Review of Rehabilitative Treatments for Reactive Attachment Disorder

An older couple, eager to adopt and love a child in need, had their dreams answered when they adopted four-year old Joshua[1] from a Korean orphanage. However, things quickly became a nightmare when they brought the young, tiny little boy home. Filled with rage and hate, Joshua was extremely self-destructive, manipulative, and hurtful to his new parents and displayed violence and aggression to animals and younger children. To make matters worse, Joshua's parents were not able to find a therapist to help them. Their friends disbelieved the stories and family criticized their parenting techniques.

Finally, the family found out about an organization in another state and immediately flew there with their, then, six year old boy. Upon receiving an official diagnosis of Reactive Attachment Disorder and beginning the necessary treatment, Joshua's family began to understand the magnitude of their son's pain. Joshua, found at two years old wandering the streets of Korea as he dug through garbage cans for food, entered the orphanage where he was "pimped" out by several officials. The degree of damage instilled in the boy affected his social and behavioral processes, triggering a chain of bottled-up feelings, thoughts, and actions that culminated with Joshua's victimization of others. The extent of his delinquency was far-reaching: sexual molestation of neighborhood children, cruelty to animals, threatening violence with a weapon.

The correlation between mental health problems and high offending rates is recurrently familiar, yet rarely receives much attention in juvenile crime literature (Markowitz, Cuellar, & Libby, 2002). Comprehensive study of and attention to the varying types and severities of child/adolescent mental health disorders would greatly benefit the juvenile justice system, allowing a systematic focus on pro-active programs with purposeful treatments and preventions. The purpose of this essay is to examine several key rehabilitative, attachment-focused treatments, and their subsequent implications for children diagnosed with Reactive Attachment Disorder (RAD). In particular, this writing will focus on Holding Therapy, TheraPlay, and Therapeutic Parenting.

Attachment and Attachment Disