touch, movement (rocking),
care, smiles from caregivers.” The therapist explains the importance of
eye contact, smiles, loving touch, and other caregiver–baby behaviors,
as they relate to secure attachment. Annie is attentive.
Therapist: So, how does the little baby tell the mother or father she
has needs when she can’t talk?
Annie: Cry.
Therapist: That’s right. Is it a little cry or a big cry?
Annie: A loud cry! [Screams out in a loud baby-like cry.]
Therapist: Very good. You sound just like the baby who has many
needs. [Annie smiles, enjoying the “game.”]
The therapist explains that babies use various signals of arousal (crying,
screaming, kicking, facial expressions) to let caregivers know they have
needs and/or discomfort. Annie participates eagerly in the dialogue.
Therapist: Now, let’s say the baby has a really good mom or dad,
who comes along and takes care of the baby’s needs. What does
that mom or dad do?
Annie: Feeds it.
Therapist: Yes, and rocks, holds, gives loving touch and eye contact
and smiles. What do we call this: can you sound it out? [Writes
gratify on paper.]
Annie: G-R-A-T-I-F-Y.
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Therapist: Very good. You sure have a smart brain. Gratify means to
take care of, to meet the baby’s needs.
Annie maintains good eye contact with the therapist during this
dialogue, but seems to be getting more agitated and anxious. Emotions
and memories are provoked by the discussion of caregivers and babies.
Therapist: So, the baby has needs, expresses those needs by crying
and other signals, the mom or dad takes good care of the baby.
What does the baby feel toward that mom or dad?
Annie: Cared for?
Therapist: That’s right, what else does that baby feel?
Annie: Happy.
Therapist: Yes, what else?
Annie: Loved.
Therapist: That’s right. Is that baby feeling safe?
Annie: Yeah, safe.
Therapist: And there is a special feeling that the baby has toward
the person who is taking good care of her. I’ll write it down. Can you
sound it out? [Writes trust on the paper.]
Annie: T-R-U-S-T.
Therapist: Very good! That baby learns to trust the mom or dad who
takes care of her in a good and loving way.
The therapist explains that the baby learns to trust caregivers, self (“my
needs are OK”), and the world in general (“life is good, I feel safe”). The
therapist also explains how trust leads to the perception of caregivers
as safe, reliable, and loving. Annie is still engaged and responsive.
Therapist: Now, how did this circle work out for you when you were
a little baby?
Annie: I wasn’t taken care of. I had to crawl in crap. There was cat
crap all over the house.
Therapist: How do you know this? Do you remember or did someone
tell you about it?
Annie: My mom told me. [Referring to current pre-adoptive mother.]
Therapist: Yes, it is true. Let’s talk about what else happened to you
and how it made you think and feel. You had a birth mom, right?
Annie: Yes, Angie; she threw me away. She put me up for adoption.
Therapist: Angie was only 16 years old when you were born. She
didn’t take good care of herself when you were in her tummy, and
after you were born.
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Therapist: If you could not trust adults to take care of you, what did
you do?
Megan: I wanted to be bossy.
Therapist: You couldn’t even be a little girl? How did that make you
feel?
Megan: Sad. [Cries, genuine sadness for the first time.]
Megan began to sob and talked about holding in her sadness for a long
time. Next, she talked about being afraid (“someone will hurt me”) and
compensating for fear via aggression.
Therapist: You have lots of scared feelings too?
Megan: Yes. [Maintains good eye contact.]
Therapist: What do you do with all that scared?
Megan: Hurt people; I let it out on other people. That’s not good!
The first-year-of-life attachment cycle exercise was an effective vehicle
for Megan to become genuinely involved and emotionally available in the
initial stage of treatment. Information gleaned from this experience was
integrated into a treatment contract (e.g., learn to be less “bossy,” more
honest about feelings, verbal communication rather than aggression).
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• Break things.
• Hate myself.
• Mean to my family.
The goals were achieved: Adam was honest, worked cooperatively with
the therapist, and began to experience and share genuine emotions
as he discussed his problems. The parents felt more optimistic as they
observed their child’s efforts. The “list” was translated into a treatment
contract and served as the foundation for subsequent therapy.
Rules of Therapy
The child is told the rules of therapy during the initial interview. Each rule
is explained and discussed. Rules become contracts for specific behavior on
the part of the child and the therapist. Rules also provide structure, necessary
for developing a feeling of safety and security. Listed below are the rules of
therapy.
• Eye contact is encouraged in all therapist–child dialogues: Eye contact is a
crucial component of secure attachment.
• “We will not work harder on your life than you”: The child is told that
the treatment team will work hard to provide help, but it is the child’s
responsibility to also work hard. A discussion ensues about personal
responsibility and the desire to change.
• The Four Rs: We share our philosophy that all children are expected to
be respectful, responsible, resourceful, and reciprocal.
• “I don’t know” is not an acceptable answer: Children generally say, “I
don’t know” as an avoidance technique. Two alternative responses are
acceptable: the child can ask for help from the therapist—children
with attachment disorder have difficulty asking for help, or the child
can offer his or her best guess, which encourages introspection and
resourcefulness.
• Verbal responses must be expressed in a timely fashion: A form of
interpersonal control and passive aggression is making others wait for
a response. Instead, we encourage a timely response.
• No physical violence: Most of these children have been physically
abused and/or witnessed violence. Consequently, they act out abusively
and aggressively. They are encouraged to express their anger verbally. A
mutual contract is established between the therapist and the child, to
protect both from harm.
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Therapist: What a start you had. How did that make you feel about
yourself?
Danny: I felt like people dumped me all the time, like I was a piece
of garbage.
Danny is deeply involved in the dialogue provoked by the social service
records. His negative working model (“I felt like a piece of garbage”)
is surfacing, and he is honest and open with the therapist. Parents
later reported being surprised by his level of honest disclosure and
vulnerability.
Therapist: Here it says that your birth mother was intoxicated, gave
you watermelon filled with liquor, and you received a severe sunburn
in a park. She was told to get counseling in order to keep her children.
She either missed her appointments or came to counseling drunk.
What does that tell you?
Danny: Alcohol and drugs were more important than me. [Starts to
cry.]
Therapist: So, what happened?
Danny: They took me away.
Danny is facing the reality that his birth mother made a choice; she
chose drugs and alcohol rather than her child. This initiates the process
of cognitive rescripting (“I was not a bad baby; my mother made bad
choices”), and sets the focus on choices and consequences.
Therapist: What are you thinking and feeling about this information?
How has this affected your life?
Danny: I have been acting like her; saying I don’t have to do things
and I don’t want help!
Therapist: If you continue to make these kinds of choices, how will
your life work out?
Danny: I’ll end up just like her, or in jail.
Therapist: Is that what you want for your life?
Danny: No.
Therapist: What do you want to do about this?
Danny: I better get to work. [Crying, gazing at therapist.]
This intervention accomplished several goals: his negative working model
and genuine emotions surfaced, a positive therapeutic relationship
developed, a contract was established, and he was motivated to work
hard in therapy.
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because your birth mom was poor and young”). The use of an external symbol
(teddy bear) facilitates expression of perceptions, memories, and emotions in
a less threatening manner. The child is asked to speak directly to the “little
girl,” and they make statements such as, “You needed love, you thought it
was your fault, you needed a mommy.” The child is asked to review stages,
milestones, and significant events in her development.
“What does that little girl want to say (to mommy, daddy, or other
caregivers?) Can you pretend you are that little girl? What is she thinking and
feeling?” Children find it easier to share perceptions and emotions associated
with early loss and trauma by putting a “voice” to the “little girl.” Common
responses are: “I’m afraid of you; I hate the way you treat me; you don’t take
care of me.”
“Have you taken very good care of this little girl?” The response to this
question reveals the child’s self-contempt and the vicious circle of attachment
disorder (“My caregiver mistreats me; I feel defective and unlovable; I hate
myself; I treat others badly; others mistreat me”). The child is encouraged
to display nurturing, supportive behaviors toward the “little girl” in order
to teach self-acceptance and self-love, thereby breaking the negative cycle
and promoting the development of a positive working model. The child’s
ability to identify and meet the needs of the “little girl” reflects the extent
to which her negative working model is changing. The goal is to change
from a negatively internalized self (“I am bad and do not deserve love”) to a
positively internalized self (“I am good and I do deserve love”).
“Can she forgive you for not taking good care of her?” The response is
diagnostic of the child’s capacity to mitigate self-contempt. The therapist
informs the child, “You were treated badly and you learned to treat yourself
badly.” Self-empathy and self-forgiveness are encouraged over time.
“Who is in control of your life if you continue to treat yourself badly?” This
question elicits the paradox of control. These children are motivated by a
profound need to control, yet their choices and actions are driven by prior
events and relationships (lack of self-control). The basic message to the child
is: “As you learn to accept, support, and love yourself, you are free to make
healthy choices.”
“How does life work out for her?” The therapist instructs the child to give
the “little girl” a detailed accounting of her life up to this point in time,
emphasizing the information gleaned from therapy. This exercise provides a
vehicle for the child to synthesize and integrate therapeutic experiences, and
is diagnostic of his or her capacity for awareness, disclosure, and cooperation.
“Do you know anyone else who can help you love this little girl?” Children
consistently respond by identifying their current caregivers (e.g., adoptive
mother or father) as an appropriate source of love and protection. This
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represents a shift from pushing the caregiver away to inviting the caregiver
into their life. Children express this change concretely by inviting the mother
and/or father into the session and asking her for help (“Mom, will you help
me learn how to love my ‘little girl’?”). The mother is instructed to place the
child and “little girl” into the “in arms” position, and to provide a healthy
model of affection, support, and comfort. This enhances positive mother–
child attachment as well as the bond between the child and her “little girl”
(positive internalized self ). Mothers (and fathers) who were previously angry,
defensive, and emotionally unavailable to their child, can now experience the
giving and receiving of affection. The parent(s) and child are connecting in a
safe, secure, trusting, and intimate manner, often for the first time.
“Do you wish this could have been your mom from the beginning?” This
question serves as a springboard for enhancing mother–child attachment.
Mutual acceptance and affection increases intimacy, trust, and secure
attachment. The mother is asked a similar question (“Do you wish you could
have been this child’s mother from the beginning?”). Mother now has the
opportunity to tell the child her thoughts and feelings about the child’s prior
trauma and how she is wanted and loved.
This portion of the session ends with 10–20 minutes of positive attachment
(eye contact, smiles, snuggles) between mother and child. Mother–child and
father–child attachment exercises are repeated many times during treatment.
Repetition and rehearsal are crucial to the process of change for parents and
children.
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Kelly: I wasn’t taken care of, so I won’t take care of you. I take care of
myself, so you should take care of yourself.
Kelly’s self-contempt, which she developed by internalizing the abuse
and neglect, was identified and expressed:
Therapist: How mad have you been towards little Kelly?
Kelly: I’m really mad at you, little Kelly. [Yells.]
Therapist: Tell her how you have been feeling toward her.
Kelly: I hate you! [Screams.]
Therapist: Is that true, you’ve been hating little Kelly?
Kelly: I hate you because you’re a rotten kid; I’ve been hating myself
for a long time. [Cries.]
Cognitive rescripting now begins: an opportunity for Kelly to change
her interpretation of prior events and attribute responsibility for
maltreatment to the hurtful adults, rather than towards herself.
Therapist: Can you tell little Kelly what she was thinking back then?
Kelly: Little Kelly, you thought you were bad and that you didn’t
deserve love.
Therapist: You thought you were bad because bad things were
happening to you?
Kelly: Yes, I was a bad kid. [Cries.]
Therapist: It wasn’t your fault, but when you were very young, you
couldn’t figure that out. When babies are loved they feel lovable and
good. But if they are treated bad, they feel like they don’t deserve
love, and feel bad about themselves. Tell little Kelly the truth as you
know it to be now, as a big girl.
Kelly: You did deserve love, because you were just being a baby, but
your mom didn’t come to help you. You thought you were bad, but
you weren’t. [Cries.]
Kelly is now ready to experience positive feelings towards herself (self-
acceptance, support, and love), rather than self-contempt and self-
blame.
Therapist: You have been treating little Kelly badly, do you want to
keep doing that? This is your chance to change.
Kelly: I want to treat her good now.
Therapist: How can you show little Kelly you are caring for her?
Kelly: I can give her a hug. [Wraps the “baby” up in her arms, hugs
her tightly, gently strokes her leg.]
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Therapist: Feel your love going into the baby’s heart; what is the
baby feeling?
Kelly: She’s feeling safe and happy; I’m giving her a real hug. [Kelly
appears relaxed and calm.]
At this point the therapist recommends that Kelly tells the story of “little
Kelly” to her mother. Mother and child dialogue about the early life
experiences, how Kelly was hating herself and her birth mother, and the
positive changes now occurring. Mom provides empathy and support;
they feel close for the first time.
Psychodramatic Reenactment
Children, in general, are less apt to verbally express cognitions and emotions
and are more likely to demonstrate internal states through action and
behavior. This is the principle behind play therapy; increasing motivation,
involvement, and self-expression through action-oriented tasks. Children
with attachment disorder are emotionally and socially detached, avoiding the
painful realities of their past and current lives. Psychodramatic reenactment
reduces the child’s denial and detachment, while encouraging genuine
participation. This intervention is also used with adults.
During psychodramatic reenactment, treatment team members role-play
individuals and scenarios from the child’s life to “revisit” and work through
prior attachment trauma. The goals of this intervention include the following:
• To enhance genuine involvement in the therapeutic process via an
action-oriented activity.
• To encourage the child to experience and express the perceptions,
emotions, and behavioral responses associated with early life
attachment-related and traumatic events.
• To discuss the thoughts and feelings associated with early trauma and
loss in a safe and secure therapeutic context.
• To achieve a corrective and curative experience, involving alternative
ways of perceiving self and others, managing emotions, and responding
behaviorally.
• To promote a healing experience that leads to emotional resolution,
enhancing the child’s sense of mastery, and rewiring the limbic brain
via interpersonal experience.
It is important to prepare children, adults, and parents for these emotionally
challenging experiences. A contract is established with both the child and
parents; they are informed of what to expect during the exercise and asked
if they are willing to participate. Psychodramatic reenactment is an effective
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therapeutic method that enables the child to confront and resolve traumatic
emotions and memories, revise maladaptive perceptions of events, feel
increased competence, and connect in a secure and trusting way with his or
her parents. The child has an opportunity to perceive the parents as protective
and caring, rather than threatening and untrustworthy. Parents are able to
take concrete and positive action to help, protect, and defend their vulnerable
child, which diminishes their feelings of helplessness and pessimism.
Preparation for psychodramatic reenactment involves three components:
• Prepare the child: The therapist explains why this exercise is
recommended and what will happen. This reduces the child’s anxiety
and enables him or her to feel a sense of control. A verbal agreement
(contract) is established if the child gives permission.
• Prepare the parents: The therapist gives a similar explanation to the
parents, and the roles and responsibilities of each participant are
defined. This reduces the parents’ level of anxiety regarding the safety
of their child and helps to clarify their own emotions. A contract is
established.
• Set the stage: The client gives a detailed description of a prior traumatic
situation, including feelings, perceptions, body sensations, reactions
of significant others, and consequences. The client is given the role
of “director,” telling participants how to play the roles of others in
the reenactment. This helps the client feel empowered and enhances
genuine involvement and motivation. Child and parents are encouraged
to “be real,” to allow genuine emotions and reactions.
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In phase two, the “boyfriend” once again pretends to threaten Sara, but
this time Sara’s adoptive parents storm into the room and shout at the
“boyfriend.”
Parents: You get out of here. Leave our daughter alone. We won’t
let you hurt her anymore! [They then embrace Sara and hold her on
their laps.]
Sara: I really know you guys will protect me and I’m learning to trust
you more.
Twenty to 30 minutes of “positive attachment time” follow the
reenactments. During this time, parent(s) and child integrate and enjoy
the positive emotional experience of secure attachment (increased
trust, safe and relaxed closeness, positive affect).
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therapy the next day. The parents reported that they had never seen
Lauren this honest, open, and intimate.
Revitalize
The final stage in the therapeutic process is revitalize. During the first two
stages of Corrective Attachment Therapy, the focus is on revisiting and
revising the past. This final stage is oriented more toward the present and the
future. The key components of revitalization are discussed below.
Redefining Self
The child who has successfully dealt with prior attachment trauma is able
to develop a new and increasingly more positive identity. People and events
from the past are placed in perspective, and the child is able to function
without feeling overwhelmed or devastated by traumatic memories.
Discussing the past no longer provokes intense negative emotions and
physiological reaction. The old self has been mourned, and a new sense of
self is emerging—new beliefs, relationships, coping skills, and a sense of
hopefulness. Helplessness and isolation, the core experiences of the old self,
are replaced by empowerment and connection with others. The child no
longer feels compelled to consciously or unconsciously reenact pathological
patterns; new choices of thinking, feeling, and interacting are now available.
The child is capable of trust, affection, empathy, and reciprocity in his or her
relationships with family and others. The old need for power and control
over others, to compensate for feelings of fear and helplessness, are replaced
by a sense of personal competency and power. Pseudoindependence is
transformed into genuine autonomy and self-reliance. As the child allows
attachment needs to be fulfilled (intimacy, interdependence, trust, safety), he
or she develops a stable sense of self.
Secure attachment is a protective factor, creating resilience in the face
of adversity. The child now has an emotional storage bank from which he or
she can draw during stress. The child becomes equipped to cope effectively
with emotions, relationship conflicts, developmental milestones, and the
challenges of life.
Family Renewal
Revitalization of the family occurs on two levels: relationships within the
family and interactions between the family and others. Family members
experience safety, enhanced trust and intimacy, effective communication,
improved problem-solving and conflict-resolution abilities, clear and
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Forgiveness
Forgiveness is an important component of emotional recovery following
interpersonal trauma. Forgiveness is associated with mental, relational,
physical, and spiritual health. Research has shown that anger declines after
forgiveness and that unforgiveness leaves people hostile and ruminating
about their pain and trauma (Harris and Thoresen 2005; Lawler et al. 2005).
Forgiveness involves cognitive, emotional, and behavioral elements, and
focuses on two emotional processes: 1) resolving anger, hurt, shame, and
fear; and 2) generating positive emotions of empathy, understanding, and
compassion. Thus, forgiveness reduces negative feelings and increases positive
feelings. Corrective Attachment Therapy facilitates a variety of forgiveness
experiences:
• self-forgiveness
• child forgives birth parents for maltreatment and abandonment
• adoptive parents and child forgive one another
• siblings and child express forgiveness for each other.
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9
Corrective Attachment
Therapy
The Family System
Basic Principles
Historically, much of attachment theory and research has focused on the
mother–child relationship. This is a simplistic and limited view; attachment
occurs within the broad emotional network of the family system, including
the role of father, siblings, extended kin, and external social systems. The
basic principles of a systems approach, context, circularity, and organization,
are outlined below.
• Context: No family member (or relationship) can be understood
outside of the context in which he or she functions. Thus, mother–
infant attachment patterns can only be understood within the network
of all other family relationships (e.g., husband–wife, father–infant,
parent–grandparent) and extrafamilial systems (e.g., extended kin,
cultural context, social programs).
• Circularity: Traditional models in the mental health field were based
on the belief that relationships are “linear,” i.e., there is a cause and
effect. The systems model presumes that relationships are “circular,”
i.e., based on ongoing, reciprocal, interactive patterns, in which each
family member’s behavior serves as both a trigger and a response. A
clear example is the reciprocal nature of mother–infant attachment
behavior (see Chapter 3).
• Organization: Family systems are organized around rules, role,
boundaries, and subsystems. For example, subsystems in the
family include spouse subsystem, parental/executive subsystem
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Intergenerational Transmission
Patterns of attachment are transmitted over generations. The parents’
attachment histories influence their current relationships and parenting
practices. “A child attaches not only to his or her primary caretakers, but also
attaches through the primary caretaker(s) to the entire emotional field” (Donley
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1993, p.11). Thus, there is a high correlation between the child’s patterns of
attachment and the experiences the parents had in their childhoods. Parents
who can make sense of their childhood experiences in an honest, responsible,
and realistic way (“coherent” story), are more likely to have securely attached
children. Parents who are dismissive, preoccupied, or unresolved in reference
to childhood attachment difficulties (“incoherent” story) are likely to have
children with insecure/anxious attachment (Main, Kaplan and Cassidy 1985).
Parents with unresolved traumatic experiences (e.g., abuse, abandonment,
severe parental psychopathology) more often have children with the most
dysfunctional attachment pattern, i.e., disorganized–disoriented attachment
(Main and Hesse 1990). These parents have not mourned the loss of prior
attachment figure(s), remain anxious and unresolved about past trauma, and
may even dissociate to avoid their pain. They transmit fear and anxiety to
their children, inhibiting the establishment of secure attachment.
Parents with a history of childhood trauma often develop dismissing and
avoidant attachment styles. They experienced suboptimal care as children
(e.g., rejection, abandonment, abuse), resulting in the undermining of a sense
of security, self-regulation difficulties, and negative core beliefs. Interactions
with their own children reactivate or trigger early trauma and attachment-
related distress. Parents with dismissing and avoidant attachment styles
use deactivating strategies to avoid thoughts and feelings related to early
trauma. That is, they deny emotional needs and avoid closeness to prevent
anticipated rejection, abuse, and pain. Their difficulties with attachment cause
considerable problems with parenting, particularly when parenting children
with their own attachment problems. These parents must understand their
attachment history (Life Script), grieve prior losses, develop positive internal
working models, and learn effective parenting skills (Corrective Attachment
Parenting), so that they can facilitate secure attachment with their children
(Foroughe and Muller 2012).
Parents who have troubled and unresolved attachment histories often do
not relate to their infants and young children in a genuine and meaningful way,
but rather, they script their children into some past drama from their family
of origin (or other childhood experiences, such as foster care placements).
Parents may have conscious or unconscious scenarios from childhood that
they repeat or reenact with their own children (“replicative script”). For
example, abuse or neglect from childhood is repeated in the next generation
(“cycle of abuse”). Parents may react to uncomfortable childhood experiences
by attempting to be different with their own children (“corrective script”).
A parent who was abandoned in childhood, for example, may become an
overindulgent and overprotective parent with his or her own children.
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Fathers
Multiple attachments during infancy are common. The father is particularly
likely to become an attachment figure early in the infant’s life. Just as with
mothers, infants are more likely to be securely attached to fathers who have
been sensitively responsive. Although an “attachment hierarchy” usually
exists—a strong tendency for infants to prefer a principal attachment figure
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• More than one million American babies (one in four) are born each
year to unmarried mothers, most of who are in households without
fathers.
• Thirty-five percent of children living with mothers never see their
fathers; 24 percent see their fathers less than once a month (Crowell
and Leeper 1994; Hutchins 1995).
There are a number of negative effects of father absence on the family and
in reference to the psychosocial adjustment and development of children
(Lamb 1997). First, there is the absence of a co-parent, i.e., two partners to
help with child care, participation in decision making, and giving the mother
a break from the demands of parenting. Second, there is the economic stress
that accompanies single motherhood; the income of single mother-headed
households is lower than any other family group (Peterson and Thoennes
1990). Third, a high degree of emotional stress is experienced by single
mothers who feel isolated and alone, and by children who are affected by
perceived or actual abandonment. Last, children suffer as a result of hostility
and destructive conflict between caregivers (e.g., predivorce and postdivorce
marital conflict). Children living with their mothers are often exposed to
violence and conflict between parents (current or historical). Overt hostility
between parents is associated with child behavior problems, including
childhood aggression (Grych and Fincham 1990; Cummings 1994). Thus,
father absence is harmful to children and families, not only due to the lack of
a gender-specific role model, but because the emotional, social, and economic
aspects of a father’s role are not fulfilled.
Research has shown that fathers tend to spend a larger percentage of
time interacting with children through play than do mothers (Pruett 2001,
2009). Paternal play with children is characterized by more active and
stimulating interactions (“rough-housing”). This type of play may serve the
purpose of preparing children for the rough and tumble “real world” beyond
mother’s more intimate attunement style. Young children who play regularly
with their fathers have better peer relationships, greater self-confidence, and
are better at coping and learning, compared to children who do not have
engaged fathers (Pruett 2001).
When men do care for their children, they tend to interact with, nurture,
and generally rear children competently, but differently from women. Not
worse, not better, but differently (Pruett 2001). Mothers typically hold their
infants in a relaxed and quiet manner, whereas fathers more often activate or
stimulate their infants prior to holding them close. Again, this trait leads to
more playful and novel interaction over time (Parke 1990). Fathers encourage
their babies to solve physical and intellectual challenges, even past the signs
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of frustration. Mothers encourage exploration but are more apt to help the
child once frustration is apparent (Biller and Meredith 1974).
Research and family observation (and fathers who know) clearly reveal
that fathers are important and highly valued attachment figures in many
families. Pedersen (1980) found that the more actively involved a 6-month-
old baby had been with his or her father, the higher the baby scored on infant
development scales. Paternal involvement was also found to significantly
reduce the effects of long-term vulnerability for at-risk, premature infants
(Yogman 1989). Laboratory procedures designed to assess separations and
reunions found that the father’s presence had similar effects on babies and
toddlers as the mother’s, just less intense: babies cried when the mother or
father left, but cried less for the father; they explored and played less during
the absence of either parent, but less so when the mother was gone; they
would cling to the mother and father on reunion, but less intensely to the
father. The children clearly related to their fathers as attachment figures who
served as a secure base (Kotelchuck 1976).
Infants observed in the home, ages 7 to 13 months, showed no preference
for mothers over fathers on most attachment measures (e.g., proximity seeking,
touching, crying, signaling a desire to be held, protesting on separation,
greeting on reunion) (see Lamb 1997 for a research review). When infants
are distressed, however, they consistently prefer their mothers, supporting
the notion that children arrange their attachments in a hierarchy. Finally, the
distribution of infant patterns of attachment to mothers is basically the same
as for fathers (65% secure, 25% avoidant, 10% resistant) (Main and Weston
1981). While one secure attachment was better than none, children found
to be securely attached to both parents were most competent and confident,
and displayed more empathy (Main and Weston 1981; Easterbrooks and
Goldberg 1991).
Karen writes, “Although fathers are usually secondary caregivers, they
are not merely secondary mothers” (1994, p.204). They provide valuable
stimulation, playfulness, and serve as a stepping-stone to the outside world,
where people are commonly not “in-synch” and attuned. They facilitate the
child’s ability (especially sons) to move outside the mother’s orbit. They
provide role models for their sons and invaluable models to daughters
regarding a relationship to male figures. Lamb (1997), in his book on the
father’s role in child development, offers a number of salient conclusions
based on 30 years of research and observation in the field:
• Fathers and mothers influence their children in similar ways; warmth,
nurturance, and closeness are associated with well-adjusted and healthy
children whether the caregiver is a mother or father.
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Siblings
Sibling relationships are typically the longest-lasting close relationships
in life. The quality of sibling relationships is associated with each sibling’s
attachment to the mother. Studies found that infant–mother attachment
security resulted in less sibling conflict in the home five years later (Volling
and Belsky 1992), and that infant–mother attachment security was related to
positive treatment from an older sibling (Teti and Ablard 1989).
Sibling relationships serve an important function in the emotional and
social development of children. Siblings actively shape one another’s lives and
prepare each other for later experiences both within and beyond the family.
Many crucial lessons children learn about sharing, competition, rivalry, and
compromise are learned through their negotiations with siblings (Lobato
1990). Sibling relationships also provide an arena in which children learn
about intimacy, empathy, and love.
Conflict is inherent to all sibling relationships. Sibling conflicts, however,
are amplified and multiplied in the family with a child with attachment
disorder. These difficulties and disagreements go beyond “normal” sibling
squabbles. The infant who had consistent and appropriate need fulfillment
becomes secure and has a higher tolerance for sharing attention, affection,
and possessions with siblings. Early unmet needs and insecure attachment,
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don’t want to ride in cars with her because my head aches with her
awful behavior and screaming. I can’t do anything fun with her or
anything at all because she can’t be still and under control unless
everything goes her way. She’s more a pain than anything else.
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ATTACHMENT, TRAUMA, AND HEALING
supportive therapists helps them to become aware of issues from their past
that are triggering strong emotional reactions. Support is crucial. Studies have
shown that support and social connectedness reduce the emotional strain
and increase positive coping abilities of caregivers and parents of children
with severe emotional and behavioral problems (Munsell et al. 2012). We
provide substantial support to parents and encourage them to develop and
maintain helpful support systems at home (e.g., family, friends, religious and
community connections).
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Megan: I said it, but inside I don’t really mean it. I’m sorry deep down,
but I won’t let it come out.
Father: What’s holding it in, sweetie?
Megan: The bad part of me. [Sobs, buries head in father’s chest.]
Father: Do you want to feel bad about the things you’ve done to
your brother and sister?
Megan: I want to feel bad; but I’m not sure I really do.
Father: Why do you lie so much?
Megan: I feel safer when I lie, like I have some control over things, like
I have a secret and you don’t know what it is.
Father: I’m so glad to hear you say that. Thanks for being honest now.
I’m proud of you. I love you. [They hug one another, Megan sobs.]
During this session, the father later reported, Megan let go of “needing
to be in control” for the first time. Her aggression and dishonesty had
been control strategies.
Triangulation
Children with attachment disorder are experts at “working one against the
other.” For example, a child may form a coalition with one parent against
the other, or with a counselor against the parents. This is one of the child’s
strategies of manipulation and control. The structure of treatment prevents
this triangulation. The treatment team and parents create a strong and
unified collaborative alliance, while the parents are also helped to develop
and maintain a unified parental team. An emphasis is placed on the parents’
learning communication and problem-solving skills so that they can be “on
the same page.” It is also important that treatment team, parents, and external
systems (e.g., social services) are united and working toward common goals.
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She shared these fears with both her mother and father. A plan was
developed so that Annie can express her anxieties verbally, rather than
act out with aggression and control.
Annie: I’m afraid to love you, Mom. [Sobbing, looking in mother’s
eyes, in arms.]
Therapist: Love is scary for you, Annie. Can you tell your mom why?
Annie: I’m afraid you’ll leave me, like Angie did. I’m afraid you or Dad
will hurt me, too.
Mother: [Crying; holding daughter.] I’m sorry you were hurt. We will
never hurt you or leave you. Maybe with time, you will learn to trust
us. It’s good you are using your words to tell me how you feel.
These mother–daughter sessions point out the importance of both
content and process. Content includes the verbal sharing of important
issues. Most important, however, is the process that is occurring, i.e.,
the context of the attachment experience. The ingredients of secure
attachment (eye contact, loving closeness and touch, empathy, limbic
resonance, positive affect, protection) are experienced and rehearsed
by mother and daughter.
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Mother: You do? OK. [Seems amazed at his desire for closeness.]
Jeepers, this feels good. I don’t think you’ve ever given me a hug like
this before.
Therapist: Does it feel like Adam is giving you a real hug and
accepting yours?
Mother: Yes. [Begins to cry.] Have you ever felt this before?
Adam: No. [Mother and son hold one another for several minutes.]
Adam: Why are you crying? [Seems concerned about his mother’s
tears.]
Mother: Part of me is sad; part of me is happy; and part just feels good.
Adam: Do you think I’ll be OK when we go home?
Mother: We are all working on it. I hope so.
It is important not to allow the content to get in the way of the process.
Considerable time is spent in mother–child attachment “practice”
(eye contact, gentle touch, positive affect, smiles, attunement, and
reciprocity).
Therapist: Can you tell your mother what happened to baby Adam?
Adam: He had worms in his tummy, didn’t get milk, good care, or a
blanket. [Good eye contact with mother.]
Therapist: You didn’t get what you needed as a baby, but you can
now. Let’s pretend you are that little baby and your forever mom will
take good care of you.
Adam and his mother spend half an hour in arms. He relaxes into his
mother’s arms, and they remain quiet and close. The increase in mutual
caring, empathy, and honest communication—as well as the decrease
in anger, defensiveness, and control struggles—initiated the process of
establishing secure attachment between mother and son. Subsequent
sessions continued the Corrective Attachment Therapy.
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Ecological Patterns
Changes occur in the relationship between the family system and other social
systems (i.e., school, mental health and social services agencies, extended
family, and other support networks). For example, parents are encouraged
to join support groups in their local community. Also, identifying and
facilitating effective follow-up therapy is important to maintain positive
change. The treatment team is instrumental in helping the parents develop
positive attitudes and working relationships with resources outside the family.
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10
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Adult and Couple Attachment
Low Avoidance
SECURE ANXIOUS
ANXIOUS–
AVOIDANT
AVOIDANT
High Avoidance
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Secure – Autonomous
Child (Secure)
• Strange Situation (attachment assessment procedure): distressed on
separation, very happy on reunion; mother and child greet warmly;
calms down quickly and resumes play.
• Can trust and depend on parent to be safe, loving, and meet needs,
especially in times of distress; uses parent to help regulate distress.
• Positive internal working model (IWM): “I trust parent; I am worthwhile
and lovable; I feel safe”; expects and anticipates positive relationship.
• Parent is a secure base: can explore environment, learn, and develop,
knowing parent is available and supportive if and when needed.
• Parent attuned to child’s needs (“limbic resonance”).
Adult (Autonomous)
Adult Attachment Interview (AAI):
• Coherent view of attachment and its importance; details about past are
consistent with memories.
• Balanced and objective perspective regarding positive and negative
qualities of past relationships.
• Able to easily access autobiographical information; comfortable
discussing prior experiences.
• Can reflect on mental processes of self and others (“reflective function”);
self-aware and insightful.
Traits
• Comfortable in a warm, loving, emotionally close relationship.
• Depends on partner and allows partner to depend on them; is available
for partner in times of need.
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Avoidant – Dismissive
Child (Avoidant)
• Strange Situation: does not show signs of being upset when mother
leaves, explores surroundings; ignores mother on reunion; mother also
avoids child, looking away; when picked up wants to be put down; plays
alone (heart rate and cortisol level are elevated despite calm façade).
• Learns not to trust or depend on parent, who is emotionally unavailable,
insensitive, and rejecting; suppresses (deactivates) attachment behavior
to avoid rejection.
• Negative IWM: “I can’t trust parents so I must rely on myself; I am not
worth loving; I feel unsafe but will pretend to be independent.”
• Deactivates emotional needs; avoids closeness with friends and family;
devalues relationships; disconnected from own emotions.
Adult (Dismissive)
Adult Attachment Interview (AAI):
• Incoherent view of attachment; details not consistent with memories;
description of past contradicted by facts.
• Dismissing of relationships; little recall of relationship experiences.
• Brief responses; does not want to reflect on the past.
• Reports lack of emotional connections; rejection and neglect from
parents.
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Traits
• Emotionally distant and rejecting in a relationship; keeps partner at
arm’s length; partner always wanting more connection (deactivates
attachment needs and behaviors).
• Equates intimacy with loss of independence; prefers autonomy to
togetherness.
• Not able to depend on partner or allow partner to “lean on” them;
independence is a priority.
• Communication is intellectual, not comfortable talking about
emotions; avoids conflict, then explodes.
• Cool, controlled, stoic; compulsively self-sufficient; narrow emotional
range; prefers to be alone.
• Good in a crisis; non-emotional, takes charge.
• Emotionally unavailable as parent; disengaged and detached; children
likely to have avoidant attachment.
Anxious – Preoccupied
Child (Anxious)
• Strange Situation: extremely upset when mother leaves, clingy, stays
near door crying; rushes to mother on reunion then pushes her away in
anger; fails to settle down and accept comfort; clings and does not play.
• Anxious and preoccupied with parent’s whereabouts, due to parental
anxiety and inconsistency (intrusive one minute, then aloof or gone);
desperate for contact but unable to be soothed.
• Learns to hyperactivate attachment behavior: protests and cries loudly
and persistently; hypervigilant about loss of support and separation;
works hard to get parent to respond; controlling, demanding, clingy,
babyish, caregiving toward parent.
• Negative IWM: “I can’t rely on parent or feel secure with love; I’m not
worth loving; I am always anxious and uncertain.”
Adults (Preoccupied)
Adult Attachment Interview (AAI):
• Incoherent and confused; preoccupied with unresolved emotional
issues.
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Adult and Couple Attachment
Traits
• Insecure in relationship; constantly worried about rejection and
abandonment; preoccupied with relationship (hyperactivated
attachment needs and behavior).
• Needy; requires ongoing reassurance; want to “merge” with partner,
which scares partner away.
• Ruminates about unresolved past issues, which intrude into present
perceptions and relationships (fear, hurt, anger).
• Over sensitive to partner’s actions and moods; takes partner’s behavior
too personally.
• Highly emotional; can be argumentative, combative, angry, controlling;
poor personal boundaries.
• Communication not collaborative; unaware of own responsibility in
relationship; blames others.
• Unpredictable and moody; connects through conflict, “stirs the pot.”
• Inconsistent attunement with own children, who are likely to be
anxiously attached.
Disorganized – Unresolved
Child (Disorganized)
• Strange Situation: no organized strategy for handling separation or
reunion; displays both avoidant and anxious reactions; may freeze,
become disoriented, and/or move away from mother suddenly.
• Approach–avoidance conflict: due to severe abuse and neglect,
attachment figure is the source of fear and terror; need to move toward,
and impulse to go away from parent.
• Negative IWM: “Expect pain from parent; I’m bad, worthless,
unlovable; I never feel safe.”
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Adult (Unresolved)
Adult Attachment Interview (AAI):
• Incoherent narrative; confused and disoriented during discussions of
maltreatment, loss, and trauma.
• Disorganized thinking; lapses in reasoning, incomplete sentences,
prolonged silences; may dissociate.
Traits
• Unresolved mindset and emotions; frightened by memories of prior
trauma; losses not mourned or resolved.
• Cannot tolerate emotional closeness in a relationship; argumentative,
rages, unable to regulate emotions; abusive and dysfunctional
relationships.
• Intrusive and frightening traumatic memories and triggers; dissociates
to avoid pain; severe depression, PTSD.
• Antisocial; lack of empathy and remorse, aggressive and punitive,
narcissistic, no regard for rules, substance abuse, criminality.
• Maltreats own children; scripts children into past unresolved
attachments; triggered into anger and fear by parent–child interaction;
children developed disorganized attachment.
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Secure Attachment
Numerous studies have shown the positive effects of adult attachment security
on self-image, stress management, values, and overall mental, physical, and
relationship health. The ability to trust and depend on a partner results in
a “broaden-and-build” cycle, i.e., the sense of security increases a person’s
emotional stability in times of stress, acting as a resource for resilience, the
ability to recover following adversity (Fredrickson 2001).
Secure attachment in adults is positively associated with measures of well-
being and negatively associated with depression and anxiety (Birnbaum et al.
1997; Mickelson, Kessler, and Shaver 1997). Securely attached adults have
constructive and optimistic beliefs and attitudes. They appraise problems as
manageable, view stressful events as opportunities for learning, and have a
more positive view of human nature (Collins and Read 1990). They have more
positive expectations regarding their partner’s behavior, and are less negative
when reacting to a partner’s hurtful behavior (Baldwin et al. 1996). Secure
adults score higher on measures of trust, intimacy, open communication,
prosocial behavior, self-disclosure, support seeking, marital satisfaction, and
self-esteem (Mikulincer and Shaver 2007). Attachment security has been
found to be associated with curiosity, learning, change, taking calculated
risks, facing challenges, and engaging in exploration of new and different
information and situations (Elliot and Reis 2003).
Achieving secure attachment—having a partner who fulfills our intrinsic
attachment needs and serves as a secure base—is vital to emotional and
physical health. Securely attached adults are more calm and confident, have
prosocial values, a sense of purpose and meaning, are able to maintain intimate
and reciprocal relationships, and are better able to cope with life’s challenges
and hardships. In 1938, researchers began a study of students at Harvard
University and tracked them throughout their entire lives. Over time, the
importance of intimate relationships became clear. During the 1940s, the
men who grew up with warm and loving parents were much more likely to
become lieutenants and majors in World War II, while those who had cold
and unloving parents were more likely to be privates. Resilience was affected
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by secure attachment. The positive effect of even one loving and supportive
friend, mentor, or relative helped to overcome adverse events in the men’s
lives. Those who were better at maintaining intimate relationships also lived
longer. The study concluded that the capacity for intimate relationships
was the primary factor related to flourishing in all aspects of the men’s lives
(Vaillant 2002). The following is a list of traits associated with attachment
security in adults:
• Desires closeness: Seeks and enjoys intimacy without being afraid of
becoming “too close”; does not fear rejection, have a need to push
partner away, or engage in a negative relationship “dance” (e.g., pursuer–
distancer dynamic; one wants closeness and the other maintains
distance); positive mindset about closeness—desires closeness and
assumes partner wants closeness too; allows intimacy to evolve over
time; doesn’t “play games.”
• Emotionally available: Aware of, and able to regulate, own emotions;
able to discuss feelings in an honest and coherent way; has empathy
and understanding for partner’s emotions; not afraid of commitment
or dependency.
• Protective: Partners feel safe and sheltered, helping them to face the
realities of life with a secure feeling; treats partner with consistent
support, respect, and love.
• Communication and conflict-management skills: Open and honest
sharing and empathic listening; able to have a disagreement without
becoming defensive or attacking, which avoids escalation and expedites
resolution; confident that problems can be solved and the relationship
will thrive; makes decisions as a team.
• Flexible: Adaptable, not rigid in thinking; able to accept feedback and
consider partner’s ideas without feeling criticized or controlled; can
modify ideas and actions when appropriate.
• Forgiving: Can forgive partner for mistakes or hurtful actions, and can
practice self-forgiveness; does not hold onto resentments; positive view
and expectation—assumes partner’s intentions are good and realizes
no one is perfect.
• Sexuality: Realizes that sex is part of emotional intimacy, not merely
physical; is both emotionally and sexually intimate; partner is secure
in his or her commitment and faithfulness (avoidants most likely to
have affairs).
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Contact with a secure partner acts as a buffer against stress and anxiety.
Researchers at the University of Virginia studied how physical contact with
a spouse reduces anxiety, both psychologically and biologically. They used
functional MRIs to scan the brains of women under stressful conditions
(telling them they would receive an electric shock). The brain scan focused
on the hypothalamus, a region of the brain that becomes activated under
stress. When the women held a stranger’s hand, the scans showed some
reduced activity in the hypothalamus. When they held their husband’s hand,
the activity in the hypothalamus was negligible, indicating no stress response.
The women who reported the highest marital satisfaction had the best results
from spousal hand-holding (Coan, Schaefer, and Davidson 2006).
Numerous studies show that when two people have a significant
attachment they regulate each other’s physiological reactions (i.e., heart rate,
blood pressure, breathing, hormone levels). A study at Case Western Reserve
University found that negative relationships undermine health. Men with a
history of high blood pressure and angina were asked, “Does your wife show
you love?” The men who answered “no” had twice as many angina episodes
over the next five years as compared to those who answered “yes.” Women
who report significant conflict in their marriages are more likely to have high
blood pressure, high levels of stress hormones, and are three times more likely
to have a second heart attack than women with less discord in their marriage
(Kiecolt-Glaser et al. 2005). Researchers at the University of Toronto found
that being in a satisfying marriage lowers blood pressure in men and women
with high blood pressure. Conversely, having contact with a spouse in an
unsatisfying marriage raises blood pressure, which remains elevated while in
physical proximity (Baker et al. 2003).
The quality of our adult attachment relationships affects our emotional
and physical health. When our partner does not meet our basic attachment
needs for security and safety, our emotional well-being and physical health
decline. People in high-conflict marriages have a ten times higher risk for
depression (O’Leary et al. 1994). Attachment insecurities have been linked to
many health problems: chronic pain and other somatic symptoms, troubled
sleep, non adherence to medical regimes, fewer health care visits, and negative
patient–physician relationships (Mikulincer and Shaver 2007).
Dependency Paradox
Western culture has a long history of emphasizing self-sufficiency and
independence. John Watson and the behaviorists in the 1940s warned parents
that children should learn to soothe themselves; otherwise they would become
weak and overly dependent (Watson 1928). Parents were advised to maintain
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Attachment Insecurity
As previously noted, each attachment style involves specific strategies to deal
with closeness, dependence, avoidance, and anxiety. Anxiously attached adults
employ hyperactivating attachment behaviors, avoidantly attached adults
deactivate attachment needs and behaviors, and adults who are unresolved
have no organized strategy to manage their emotions and relationships.
The list that follows describes the goals and traits of each adult insecure
attachment style.
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Disorganized (Unresolved)
• Fears the negative consequences of closeness and reliance on others,
due to severe abusive and attachment-related trauma.
• Enacts both deactivating and hyperactivating strategies in confused
and chaotic manner; vacillates between approach and avoidance
behavior; scores high on anxiety and avoidance measures.
• PTSD symptoms: attempts to avoid frightening thoughts and
memories; unable to control intrusive traumatic emotions and
memories (“flashbacks”); hyperarousal of anxiety, emotions, and
physiology.
• Least secure and trusting; most severe psychological problems;
extremely distressing and violent relationships; personality disorders.
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There are two basic strategies people use in these situations. The first
is characterized by increased attachment behaviors (“hyperactivated”),
including anxious clinging, pursuit, and other frantic attempts to connect
with their partner. The second strategy is detached avoidance; attachment
needs and behaviors are reduced (“deactivated”) to avoid the pain of loss.
Couples can get engulfed in ongoing and repetitive patterns using one or
both of these strategies, which is extremely damaging to the relationship.
For example, there is a high incidence of divorce among couples who have a
pattern of angry accusations followed by avoidance and emotional distance
(Gottman 1999).
Many of the behaviors and patterns of interacting in adult intimate
relationships can be traced back to the internal working models formed
early in life. These mindsets and core beliefs become biases and expectations,
the lens through which we view ourselves and our partners. Secure adults
view themselves as worthy of love, and trust their partners to be dependable
and supportive. Adults with insecure attachments view themselves as not
deserving of love, and expect their partners to reject, abandon, or abuse them.
These mental models and beliefs influence behavior and emotional reactions,
and eventually develop into ongoing patterns—the dance of relationships.
A useful and practical way to change negative patterns is to learn how
to communicate effectively: how to share and listen in honest, deep, positive,
and constructive ways. This can be accomplished by learning the concepts
and skills of Attachment Communication Training (ACT). After completing
the Life Script, family members are ready to create secure and fulfilling
relationships, using the communication skills outlined in the next section.
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This communication method will help you to be a secure base for one
another; meaning you will be supportive, safe, and dependable. For this
exercise to work well, you will have to follow the guidelines, which I will
describe in a moment. Are you both willing to learn the skills I’m going
to describe and follow the “rules?” When you first try this communication
approach it will probably feel unnatural and sort of contrived. That’s OK;
with practice you will find it to be helpful and rewarding. Are you willing
to try this?
I’m going to tell you the rules for sharing and listening. When you
are sharing with your partner it is important to: 1) be honest, even if
you think you might “make waves”; 2) share your thoughts and feelings;
they are separate; 3) make “I statements”—share your own perceptions
and emotions; no questions, blaming, or criticizing; 4) be brief, specific,
and give examples: “when you did _____, I viewed this as _____, and
then I felt _____”; and 5) be aware of your body language, such as facial
expressions, posture, tone of voice—these are powerful messages.
Next are the rules for listening—this is called nonjudgmental and
empathic listening: 1) be nonjudgmental; put aside your judgments of
what your partner is saying as right or wrong, good or bad, and try to
understand your partner’s thoughts and feelings; 2) have empathy; try
to “walk in your partner’s shoes,” even if you have a different opinion; 3)
don’t censor what you hear (“selective listening”) or rehearse your rebuttal;
try to really hear your partner without being defensive; and 4) be aware
of your body language; are you looking safe, supportive, and interested? If
not, your partner may not feel comfortable in opening up.
At this time, the therapist asks if there are any questions regarding the
rules of sharing and listening. This is a time to respond to concerns, clarify
the skills to be practiced, and address any additional issues. The therapist
describes next the five steps in the ACT exercise: share, listen, restate, feedback,
and reverse roles. The therapist explains the steps in the following way:
Step 1 is sharing. It is important to use the rules of sharing that I previously
described. Step 2 is listening. While your partner is expressing his or her
thoughts and feelings, your job is to be a good listener. Remember to
follow the listening guidelines that I talked about. Step 3 is restating. This
is also called reflective listening, or mirroring, because you are reflecting
back to your partner what you heard. “What I heard you say is _____.”
The next step is giving feedback; tell your partner how he or she did as a
listener. If you feel your partner listened well, then say, “You heard me,
you got my messages, thank you for listening.” It is always good to thank
the other person for listening. If you feel your partner did not hear you,
or misinterpreted your messages, you can tell them so and try once more.
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• have “come to terms” with their past and are able to fully invest in the
relationship
• are able to balance togetherness and autonomy, dependence and
independence
• can trust and rely on one another; be a “secure base” for each other
• have good communication and problem-solving skills; are respectful
and constructive when talking about conflicts and disagreements
• do not become defensive, angry, critical, or aggressive when their
partner shares feelings or gives feedback; apologize for wrongdoings
• share power and control; are a partnership between equals
• meet one another’s needs for security, support, affection, and love
• both take responsibility for their own part in problems and solutions:
no blaming, avoiding, or stonewalling
• keep the relationship alive, vital, and a priority; spend time, have fun,
show love regularly
• use self-control; do not take out stress and frustration on their partner
• resolve problems; continue to repair grievances and wounds so hurts
do not grow into big resentments
• adapt successfully to changes and challenges, such as having children;
form a united team in raising children
• are both comfortable with closeness; do not take part in destructive
dynamics, such as “pursue–distance” pattern
• share basic values, interests, and moral codes of behavior.
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freak, alone, helpless.” She has suffered with anxiety and depression
most of her life and is currently on medication, which she reports to be
helpful. Lynne requested help and contracted to participate in therapy.
The session begins with Lynne and her husband in the context of the
Limbic Activation Process. Dave said he wanted to help Lynne through
the therapy, and was instructed to provide emotional support during
the session.
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Psychodramatic Reenactment
The goal of this intervention is for Lynne to “give a voice” to little Lynne;
to tell her parents her honest thoughts and feelings. One therapist (MO)
role-plays father and another (MV) role-plays mother.
TML: Little Lynne needs to talk with mom and dad, say things she
didn’t feel safe to say back then.
Lynne: [Speaking to mother] Are you OK Mom?
TML: Tell mom how little Lynne was feeling.
Lynne: You made me feel like I had no value unless I was taking care
of you. And you left me alone; I was terrified.
MV: I need you to listen to me; to help me.
Lynne: [Gets angry and shouts] I don’t want to hear it, Mom! Get
a friend; get a therapist; I don’t want to hear it anymore. [Lynne is
sounding and looking like the helpless child.]
TML: Tell Mom what you have learned and how you have changed, in
a more powerful voice.
Lynne: I am valuable; I’m not your therapist; I love you, but I can’t fix
you.
MO: Just say “No more, Mom. I have worth; I have value.”
Lynne: No more, Mom. [Lynne is now looking and sounding confident
and assertive, not the helpless child.]
TML: If you don’t have to fix your mom anymore, do you still have to
be the fixer for your husband? Tell Dave how you are changing.
Lynne: [Looks at mom, cries and says] I thought you would die and
I wouldn’t have anybody. [Looks at Dave and says] I’m afraid you’ll
die, too. [Dave cries and says “I’m not going to die.” They hug one
another.]
TML: Are you that frightened, helpless little child anymore?
Lynne: [Looks at mom and then husband and says] I hope you don’t
die but I’m not helpless; I can make it; I’m strong.
Lynne is changing her internal working model from “I’m helpless
and have to rescue others” to “I’m competent and others can help
themselves.” The role-playing is an experiential context to facilitate
changes emotionally, neurobiologically, cognitively, and interpersonally.
MO: [Role-playing father, looks at Lynne and says] What the hell is
wrong with you?
Lynne: [Looks into father’s eyes] You are so wrong, Dad; I know who
you are, just a scared little boy. I’m not going to let you hurt me
anymore. [Lynne appears confident, assertive, and composed.]
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Dave: [Pauses to think about his emotions, then says to his wife] It
makes me feel safe, when I’m inadequate and you take charge.
Dave never had security, protection, or safety with his parents growing
up, so he maintains the “helpless” role in his marriage so that Lynne
takes control—then he feels safe, his partner is protecting him.
This is the “dance” in their relationship: Dave acts helpless and
inadequate; Lynne takes control, the “parental child.” This has negative
consequences in their marriage.
TML: But for you Lynne, this keeps you in the role you always had—
the “parental child”—in charge, in control, responsible for others;
how is that working for both of you?
Dave: Not good. We talk about this all the time.
Lynn: It’s not working for me! [She looks angry and frustrated about
this pattern in her life and marriage.]
TML: Lynne, how do you really feel when your husband tells you that
you are smarter and more capable than him?
Lynne: I hate it. I’m really angry right now. I hate it! I think it’s a cop-
out; it keeps you from having to do scary stuff.
Dave: You are right. But you get angry with me, criticize me, then I
retreat and feel like, “Why bother? I’ll just let you run the show if you
don’t like the way I do things.”
Dave is honest about his anger regarding feeling judged and criticized
by Lynne. They are both repeating patterns from their childhood: Dave
acts helpless and expects a critical and punitive response; Lynne takes
control, resents this role, then gets angry with Dave, just like her father
was angry with her.
TML: [To Lynne] Dave says you are mean-spirited and you put him
down. Is that true?
Lynne: I’m angry at you [Dave]. But I don’t want to treat you mean. I
really think you are very smart.
MO: [To Lynne] From your Life Script, your father was mean to you.
Are you acting like him?
TML: So are you doing to your husband what your father did to you?
Lynne: I feel horrible. I don’t want to be like him. He was a bully.
[Lynne realizes she is acting hostile and punitive toward her husband,
repeating a childhood pattern.]
TML: Hold hands. Dave, tell your wife what you are going to change.
Dave: [Looks into Lynne’s eyes] I’ve always thought of myself as a
“goober”; it’s been part of my identity. But it’s time to let go of that.
TML: Lynne, what are you willing to change?
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Intensive Outpatient
Psychotherapy
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are reviewed and reinforced each day in therapy sessions, and family members
are encouraged to continue the process of change by repeated practice
following therapy sessions.
Third, the consistency, momentum, and intensity of daily therapeutic
experiences increase motivation, reduce defenses, and enhance therapeutic
rapport. Well-established defenses are difficult to penetrate in traditional
once-a-week outpatient psychotherapy, especially with traumatized
individuals who are reluctant to reveal deeper emotions and are fearful of
vulnerability. Defenses are more likely to be lowered in the intensive format.
Motivation and hope are enhanced as goals are set and achieved, and family
members have a sense of master (from “victim” to “survivor”). Trust in
therapists increases as children and adults perceive these helping agents as
knowledgeable, supportive, understanding, and helpful.
The fourth benefit of the IOP approach is “family togetherness,”
opportunities for new, positive, and enjoyable experiences. Traumatized
families rarely have positive interaction in their day-to-day lives. Even
though therapy is emotionally challenging and painful at times, there is ample
time for families, couples, and individuals to have satisfying and fulfilling
experiences. We encourage entire families to come, including siblings.
Fathers, for instance, who are typically away from the family working, are
now available to the spouse and children. Family members can learn and
grow together, creating an enhanced level of intimacy and connection.
Another advantage of the IOP model entails the possibility for continued
positive growth and change during follow-up therapy. Intensive therapy
fosters self-awareness, facilitates emotional, behavioral, and interpersonal
change, and incorporates parent training and trauma therapy, and “opens the
door” for conventional outpatient therapy to be more effective in the future.
Referring therapists are invited to participate with the family in the IOP,
which results in better follow-up treatment, and also provides training and
supervision to those mental health professionals.
Sixth, the IOP uses a treatment team of four therapists. Male and female
therapists provide diverse input, role models, viewpoints, and opportunities
for transference. The treatment team is advantageous and necessary during
various therapeutic interventions. For example, one or two therapists will
communicate with the child, while other treatment team members offer
support and guidance to parents observing via closed-circuit TV. Another
example is one therapist role-playing a family member (e.g., “birth mother”),
while other therapists help the child or adult process their emotions regarding
past interpersonal trauma. The treatment team is also a support system for
family members and therapists. Working with traumatized individuals and
families can be stressful, and the supportive nature of the treatment team
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Intensive Outpatient Psychotherapy
Population
There are two IOP programs at Evergreen Psychotherapy Center:
1) children and families; and 2) adult/couples. Many families that seek
treatment are adoptive families; parents have adopted children with histories
of maltreatment and interpersonal trauma from foster care in the United
States or foreign orphanages. The IOP includes the traumatized child or
children, parents, and siblings—the entire family system. The traumatized
child or children display many challenging behaviors and symptoms,
including: angry, aggressive, defiant, controlling, and distancing; negative core
beliefs; antisocial attitudes and behaviors; depression, anxiety, and shame;
school and peer group problems. Additionally, the entire family is under
extreme stress—a “traumatized family system.” The parents were typically
emotionally unprepared to deal with the child’s problems, and were often
not given pre-placement and post-placement services. Many parents have
experienced their own losses (e.g., infertility) and have histories of unresolved
trauma that contribute to the parent–child conflicts. Ongoing negative and
destructive relationship patterns create a climate of tension, hostility, and
despair. Triangulation is common, in which a child forms an alliance with
one parent against another. For example, the child is rejecting with mother
and cooperative with father, resulting in a lack of unified coparenting as well
as marital conflict. Marital stress and conflict are common, as is severe sibling
conflict. Traumatized children are often abusive and resentful toward and
jealous of siblings. Siblings commonly feel resentful toward their parents
because of the amount of time and resources devoted to the “problem child.”
Traumatized children reenact negative relationship patterns learned earlier
in life. For example, children will provoke rejection or abuse from parents to
confirm their core beliefs (“I’m not worth loving; parents are hurtful”). Parents
and siblings frequently have STS—anxiety, depression, and “burnout.”
Families with biological children also participate in the IOP. Interpersonal
trauma and a breakdown in family functioning occur due to many factors,
including medical problems of children and/or parents, postpartum
depression, parental mental illness and/or substance abuse, abuse and neglect,
absence due to military deployment or incarceration. Attachment problems,
PTSD, depression, and acting-out behaviors are common in family members.
The second IOP program involves adults and/or couples. Individual adults
with histories of maltreatment, compromised attachment, and relationship
failures participate in the IOP. They present with PTSD, depression, anxiety,
substance abuse and other self-destructive behaviors, and severe attachment
disorders in childhood and adulthood. These adults have usually been in
outpatient psychotherapy on a number of occasions, but are in need of a
more intensive therapy format for positive change to occur. Mental health
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professionals identify this need and refer these individuals to our IOP
program.
Adults in committed, romantic relationships participate in the IOP. These
couples are experiencing individual and interpersonal problems that create
destructive patterns of attaching and relating. The IOP focuses on learning
new, healthy, and fulfilling ways of communicating, problem-solving, and
managing conflict. The goal is to both heal from personal trauma and develop
secure adult attachment relationships with trust, intimacy, need fulfillment,
honesty, and safety.
Treatment Goals
This section describes the treatment goals of the ten-day IOP for children,
parents, and family.
Session One
Therapeutic goals:
• parent interview and assessment
• assessment of the child
• developing a therapeutic relationship
• contracting.
The parent interview provides detailed information regarding the child’s
early history, current symptoms and behavior, parenting styles, and family
dynamics. Important issues to identify include strengths and deficits of marital
relationship; support systems of the parents; similarities and differences in
the parents’ perception of the child’s behavior; level of functioning of the
siblings; parents’ level of stress, frustration, and emotional availability to the
child; effectiveness of specific parenting attitudes and techniques; and parents’
prior attempted solutions. Parents are asked to bring such historical records
as life books, family albums, court documents, diaries, social service reports,
and letters and adoption records, which provide additional information and
can be used therapeutically at a later time.
Parents often present as highly frustrated, desperate, wary, and exhausted.
For example, adoptive parents are often told by professionals, “All this child
needs is love and a stable home.” However, the child with attachment disorder
has little or no foundation to understand or accept love, and therefore, the
parents typically experience rejection, feelings of inadequacy, despair, and
hostility toward the child. They are often blamed for their child’s inability to
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respond positively to the family environment. One of the primary goals of the
initial session is to join with the parents and let them know we understand
the nature of their frustration. The parents are educated about the causes
and consequences of attachment disorder, and that knowledge enables them
to be more objective and feel less responsible and guilty regarding their
child’s problems. The therapists provide considerable empathy, support, and
validation in order to build a working alliance with the parents.
Another primary goal is the development of a specific treatment contract
in which parents and therapists agree on certain desired outcomes (e.g., learn
parenting skills or reduce resentment toward the child). It is important that
parents end the initial session with a sense of hope and enhanced expectation
of success, thereby increasing their investment in the treatment process. Also
during the initial session, the child is asked to fill out a sentence completion
questionnaire (Appendix C) that provides information about content
(attitudes, perceptions, and emotions) and process (how the child responds
to the task). The child is also asked to complete drawings (i.e., “house–
tree–person”; family as animals), which provide additional psychosocial
information. These initial contacts with the child offer opportunities for
rapport building.
During the first session with the parents it is often possible to begin
parent training, i.e., teaching the concepts and skills of Corrective Attachment
Parenting. Homework assignments are provided. For example, parents are
encouraged to communicate differently, set boundaries, and offer choices
and consequences to their children. It is essential to instill an expectation of
success and a sense of hope, because most parents (as well as children, adults,
and couples) are feeling demoralized and pessimistic. The treatment team
informs them that if they are willing to work hard goals can be achieved and
progress can be accomplished.
Parent training is psychoeducational, skill-based, and involves an
understanding of the parent’s attachment histories. The parents are informed
that conventional parenting skills are often ineffective with children who
have attachment disorder, due to their desperate need to control, lack of trust
with and attachment to the parents, and perception that authority figures are
abusive, neglectful, and unreliable. The parenting skills taught in this session
(and reviewed and reinforced throughout therapy) stress the importance of
the parents “not getting hooked” into the child’s attempts to manipulate,
control, and compulsively replay prior dysfunctional relationship patterns.
Parents are taught to stay neutral and provide logical consequences in an
empathic manner, in contrast to becoming angry, hostile, and punitive. The
angry, punitive parent is unknowingly “playing the child’s game,” allowing the
child to maintain control and repeating prior patterns of parental hostility
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and rejection. These and other parenting techniques provide concrete tools
that enhance the parents’ sense of competency, improve their self-esteem,
prevent further marital discord, and offer an alternative context in which the
child’s chances of changing are improved (see Chapter 11 for a discussion on
parenting skills).
It is necessary to help the parents identify and explore psychosocial
issues from their family of origin. The parents complete the Life Script in
a discussion session with the therapist to obtain such information as the
roles, messages, and discipline techniques of their own parents; their parents
as role models regarding conflict management, communication, and affect;
family relationship patterns; and their self-perceptions as children. The
therapists encourage the parents to examine the association between their
own attachment history, family of origin, and current marital and parent–
child relationships.
Session Two
Therapeutic goals:
• process past 24 hours
• Life Scripts with parents, adults, or couples
• teach parenting skills.
The second day, and each subsequent session, begins with a discussion of the
prior 24 hours. How did it go? What specifically happened? What were the
results of using new parenting skills and strategies? Parents are asked to keep
a written log of situations and behaviors, so that we can review and provide
specific feedback and recommendations.
The parents, adults, or couples complete their Life Script. First, treatment
team members ask specific questions from the Life Script (see Appendix H)
and the clients write down their answers. Next, these answers are discussed
with the entire treatment team. This provides valuable information about
family-of-origin and attachment history, which affects their parenting
behavior and adults’ relationships (e.g., marriage). The Life Script typically
evokes memories and emotions, and is an opportunity to assess the way in
which clients deal with their feelings, manage stress, perceive situations, and
relate to one another.
Parenting skills training is continued on the second day, and is worked
on each subsequent session. Parents are given an outline of salient concepts,
strategies, and skills in addition to our book, Healing Parents. We discuss
parenting issues in detail, in reference to specific parent–child issues that
occur in the family. Parent–child interactions are role-played with treatment
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team members to give parents practice with new methods, behaviors, and
attitudes. Next, parents are encouraged to practice these new behaviors and
approaches with their children post-session (e.g., in hotel, car, restaurants,
activities). We discuss the results each day and help the parents “fine-tune”
their parenting approach. Parents commonly refer to their Life Scripts as
they become aware of issues from their pasts that influence the way they
perceive and respond to their children. For example, a father who grew up
in a harsh and controlling family may have difficulty setting limits with his
own children; he wants to give his children what he missed. A mother who
lacked warmth and affection as a child may find it challenging to be loving
with her own children.
Session Three
Therapeutic goals:
• initial interview with child
• complete Life Scripts
• teach parenting skills.
The initial interview with the child takes place in a treatment room with the
parents observing on closed-circuit TV in another room (with the child’s
knowledge). This allows the parents to observe without the distraction of
being in the same room, and enables the therapists to serve as role models
of communication. This interview provides information about the child’s
motivation, self-awareness, honesty, emotional availability, perception of self,
parents and family (“internal working model”), level of stress, and ability to
handle questions, feedback, and nonthreatening confrontation. Reviewing
the Sentence Completion and drawings furnishes additional information.
The child and therapists generate a “list of goals,” the child’s goals while
in the program (e.g., argue less with parents, be more respectful, learn to
communicate, be less angry, get along with siblings better). The child is more
motivated to work hard in therapy if he or she feels a sense of ownership—
“these are my goals.” The list of goals becomes a contract between the child
and therapists, and the child and parents. Contracts are agreement about
specific goals, ways to achieve those goals, and desired outcomes. There is
a direct correlation between the strength of the treatment contract and the
desire, commitment, and motivation to change. On the last day of the IOP,
we review the list of goals and discuss the child’s achievements.
The therapists inform the child about the “rules of therapy” during the
initial interview. These rules are expectations for positive and constructive
behavior: “I don’t know” is not helpful, so take a guess or ask for help rather
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than saying “I don’t know”; try to look at us when we are talking; please don’t
make us wait a long time for your answers (the “silent treatment”); we will
work hard to help you, but you also have to work hard (reciprocity). When
the child follows the “rules” we offer praise; and when they break the rules
we can discuss their thoughts and feelings about compliance and defiance.
The parents and therapists discuss the child interview, which generates
useful information about the parents’ attitudes, perceptions, and parenting
methods. We continue teaching parenting skills, often role-playing scenarios
from real-life parent–child interactions. We also complete the Life Scripts
from the previous day. The Life Scripts are of vital importance in reference
to understanding the histories, mindsets, and patterns of the parents, and
therefore, we spend considerable time on this assessment procedure—both
content and process.
Session Four
Therapeutic goals:
• process with parents
• first-year-of-life attachment cycle intervention
• continue parent training
• discuss results of Life Script.
As always, the session begins with the parents and treatment team discussing
their progress implementing new parenting ideas and methods. This is also
a time to discuss their thoughts and feelings regarding the Life Scripts. We
talk about individual, marital, parent–child, and family-of-origin issues. The
therapists encourage the parents to examine the association between their
attachment histories and current parent–child and marital relationships.
Next, the child and therapists discuss the “first-year-of-life attachment
cycle.” This is an experiential therapeutic intervention using the context
of the LAP. This discussion focuses on need fulfillment, basic trust, and
the establishment of secure and insecure attachment during infancy. The
explanation of the first-year-of-life attachment cycle is as follows (with
variations in age- and stage-appropriate language):
The first year of life involves four stages: needs, arousal, gratification,
and trust. The baby is a bundle of needs, and expresses those needs and
discomfort through signals (cries, screams, kicks). The sensitive and
loving parent or caregiver gratifies the baby’s needs (smiles, eye contact,
love, affection, nourishment, rocking, holding, touch), which leads to the
development of trust and secure attachment. When the baby’s needs are
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not met and his or her discomfort is not reduced because of unreliable
and insensitive care or because of lack of care, the baby learns to mistrust
and anxious attachment occurs.
The child is informed about the consequences of anxious attachment:
anger and rage; discomfort with touch, closeness, and intimacy; lack of eye
contact for affection; unable to trust others and him- or herself; views self as
defective and “bad”; views relationships as unsafe; inordinate need to control
situations and people; lack of compassion and remorse; and oppositional and
defiant behavior.
Educating the child about his or her early attachment experiences and
the resultant psychosocial difficulties gives the message, “We understand
how you got to be this way, and we can help you.” Further, this positive
reframing gives the message, “This is not your fault, but rather, an appropriate
and predictable response to unfortunate circumstances.” This sets the stage
for cognitive–affective revision, the development of positive regard for him-
or herself and others, and the working through of emotional trauma.
A specific therapeutic style and response is essential for treatment to be
effective. The therapist must provide a balance of confrontation and support,
be nurturing yet firm, avoid power struggles, maintain a positive focus,
provide validation and encouragement, and instill hope.
The child’s negative working model is now addressed. Specific perceptions
and expectations are identified: “I am bad, defective, and deserve to be
abandoned and abused”; “Adult caregivers can never be trusted”; “To survive
I must be in control at all times”; “It was my fault that I was maltreated”;
“If I get close to people I will be hurt and abandoned.” The process of
cognitive rescripting begins, which will be repeated many times in current
and future interventions. The goal of cognitive rescripting is to modify the
child’s trauma-based negative belief system (“I am bad; it was my fault I was
maltreated; adults cannot be trusted”), and help the child to develop a more
optimistic and positive mindset. Therapists are empathic regarding negative
perceptions; “We understand that you don’t trust adults because you were
abandoned and/or abused.” However, these negative mental models must
be challenged, helping the child to consider new possible viewpoints; “Your
adoptive mother and father love you and treat you well, so maybe you can
start trusting them.”
When age appropriate, the child is helped to understand the relationship
between current behavior and prior traumatic experiences. This information
is not provided with the premise that insight produces change, but rather,
because it helps the child realize that he or she was a victim of another’s
maltreatment, reducing the burden of self-blame and shame. The therapists
offer empathy and validation, giving the message: “It was not your fault.
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You were not responsible for the maltreatment, but you are responsible
for your behavior and choices now and in the future.” This discussion is
often very emotional for children, and it is an opportunity to help them
identify and learn to effectively manage their feelings. The child is helped
to label specific emotions (“are you mad, sad, scared?”), and encouraged
to verbalize feelings eye to eye with empathic and supportive therapists.
The ability to verbally communicate emotions in a safe relationship builds
trust, reduces acting-out behavior, and helps children to work through their
traumas. This communications skill is subsequently transferred to the child–
parent relationship.
The parents observe the first-year-of-life discussion on the closed-circuit
TV in a separate room with treatment team members to provide support
and information. Parents are often impressed with their child’s ability to
participate in the therapy and develop increased understanding and empathy
for their child in reference to the traumas suffered. The parents also benefit
by observing the therapist’s way of relating to their child—role models of
communication, support, empathy, limits, boundaries, and how to respond to
the child’s emotions.
Session Five
Therapeutic goals:
• process with parents
• Attachment Communication Training (ACT)
• process with child
• prepare for weekend.
The treatment team and parents begin the session reviewing parenting
methods and skills, discussing their progress implementing these new
ideas and methods, and addressing any additional thoughts and emotions
related to the Life Script. Parents commonly share many insights regarding
emotional and relationship issues, current and historical, and are working
hard to change and grow in their marital and parent–child relationships.
This session focuses on teaching family members the concepts and skills
of effective communication, problem-solving, and conflict management—
Attachment Communication Training (ACT). We begin with the parents,
so that they can apply these skills of communication with their children. We
also commonly facilitate sibling communication.
ACT is a structured, directive approach to teaching communication skills
and mitigating destructive patterns of relating (parent–child, adult partners
in marital and coparenting relationship, siblings). Parents must learn effective
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Session Six
Therapeutic goals:
• review weekend
• inner child metaphor
• parenting skills training
• ACT with siblings.
This session begins with the parents and treatment team reviewing the
weekend: the children’s behavior, parenting skills, coparenting relationship,
marital and family interactions, and other psychosocial issues. Parents
typically report mixed results; they have some positive experiences mixed
with some stressful ones. We encourage an “opportunity mindset”; everything
that happens is a learning experience, a teachable moment, and a springboard
for change.
Another primary experiential therapeutic method with the child is the
“inner child metaphor.” The child chooses a teddy bear to symbolize his or her
“inner child,” to “pretend that this is you when you were young.” As children
review their life experiences with their “inner child,” they revisit prior losses,
traumas, and other painful events. With support and understanding, they
begin to modify negative perceptions (“cognitive rescripting”), process their
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emotions (anger, fear, sadness, and shame), and initiate a sense of mastery
over the trauma (from victim to survivor).
At this time, we invite the parents to participate with their child
(using the LAP format). The child talks with his or her parents about the
information previously shared with the therapists: “Tell your mom and dad
what happened when you were young, how it affected you, and how you
are changing now.” As the parents listen with understanding and empathy,
this communication serves several purposes: reduces child’s shame about
maltreatment (“it wasn’t my fault”); reduces the negative emotional impact
of prior trauma (desensitization); allows parents to “bear witness” with
compassion; and enhances closeness and trust between child and parents. The
session ends with 10–20 minutes of positive connection time; the therapists
leave the room and allow the parents and child to savor their closeness.
Parents and other children in the family take part in ACT. Siblings of
the child with attachment trauma are often traumatized due to abuse and
family stress. Siblings are taught the concepts and skills of ACT. Parents
and siblings also spend time in communication sessions. The IOP is a family
systems treatment program, and all family members must participate to
modify family dynamics and improve family relationships.
Session Seven
Therapeutic goals:
• process with parents
• psychodramatic reenactment
• ACT with parents.
Session seven begins with the parents discussing various issues with the
treatment team: progress with learning and implementing therapeutic
parenting; emotions regarding the Life Script, coparenting, and marital issues;
evaluating the progress of their children; stress management techniques
utilized; extended kin (e.g., grandparents and other family).
Next is another important experiential procedure, “psychodramatic
reenactment (PDR).” Treatment team members role-play individuals from
the child’s life to revisit and work through prior interpersonal trauma. For
example, a child will speak to his or her “birth mother” from the vantage
point of the inner child—a time when he or she was younger. This exposure
therapy technique enhances genuine emotional involvement and facilitates
the expression of perceptions, emotions, and defenses associated with
prior trauma. Positive change occurs as the child learns alternative ways
of perceiving him- or herself and others (cognitive rescripting), managing
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Session Eight
Therapeutic goals:
• process with parents
• forgiveness ritual
• ACT—parents and children.
The session begins with the parents and treatment team discussing progress
and issues regarding parenting, the coparent and marital relationship, the
children’s behavior, family-of-origin issues, and family dynamics. Parents
role-play scenarios to practice parenting and communication skills.
Grieving and mourning loss is an essential component of the healing
process. Although sad and painful, it promotes a letting go of the past, creates
the possibility of a new future, and can lead to the beginning of forgiveness.
A “magic wand ” technique is used, in which the child can speak directly to
“birth parents,” who are role-played by treatment team members. The child
is told, “For the next ten minutes your birth parents will be healthy. They
will be open, honest, and available to address your comments, questions,
and concerns.” The child can move toward closure on birth parent issues by
expressing feelings of loss and asking questions about the parents’ lives. For
example, the “parents” may explain what happened to them in their own
childhoods that influenced them to be abusive or neglectful. The child’s
increased understanding of the parents serves several purposes. It helps
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the child understand that he or she now has the tools to break the cycle
of abuse. Unlike the parents, the child is receiving help and is now free to
make different and better choices. Second, it promotes a more empathic and
forgiving attitude. Therapeutically, forgiveness involves the release of pain
and anger associated with a traumatic event. The goal is for the child to
acknowledge the parents’ responsibility for maltreatment, but also to release
him- or herself from the burden of emotional pain.
The forgiveness ritual also serves to further enhance the parent–child
bond. The parents provide emotional support to the child during the grieving
and forgiveness discussion. Their empathy, understanding, and support
during this emotional experience increase the trust and closeness in the
parent–child relationship.
ACTs are done again with the parents and all the children in the family.
This provides another opportunity for the parents to communicate with the
“identified patient” and his or her siblings, and an opportunity for siblings
to communicate with one another. Sibling conflict is often severe in these
families, and it is necessary to discuss and resolve anger, fear, shame, abuse,
and other sibling issues. Siblings often decide to “start over” with a more
caring and healthy relationship.
Session Nine
Therapeutic goals:
• process with parents
• family meeting
• parenting practice.
Following the initial processing with the parents, there is a family meeting
to discuss a variety of behavioral, emotional, and social issues, and to develop
contracts for new ways of relating. The Autonomy Circle (see Figure 12.1)
is explained to the children, so they understand that receiving privileges,
freedom, and rewards in the future is based on them demonstrating
competencies: knowledge, skills, judgment, and self-control. A parent–child
contract is established—an agreement about the parents’ expectations and
“rules,” and an understanding of the consequences for following and violating
the agreements. The goal is a win–win: the parents are pleased that they are
creating a more positive relationship with their children, and the children
are “buying into” the contract in order to earn privileges and rewards by their
own positive behaviors and attitudes. Many additional topics are discussed in
the family meeting: school, homework, sibling relationships, chores, changes
in routines at home, extended kin, and quality family time.
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Session Ten
Therapeutic goals:
• process with parents
• review list of goals
• follow-up plan
• final ritual.
This is the final session with the parents; a time to review progress, address
concerns and follow-up issues, and reinforce positive changes. A family
meeting follows. First, the “list of goals,” created in the third session with
the child and therapists, is reviewed. The child is asked to what extent he or
she believes these goals were achieved. It is customary for children to report
significant satisfaction with the attainment of their goals. Parents and siblings
typically feel proud of their child, brother, or sister, which is reinforcing for
the child and also helps to change the child’s role in the family from “problem
child” to a healthy family member.
Follow-up issues are also discussed in the family meeting: school,
medication, follow-up therapy, contracts for new behavior, and other topics
for the future. These follow-up treatment issues become plans and goals for
follow-up therapy in the future.
The final ritual involves asking each family member, “What have these
two weeks meant to you; what are the most important things you have
learned?” Parents often share their relief because of having learnt skills and
solutions, their joy regarding improved family relationships, and their hope
for a better future. Children commonly share their increased confidence and
self-esteem, their reduced depression and increased sense of contentment,
and their feelings of trust and closeness to parents and siblings.
We end with hugs, tears, smiles, and a photo of family and therapists all
together.
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Effectiveness
Benefits and Risks
Treatment outcome research as well as anecdotal feedback indicates that
significant improvement occurs for children, adolescents, adults, couples,
and families in the following areas: symptom reduction, core beliefs (internal
working models), attachment styles, communication, problem-solving,
conflict management, parenting practices, marital and sibling relationships,
trauma-related problems, depression, anxiety, and morality.
As with any therapeutic process there is a level of emotional discomfort
when dealing with painful and anxiety-provoking issues, events, and memories.
To mitigate this emotional distress the therapists provide an environment of
support, compassion, and safety, and parents are encouraged to be empathic
and supportive with their children. Treatment is developmental, with the
initial stages focused on rapport, trust, contracting, assessment, and emotional
preparation. The timing of interventions is crucial, and based on an accurate
assessment of clients’ level of readiness and capability. When working with
traumatized children, adults, and family systems, there are some individuals
who do not achieve their goals. Rarely, however, is it reported that symptoms
increase or family relationships decline following the IOP.
Findings: Part 1
Table 11.1 Adoption Background
Adoption Background % of Studied Group
Adopted 84
Different race/ethnicity than adoptive parents 46
Adopted as part of sibling unit 45
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Findings: Part 2
An analysis was conducted of the pre- and post-Symptom Checklist scores,
measuring the child’s improvement on six symptom categories (behavior,
emotion, cognition, relationships, physical, and moral/spiritual).
Statistically significant positive changes were found on all six symptom
categories up to three years after therapy. Improvements held over time. Children
improved more when they had the following characteristics:
• fewer moves in the foster care system
• fewer pre-therapy diagnoses
• were not adopted as a sibling unit
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never got the feeling from him, or from my mother and my whole
family, that he was working that hard, which is really sad ’cause I know
he was. My grandparents were wealthy, and we were wealthy for our
small town, so we never hurt for anything; we never really had to
work for anything or earn anything. And I don’t really appreciate and
understand the value that comes behind really making something
of yourself and working hard. I know that’s what you’ve done ’cause
you started out doing this all by yourself. You didn’t have any help,
or any dad’s business to go into.
Adam and Beth are following the rules of honest sharing and empathic
listening. Consequently, they are connecting intellectually and
emotionally, as evidenced by their body language (e.g., eye contact,
holding hands, both leaning into one another).
Beth: [After Adam repeated back Beth’s message, Beth took
responsibility by offering a solution; showing her desire to appreciate
and validate her husband’s efforts.] Now that I’m not working, if I
would have a nice dinner fixed every night, I think that’s important
to you.
TML: Would that matter to you, Adam?
Adam: Yeah, it would matter to me. I thought about it but I felt silly
saying that I want a nice supper on the table when I got home.
TML: What’s silly about that?
Adam: See, we never ate at home when I was growin’ up. We never
had that. I guess I’m not used to a home-cooked meal. [Adam’s
parents owned a restaurant.]
MO: Oh, so that’s doubly important to you.
Adam lowers his head and is reluctant to accept his wife’s generous
offer, due to 1) growing up in his parent’s restaurant (“no home-cooked
meals”); and 2) lacking the self-esteem to feel he deserves his wife’s
positive gesture.
Later in the session TML makes a process comment about Beth’s
controlling behavior.
TML: You’re a bit like Kristina; you like things your way.
Beth: Yeah, I do. I’m a brat. Even in my marriage, I want things in my
way, in my time.
TML: How are you going to expect to help your daughter not be
bossy and want everything her way, at her time, if you’re gonna
model that?
Beth: Mm-hmm.
MO: Because kids do what we do, not what we say.
Beth: I know.
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Adam: I know.
The family dynamic is revealed. Beth and Kristina, both oriented toward
control, engage in arguments and power struggles. Adam, with his
history of witnessing domestic violence, responds with anxiety and
withdraws from his wife and child. Triangulation results: marital conflict,
lack of coparenting team, child has too much power.
At the end of the session, the couple is asked to evaluate their ACT
experience.
TML: What is it like to talk like this, to be open, to communicate, to
listen, to share?
Adam: I really got that this has really moved you. And I really
appreciate it. I’m so glad you’re with me. You know I’m here for you.
Adam and Beth are both tearful, and Beth reaches out for Adam’s hand.
Their emotional honesty, compassionate listening, and body language
(i.e., physically close, hands intertwined) signify “limbic resonance,” a
connection of minds, brains, emotions, and bodies.
Beth: I’m going to figure this out. I think it’s going to make our
marriage better. I don’t know why I couldn’t see it before. ’Cause
you’ve said things to me over and over again, and I just couldn’t
hear it, couldn’t see it before now. I’m gonna take this, and I’m gonna
grow from this. I’m gonna be a better partner because of this.
We conclude the ACT with the couple giving one another a hug. Adam
and Beth’s prolonged genuine and affectionate embrace reflected their
positive experience with the ACT, their enhanced trust and attachment,
and their readiness to coparent Kristina in a healthy way.
Session four began with discussing parenting issues and processing
Adam and Beth’s communication from the prior day. They both
reported the ACT was very helpful in building trust, reducing conflict,
and improving cooperative coparenting. We discussed and role-played
parenting methods in order to practice the skills of limit-setting,
communication, consequencing, and connecting, using the COPE
approach (calm, opportunity mindset, predictable, empathic).
The next task of Session four focused on Kristina and the mother–
daughter relationship. The First Year Attachment Cycle intervention
was done in the context of the LAP. The goals were: 1) activate the
brain’s limbic region via the cues of attachment (eye contact, smiles,
positive affect, nurturing touch, emotional safety, empathy); 2) explain
to Kristina in a child-friendly way her history, to foster a constructive
narrative and normalize her behavior; 3) initiate the grieving process;
4) emotional processing regarding loss of her birth mother, orphanage,
negative working model; and 5) begin building a positive connection
with her mother, including trust, safety, closeness, dependency, and
limbic resonance.
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Kristina: When I was a baby I didn’t have enough love in the hospital.
I was alone a lot without my mommy. I was sad. [Kristina cries.]
Kristina is asked to tell her story to AJ, in her eyes, for several reasons:
telling your story in the eyes of someone you trust is healing; “limbic
resonance” is achieved as Kristina shares her early experience in Russia,
and AJ listens with a look of understanding and empathy; Kristina is
learning the skill of verbalizing emotions rather than acting out; she
acknowledges the sadness and loss which was previously repressed
and denied. The therapist (AJ) provides gentle and nurturing touch,
caring facial expression, and soothing voice—the cues of attachment,
stimulating Kristina’s limbic brain, which is prewired for attachment.
Kristina starts to cry, her first expression of loss and grief with
anyone. She is becoming emotionally available to grieve her loss with
caring others. She also talks about feeling scared as a baby, lowering
her defenses to allow more vulnerable emotions to surface (i.e., pain
and fear).
TML: Are you ready to tell Mommy the story about what happened
to you when you were a baby in Russia?
Kristina: I don’t want to tell her. [Shakes her head.] No.
TML: Would you do it anyway? Just because we’re asking you to do
it?
Kristina: Yeah, OK.
TML: Oh, thank you.
AJ: Thank you, sweetheart. [Gives Kristina a hug.]
At this point, we determined that Kristina was ready to communicate
with her mother in order to facilitate secure attachment. We had checked
with Mom as she observed the session on a TV in another room, and
observed her appropriate affect (i.e., crying) and emotional availability.
Kristina first refused to bring Mom in, but then said “yes,” a result of her
feeling safe and trusting with the therapists.
The next task is for Kristina to call for her mother: “Mom, I need you;
please come in.” This is a corrective emotional experience. When Kristina
needed her birth mother in the early stages, she was not there. This
time, her adoptive mother will respond to her needs in a sensitive and
timely way. Limbic wiring changes via emotional experiences. Initially,
Kristina does not want to call for Mom, but then decides to take a risk.
TML: So, call Mommy. Say, “Hey Mom … come on in; I need you.” Can
you do that?
Kristina: I don’t want to.
AJ: Could you call for Mom?
Kristina: [Whispers] Mommy.
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Mom: Let me wipe your tears. There we go. There, let me get them.
There we go. [Kristina allows herself to be vulnerable and accept
comfort.]
TML: What you need to do honey is you need to cuddle up with your
mom. No talking.
This is the “window of attachment,” the moment when Kristina allows
comfort, support, and connection when she is distressed. This begins
to change the internal working model from negative (“I can’t trust”) to
positive (“I can trust and feel safe”), initiates the rewiring of the limbic
brain through positive interpersonal experience, and allows Kristina to
grieve her losses in the context of a secure mother–child relationship.
Mom’s maternal instincts are displayed (e.g., gentle stroking of hair,
rocking) as her limbic brain is also activated. Kristina allows Mom to
wipe her tears, reflecting her openness to Mom’s caregiving.
The therapist (TML) instructs Mom and Kristina to “cuddle up; no
talking.” The goal is to maintain the limbic connection via emotion,
touch, and nonverbal communication, rather than go to the cerebral
cortex, which is intellectual and cognitive.
TML: It’s so good that you’re letting your sad feelings out with the
mommy who loves you. That’s a good thing, honey. Yeah, you hold
onto that momma. [Kristina holds on tight to Mom as she releases
sadness.]
All the cues of attachment are evident in the mother–child relationship:
eye contact, smiles, loving touch, safe and secure connection in the “in
arms” position. This facilitates secure attachment.
TML: Can you look at your mommy and ask her, “Mommy, will you
ever leave me?”
Kristina: Mom, will you ever leave me?
Mom: [Looks into Kristina’s eyes] No.
Kristina: [Appears relieved and hugs Mom tight.]
Mom: No. No, no, no. Never, ever, ever.
Kristina’s deepest fear is abandonment; her core belief is that mothers
leave. As Kristina looks into Mom’s eyes at this moment of genuine
connection, she receives reassurances that Mom will not abandon her—
part of the process of changing her fear-based expectation.
TML: [Explains to Mom] The most important thing about attachment
is when a child is scared, lonely, or needy, without words, and the
child feels the love and comfort of the mommy or daddy. That’s
when it happens. This is when it’s going to happen, so we want to
take advantage of moments like this.
Kristina: I love you so much. [First time Kristina said I love you to
Mom.]
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TML: So, can you look in my eyes and say, “I have anxiety about
addressing these issues”?
Adam: [Looks into TML’s eyes and says] I do; it’s scary to deal with
those issues. [Adam shares his fear and anxiety in the eyes of the
therapist, which is an experience of emotional honesty and positive
connection.]
TML: Thank you. When we have fear there are two options—let it
stop us or proceed anyway. What do you want to do?
Adam: Yeah, I want to do this.
This is a therapeutic contract. Adam expresses his apprehension and
his desire to push ahead and work on his issues. TML agrees to support
Adam through the process. The cues of attachment are present:
eye contact, supportive touch, safety, empathy, emotional honesty,
understanding (limbic resonance).
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Traumatized children often become adults who are not able to self-
soothe or display self-care. This intervention provides an opportunity
for adult Adam to nurture and support little Adam, the beginning of
cognitive rescripting—changing from a negative to a positive internal
working model (core belief). Valuing and loving his “inner child” is a
vehicle for positive change in self-concept and neural rewiring, and is a
valuable coping strategy to reduce anxiety.
TML: You know, little children take these things very personally. An
adult can say “It wasn’t my fault, it was them.” A little kid can’t say
that. So, how is he feeling about himself?
Adam: Yeah, you weren’t feelin’ too good about yourself. You thought
it was your fault. [Adam confirms that he viewed himself negatively
as a child.] It must be my fault, I’m a bad kid.
TML: Was it?
Adam: No.
TML: Alright then. Tell him the truth.
Adam: This was not your fault. They did this to you. You didn’t do
it to them. [Adam looks into the eyes of little Adam and strokes his
head lovingly] It must have been your fault, that’s what you thought.
TML: How did that affect his self-confidence and self-esteem,
thinking it was his fault?
Adam: You suffered from that. You were afraid, and you didn’t feel
good about yourself. They robbed you of that childhood, that sweet
childhood that you should have had.
Adam appears sad as he processes his early emotional pain. He begins
to realize that he has been blaming himself, resulting in self-contempt
and depression. He is beginning to change his narrative.
TML: By the way, can you understand how Kristina triggers you?
What have you realized about that?
Adam: I feel sorry for her, just like I feel sorry for myself as a little
child. Then I don’t do what I need to do as a parent. I don’t set limits.
Adam realizes that his childhood issues are affecting his parenting of
his daughter. As he resolves the early pain and self-blame, he will be
able to be a better parent (e.g., firm but loving) and husband (e.g., stop
avoiding conflict).
PSYCHODRAMATIC REENACTMENT
The next intervention is psychodramatic reenactment. A female therapist
(AJ) role-plays Adam’s mother (she has a cigarette, because the mother
smoked). The task is for Adam to give a voice to little Adam as he talks
with his mother.
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TML: What’s that like for a little kid to think it’s his fault, he put his
mother in the hospital? [Adam was told by his mother that it was
his fault that she had to be hospitalized for a “nervous breakdown.”]
Adam: I just feel terrible about that. I want you to be with me, Momma.
“Mother”: I’m too busy [pretending to smoke]. Go sit in the booth.
[Adam spent many hours sitting in the booth in the family restaurant.]
Adam: I was sitting in the booth, waiting for you to come home. Other
times I was home by myself a lot of the time. And I’d be standing
out on the road waiting for the car to come home. [He begins to cry,
feeling the loneliness, fear, and pain of his childhood.] I’d be scared
somebody was after me.
TML: What a sad picture that is, standing on the road waiting. She
broke your heart, that’s your pain.
Adam: [Looks at Mother and says] You broke my heart; I needed you
and you weren’t there.
There are several therapeutic components to psychodramatic
reenactment. It is healing to speak the truth, eye to eye, face to face.
The limbic brain is rewired by the “corrective emotional experience,”
expressing the emotions of the “inner child” in a supportive, empathic
milieu.
TML: Is it true, by the way? Did you put her in the hospital? Did you
make her crazy or depressed, or cause her nervous breakdown? Did
you do that? Was that your fault?
Adam: [Looks at Mother and says with anger] I’m not buying it
anymore. It’s not my fault. I’m not going on a guilt trip anymore. It
was your fault.
Next, MO enters the room in the role of “Father,” and initiates a heated
argument with “Mother,” to simulate the domestic violence Adam
experienced as a child.
TML: What is little Adam feeling?
Adam: I feel scared. [Adam starts crying and sweating, clutching
the teddy bear in his arms. He is re-experiencing fear and panic, and
begins to dissociate.]
TML: Open your eyes and look at me. Tell me what you’re feeling.
[The therapist uses a calm voice, supportive touch, and empathic
listening to convey safety and understanding.]
Adam: I’m so afraid. [Adam looks into the therapist’s eyes, and is
comforted by the support and compassion.]
TML: Must have been so terrifying for you.
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FORGIVENESS RITUAL
We pretend that “Mother” and “Father” are healthy and Adam can talk
with them for forgiveness and closure.
Adam: [To “Mother”] I forgive you. I know you had your own problems.
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TML: Can you tell your Mom how life will be different for you now
that you released all this?
Adam: I’m no longer a victim of my past. I’ve let go of my fear and
anger. I can move on.
MO: [Role-plays “Father” and says to Adam] I’m sorry for what I did
to you. I didn’t know any better.
Adam: I’m no longer angry with you. I’m doing good, aren’t I, Dad?
MO: You sure are. I’m really proud of you.
Follow-Up
An analysis of post-treatment symptom checklists indicated a significant
reduction of Kristina’s symptoms in all six categories. The parents wrote,
“Her behavior at school and home is so much better and we are really
enjoying our family life together.” The father (Adam) reported a significant
reduction in his depression, and was able to discontinue antidepressant
medication. Adam and Beth reported continued improvement in their
marital relationship, regarding trust, intimacy, communication, support,
and conflict management. They also reported improvement in their
coparenting relationship, and wrote, “We are now on the same page
when parenting our daughter.”
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Parenting
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goals (“I know I can do this”), and have the ability to move consistently
toward these goals (“I have the skills”). This leads to success, and hope is a by-
product of success. Confident parents are more likely to succeed with their
children, and children feel more hopeful when their parents are confident
and optimistic.
The importance of a positive expectation of success is found in the
placebo effect. A placebo is a harmless substance (sugar pill) given as if it were
medicine. Research has shown many people have positive reactions because
they believe they will get better—they have a positive expectation of success.
In other words, if we believe in something enough, we can make it happen.
Therapeutic parents realize that their relationship with their child is
the primary vehicle for creating positive change. Through thoughtful
and corrective actions, reactions, and a safe and constructive emotional
environment, parents can foster positive behaviors, character traits, mindsets,
and brain growth. Parents help shape the growth of their child’s brain by
helpful and healing experiences. Brain cells (neurons) “fire” during social and
emotional experiences, and neurons firing together facilitate the growth of
new connections, causing a “rewiring” in the brain.
By employing the concepts and skills of CAP, children can develop the
following skills and abilities, which are essential for success in life:
• experience secure attachments with parents/caregivers; give and receive
affection and love; feel empathy and compassion; and have a desire to
belong
• view oneself, others, and the world in a realistic and positive way; have
positive core beliefs, mindset, and self-esteem
• identify, manage, and communicate emotions in a constructive manner;
exercise anger management, stress management, and self-control
• make healthy choices; solve problems and deal with adversity effectively
• utilize an inner moral compass, prosocial values, morality, conscience,
and a sense of purpose
• be self-motivated; set and persevere toward goals, and achieve a sense
of mastery, competence, and self-confidence
• maintain healthy relationships; be able to share, cooperate, resolve
conflicts, communicate effectively, and be tolerant of others
• experience joy, playfulness, creativity, and a sense of hope and optimism.
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Neuroscience of Parenting
Researchers have used functional MRI scans to investigate which regions
of the brain are activated during parenting—how our brains are wired for
rearing children, and how parenting can shape our brains. They found that
humans’ neural circuitry is primed to respond to babies in ways that are key
to the infant’s development. Mothers’ brains actually grow in size in the early
months of parenting. The brain regions associated with motivation, reward,
emotional processing, and reasoning and judgment (hypothalamus, amygdala,
and prefrontal cortex), increase in size in the first three months. Looking at
an infant’s face activates the inferior frontal gyrus, an area associated with
empathy and emotion. Seeing a baby’s face also prompts increased activity in
the supplementary motor area, the part of the brain involved with talking to
and moving toward the baby. By the time their babies are 3 months of age,
mothers’ brains are attuned to their faces, and infants’ brains are attuned to
their mothers’ faces (Winerman 2013).
There is considerable evidence regarding the effects of stress and trauma
on the developing brains of children. It is also important to understand how
stress affects parents’ brains, and how changes in neurobiology influence
parenting behavior. When parents and children are attuned, emotionally
close, and securely attached, the neurotransmitters oxytocin and dopamine
are released in the parents’ limbic brain region, activating the pleasure and
reward systems in the left hemisphere. The parent experiences calm, loving,
and gratifying feelings, and can rely on the higher brain centers for emotional
regulation, empathy, and self-awareness. This is the neurobiological state
that brings about limbic resonance and positive parent–child relationships
(Baylin and Hughes 2012).
Parents of traumatized children commonly experience severe stress and
conflict, due to habitual rejection, defiance, anger, and controlling behavior
from their children. Parents also have stress reactions when children trigger
unresolved emotional issues from the parents’ past. The parents’ brain systems
go into survival and stress response mode—“fight, flight, freeze.” They
become rooted in the primitive brain regions which activate defensive and
self-protective reactions, and deactivate the balanced and mature responses
of the cerebral cortex. Oxytocin and dopamine, the “feel-good” biochemicals,
are blocked. Cortisol and epinephrine, the anxiety-producing chemicals,
are released. The result is a deficiency in warm and caring feelings toward
the child, an increase in fearful and avoidant responses, and an inability to
problem-solve in a composed and creative manner.
Parents must learn to identify and tone down their neurobiological stress
responses. It is helpful for parents to learn how to remain calm by modifying
negative self-talk, being aware of their emotional triggers, not personalizing
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others who work with children. For instance, children labeled as biochemically
imbalanced are given medicine to change their behavior. Parents who see their
child as emotionally and socially delayed often become “helicopter parents”—
hovering over the child, rescuing, and overprotecting—thereby reinforcing
the very incompetency they worry about. Understanding a child’s behavior
as symptoms of interpersonal trauma changes the lens. Therapeutic parents
endeavor to connect with their children, and avoid becoming triggered into
destructive reactions and interactions.
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Opportunity Mindset
In order to create a healing environment parents must be aware of their
mindsets. Healing parents don’t just do things differently—they see things
differently. Do you view stressful and challenging situations as crises to be
dreaded or as opportunities for teaching, learning, and growth? One’s frame
of reference will determine how you respond.
The opportunity for learning and growth is available for parents, not just
for children. When a parent is triggered into a strong emotional reaction,
he or she can ask: “What can I learn about myself; what can I change?”
Parents often report in therapy that their children provide rich opportunities
for personal and marital growth.
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Connection
Connecting with children involves empathy, support, nurturance, structure,
and love. The ability to form and maintain positive connections is essential
for healthy childhood development. Parents who successfully connect with
their children are emotionally available, actively involved in their lives, and
model respect and compassion. Children are most influenced by those with
whom they feel the deepest respect and strongest connections.
Calm
To be calm is synonymous with being levelheaded, peaceful, patient, and
composed. The only effective way to positively influence children is to gain
their trust, and a calm and consistent approach works best. Although it is
important to be calm and centered with all children, it is critical to remain
emotionally balanced with children who have compromised attachment.
These children did not receive adequate emotional regulation from caregivers,
and did not develop the ability to regulate their emotions and impulses.
Parents must teach them to be calm by providing an example of calmness,
which reduces the “alarm reaction” (fight, flight, freeze), and allows them to
feel safe and secure enough to think rationally and learn.
Commitment
A parent cannot create secure attachment without a commitment.
Commitment is a promise and a pledge to be available to a child through
thick and thin; a moral obligation to take certain actions and respond in
certain ways, which leads to safety, security, and trust. Parents must commit
to the following: keeping their child safe; truly knowing their child; providing
appropriate structure; having compassion for their child; being a positive
role model; and supporting their child’s growth and development. Healing
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parents make a commitment not only to their child, but also to their own
emotional, social, and spiritual health. Helping challenging children requires
that parents are “on top of their game.”
Consistency
All children need consistent nurturance and stability, as a supportive
framework to guide, organize, and regulate their behavior. Children who
have endured adverse conditions—lack of protective, loving, and secure
attachments—need even more. Failing to receive the requisite nurturance
and structure in the early stages of development has left these children
emotionally, behaviorally, and biochemically disorganized. These children
desperately need consistent routines, guidelines, and love. Consistent and
appropriate structure—rules, limits, and consequences—enables children to
depend on a reliable caregiver, whom they begin to respect and then trust.
Providing structure engenders feelings of safety and security in children, anchoring
them for the rest of their lives. It is important for consistency to occur among
all the adults in the child’s life. Teachers, counselors, daycare providers, child
welfare workers, and family members must all be on the same page. Children
will be more likely to learn and improve when everyone provides consistent
messages.
Communication
Communication is at the heart of attachment. To communicate is to connect.
There is no greater gift to children than to be attuned; they see it in their
parents’ eyes, and hear it in their tone of voice. Parental sensitivity to the child’s
signals is the essence of secure attachment. Communication begins in the womb,
via a neurohormonal dialogue between mother and unborn baby. From
the moment of birth, babies communicate with their caregivers verbally
and nonverbally through facial expressions, gestures, crying, cooing—the
language of infancy.
Effective communication is the foundation of all relationships.
Communicating for attachment creates the conditions in which a child is
more likely to confide and connect. Realizing that so much of communication
is nonverbal (eye contact, facial expressions, tone of voice, body language,
touch), a parent’s style of delivery is often more important than the words.
Messages register in the emotional region of the child’s brain (limbic system),
and affect learning, trust, stress response, memory, and development.
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Confidence
Confidence is the ability to rely on yourself with assuredness and certainty.
Confident parents have trust in what they are doing to help their children.
Children feel safe with confident parents, who they see as capable and
dependable. Parents need information, skills, support, self-awareness, and
hope to develop confidence. When parents understand their children they
are more likely to help them. Learning the skills of CAP leads to success,
and success builds confidence. Having support provides the care and
encouragement so crucial during difficult times. Self-awareness prevents
parents from responding in negative ways. Knowing children do change
under the correct conditions creates optimism and hope.
Cooperation
Children with compromised attachments become self-absorbed, believing
their survival depends upon “looking out for number one.” Children need
opportunities to learn about the give and take of relationships, including
cooperation, empathy, and reciprocity. Parents who are resonant in their
attitude and delivery are more likely to have children who are motivated to
cooperate. Resonant parents are attuned to the feelings, needs, and mindsets
of their children. Parents who are dissonant are out of sync with their
children, and their children are not motivated to cooperate. Parents must
model cooperative attitudes and behaviors with children, spouse, extended
kin, friends, and others. Children learn by watching what we do, not what
we say.
Creativity
An important rule when dealing with wounded children is: if something
doesn’t work, do different, not more of the same. When children experience
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interpersonal trauma their limbic brains are primed for a fight and they
remain in a state of high stress and arousal. The part of the brain responsible
for controlling rational thinking, problem-solving, and creativity does not
function normally. Creativity is the “language of childhood.” These children
are focused on survival at the expense of flexibility and imagination.
An important aspect of creativity is humor. Laughter is the best medicine.
It reduces stress, creates positive connections, and gives a new perspective on
one’s situation. Laughing with, not at, a child increases emotional bonding
and interrupts negative patterns of relating.
Coaching
A coach is a mentor who guides, teaches, supports, motivates, and inspires
positive values and characteristics in children. Healing parents are role models
and coaches and set an example of who to be and how to behave. Children
learn more from modeling than by any other way. A good coach not only
imparts knowledge, but also facilitates the attainment of wisdom. Wisdom
is knowledge applied: figuring out a problem for yourself by using critical
thinking and problem-solving skills. Coaches teach life skills, including self-
awareness, self-control, conflict resolution, communication, and cooperation.
Coaches encourage the development of positive traits such as tolerance,
enthusiasm, industriousness, integrity, loyalty, and perseverance.
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Consequences
A consequence is the result or direct effect of an action. The goal for giving
consequences is to teach a lesson that leads to positive choices. It encourages
self-examination, accepting responsibility for one’s actions, the ability to
learn from mistakes, and the development of an inner voice of self-control.
The definition of punishment is to cause to suffer. The goal is to inflict hurt,
pain, and get even. Punishment causes resentment, rarely teaches a child a
lesson, and does not facilitate secure attachment. One primary job of a parent
is to prepare children for life, and the real world operates on the principle
of natural consequences. Children who forget their coats are cold, and who
don’t study fail a test. Parents must allow their children to learn from the
consequences of their choices and actions.
Clear Expectations
Expect children to be four Rs: 1) Responsible: hold children accountable
for their choices and actions, and also allow them to be responsible family
members by having a role and contributing; 2) Respectful: children must first
respect parents in order to trust, and trust is essential for attachment. Parents
should model respect, act respectfully toward children, and talk with their
children about disrespectful attitudes and behaviors; 3) Resourceful: using
skills and abilities to accomplish a goal rather than acting incompetently.
Give children a “can do” message; failure is only a stepping-stone to success;
and 4) Reciprocal: the give and take of healthy relationships. Everyone in the
family “pulls their weight,” with a balance of giving and getting. Encourage
sharing, cooperation, and empathy for others’ feelings and needs.
Competency-Based Parenting
How do you know how much structure or freedom to give a child? The answer
is found by using the ideas of competency-based parenting: children need
to be contained within the limits of their capabilities. The amount of structure
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Adulthood
Teen Society’s
Rules and
Preteen Structure
Child
Infant
Units of Concern
Children are only motivated to solve a problem when they “own” the problem.
Without a sense of ownership there is little concern, accountability, or
motivation. Instead, there is avoidance, denial, and blame. Parents who take
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on too many units of concern for their child’s problems are unintentionally
teaching him or her to be irresponsible and helpless. Let’s assume that for
any problem in life there are ten units of concern, ten slices of pie. There is a
direct correlation between the number of units a parent has and how many
the child accepts. When a parent takes on too many units of concern, the
child will take on too few, robbing him or her of valuable experiences that
can lead to the learning of life skills, maturity, and wisdom. It is important
to determine “whose problem is whose.” If it is the child’s problem (e.g.,
doesn’t do homework), show empathy but expect him or her to work it out.
It is the parent’s problem if it impacts the parent directly (e.g., stealing from
parent), and then the parent takes action. Parents who take on too much
responsibility for solving a child’s problem, or rescue a child, only reinforce
the child’s sense of inadequacy.
Chores
In today’s world, children are not needed to preserve the family. They have a
significantly lower level of maturity and sense of responsibility compared to
earlier generations. Children now spend much of their time uninvolved in
the family. They are involved in sports, lessons, the Internet, video games, TV,
and social media. They have become “me” directed rather than “us” directed.
Doing chores is a way for children to increase self-confidence, internalize
values, and become cooperative family members. Parents who do not have
their children doing chores are missing an opportunity for character building.
Chores build responsibility, strengthen moral development, and enhance
self-esteem. Give children chores when they are young to learn good habits,
make chores age-appropriate, and show them how to do the chore initially.
Do not pay for chores; chores are done to be part of the family. Post a list
of chores and show appreciation; praise reinforces behavior and strengthens
attachment.
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Calm
It is difficult to stay calm when feeling threatened, angry, or frustrated.
However, this is the most important time to do so, especially when dealing
with wounded children. Losing one’s temper and overreacting only leads to
saying or doing something nonconstructive. There are three steps to staying
calm:
• Stop: Don’t act impulsively. Take a deep breath. Relax your body. Calm
your mind.
• Be aware: Be aware of self-talk. Positive self-talk is calming (e.g., “I
can be a good role model”); negative self-talk is emotionally agitating
(e.g., “My child will never learn”). Be aware of body signals. Physical
reactions such as racing heartbeat and clenched jaws are signs that a
parent needs to calm down.
• Act: After calming down, the parent can think logically, use constructive
problem-solving, and communicate in a clear, honest, and helpful way.
Parents can help their child to calm down (“down-regulating”). When
children feel threatened, their brain’s limbic system triggers the “fight, flight,
freeze” response. Parental calmness switches the child’s brain out of survival/
fear mode into emotional safety and reasonable thinking, reducing the flow
of stress hormones throughout the child’s brain and body. Parents can down-
regulate children’s agitation and stress response by:
• Responding therapeutically: Do not escalate with the child (e.g., child
is angry and parent becomes angry). Do not give in to the child’s
demands or threats to avoid conflict. Rather, communicate calmness
in tone of voice, facial expressions, and body language, and “stay the
course.”
• Using one-liners: These are brief responses that prevent a parent
from being “hooked” into an argument and negative interaction: “I
understand how you feel”; “Thank you for sharing”; “What do you
think I think?”
Proactive
Parents create the emotional climate in the family when they are proactive,
and children create the emotional climate when parents are reactive. Parents
remain proactive when they have skills, goals, and persevere consistently
toward achieving their goals. Anger management skills are particularly
important in order to be proactive (see pages 206–208). The following are
examples of a parent being reactive and proactive:
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• Reactive parent: Every time 10-year-old Kyle plays Monopoly with the
family, he tries to control the game and throws a temper tantrum if he
doesn’t win. Dad gets upset, yells at Kyle, sends him to his room, and
the game is ruined for everyone.
• Proactive parent: Before the game begins, Dad tells Kyle, “I notice you
get very upset when we play this game, so at the first sign of losing
your temper, you will be given a time out to think about your choices
and calm down.” Kyle knows what to expect and the consequences of
his actions. If he loses his temper and receives a consequence, it can
be a learning experience. Over time, he will learn new and better ways
to cope with his frustration, while building a healthy bond with his
father. By being proactive, Dad is prepared, and the game is not ruined
for everyone.
Secure Base
Fear and discomfort activate attachment needs in young children. When
frightened, lonely, and feeling stress, children rely on their caregivers for
protection and need-fulfillment. When a child’s fear and stress are reduced
by a dependable caregiver, he or she associates closeness with safety and
security. This is the essence of secure attachment. When young children have
no emotionally available caregiver to depend on, they must face anxiety and
stress alone. With little or no support, the child is overwhelmed with stress,
associates closeness with pain and fear, and concludes he or she is better off
alone. This is the essence of anxious–avoidant attachment.
The elements necessary for a caregiver to provide a secure base are:
• emotional availability: accessible, dependable, self-aware (does not
personalize, knows own triggers), mature, good role model
• sensitivity: attuned to child’s feelings, needs, anxieties, and defenses;
empathic, nurturing, patient, and loving
• responsiveness: responds appropriately to behavior and needs; firm and
loving; does not ignore negative behaviors; proactive, not reactive;
promotes safety not fear; provides consistent, predictable, and
developmentally appropriate structure and support
• helpfulness: mindset of opportunity rather than crisis; helps child
learn coping skills, such as anger management, communication, and
problem-solving; understands the role and attitude of a healing parent.
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Communication
Communication is the key to secure attachment. Sharing and understanding
emotional information enables us to feel deeply connected. Communication
begins even before birth. Pregnancy is the dawn of attachment, the time
in which parents and unborn baby begin to communicate and attach. A
mother’s thoughts, feelings, and stress are communicated via a neurohormonal
dialogue, and are preparation for communication after birth.
Reciprocal and collaborative communication is the basis of attachment
after birth. The caregiver’s sensitivity to the needs and signals of his or her baby is
the essence of creating secure attachment. Infants communicate their needs and
feelings by crying and body language. The way the primary attachment figure
responds determines the type of attachment pattern established (secure,
avoidant, anxious, or disorganized).
A parent’s style of communication often determines the quality of the
relationship. Effective and secure communication includes:
• Connect with eye contact: This is the key to gaining your child’s attention,
giving and receiving clear messages, and creating an emotional
connection.
• Be aware of nonverbal messages: Body language, facial expressions, and
tone of voice send powerful messages. Gently touch a child’s arm or
shoulder; have a firm, yet empathic, tone and look. Get down to the
child’s level, eye to eye, rather than being in an intimidating position,
such as standing over him or her. The goal is to teach and connect, not
intimidate or control.
• Set the stage: Take the time to find a quiet space where the focus is on
the child. Be in the right mood so that the child is more likely to be
receptive.
• Focus on the behavior, not the child: Convey the message, “I dislike your
choice and behavior, not you.” The goal is for the child to learn from
the experience rather than feel criticized, rejected, or ashamed.
• Work as a team: It is important that parents talk about behavior and
consequences so they are on the same page.
• Don’t lecture: Listen more, talk less, and children are more likely to
trust and open up.
• Control anger: Children learn more when adults are firm, yet calm.
Yelling, criticizing, and lecturing do not provide a positive role model
of coping and communication, and create anxiety in children.
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Sense of Belonging
A sense of belonging to family and community is essential for healthy
emotional and social development. Children are social beings. Beginning in
infancy, they have a strong need to fit in and find their place in the group.
Securely attached children have a deep sense of belonging; they feel connected
to parents, extended family, friends, community, and culture. The experience
of being a part of a clan, with regular customs and traditions, gives children a
feeling of security, a sense of identity, and teaches loyalty and altruism.
When attempts to belong are met with rejection, betrayal, and shame,
children do not develop a sense of belonging or identification with family,
community, and culture. Children develop several strategies to deal with
the lack of belonging. The first is self-protection; they isolate and alienate
themselves from the group, denying their need to belong. The second
strategy is to desperately try and fit in by getting attention any way possible.
They become superficially charming and engaging, chatter incessantly, have
tantrums, whine—all attention-getting behaviors to let you know “I am here
trying to belong.”
Family routines and rituals increase children’s sense of belonging. Family
routines, such as eating dinner, getting dressed, or preparing for bed, are
“patterned interactions that occur with predictable regularity in the course
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Praise
Praise is one of the most basic methods parents use to encourage good
behavior and positive self-esteem. However, children will only accept positive
comments if consistent with their self-image. Unconditional praise and
approval backfire with children who have negative core beliefs, because they
contradict their self-perceptions, and two reactions may occur: the parent
loses credibility (“You are stupid; you don’t know the real me”); the child’s
acting out increases (“I’ll show you how wrong you are”). When praising a
child with low self-esteem, consider the following: 1) be specific, giving the
child praise for specific actions; 2) be genuine, never praising a child if not
authentic; and 3) be positive, noticing and validating something positive—
“catch a child doing something right.”
Play
Play is crucial to children’s cognitive, physical, social, and emotional
development. Through play, children learn communication, creativity,
problem-solving, morality, and social skills, essential to success in family,
school, and life. Play is a primary way for children and caregivers to connect.
Through play, parents learn about their child’s special needs and talents,
convey love and support, and build a positive and enjoyable relationship.
Children with backgrounds of maltreatment and disrupted attachment have
had little experience with play and have not had caregivers who engaged
with them in playful ways. These children need to be taught how to play.
Teaching children how to play will take time, but with patience, support, and
perseverance, they will eventually learn to play by the rules, cooperate, and
even have fun.
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°° anniversaries can trigger fear and acting out (e.g., day removed from
home)
• hyperarousal
Parenting Tips
Resilience means “bouncing back” from adversity. The primary factor in
resilience is having supportive and caring relationships that include trust, love,
good role models, encouragement, and reassurance. Nurturing relationships
between therapeutic parents and children have the power to heal trauma.
Therapeutic parents offer a sense of safety. Traumatized children do not
believe the world is safe or that adults will protect them. Promoting a sense
of safety reduces their alarm reactions and changes those negative beliefs.
Exposure to trauma makes children feel out of control. They crave structure
and a stable environment. All children need calm and caring caregivers, but
especially traumatized children. Remaining calm when they are agitated and
teaching calming techniques reduce the anxiety and emotional arousal that
affects their mood, sleep, and concentration.
Children need to learn that adults can be dependable, caring, patient,
and loving to counteract the negative messages they received in the past.
Therapeutic parents become their secure base by being emotionally available,
sensitive, responsive, and helpful. To do so means you have to be able to
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manage your own feelings and stress. The following tips for therapeutic parents
facilitate healing:
• Talk with your child: Communication builds trust and is a constructive
coping skill; find times they are likely to talk; start the conversation—
let them know you are interested.
• Listen: Listen to their thoughts, feelings, and point of view with
empathy—don’t interrupt, judge, or criticize; this opens the door to a
healing relationship.
• Accept feelings: Anxiety, irritability, anger, and depression are normal
reactions to loss and trauma and will subside over time in a safe
environment.
• Be patient and supportive: It takes time to come to terms with trauma
and grieve losses; each child’s path to recovery is unique; offer comfort
and reassurance and be available when they are ready.
• Encourage healthy expression: Children act out distress negatively
without constructive outlets; foster the use of talking, art, play, music,
sports, journaling, and other healthy methods.
• Maintain consistency: Structure and routines enhance security and
stability; provide appropriate rules, expectations, boundaries, and
consequences.
• Promote a sense of control: Children feel helpless and powerless in
response to trauma; help them believe they can successfully deal
with challenges via constructive activities (e.g., hobbies, sports, clubs,
volunteering).
• Make home a safe place: Your home should be a “safe haven,” a place
of comfort, security, and peace; stress and chaos provoke traumatic
reactions; minimize conflict and discipline with calmness and love.
• Foster new beliefs: Children were often taught not to talk, trust, and
feel by hurtful adults; offer “listening time” and “meeting time” to give
children a chance to share feelings, problem-solve, bond, and establish
trust.
• Be honest: Children make up their own stories if adults don’t help them
understand the truth; honesty is essential, but keep in mind their age
and emotional ability; avoid details that could re-traumatize them.
• Help with trauma stories: Children are asking for help when they tell
their stories; listen, be supportive, help them “make sense” of what
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happened, send the message it was not their fault, and help them
understand their feelings.
• Advocate for ongoing connections: It takes time to build trust; children
should remain with the same caregivers over time (e.g., foster parents,
child care workers); the “looping” model in schools keeps young
children with the same teacher for two years.
• Don’t take it personally: Children can “push your buttons”; you are less
likely to be angry or anxious if you know your triggers—then you can
remain calm and respond therapeutically.
• Focus on the positive: Notice and praise positive behavior; “catch your
child doing something right”; have fun, laugh—humor reduces tension
and creates connection; playing is a great way to bond.
• Limit media: TV, movies, and video games may be frightening and
over stimulating; monitor and supervise based on your child’s needs
and reactions.
• Be aware of body language: Your tone of voice, facial expressions, and
body language communicate more than your words; show via nonverbal
messages that you are safe, understanding, and dependable.
• Maintain perspective: You can’t change the fact that tragic events
happened, but you can change how you interpret and respond to those
events; help children accept what can’t be changed and focus on things
that can be changed.
• Have an “opportunity mindset”: People often grow following tragedy and
hardship—better relationships, self-worth, inner strength, spirituality,
and appreciation for life; help children use their experiences to learn
and grow.
• Inspire a sense of belonging: Being a part of a family and community
enhances children’s security, identity and loyalty; traditions and rituals
increase their sense of belonging (e.g., celebrate birthdays, holidays,
cultural customs and practices).
• Volunteer as a family: Charitable actions turn pain into something
positive, create a sense of purpose and control (“I can make a
difference”), and lead to reclaiming hope; assisting others also benefits
the helper.
• Avoid labels: Labeling a child can have negative consequences; the
child labeled as “difficult” can develop a reputation that follows him
or her everywhere; when children see themselves as bad they act bad.
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• Take care of yourself: Stay healthy so that you can take care of your
children; be a good role model of self-care and stress management—
eat well; exercise; get plenty of rest and support; avoid alcohol and
drugs; do yoga, meditation, and spiritual practices; surround yourself
with love.
Medication
Many mental health professional are concerned about the rapid rise in the use
of psychotropic medications by adults and children. The use of psychotropic
drugs by adults (e.g., antidepressants, antipsychotics) increased 25 percent
from 2001 to 2010; one in five adults now takes at least one psychotropic
drug, and one in ten takes antidepressants (Smith 2012). One in five
American youth experiences mental health problems each year, and many of
these children are treated with medication alone. ADHD is the most widely
diagnosed mental health disorder in children: 11 percent of school children
and 20 percent of high school boys have been diagnosed with ADHD. Up
to two-thirds are given stimulant medication such as Ritalin and Adderall
(Morris et al. 2013). Alarmingly, there is virtually no information regarding
long-term effects of these drugs on child development and the developing
brain.
Many children and adults in the United States are prescribed
psychotropic medications by their primary care physicians. In fact, four out
of five prescriptions are written by physicians who are not mental health
professionals (Smith 2012). This is problematic, because primary care
physicians have limited training in treating mental health disorders, and
often their patients are not made aware of psychological treatments that
might work better, without the risk of side effects. Especially for children, it
is always best to consider psychological and behavioral treatments with the
child and family before giving medication. The primary care physicians and
mental health professionals should always work collaboratively to determine
the best treatment plan and the appropriate use of medication.
There are many unanswered questions about medicating children and
teens. The majority of medications, with the exception of those for ADHD,
have been tested and approved by the U.S. Food and Drug Administration
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(FDA) for adults only, and are being used “off label” for children. This practice
is legal but risky for a number of reasons. The brain chemistry of children
is different from that of adults. The brain’s frontal lobes, vital to “executive
functions” like managing feelings and mature decision making, do not fully
mature until about age 25. Children metabolize medications differently
than adults. Many experts are concerned about what these drugs are doing
to still-developing brains. How does medication affect a child’s ability to
learn emotional and social skills? Do antianxiety drugs prevent a child from
learning to manage stress and anxiety without medication? Side effects can
also be alarming and dangerous, including weight gain, high blood pressure,
jitteriness, and flat emotions.
On October 15, 2004, the FDA issued a “black box” warning, its strongest
safety alert, linking antidepressants to increased suicidal thoughts and
behavior in children and teens. One theory regarding the suicidal tendencies
is antidepressants lift fatigue and passivity, resulting in a more energized
but still very depressed person (DeAngelis 2004). The response in England
has been even stronger. NHS England does not recommend the use of
antidepressants for children. The National Institute for Clinical Excellence
recommends doctors encourage children to improve diet, get more exercise,
and provide therapy focusing on the family, school, and social network. In
cases of severe depression when antidepressants are absolutely necessary,
they recommend using Prozac, which has shown the weakest link to suicidal
tendencies, monitoring children weekly for adverse reactions, and using the
medication only in conjunction with ongoing therapy (Cooper 2005).
On February 9, 2006, the FDA suggested issuing a “black box” warning
for ADHD drugs, including Adderall, Ritalin, and Concerta. It was found
that between 1999 and 2003, 25 people died suddenly and 54 others
developed serious cardiovascular problems after taking these medications.
Children accounted for 19 of the deaths and 26 of the cases of cardiovascular
problems. The FDA reported “uncertainty” about the safety of these
medications (Bridges 2006).
There are various factors that have contributed to the widespread use of
psychotropic medication in the United States. The first is “medicalization”—
for example, labeling children as medically ill without knowing all the
individual, family, social, and cultural aspects of the child’s behavior. In our
treatment program, we find that children are often diagnosed with ADHD
when, in fact, their symptoms (inattention, hyperactivity, impulsivity) are the
result of trauma and compromised attachment.
The next influence is the pharmaceutical industry. In 1998, the FDA
changed their rules and allowed direct-to-consumer advertising (e.g. TV),
which resulted in a 50-fold increase in the sales of psychotropic drugs from
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1985 to 2008 (Morris et al. 2013). This sends a dangerous message to children:
“If you do not like the way you are feeling, take a drug.”
The third factor is managed care. Pressure from insurers and health
maintenance organizations (HMOs) has dramatically shifted the way health
care services are delivered. In an attempt to reduce costs, HMOs dictate
to psychotherapists how many sessions they can provide and how much
they can charge for services. Managed care views short-term therapy and
medication as a more economical approach. Consequently, psychotherapists
are finding it difficult to remain in practice, pharmaceutical companies are
increasing profits, and children are not receiving adequate care.
The increase in psychological and behavioral problems is the next
contributing factor. Surveys show a constant increase in depression, stress,
and other emotional and behavior problems. The World Health Organization
estimates that by 2020 psychosocial disorders in children will increase by
50 percent, making them one of the five leading cause of childhood illness,
disability, and death (DeAngelis 2004). As the number of children with
serious problems rises, so does the use of powerful medications.
The fifth factor involves symptom-focused treatment. Many mental health
professionals believe we are over-reliant on chemical solutions for emotional
problems in children, focusing on the suppression of symptoms rather than
addressing the underlying issues that contribute to problem behaviors. A
growing number of mental health professionals realize children are being
medicated for impulse control problems and thought patterns caused by a
combination of unfavorable social influences and ineffective parenting, not
for true neurological disorders.
The last factor that has contributed to the increase in medication entails
child-centered rather than relationship-focused diagnosis and treatment.
Child-centered approaches that do not address family interactions and
influences are often ineffective. Attachment disorders are created in
relationships and can only be healed in relationships. Effective therapy needs
to address the child’s prior attachment-related traumas while also promoting
secure attachment in the current parent–child relationship. We have found
when the right type of help is provided for children, parents, and the family
system, there is a reduced need for medication.
The decision whether or not to medicate a child is difficult. Under the
right circumstances children can benefit from medication. Advocates argue
there can be negative consequences for not using medication for children
who lack impulse control, cannot concentrate, or are depressed. An out-of-
control child does not feel good about him- or herself or function successfully
at home or at school. If brain chemistry is out of balance owing to genetic
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School
Infants and young children who are insecurely attached are more likely to
be oppositional, impulsive, and aggressive, and these behaviors are often
displayed in the classroom. Schools are generally well equipped to teach the
“average” child. However, children with histories of trauma and compromised
attachment have special challenges. They are commonly behind academically,
have social problems with children and teachers, and exhibit behavior patterns
that are barriers to learning.
Children whose parents are involved with their school in positive
ways have both academic and emotional advantages: higher test scores,
better self-esteem and attitudes, improved attendance, and fewer behavior
problems. There is a positive two-way effect: parents implement teacher
recommendations at home, and teachers feel more positive toward children
in school (Christenson and Sheridan 2001). With middle- and high-school-
age children, this may mean that parents do not rescue the children, but allow
them to deal directly with teachers. Children are responsible for homework
and face school-related consequences if necessary.
A common complaint we hear from parents is a lack of cooperation
and communication with the school. The parents and school personnel are
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Motivation
Parents spend a great deal of time trying to motivate their children.
They cannot motivate their children directly, but can create an emotional
environment in which children will become self-motivated. Children
with positive mindsets and attitudes are motivated and resilient; they deal
constructively with challenges and accomplish goals. Wounded children have
a negative sense of self; they view themselves as damaged, inadequate, and
powerless. A child who sees him or herself as a failure will find a way to fail.
Thus, the first step to increasing motivation is to help the child develop a
more positive and hopeful self-image. The self-image is changed for better
or worse through experiences. The best way to help a child to change a belief
acquired through a life experience is to provide an alternative life experience.
Children cannot be taught about love, empathy, and compassion; they must
experience it. They can only become what they experience. They require
relationships that promote self-worth and dignity, which enables them to
reevaluate their beliefs and see themselves in a new light. Children who view
themselves positively are motivated to succeed.
The second ingredient to help children develop motivation involves
parents’ attitudes and practices. A parent’s job is to prepare their child for
the real world. However, some parents enable, rescue, and over-protect their
children. For various reasons—feeling sorry for their child, avoiding conflict,
meeting their own needs—they do not want their child to experience pain,
frustration, distress, or disappointment. This prevents the child from learning
to cope, handle life’s struggles, and develop inner strength. They grow up
in a bubble of over-protection and feel lost and helpless in the real world,
resulting in little belief in their abilities and in lack of motivation.
Parents must provide love, limits, and allow children to learn from
consequences. Children only develop true self-esteem and self-motivation
when they learn the skills associated with fulfillment and success—
perseverance, resilience, sense of meaning and purpose, responsibility,
accountability, and the give and take of meaningful relationships.
Media
In 2005 the American Psychological Association released a resolution on
videogame violence linking violent videogames with aggressive behavior,
thoughts, and affect, and decreased prosocial behavior (APA 2005). Since
that statement, some researchers suggested the APA’s position is not valid
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and there is not sufficient scientific evidence to prove the link between video
games and violence.
Common sense and anecdotal evidence indicate that children who are
stable, have prosocial values and morality, and have loving and trusting family
relationships, are generally not at risk of violence due to playing videogames.
However, children with histories of interpersonal trauma and who display
symptoms of anger, aggression, and antisocial behavior are at increased risk
of violence after playing violent video games. These children often displace
their anger on others (e.g., parents, sibling, peers), are biochemically and
emotionally dysregulated, and perceive others to be threatening, even when
they are not. The violent and revenge-seeking elements of some video games
and media can provoke aggression, anger, and destructive behavior in children
and adolescents who display serious psychosocial problems.
The American Academy of Pediatrics Council on Communiaction
Media (2010) set guidelines suggesting children under 2 years old should not
spend any time in front of screens (i.e., TV, computers, video games). This
is the time when parents and caregivers should be interacting, playing, and
talking with their children. Talking to a child is the most important vehicle
for language development. Interacting with young children with warmth,
empathy, and support leads to secure attachment.
Research has shown there are four main effects of viewing media violence:
aggression, desensitization, fear, and negative messages. The average American
child spends three to five hours per day watching TV. Children’s TV shows
contain about 25 violent acts per hour. The average child sees 8000 murders
by the end of elementary school and 200,000 acts of violence by age 18. More
than 60 percent of TV programs contain violence. Preschoolers who watch
violent cartoons are more likely to hit playmates and disobey teachers than
children who view nonviolent shows. Children between the ages of 6 and 9
who watch a lot of media violence are more aggressive as teens and adults,
including spouse abuse and criminal offenses (Murray 2000).
Children who witness considerable media violence can become
desensitized—less shocked, less sensitive to the pain and suffering of others,
and less likely to show empathy for victims of violence. Many of the popular
video games can desensitize youngsters to violence. These violent video
games are similar to modern military training techniques that desensitize
soldiers to killing.
Fear is another result of media violence. Children can be made anxious
by the violence they see on TV and in movies. Studies have found when
children, ages 8 to 13, view media violence, the part of the brain activated
(right posterior cingulate) is an area used for long-term memory of traumatic
events. Just as in nightmares and flashbacks common in PTSD, these violent
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Sibling Conflicts
Sibling fighting is a common cause of parental annoyance and frustration.
Many parents believe it is their duty to settle disagreements and protect the
innocent. Other parents believe it is best to stay out of sibling conflicts. The
key is to know when to intervene and when not to. Children need coaching in
how to resolve conflicts in a healthy way. It is part of the job of a healing parent
to model and teach children communication and problem-solving skills.
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Therapy
Parents routinely tell us they have endured years of therapy for their children
with limited results. They also share their confusion and frustration in being
given different types of, and often contradictory, parenting advice. The first
step is to get a proper assessment. Assessments should only be done by
knowledgeable and skilled mental health professionals who can determine
the proper diagnosis and who understand child development, family systems
issues, and the effects of interpersonal trauma. Assessments should include
the following perspectives:
• Ecological: An understanding of the family and social systems that
influence children.
• Comprehensive: Focuses on diverse aspects of the child’s and family’s
functioning. Includes emotional, mental, social, physical, and moral
behavior as well as strengths, coping abilities, and the desire for growth
inherent in most children.
• Eclectic: Involves a variety of methods and settings. Children’s behavior
often varies in different contexts, and it is necessary to understand
their behavior under different conditions (i.e., home, school, day care,
and friends).
• Culturally sensitive: Careful not to apply their own beliefs and traditions
to families from different cultural backgrounds. Behavior considered
normal in one culture may be labeled as abnormal in a different culture
or society.
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13
Attachment disorder permeates the social service, mental health, and child
welfare system in the United States. This chapter will examine the problems
and challenges inherent in foster care, adoption, and substitute child care,
and provide possible solutions. Early intervention, education, and prevention
programs, which have successfully enhanced healthy family attachment and
child development, will be described.
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behavior and aggression, use alcohol and drugs, and become involved in
the juvenile justice system, compared with their peers. There are lifetime
consequences of early trauma. Researchers have found that many of the most
life-threatening health conditions, including heart disease, immune system
disorders, obesity, and substance abuse, are related to childhood trauma
(Pynoos et al. 2008).
Child welfare agencies receive about six million referrals per year
regarding child maltreatment, with over 700,000 substantiated. There are
multiple family and environmental factors associated with maltreatment
and interpersonal trauma. Family factors include parents’ history of abuse,
substance abuse, mental health problems, and negative parenting behaviors.
Maltreatment is more likely to occur in single-parent families, and the
younger the parent is. Environmental factors include socioeconomic status,
social support network, and work history. Families living below the poverty
line are 25 times more likely to experience child maltreatment. Parents who
are cyclically employed versus consistently employed, and who lack a positive
support network, are also at higher risk (McWey et al. 2013).
A prime predictor of child abuse and neglect is the parents’ own
childhood histories of maltreatment. There is an intergenerational pattern of
maltreatment and compromised attachment. While not all abused children
grow up to abuse their own children, many parents who are reported for
child abuse were abused themselves. For example, a maternal history
of abuse accounts for 30 to 50 percent of the risk for such maltreatment
(McWey et al. 2013). Thus, multiple generations in the same families are
involved in the foster care system.
Historical Overview
Prior to 1800, children rarely were involved in public care. In the 19th
century, the development of public concern and policy for dependent,
abused, and neglected children came almost exclusively from private, secular
agencies like Societies for the Prevention of Cruelty to Children. These
organizations were the leaders in protecting children, advocating for better
legislation and public sector support for safeguarding children’s interests.
Only one state, Indiana, had a governmental body to overlook child welfare.
The community’s responsibility for abandoned and unwanted babies led to
the creation of foundling hospitals in the early 19th century, and the practice
of institutionalizing children (Schene 1996).
In 1920, the Child Welfare League of America was founded. The
CWLA helped to standardize national child welfare programs that stressed
temporary rather than permanent institutional care for dependent children,
and attempted to preserve the natural family whenever possible. By the
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1930s, the private humane societies’ functions of child protection were being
taken over by public organizations. The Social Security Act of 1935 marked
the first federal government attempt to fund child welfare services. Title IV-
A, later Aid to Families with Dependent Children (AFDC), addressed the
financial needs of children deprived of parental support. Title IV-B (Child
Welfare Services) encouraged the expansion of services to vulnerable children
by providing states with formula grants. Funds were available through IV-B
to pay for foster care, but not to provide supportive services to biological
families.
In the 1930s and 1940s, the development of social casework methodologies
led to a change in child protection from a law enforcement, punitive model,
to an emphasis on an aggressive social service rehabilitative model. In the
1960s and early 1970s there was a significant increase in federal funding
for state social service programs. Child abuse emerged as an issue of major
importance. Reporting laws were passed in all states mandating professionals
to identify children who needed protection.
The Child Abuse Prevention and Treatment Act, passed in 1974, provided
funds to assist in developing programs and services for abused and neglected
children and families. The Adoption Assistance and Child Welfare Act of
1980 was the federal government’s first attempt to develop and implement
a national policy regarding child welfare. A major goal of this policy was to
maintain and reunite children with their families (family preservation) and
to reduce the large number of children who were drifting permanently in the
foster care system (Schene 1996). This legislation initiated federal adoption
assistance, which spurred the effort to find homes for children with “special
needs” by offering monthly subsidies to families who would adopt. The term
“special needs” was introduced as social service agencies began to increase
their efforts to find homes for hard-to-adopt children. This group included
children who had varying racial backgrounds, were older, in multisibling
situations, and were physical and/or mentally disabled. Prior to the 1970s
most adoptions were with healthy same-race infants. Today, approximately
90 percent of children adopted from agencies are “special needs.”
Most social service and mental health programs did not realistically
anticipate special needs problems and were not adequately prepared to
respond. Adoption agencies and social services had little experience or
training to enable them to deal with the problems confronting this new wave
of adoptees and their families. The system became severely taxed in its ability
to meet the needs of children in placement. In 1989, the Select Committee
on Children, Youth and Families of the U.S. House of Representatives issued
a report entitled No Place to Call Home: Discarded Children in America. The
report exposed the nation’s failure to provide for children and families in
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ABC Intervention
A successful program for foster children and foster parents is the Attachment
and Biobehavioral Catch-Up (ABC) Intervention. This program helps foster
parents overcome their own emotional issues that diminish their abilities
to nurture children, and to create an environment that promotes positive
attachment and biobehavioral regulation. ABC is a ten-session program that
targets four critical issues. First, parents are taught to provide nurturance
even when children are avoidant or resistant. Young children who have
experienced interpersonal trauma often push parents’ care and support away.
Second, parents learn to “override” their own issues, so that they can respond
with support and nurturance. Third, parents are taught to pay close attention
to children’s signals and needs, and respond in calm and empathic ways.
Children with histories of trauma are extremely susceptible to frightening
behavior. Finally, parents are coached on how to enhance children’s self-
regulation abilities. Traumatized children often are behaviorally and
biologically dysregulated. Research has shown that the ABC intervention
helps children develop secure attachments, improved behavioral and
biological regulation, and fewer problematic behaviors, compared to children
in a control intervention (Dozier, Lindhiem, and Ackerman 2005).
Recommendations
Family Preservation
The goal of keeping families together failed because the child welfare and
mental health systems could not keep pace with the vast increases in drug
abuse, poverty, violence, and resulting child maltreatment. The “myth of
family preservation” (Pelton 1997) suggests that there have actually been two
child welfare systems operating—one oriented toward preserving families,
and the other toward removing children from maltreating homes. The reality
is, it is impossible to keep families together when children are at risk of abuse
and neglect. Removing a child from a dangerous environment, placing him
or her in temporary foster care, then returning that child to abusive parents
is not family preservation—it is insanity!
Early intervention and prevention programs that focus on training and
supporting high-risk parents and encouraging secure parent–child attachment
in the first three years of life offer the best hope for family preservation.
Programs that identify high-risk families and provide education, support,
and appropriate treatment before and during pregnancy, and during the
crucial early developmental stages of infancy and toddlerhood, have been
successful in preventing family disruption, establishing secure attachments,
and improving psychosocial functioning of children as they develop.
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Kinship Care
Fifty percent of foster care placements in larger states are now through
kinship care—placing children with grandparents, aunts and uncles, cousins,
or other extended family. Siblings are more likely to be placed together
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through kinship care than within traditional foster homes. Relatives are
more likely to make a commitment to a sibling group, and the children are
better able to maintain a sense of identity, connection, and continuity. Since
attachment disorder and its causes (maltreatment, poverty, violence, drug
abuse) are intergenerationally transmitted, it is crucial that extended kin are
evaluated regarding their ability to care for the children being placed.
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you before you reject me”). They accomplish this by provocation, aggression,
and other antisocial behaviors. The other coping strategy is to be acquiescent,
compliant, and withdrawn (“If I please you and stay out of your way, you
won’t leave me”). Regardless of which approach is used, most children who
have been abandoned have issues in one or more of the following areas:
separation and loss, trust, rejection, guilt, shame, intimacy, identity, loyalty,
power, and control.
Although, as previously stated, many infants adopted early do establish
secure attachments, it is not uncommon for children adopted at birth or
soon after to display attachment difficulties. Recent advances in prenatal
psychology have provided insight into why this is so. The fetus and
mother shared a nine-month experience where they were biologically and
emotionally bonded. For example, the womb is a sound chamber where the
fetus is never beyond the range of mother’s voice or heartbeat. A newborn
will recognize and respond to the mother’s voice, face, and biorhythms (Stern
1985). Neonates can also recognize the mother’s smell: sweat, urine, breath,
saliva, and breastmilk all contain scent-communicating chemicals (Furlow
1996). At birth, the newborn “knows” who his or her mother is and is not.
A child’s primary connection is the lifeline to his or her biological family,
no matter how insufficient or limiting it is. Even children with strong,
enduring attachments with adoptive parents have this lifeline to biological
parents. The best adoptive parents cannot replace what the child yearns for.
This longing is always there, either on the surface or unconsciously. Until
they are able to come to terms with deep unresolved feelings toward their
birth family, children may continue to experience both profound grief over
their loss and rage directed toward a world that hurt them ( Jernberg 1990).
An Adoption Saga
Genuinely warm and caring parents adopt children and bring them into
their homes with the intention of offering a stable, loving environment and
a commitment to making them a part of the family. They have a vision of
bestowing on the child all the love required, and believe they will be loved and
appreciated in return. However, it does not take long before some children
are showing their skills and imagination in maintaining chaos in the family.
No parenting methods seem to work and punishment only seems to make
the child worse. After vacillating between techniques, and experiencing
confusion, anger, and despair, some parents finally give up (Orlans 1993).
An adoptive parent writes:
We’ve tried point systems, rewards for good behavior, and taking privileges
away. I have never been successful making time out work. Our family has
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been torn apart by him. We have a hard time finding babysitters who can
handle him, so we don’t go anywhere anymore. We feel totally helpless
and hopeless. We are tired of all this craziness and manipulation. We just
feel terribly frustrated, angry, and want to give up. We want to believe
that somewhere out there is a way to break the stranglehold on him and
offer our whole family the bright future that could be.
The desperate family begins to seek help, but counselors unfamiliar with
attachment issues offer few solutions. They are told by therapists and social
workers that “all the child needs is love and a stable home.” Little do these
professionals realize that these children have no foundation upon which to
understand or accept love. The parents have exhausted every resource only
to receive frustration, placation, and even condemnation for their efforts.
Uneducated friends and extended family also add to the adoptive parents’
frustration.
Another adoptive parent writes:
As far as others are concerned, Sarah is a perfectly normal … even “sweet”
little girl. When we attempt to correct her in front of my family, they
make excuses for her: “Oh, that’s just little girls,” or “It’s the age,” or “I
don’t’ mind, she’s so cute,” or “Don’t be so hard on her.”
A vicious cycle soon develops where, due to extreme exasperation, the parents
(particularly the mother) appear increasingly angry and frustrated. The child
is an expert at appearing charming and engaging to others, and the problem
is assumed to be due to rejection and hostility from the adoptive parents.
Unwitting professionals see this anger and frustration as reaffirming of
their assumptions that the parents need to “lighten up” and be more loving.
This total lack of understanding serves to further alienate the family and
to increase their isolation, resentment, and hostility. Many mental health
professionals are still under the false presumption that a loving adoptive
home is a cure for children who have been abused and neglected and who
have attachment disorder. We have learned, however, that abuse most often
has lingering effects that love alone is incapable of curing. The child with
severe attachment disorder who comes into an adoptive home is unable to
respond positively to stability or love. He or she is bent on maintaining chaos,
perpetuating hostility, and avoiding closeness.
International Adoption
Since 1971, over 450,000 international children have been adopted by United
States citizens. Although many show significant improvements, a considerable
number of these children are at risk of various health, emotional, behavioral,
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Transracial Adoption
Approximately 50,000 children per year are legally free for adoption in
the United States, and more than one-half are children of ethnic and/or
cultural minorities, primarily African American (Child Welfare League of
America 1993). Nationally, these children constitute more than 60 percent
of the 500,000 children in foster care, which is twice their representation in
the total United States child population (47% African American compared
to 15% of the U.S. child population). The number of European American
children entering foster care each year is greater than the number of African
American children. Yet, African Americans make up a disproportionate and
increasing number of children who remain in the system (Adoptive Families
1997a). African American and interracial families adopt at a higher rate than
any other group in our population. Generally, agencies try to place African
American children with African American families. However, due to the
high numbers of African American children in need of homes, the minority
community has been stretched to its limits. If they are not to grow up in
institutions or the foster care system, many of these children have to be
adopted by European American families (Schaffer and Lindstrom 1989).
An institutional belief persists that the emotional and developmental
needs of minority children can only be met by adoption into families of the
same race and culture. To date, there is no scientific evidence suggesting that
African American children raised in European American or interracial homes
are poorly adjusted and/or isolated from the African American community
(Vroegh 1997). More than 20 years of transracial adoption (TRA) research
has confirmed that it is better for African American children to be placed
with European American families than to remain without permanent homes
(Silverman 1993). In one long-term study of 300 Midwestern families in
which European American parents had adopted African American children,
it was found that these children developed into teenagers and adults who
fared well personally and in their families. They had little problem with
racial identification and did not develop more psychosocial problems than
other adoptees (Simon and Alstein 1992). Another longitudinal study,
begun in 1969, compared African American children adopted transracially
and within race. No differences were found among adoptees regarding
general adjustment, self-esteem, racial self-identity, and family relationships
(Shireman and Johnson 1986). Opponents of transracial adoption suggest
that it undermines a child’s sense of racial identity and leads to a form of racial
and cultural genocide (National Association of Black Social Workers 1994).
Although secure attachment patterns develop and are maintained in
transracially adopted families, raising a child from another culture or race
requires knowledge and sensitivity. Parents must be aware that the child has
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a right and a need to know who he or she is, culturally and racially, as well
as confirming the child’s identity as a family member. Parents also need to
be conscious about the prejudicial reactions of others toward the child and
family (Schaffer and Lindstrom 1989). Vroegh (1997, p.568) writes, “The
ideology of transracial adoption opponents appears to lie in an adult political
agenda of separatism rather than in a humanist agenda of fulfilling children’s
best interests.” Secure attachment in the family, including trust, intimacy,
and morality, appears to be more important for the healthy psychosocial
development of children than racial and cultural differences.
Courtney (1997, p.765) writes, “A consideration of available evidence
suggests that TRA does not have the potential at any time in the near future
to move a significant proportion of African American children from out-of-
home care.” He cites considerable evidence to suggest that the major reasons
for out-of-home placements (poverty, substance abuse, child maltreatment)
are prevalent among African American families, which results in these
children being placed in the category of “special needs.” A child’s race, even
more than physical or emotional disability, influences the preferences of
potential adopters. Consequently, Courtney suggests, minority children have
an extremely low chance of adoption, transracially or otherwise. “Nothing
short of a massive effort to improve the condition of impoverished families is
likely to significantly stem the tide of children being placed in out-of-home
care” (Courtney 1997, p.768).
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infertility, and feelings of loss often continue for years. Adoptive parents also
have feelings of loss associated with miscarriage, death, sense of inadequacy,
lack of control over their own bodies and events, and the difference between
the fantasy of the child they planned to adopt and the reality of the child who
entered their home.
A child’s reaction to separation and loss is determined by two major
factors: the nature and quality of the attachment being disrupted, and
the abruptness of the separation. The stronger the relationship, the more
traumatic the loss. The more abrupt the transition, the more difficult it is
to work through the loss. Fahlberg (1991) describes additional factors that
influence a child’s reaction to loss of an attachment figure:
• age and developmental stage
• attachment to birth parents/caregivers
• prior separation experiences
• child’s perception and interpretation
• preparation for move
• parting and welcoming messages received
• child’s temperament
• environment child is leaving and moving to.
Infants can feel the effects of separation and loss associated with a disruption
of the maternal bond, inadequate early care, and multiple moves. It is between
the ages of 6 months to 4 years, however, that the loss of attachment figures
can cause the most emotional change. Loss at this stage of development
often results in a lack of trust in caregivers, and problems with autonomy,
identity formation, and social adjustment. Children commonly react to
loss with regression of recently acquired skills. The toddler, for example,
may display regressive eating, sleeping, or elimination behaviors. Important
developmental tasks may not be accomplished when the child is preoccupied
with feelings of loss. The child with multiple moves, for instance, may show
little reaction to another separation, as a defense against emotional pain.
This child will lag behind developmentally, be less likely to form subsequent
attachments, and is more likely to act out in ways that lead to additional
moves. Studies show that children with attachment disorder have numerous
moves in the foster care system (Widom 1991).
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Intense Emotions
Children commonly are dealing with a variety of powerful and confusing
feelings associated with loss, grief, and interpersonal trauma: anger (often
rage), sadness, fear, helplessness, hopelessness, shame, and guilt. It is crucial
that adoptive parents are given training and support so they can respond
in helpful ways to this emotionally. Effective therapy can aid the child in
managing and resolving emotional difficulties, as well as provide education
and support to the parents. The child’s pain cannot be avoided. Again,
parents with unresolved emotional issues may be “triggered” by the negative
emotionality of the child, which can result in destructive responses and
negative ongoing relationship dynamics.
Belief Systems
Negative perceptions and interpretations (i.e., cognitive appraisals) of
separation and loss have long-term harmful influences on the development
and stability of children. The child may believe, “I was given away” (not
wanted); “taken away” (angry at “the system”); or “it was my fault” (feels
responsible). Young children employ magical thinking, a natural component
of the egocentric stage of development and blame themselves for the losses.
This leads to self-contempt, damages further self-worth and identity, and
prevents the formation of future attachment (“I am not worth loving”).
Preparing children for transitions can prevent damaging perceptions.
Loyalty Conflicts
As previously stated, every child has a bond with his or her birth mother.
Children in foster or adoptive families must deal with several sets of parents
(birth, legal, parenting). Caregivers must accept the place of birth parents in
the child’s emotional life. Children who have experienced abuse, neglect, and
abandonment from birth parents need a way to “come to terms” with those
important biological attachment figures. Children must be protected from
adult conflicts and rivalries, whether these are legal battles (e.g., visitation,
custody, termination of parental rights), or emotional battles. Adoptive parents
often feel threatened by a child’s desire to maintain ties with biological or
prior foster parents. These ties, however, when appropriate and supervised,
can enhance the child’s sense of self, reduce internal emotional conflict, and
allow more energy to be available for current family relationships.
Belonging
Feeling alienated, isolated, and disconnected, are common feelings for
children in adoptive families. They lack a secure attachment to both prior
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and current caregivers, and often act out to get attention. It is important that
the child and family learn to feel they belong to one another (“claiming”)
and develop a family identity that includes the adoptive child. Parents are
sometime impatient and need to realize that trust and attachment take time,
particularly when the child has a history of painful loss and maltreatment.
Moves
Losses are psychologically traumatizing and interrupt the necessary tasks of
child development. Abrupt, unplanned moves are most traumatic for children
and adults alike. It is common, however, to move children through the foster
care system; one study reported an average of between three and five moves for
children in foster care in a five-year period (Widom 1991). It is easy to blame
“the system” for these placement moves, but research shows that, in fact, it is
usually the acting-out children with attachment disorder who are moved most.
Approximately 75 percent of children in out-of-home placements are victims
of abuse, neglect, or abandonment. The emotional and behavioral problems
of these children result in more frequent placements, as foster parents are not
able to tolerate the difficulties and disruptions on family life (Widom 1991).
Again the best outcomes for children in the foster care system are associated
with two factors: 1) place early (those placed under 1 year old did best); and
2) do not move (those who remained in one home did best).
When a child must be moved, the transition can be eased by appropriate
preplacement planning and preparation. The child (and adults involved)
needs understanding, support, and help learning to cope with the emotions
associated with separation and loss. Additionally, children do better when
they have a sense of control during stressful times; explaining to the child
what is happening and what they can expect is often helpful (see Table 13.1).
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Fit
Adoptive parents go through a “psychological pregnancy,” as they prepare for
and fantasize about the new child entering their family. The closer the child is
to his or her fantasy prior to adoption, the stronger the attachment. Children
with attachment disorder deviate from these parents’ fantasies; they distance
themselves emotionally, are angry and aggressive, and do not accept limits
and authority. A poor fit also occurs when the child and adoptive parents
are different in temperament (e.g., active and energetic child, subdued
and restrained parents). Although it is not possible to match a child and
prospective parents on all dimensions, efforts should be made to consider
these factors. Preplacement services aid the parents in developing a realistic
appraisal of the child, which may differ considerably from their desires and
fantasies.
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of the child in the new family must be determined. An adopted infant has
special status, and is typically able to form attachments with appropriate and
sensitive parenting. The older adopted child, however, brings roles, patterns
of relating, and expectations learned in prior families (birth, foster). The
family and child may have difficulty in adjusting to one another. “To return
to its prior equilibrium, any system tends to cast off what it perceives as
foreign” (Reitz and Watson 1992, p.131). The adopted child who continues
prior behaviors and roles in the new family is vulnerable to rejection and
scapegoating, a major reason for relinquishment.
Preplacement Preparation
Planned transitions help to minimize the trauma of separation and loss
and facilitate the development of new attachments. The process of moving
children out of biological homes, through the child welfare system, and into
adoptive families, must incorporate the following factors:
• Address the fears, anxieties, and emotions of the child, the parents/
caregivers the child is separating from, and the new caregivers.
• Recognize and support the grieving process for child and adults.
• Educate, support, and empower the new parents.
• Encourage realistic expectations for the child and new parents.
Providing full disclosure of the child’s history and psychosocial
difficulties helps parents develop realistic expectations. Discussions
and training sessions enhance preparation. Parents can role-play
not only parenting strategies but also “being the child,” to increase
understanding, empathy, and skills. Talking to experienced foster and
adoptive parents (“old timers”) provides insight and support.
• Help the child develop accurate perceptions and reduce the harmful
effects of self-blame.
• Consider the messages that the child is given. What are the “parting
messages” as a child leaves a family (supportive, blaming, vague)?
What are the “welcoming messages” received as the child enters the
new family (apprehensive, surprised, confident, mistrustful)?
• Preplacement contacts and visits with the new family are useful in
diminishing anxiety about the unknown, dealing with loss and grief,
and beginning the process of transferring attachment. Visits are usually
supervised and evaluated.
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Postplacement Services
A major component of effectively dealing with separation, loss, and disruption
of attachment is the quality of the new family environment that the child
moves to. The new adoptive parents must be prepared to provide a healthy
balance of structure and caring, help the child cope with grief and other
emotions, and make decisions regarding the role played by prior attachment
figures in the child’s current and future life. Postplacement services involve
the following:
• Ongoing support, education, and treatment services available for
the child and new parents. This encourages effective coping and
significantly reduces disruption rates.
• Allows contacts with prior attachment figures when appropriate.
This decreases the child’s magical thinking, loyalty conflicts, denial of
feelings, and enhances self-worth, resolution of separation issues, and
the transfer of attachment. Contacts are preferably in person, but can
also occur through phone calls, letters, or audio/video tapes. Interrupt
contact when prior caregivers sabotage the goals and send damaging messages
to the child. Contact is not recommended when prior caregivers have
been severely abusive.
• An assessment process is necessary in order to measure success in
achieving specific goals with the child, prior caregivers, and new
caregivers. Positive changes in family dynamics, parenting practices,
coping skills, and the development of new attachments should be
evaluated on a regular basis, as a part of an ongoing follow-up plan.
Helping Services
There are many studies that indicate adopted children are at greater risk of
emotional, social, behavioral, and academic problems than their nonadopted
peers (Brodzinsky et al. 1984, 1990). Adopted children are more likely to
come to the attention of the mental health system. This occurs for two
possible reasons: 1) due to early insecure attachment and loss; and 2) as they
reach school age, these children develop the cognitive skills to understand
the implications of adoption (e.g., abandonment and identity issues). It is
not possible, however, to place all adopted children into one category. Each
child is unique, with differences in biological/genetic background, early life
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from child care, when the care provided is better than what they receive at
home (Rutter 2008).
The issue of substitute infant and child care has prompted a significant
amount of debate and research within the public policy and scientific
arenas. The relationship between early substitute child care and children’s
psychosocial development (as reflected in attachment style), has received
considerable attention. Some studies found that nonmaternal infant care is
strongly correlated with insecure attachment patterns, while others found
that attachment is influenced by a combination of factors, including the
quality of child care, time spent in child care, and maternal sensitivity during
the first 15 months (Belsky and Rovine 1988; NICHD 1996).
The National Institute on Child Health and Human Development
(NICHD) began a large-scale longitudinal study in 1989 to examine the
effects of day care on child development. The researchers found that more
than one-half of the babies at age 15 months displayed insecure attachment
patterns when their mothers were insensitive and unresponsive, or showed
signs of depression and anxiety. The risk of insecure attachment was
compounded by poor quality day care, being in day care for ten hours or
more a week, and switching child care arrangements (NICHD 1996). Thus,
the combination of poor quality day care and unresponsive maternal care was
most damaging for healthy attachment and subsequent child development.
More recent NICHD research provided further information about the
effects of child care. Teens who were in high-quality child care settings as
young children scored slightly higher on measures of academic and cognitive
achievement, and were slightly less likely to report acting-out behaviors than
peers who were in lower-quality child care during their early years. Also,
teens who had spent the most hours in child care in their first 4½ years had a
slightly greater tendency toward impulsiveness and risk taking than did peers
who spent less time in child care (NICHD 2010).
While the effects of day care remain a topic of debate, there is a general
consensus that the better the quality of care, the better the outcomes for
children (Young et al. 1997). Overall quality of care includes training and
education of caregivers, staff–child ratios and group size, and appropriateness
of care provided (i.e., meeting infants’ and toddlers’ social, cognitive,
physical, and emotional needs). However, even infants and toddlers who
attended a high-quality day care program were found to be more aggressive
in kindergarten than children who stayed home (Haskins 1985; cited in
Moore 1996, p.305). In addition to the quality of substitute child care, two
other factors have been found to determine attachment and psychosocial
development: the number of hours per week in substitute care, and the age
and developmental stage of the children in care. Moore (1996) found that the
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effects of substitute care vary with the child’s age and developmental level, as
well as the amount of time spent. Boys developed more behavior problems
than girls as the total amount of time in substitute care increased (aggressive
and oppositional behavior in pre school). Moore concluded, “While the first
year of life has been viewed as a critical period, the present findings suggest
that this critical period should be extended to 2½ years” (Moore 1996,
p.308). Other studies found that 24 to 36 months of age is an important
transition time for behavioral and emotional reorganization. Bowlby (1982)
suggested that after 3 years of age, most children are able to feel secure with
a subordinate attachment figure. Bowlby writes, “After children have reached
their third birthday, they are usually much better able to accept mother’s
absence … this change seems to take place almost abruptly, suggesting that
at this age some maturational threshold is passed” (Bowlby 1982, p.205).
Young and Zigler (1986) reviewed the status of day care regulations,
and analyzed the extent to which day care requirements were followed.
They found that not one state met the recommended standards for quality
day care. Ten years later, they found similar deficiencies: 67 percent of the
states received an overall rating of poor or very poor; not one state received
an overall rating of good (Young et al. 1997). Their findings indicate that
state regulations current at the time for infant and toddler day care did
not establish minimally acceptable thresholds of quality. These researchers
conclude, “As a society, it is time we recognize that the sound development
of an increasing proportion of children is compromised by inappropriate care
during their most formative years” (Young et al. 1997, p.543; Schmitt and
Matthews 2013).
Recommendations
• Continuity of caregivers: Infants and toddlers need one consistent,
responsible, and loving caregiver. Day care programs should assign a
specific caregiver for each child, and this provider should move up the
age range, caring for the same children from infancy through preschool.
• Stability of child care: For children under the age of 3, the staff–child
ratio must be 1:4, with a maximum group size of eight.
• Qualifications for day care providers: Infant and toddler caregivers
must have the training, experience, and personal emotional maturity
necessary to develop consistent, stable, and supportive relationships
with young children. These care providers should receive wages
and benefits compatible with their level of training and experience.
Providers should be knowledgeable in the fields of infant and
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Sample Programs
Although there are many successful early intervention and prevention
programs operating currently, the list below includes programs that have been
found to effectively enhance healthy parent–child attachment and prevent an
array of child and family problems.
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intervention programs can help these women with psychological and substance
abuse issues and encourage positive attachment experiences. The Harris
Program in Child Development and Infant Mental Health in Colorado uses
a relationship-based approach, and focuses on addiction, parents’ attachment
history, parenting training, and mother–infant attachment. This education,
prevention, and therapeutic program has proven successful with a high-risk
population (Bromberg et al. 2010).
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378
Appendix A
Intake Forms
Forms
Registration Form
Symptoms Checklist
Child’s Biography
Parents’ Autobiographies
Hometown Therapist Form
Adult/Couple Registration Form
Consent Form
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Registration Form
There are 4 forms required for the child/family application process: Registration Form,
Symptoms Checklist, Child’s Biography, and Parents’ Biography.
Please read these instructions (iPhone/Android not recommended!):
• You must provide your e-mail address (5th line down on the form) in order to
save your responses and then retrieve your saved responses at a later time. If you
do not provide an e-mail address, you must submit each form in its entirety in
one session. Without an e-mail address on record, you will not be able to save
your responses!
• Periodically as you are filling out each form, click on the “Save Form” button at
the bottom of the page and then continue with the form where you left off. Your
responses up to that point will be saved.
• If you need to stop and take a break, click on the “Save Form” button at the
bottom of the page, just as you had been doing periodically. You may close your
browser.
• When you return from your break, enter just your e-mail address (5th line down),
and then click on the “Retrieve Form” button at the bottom of the page. Your
saved responses up to that point will be retrieved.
• When each form is complete, click on the “Submit Forms” button on the bottom
of the page. Your completed form will be submitted and all saved responses will
be erased. Do not submit the form until you are done. You will not be able to
continue updating a submitted form.
Completed By:
Child’s Name:
Street Address:
City:
State:
Zip Code:
E-mail address:
Child’s date of birth: (mm/dd/yyyy)
Date: (mm/dd/yyyy)
Child’s Social Security Number: (nnn-nn-nnnn)
Home Phone: (nnn-nnn-nnnn)
Fax: (nnn-nn-nnnn)
Mobile Phone:
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Intake Forms
Mother’s Information
Mother’s Name: Employer:
Occupation: Business Phone:
Father’s Information
Father’s Name: Employer:
Occupation: Business Phone:
Others living at home. Please include Gender, Age, School, and Grade, as applicable.
Child’s History
Is the Child Adopted? Yes No
History of abuse, neglect, trauma, or significant separations.
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School Information
School: Grade:
Teacher: Counselor:
Teacher’s Phone: Counselor’s Phone:
Comments:
Family Information
Parents’ marriages, separations, divorces.
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Intake Forms
City: State:
Zip Code:
Phone: E-mail:
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ATTACHMENT, TRAUMA, AND HEALING
Symptoms Checklist
Please read these instructions (iPhone/Android not recommended!):
• You must provide your e-mail address (2nd line down on the form) in order to
save your responses and then retrieve your saved responses at a later time. If you
do not provide an e-mail address, you must submit each form in its entirety in
one session. Without an e-mail address on record, you will not be able to save
your responses!
• Periodically as you are filling out each form, click on the “Save Form” button at
the bottom of the page and then continue with the form where you left off. Your
responses up to that point will be saved.
• If you need to stop and take a break, click on the “Save Form” button at the
bottom of the page, just as you had been doing periodically. You may close your
browser.
• When you return from your break, enter just your e-mail address (2nd line
down), and then click on the “Retrieve Form” button at the bottom of the page.
Your saved responses up to that point will be retrieved.
• When each form is complete, click on the “Submit Forms” button on the bottom
of the page. Your completed form will be submitted and all saved responses will
be erased. Do not submit the form until you are done. You will not be able to
continue updating a submitted form.
Child’s Name:
Completed By:
Child’s Date of Birth: (mm/dd/yyyy)
E-mail address:
Phone Number:
There are six categories of traits and symptoms of attachment disorder: behavioral,
cognitive, emotional, social, physical, and moral-spiritual. Children vary in regard to the
number of symptoms they have and in the severity of their symptoms.
Please place a mark in the appropriate column for each symptom as it pertains to
your child. For each of the symptoms checked as moderate or severe, please give a brief
description of your child’s behavior. Specific examples (given by parents) are available
by clicking on a question, as desired.
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Intake Forms
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386
Intake Forms
Child’s Biography
Please read these instructions (iPhone/Android not recommended!):
• You must provide your e-mail address (2nd line down on the form) in order to
save your responses and then retrieve your saved responses at a later time. If you
do not provide an e-mail address, you must submit each form in its entirety in
one session. Without an e-mail address on record, you will not be able to save
your responses!
• Periodically as you are filling out each form, click on the “Save Form” button at
the bottom of the page and then continue with the form where you left off. Your
responses up to that point will be saved.
• If you need to stop and take a break, click on the “Save Form” button at the
bottom of the page, just as you had been doing periodically. You may close your
browser.
• When you return from your break, enter just your e-mail address (2nd line
down), and then click on the “Retrieve Form” button at the bottom of the page.
Your saved responses up to that point will be retrieved.
• When each form is complete, click on the “Submit Forms” button on the bottom
of the page. Your completed form will be submitted and all saved responses will
be erased. Do not submit the form until you are done. You will not be able to
continue updating a submitted form.
Completed By:
Child’s Name:
E-mail address:
Child’s date of birth: (mm/dd/yyyy)
Describe what you know about your child’s birth family: age of parents, number of
siblings, family dynamics, abuse and/or neglect, drug and alcohol abuse, crime, etc.
List the number of disruptions (moves away from a family) your child has experienced,
reason for each, length of time and age in each placement, and what degree of abuse,
neglect or nurturing she/he received in each placement.
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ATTACHMENT, TRAUMA, AND HEALING
Describe any medical problems your child has experienced: e.g. inner ear problems,
colic, hospitalizations, premature birth, lack of prenatal care, etc.
Describe the progression of your child’s disruptive behavior. How have you reacted?
Describe previous therapy your child and family has had, duration, and results.
Describe your hopes for bringing your child and family to Evergreen Psychotherapy
Center.
Include a brief narrative describing a typical day in the life of your child.
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Intake Forms
Parents’ Autobiographies
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Completed By:
Child’s Name:
E-mail address:
Child’s Date of Birth: (mm/dd/yyyy)
How did your parents show affection to each other and their children?
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ATTACHMENT, TRAUMA, AND HEALING
How did your parents handle disagreements and conflicts; what were their main methods
of discipline?
How many siblings do you have and what role did each sibling play in the family?
Discuss history of alcohol or drug abuse; physical, emotional or sexual abuse; mental or
emotional illnesses in the family; how was each issue dealt with?
390
Intake Forms
What are your main methods of discipline and how effective have they been?
What concerns do you have with any other member of the family?
How large of a role (if any) does religion play in your family?
Describe positive attributes, strengths, and support systems in your current family?
How did your parents show affection to each other and their children?
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ATTACHMENT, TRAUMA, AND HEALING
How did your parents handle disagreements and conflicts; what were their main methods
of discipline?
How many siblings do you have and what role did each sibling play in the family?
Discuss history of alcohol or drug abuse; physical, emotional or sexual abuse; mental or
emotional illnesses in the family; how was each issue dealt with?
392
Intake Forms
What are your main methods of discipline and how effective have they been?
What concerns do you have with any other member of the family?
How large of a role (if any) does religion play in your family?
Describe positive attributes, strengths and support systems in your current family?
393
ATTACHMENT, TRAUMA, AND HEALING
Therapist’s Name:
Child’s Name:
E-mail:
Date Completing Form: (mm/dd/yyyy)
Phone:
Fax:
Street Address:
City:
State:
Zip Code:
Clinical Background:
Additional Information:
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Intake Forms
City:
State:
Zip Code:
Employer:
Occupation:
Business Phone:
Family of Origin
Describe what you know about your family: age of parents, number of siblings, family
dynamics, abuse and/or neglect, drug and alcohol abuse, crime, adoption, etc.
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ATTACHMENT, TRAUMA, AND HEALING
How did your parents show affection to each other and their children?
How did your parents handle disagreements and conflicts; what were their main
methods of discipline?
How many siblings do you have and what role did each sibling play in the family?
Discuss history of alcohol or drug abuse; physical, emotional or sexual abuse; mental or
emotional illnesses in the family; how was each issue dealt with?
List the number of disruptions (moves away from a family) you experienced, reason for
each, length of time and age in each placement, and what degree of abuse, neglect, or
nurturing you received in each placement.
About You
Describe your challenges and problems from childhood through adulthood.
396
Intake Forms
Medical History
List any current/past illnesses/injuries that have impacted you or your family. e.g. inner
ear problems, colic, hospitalizations, premature birth, lack of prenatal care, etc.
Marital/Relationship History
Describe your current marriage/relationship (positive and negative); i.e. intimacy,
communication, problem solving, togetherness.
Current Family
List your children and give a brief description of each child.
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ATTACHMENT, TRAUMA, AND HEALING
What are your main methods of discipline and how effective have they been?
What concerns do you have with any other member of the family?
How large of a role (if any) does religion play in your family?
Describe positive attributes, strengths, and support systems in your current family?
City: State:
Zip Code:
Phone: E-mail:
398
Intake Forms
Consent Form
I _____________________________ hereby authorize
_____________________________ (therapist)
of _____________________________ (city/state) to release any and all information
contained in the record of _____________________________ (patient’s name) to
Evergreen Psychotherapy Center for professional use only.
Signed: _____________________________
Witness: _____________________________
Date: _____________________________
399
Appendix B
400
A Day in the Life…
Not surprisingly, Michael is a sore loser and behaves best after he has beaten
someone at some game.
Upon returning from school, Michael continues his defiant behavior by
refusing to do his homework and sneaking out to play when he is supposed to be
doing his homework. Sometimes we can coerce him into doing his homework
by refusing to take him to sports practice, but on occasion he has outwitted us by
claiming he has no homework. If it is an evening that he has a therapy session
he frequently runs away long enough to miss the session. To counter his running
away we intentionally do not tell him what the time session is. However, while
he doesn’t get a chance to run away, getting him into the car evolves into a
major wrestling match with one of us holding him and the other driving. After
a holding session at the therapist’s office, Michael is usually rather compliant for
the remainder of the evening (what little is left of it) and he is generally calm. If
it is an evening where Michael doesn’t have a therapy session, he often targets
his teasing at the family as a whole, or an individual member by screaming or
doing some other inappropriate action while we/they are watching a favorite TV
program, reading, or while his brother/sister are doing their homework.
Michael seldom goes to bed at his assigned time. We generally give him
about 15 minutes’ leeway, before we really press him. Again, if he throws a
tantrum someone gets hurt or he destroys the house or somebody’s property.
At times we have to physically drag him to his room and place him in bed.
Sometimes he stays in his room and sometimes he doesn’t. If he stays in his
room he normally screams and jumps on his bed for a while before settling down
and going to sleep.
The neighbors’ reaction to Michael is mixed. Generally he gets along with
them but we have had a couple of incidents where the neighbors came to us and
complained about him. In one case we paid for the damage (a broken window),
which seemed to pacify the situation. In the other case, he got into a fight with
a girl with asthma who was teasing him. The fight brought on an asthma attack,
which scared and upset our neighbor. Luckily, this neighbor was a school teacher,
who seemed more willing to understand his situation. She stated that although
she was extremely upset, she knew we were trying to take care of the situation
and doing the best we could.
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ATTACHMENT, TRAUMA, AND HEALING
April doesn’t really have much to do with the boys. She doesn’t play well
with other children. She has one girl who she plays well with (5 years old), but
other than that she doesn’t do that well with peers.
It bothers me that she has to be in control so much, that she will jeopardize
anything to get her way. April’s strong will is both positive and negative. Her
winning smile and cunning intelligence are very positive. She is a very good
reader and speller. Her school behavior has been awful. She is now in an ALC
(Alternative Learning Center) most of the day and does much better. She is
never great at responding to authority, because it challenges her own. She does,
however, have an understanding that Mrs. Smith has more control than any
other teacher at school.
Most of the school and church community have been supportive. They
are very appalled at April’s behavior. Most have had no concept, until this last
hospitalization that it was anything other than strong-willed behavior on her part
and lenient discipline on my part. Now that we have documentation that April
has an actual physical mental problem, it has helped people at least understand
my reactions. It is quite unnerving to have your child brought to you screaming
and crying, while you are in a rehearsal with forty 4th, 5th, and 6th graders. It
took three teachers to carry April kicking, biting, and cursing, and the teachers
were shocked because I didn’t immediately “spank the fire” out of her. Instead, I
isolated her to an empty room, got my sister-in-law, who is great with April, to
be with her. Then I spent the next ten minutes bandaging the bitten hand of one
teacher while explaining her explosive behavior to the others. Of course, we left
church early and she was remanded to her room.
April is constantly challenging me. Every day, every way. In the store, at
home, at church, at play. I must constantly be on my guard. I have to watch what
I say and do, and keep my wits about me at all times. On a bad day, she really
zeros in and works overtime to get me upset, as though she has won.
She is now challenging Jim with statements like, “I don’t have to mind you!”
She is less likely to disobey him, but it does happen.
This child has been a definite challenge. She has strengthened our marriage
in many respects. We know we can’t handle too much alone. We need each other.
If I call the print shop, exasperated, Jim will come home. If he senses a rough day,
he’ll take her to the shop or soccer fields. If I sense he’s had it, I make plans to
divert her attention so he gets a break. It has been quite a financial strain and a
strain on our lifestyle—we don’t take April to important places or functions. We
sit at the back and leave early if we have a problem. The boys don’t have a lot of
friends to the house because April embarrasses them so often. They never want
her at school events. Our house is messed up all the time with her “stuff.” They
call her “the bag lady.” She has made approximately 25 holes in the wall. We have
locks on all the boys’ bedroom doors, linen closet, sewing room, and pantry to
keep her out. She steals their money, breaks their radios, ruins games. Strangely
enough, they each profess to love her and are kind to her the majority of the
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A Day in the Life…
time. Since we now know that April’s left brain is deficient, we have talked to
the boys about her being mentally handicapped instead of just “mean spirited.”
This has really helped them deal with her situation better.
Personally, I am worn out. Some days I just don’t want to come home. I often
have nightmares of April dying, and wake up feeling incredible remorse. I am
working so hard to see April’s strengths and hope that long term she will be able
to contribute to society in a positive way. I need a rest, but it would take a week
just to unwind and no one can handle April for that long outside our immediate
family.
The only parenting techniques that work with April are time outs, removal
from the areas of dispute, therapeutic holds, and taking away of personal
property. A soft voice is a must. Punishment must be swift and strong. No
wishy-washy what to do. Action must be immediate with a determination to
outlast her best effort. The least effective is spanking. This really revs her up. We
have tried everything. Nothing that ever worked with any of the boys works for
her. Grounding is ridiculous, charts don’t work. She cannot be reasoned with.
Washing out her mouth was a real challenge. She would curse right through the
bubbles. She’d curse till she threw up.
When the idea of permanent residential care was first mentioned, I cried
for two days. I couldn’t eat. I still felt there must be more we could do because
“good” parents would never entertain that thought. Now, even with high dosages
of medicine, I do not see major results. I do see an increased attention span. But
I see more and more weird behaviors. More and more acting out and violence
at school. I am terrified that the school will say, “She’s too dangerous, take her
home.” I am coming more and more to the reality that I am not equipped to deal
with this type of behavior. I’m certainly better than I was eight years ago, and my
friends marvel at my newfound patience. But I fear it is not enough.
Tim is the most physically threatened. April picks on him the most. He is
most kind to her, hating to hit her back or even protect himself from her. She has
hit him with a baseball bat, plastic but very hard, bitten him innumerable times,
hit, kicked, etc. He probably loves April more than any of the boys.
My worst fear is that April will commit some awful crime or injure some
child or teacher at school or church. My best hope is that you will be able to help
April and she will develop a conscience and stop the violence.
403
Appendix C
I would like to get to know you better, and one way I thought might be easiest would be
for you to tell me what you think and how you feel about these things:
I’m afraid _____________________________________________________________
I know I can ___________________________________________________________
Other kids ____________________________________________________________
People often ___________________________________________________________
I secretly ______________________________________________________________
My greatest worry ______________________________________________________
I just can’t _____________________________________________________________
My mind _____________________________________________________________
At home ______________________________________________________________
There is nothing ________________________________________________________
My mother won’t _______________________________________________________
My family _____________________________________________________________
I wish I could stop ______________________________________________________
Mother and I __________________________________________________________
When I get mad ________________________________________________________
Most girls _____________________________________________________________
When I was very young __________________________________________________
I’m different because ____________________________________________________
I hurt when ___________________________________________________________
I’m sad when __________________________________________________________
When I grow up ________________________________________________________
404
Sentence Completion Form
I need ________________________________________________________________
Father and I ___________________________________________________________
I wish ________________________________________________________________
I hate ________________________________________________________________
It would be funny _______________________________________________________
Most boys/girls ________________________________________________________
I want to know _________________________________________________________
My school _____________________________________________________________
Three wishes I have are __________________________________________________
405
Appendix D
Patterns of Attachment
The Berkeley Adult Attachment Interview was used to assess parents’ patterns
of attachments (Main et al. 1985). This interview procedure elicits details of
early family life, relationships with parents, and unresolved emotional issues. It
assesses the adult’s early attachment experiences and their current “state of mind”
about attachment. Based on their responses, adults are assigned to one of four
categories, each equivalent to and predictive of infant/childhood attachment
patterns (secure–autonomous, dismissing, preoccupied, and unresolved):
1. Secure–autonomous
• coherent view of attachment
• secure base provided by at least one of their parents
• do not portray their childhoods as trouble free; objective regarding the
positive and negative qualities of their parents
• able to reflect on themselves and relationships (little self-deception);
comfortable talking about attachment issues; communicate in a clear,
direct and honest manner
• worked through painful issues from childhood and can discuss these
issues without much anxiety or stress; insight into the effects of early
negative emotional and family experiences; understanding and some level
of forgiveness toward their parents
• able to depend on others; accept the importance of relationships in their
lives
• most of their own children were rated as securely attached.
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Patterns of Attachment
2. Dismissing
• unable or unwilling to address attachment issues in coherent and serious
way; dismiss the value and importance of attachment relationships
• guarded and defensive answers; often not able to accurately remember
their childhoods; do not want to reflect on their past
• idealized their parents; deny true facts and feelings associated with
negative parental behavior (e.g., abuse and neglect)
• avoid the pain of early rejection and their need for love and affection
through various defensive strategies
• three-fourths of their own children were avoidantly attached.
3. Preoccupied
• confused and incoherent regarding memories; unresolved about early hurt
and anger in family relationships
• childhoods characterized by disappointment, frustrating efforts to please
their parents, and role reversals (“parentification”)
• remain emotionally enmeshed with parents and family-of-origin issues;
unaware of their own responsibility in current relationship problems
• most of their own children have ambivalent attachments.
4. Unresolved
• experienced severe trauma and early losses; have not mourned lost
attachment figures and not integrated those losses into their lives
• frightened by memories and emotions associated by early trauma; may
dissociate to avoid pain; confused and incoherent regarding past events
• extremely negative and dysfunctional relationships with their own
children, including abuse and neglect; script their children into past
unresolved emotional patterns and dramas
• produce disorganized–disoriented attachments in their children.
407
Appendix E
Symptom Comparison
ADHD, Bipolar Disorder, Reactive Attachment Disorder
408
Symptom ADHD Bipolar I Disorder Reactive Attachment
Disorder (RAD)
Age of onset Birth, 6, 13 2–3, 7, 13–35 Birth to 3
Family history ADHD, academic Mood disorders, academic difficulties, Abuse and neglect, severe emotional and
difficulties, alcohol and alcohol and substance abuse, adoption, behavioral disorders, alcohol and substance abuse,
substance abuse ADHD abuse and neglect in parents’ own early life
Incidence Approximately 6% of 2–3% of general population 3–6% of general population
general population
Cause Genetic, exacerbated by Genetic, exacerbated by stress and Psychological secondary to neglect, abuse,
stress hormones abandonment
Duration Chronic and unremittingly May or may not show clear behavioral Dependent on life circumstances, including
continuous, tends toward episodes and cyclicity; worsens over treatment and innate temperament; worsens over
improvement years with increased severe and years without treatment, resulting in antisocial
dramatic symptoms character disorders
Attention span Short, leading to lack of Dependent on interest and motivation, Usually prolonged, secondary to hypervigilance;
productivity distractible under stress can shorten
Impulsivity Secondary to inattention or Driven, “irresistible,” grandiosity, thrill- Usually deliverable actions; Poor cause-and-effect
oblivious, regret seeking, counter-phobia, little regret thinking; no remorse
Hyperactivity 50% are hyperactive, Wide ranges, with hyperactivity Common
disorganized common in children
Self-esteem Low, rooted in ongoing Low because of inherent Low, rooted in abandonment; feel worthless and
performance difficulties unpredictability of mood unlovable; masked by anger
Attitude Friendly in a genuine Highly unpredictable, dysphoric, Superficially charming, phoney, distrusting,
manner moody, negativistic emotionally distant, nonintimate
409
410
Symptom ADHD Bipolar I Disorder Reactive Attachment Disorder
Control issues Tend to seek approval; get into Intermittent desire to please (based Controlled and controlling, only for
trouble by inability to complete tasks on mood), tend to push limits and self-gain, underhand, covert, and
relish power struggles punitive
Oppositional/defiant Argumentative, but will relent with Usually overtly and prominently Covertly or overtly defiant, passive
some show of authority, redirectable defiant, often not relenting to aggressive
authority
Blaming Self-protective mechanism to avoid Disbelief/denial they caused Rejecting of responsibility, lack of
adverse consequences something to go wrong empathy
Lying Avoid adverse consequences Enjoys “getting away with it” “Crazy lying,” “self-centered,”
“primary process” distortions, remain
in control
Fire setting Play with matches out of curiosity, Play with matches/fire setting Revenge motivated, malicious;
nonmalicious danger seeking secondary to despair
Anger, irritability, Situational in response to Secondary to limit setting or Chronic, revenge oriented;
temper, rage overstimulation, low frustration attempts by authority figures to eternal “victim” position, with
tolerance, and need for immediate control their excessive behavior, can rationalizations for destructive
gratification; rage reaction is ususally last for extended periods of time; retaliation; hurtful to innocent
short-lived overt, assaultive others and pets
Entitlement Overwhelming need for immediate Feel entitled to get what they want, Compensation for abandonment and
gratification grandiose deprivation
Conscience Capable of demonstrating remorse Limited conscious development, less Very “street smart,” good survival
development when calmed down cruel than RAD skills, con artists, calculating, lack of
remorse
Sensitivity Oblivious to their circumstances; Acutely aware of circumstances and Hypervigilant, compensating for
inappropriateness shows as result are “hot reactors” past helplessness; limited emotional
repertoire, insensitive
Perception Flooded by sensory overestimation, Self-absorbed, preoccupied with Self-centered, primary process,
hyperactive, distractible, shuts down internal need fulfillment, narcissistic primitive distortions
Peer relationship Makes friends easily, but not able to Can be charismatic or depressed, Very poor, controlling and
keep them depending on mood; conflicts are manipulative; not able to maintain
the rule relationships
Sleep disturbances Overstimulated, once asleep “sleeps Inability to relax because of racing Hypervigilance creates light sleepers;
like a rock” mind; nightmares common tend to need little sleep, arise early in
morning
Motivation Less resourceful, more adult- Grandiose: believe they are Consistently poor initiative,
dependent; OK starters, poor resourceful, gifted, creative, self- limited industriousness, intentional
finishers directed, variable energy and inefficiency
enthusiasm
Learning difficulties Commonly have auditory perceptual Nonsequential, nonlinear learners, Brain maturational delays secondary
difficulties, lack fine motor verbally articulate to maternal drugs/alcohol effects;
coordination early life abuse/neglect can create
diverse learning problems
411
412
Symptom ADHD Bipolar I Disorder Reactive Attachment Disorder
Anxiety Uncommon unless performance- Emotionally wired and have Appear invulnerable, poor
related high potentials for anxiety, fears, recognition, awareness, or admission
and phobias; somatic symptoms of fears
common, needle phobic
Sexuality Emotionally immature and sexually Sexual hyperawareness, Use sex as a means of power, control,
naive pseudomaturity, and high activity or of infliction of pain, sadistic
level
Substance abuse Strong tendencies, more out of Strong tendencies in an attempt to Sporadic/uncommon need to
coping mechanisms for low self- medically treat either hypomanic/ maintain control
esteem depressive moods
Optimal environment Low stimulation and stress, support Clear and assertive, limits, Balance of security and stability,
and structure encouragement limits and clear expectations,
nurturance and encouragement
Psychopharmacology Medications very helpful: Ritalin, Medications helpful to stabilize Antidepressants, Clonidine, may
Dexedrine, Cylert, Wellbutrin; mood: Lithium, Carbamazepine, help decrease hypervigilance, do not
Clonidine, Imipramine, and Valproic Acid, Verapamil, Risperdal help characterological traits
Nortriptyline useful as adjunctive
treatments
Appendix F
413
Appendix G
Positive Psychology
Happiness
How is happiness defined? Basically, happiness denotes positive moods and
emotions in the present and a positive outlook for the future. Martin Seligman,
a founder of the positive psychology field, specified three measurable areas:
pleasure, engagement, and a sense of meaning (Seligman 2002). Happiness is
synonymous with positive emotions, including joy, gratitude, serenity, hope,
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Positive Psychology
pride, humor, inspiration, awe, and love (Fredrickson 2001). Numerous studies
conclude that happiness is causal: happiness results in success, achievement, and
fulfillment, not the other way around. Rath and Harter (2010) suggest that well-
being is based on the interaction of five elements: our love for what we do each
day, the quality of our relationships, our physical health, the contributions we
make to our communities, and the security of our finances.
Analyzing the results of over 200 studies on happiness on 270,000 people
worldwide, researchers found that happiness leads to positive outcomes in
many important realms: physical and mental health, longevity, work, school,
marriage and social relationships, energy, creativity, and community involvement
(Lyubomirsky, King, and Diener 2005). Happiness improves physical health,
protects against illness, and predicts longevity. A review of 19 research projects
found that the most satisfied people lived seven to ten years longer than less
satisfied people. The health benefits were the same as quitting smoking by age
35 (Seligman et al. 2005). In another study, researchers injected subjects with a
strain of the cold virus. People who scored higher on a happiness survey prior
to the study did not get nearly as sick as those who were less happy; they had
significantly fewer cold symptoms (Cohen et al. 2003). A common myth is that
money buys happiness. However, above the poverty line, increased income does
not contribute to happiness at all (Diener and Biswas-Diener 2008).
Individuals who report happiness and fulfillment in their lives have more
positive emotions and relationships, have a sense of meaning and purpose, focus
on gratitude, perform acts of kindness, and utilize their signature character
strengths. These primary aspects of overall happiness and well-being are
described in detail below.
Positive Emotions
In hundreds of well-controlled studies, positive emotions have been shown to
contribute to success at work, improve immune function, and lead to a longer life
and overall well-being. The “nun study” is a perfect example. Twenty-year-old
nuns began keeping journals of their thoughts and feelings. Five decades later,
these journals were analyzed for positive and negative emotions. The women
with more positive emotions lived over ten years longer than those with more
negative emotions. At age 85, 90 percent of the happiest nuns were alive, while
only 34 percent of the least happy lived (Danner, Snowden, and Friesen 2001).
People who experience positive emotions have less pain and disability related
to chronic health conditions, fight off illnesses more successfully (Cohen and
Pressman 2006), have lower blood pressure, and less stress associated with
negative emotions (Fredrickson 2009). Positive emotions are also linked to
resilience. People who experienced positive emotions before the 9/11 attacks
recovered faster from trauma than their less positive counterparts. Optimism
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ATTACHMENT, TRAUMA, AND HEALING
buffers against the negative effects of traumatic events, because it fosters active
problem-solving and constructive action (Peterson 2006).
Positive emotions activate biochemical changes in the brain. Positive
emotions flood our brains with dopamine, serotonin, and endorphins,
neurotransmitters that stimulate the brain’s reward system and are associated
with positive moods, motivation, pleasurable sensations, and enhanced cognitive
abilities. The “broaden and build” theory offers an explanation of the salutary
effects of positive emotions. Fear and stress activate the “fight, flight, freeze”
response for survival purposes, restricting our thoughts and actions. When we
have negative emotions we have a narrowed range of thought–action responses;
we are in quick and immediate stress mode. Conversely, positive emotions lead
to broadened and more flexible responses, widening the array of thoughts and
actions that are possible. We are more thoughtful, creative, and open to various
intellectual, social, and physical resources (Fredrickson 2001).
Creating a positive mindset prior to a task or experience has been shown to
produce positive results. Adults who are “primed” for positive emotions before
an experiment have more creative and diverse ideas and solutions than those not
primed (Fredrickson and Branigan 2005). High school students who were told
to think about the happiest day of their lives before taking a math test did much
better than students not positively primed (Bryan and Bryan 1991). Four-year-
olds were asked to complete several learning tasks, such as assembling different
shaped blocks. The children who were told to think about happy situations prior
to the tasks did much better than those not primed (Master, Barden, and Ford
1979).
Positive Relationships
A large body of research has shown that close relationships and social support have
a profound effect on health and well-being. Adults in close and secure romantic
relationships have more positive emotions, hope, optimism, social competencies,
and emotional self-regulation than those in less secure relationships (Lopez and
Snyder 2009). People with active and fulfilling social lives are 50 percent less
likely to die of any cause than less social people. Lack of strong social ties is a
mortality risk factor equal to smoking, high blood pressure, and obesity (Uchino
et al. 2001). Adults with good social connections are better able to fight off
illness; they are four times less likely to catch colds than those with fewer social
ties (Cohen and Pressman 2006). Strong social support is linked to positive
functioning of the cardiovascular, endocrine, and immune systems. Individuals
with few social ties are twice as likely to die of heart disease than those with
better social connections. Social support increases resilience in the wake of
adversity. For example, New Yorkers with emotional support had fewer PTSD
symptoms and faster recovery following the 9/11 attacks than others with less
social support (Fraley et al. 2006).
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Positive Psychology
Gratitude
Gratitude is an important component of a happy and fulfilling life. It is a
thankful appreciation for what you receive, whether tangible or intangible.
Gratitude is consistently linked with feeling more positive emotions, savoring
positive experiences, having better health, dealing effectively with adversity, and
building strong relationships (Watkins 2004). People who kept a “gratitude
journal” were more optimistic, exercised more, and had fewer doctor visits than
those who focused on things that displeased them (Emmons and McCullough
2003). Individuals who wrote a letter of gratitude to a person who had benefited
them, but whom they had not thanked, and delivered it, were happier and less
depressed afterward (Seligman et al. 2005). Grateful people, including Vietnam
War veterans, report fewer PTSD symptoms following trauma than less grateful
people (Kashdan, Uswatte, and Julian 2006). Gratitude even impacts memory.
Grateful individuals recollect more pleasant events than their less grateful
counterparts (Watkins 2004).
How does gratitude contribute to happiness and well-being? Gratitude
enhances positive emotions by focusing on the enjoyment of benefits. It directs
one’s focus to the good things one has and away from things lacking, thus
preventing the negative emotions associated with social comparison and envy.
Gratitude promotes prosocial behavior, positive social relationships, and trust. It
leads to adaptive coping strategies by making sense of stressful events. Gratitude
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ATTACHMENT, TRAUMA, AND HEALING
Character Strengths
Positive psychology focuses on helping people identify and augment their unique
abilities and traits—their character strengths. Positive psychologists point out
that individual strengths and virtues are as important to understand as are
individual problems. Manifesting your strengths is one pathway to happiness,
well-being, and fulfillment (Siegel 2009).
Beginning in 1999, a group of scholars, practitioners, and researchers
initiated a study of value and qualities considered prized across many cultures
and believed to lead to fulfillment in life. Six virtues, or universally valued core
characteristics, were identified (Peterson and Seligman 2004):
• wisdom: intellectual strengths that help you gain and use knowledge and
information
• courage: emotional strengths that help you accomplish goals in the face of
fear, and internal or external obstacles
• humanity: interpersonal strengths that help you tend to your relationships
and befriend others
418
Positive Psychology
419
ATTACHMENT, TRAUMA, AND HEALING
• Acts of kindness: Every day for six weeks, write down large or small acts
of kindness you have carried out. Notice how you feel at the time and
afterwards. You will improve your own life and the lives of others.
• Smile: Positive emotions are contagious. Smiling activates neurochemicals
(e.g., dopamine) that result in positive emotions for oneself and others.
Consciously add three smiles to each day, where you would not have done
otherwise. You will feel better and others will smile back.
• Savoring: Learn to place your attention on pleasure as it occurs, consciously
enjoying experiences in the moment. Enhance your ability to recognize
and enjoy everyday pleasure by: reducing multitasking, the enemy of
savoring; celebrating your accomplishments; eliminating less enjoyable
activities; slowing down and enjoying pleasurable things without rushing;
simplifying—too many choices will diminish your pleasure; sharing the
moment with someone you care about; setting new goals and planning new
activities—savor your new undertakings; reminiscing about pleasurable
events, vacations, and victories—cherish precious memories with loved
ones.
• Flow: Flow experiences—being immersed in and concentrating on what
you are doing—lead to positive emotions, short and long term. You create
opportunities for flow experiences when there is a balance between the
challenge of an activity and the skill you have in performing it. High
challenge and high skill together produce a flow experience.
• Signature strengths: Pick one of your signature strengths and use it in a
new way every day for one week—try a new activity that is challenging,
like public speaking (bravery); learn something new (curiosity); listen to
an opinion you disagree with (open-mindedness); write a note to someone
you care about (love).
• Mindfulness meditation: This is the practice of focusing attention on the
present moment and accepting it without judgment. This reduces anxiety
about the future and regrets about the past, creates a greater ability to
manage adverse events and emotions, and leads to increased wellbeing.
Practice mindfulness meditation on a regular basis.
420
Appendix H
Life Script
2. Who was living at home in your family when you were growing up?
3. Write four to six adjectives that describe each sibling, from your perspective
as a child.
1. 1. 1. 1.
2. 2. 2. 2.
3. 3. 3. 3.
4. 4. 4. 4.
5. 5. 5. 5.
6. 6. 6. 6.
Age?
Married?
Children?
Job?
How do you get along with them now?
421
ATTACHMENT, TRAUMA, AND HEALING
Did you know your mother’s parents? Did you know your father’s parents?
GF: GF:
GM: GM:
6. Who were you closest to and why? Is this who you turned to for comfort?
Were there any other adults with whom you were close as a child, or any
other adults who were especially important to you?
422
Life Script
8. What, if any, were the major/traumatic events that happened to you when
you were a child?
9. a. What were the major messages your mother gave you about yourself and
how to deal with life?
b. What were the major messages your father gave you about yourself and how
to deal with life?
10. a. Based on your observations of your mother, what did you learn from your
mother about women?
Women are…
b. Based on your observations of your father, what did you learn from your
father about men?
Men are …
423
ATTACHMENT, TRAUMA, AND HEALING
13. Write four to six adjectives that describe each significant relationship you
have had.
1 ______________ 2 ______________ 3 ______________ 4 ______________
1. 1. 1. 1.
2. 2. 2. 2.
3. 3. 3. 3.
4. 4. 4. 4.
5. 5. 5. 5.
6. 6. 6. 6.
15. What would you write on the tombstone or as an epitaph for mother,
father, (spouse), self ?
Mother:
Father:
Spouse:
Self:
424
Appendix I
Date
_________________
Child’s Name Date of Birth Age
_______________________________ ___________ ____
Therapist
_____________________________
Hometown Therapist/Agency
_______________________________________________________________
Clinical Director Treatment Dates
_____________________________ _____________________________
Diagnosis
Axis Code Diagnosis
I 313.89 Reactive Attachment Disorder
313.81 Oppositional Defiant Disorder
309.89 Posttraumatic Stress Disorder
Strengths
Parents’ commitment, understanding, and willingness to learn.
Support of hometown agency and therapist.
Extended family support.
Child’s intelligence and desire for family.
425
ATTACHMENT, TRAUMA, AND HEALING
Treatment Issues
Child’s oppositional, defiant, and aggressive behaviors.
Child’s lack of trust, reciprocity, and negative working model.
Parenting skills; high frustration and stress.
Mother’s depression and demoralization.
Father’s resolution of family-of-origin issues.
Description of Services
Services: Intensity/Frequency:
Individual, marital and family therapy. Regular schedule with hometown
therapist.
Telephone contact with therapeutic Weekly/ongoing.
foster parent.
Follow-up medication monitoring and As per hometown psychiatrist.
management
Parents establish respite system with ASAP; with hometown agency.
help of hometown agency.
426
Follow-Up Treatment Plan
By signing this treatment plan I agree to follow through with my role in carrying
out the plan or will contact Evergreen Psychotherapy Center with any changes
or concerns.
Parent Parent
____________________ ____________________
Child Treatment Parents
____________________ ____________________
Clinical Director Hometown Therapist
____________________ ____________________
Primary Therapist Date
____________________ ____________________
427
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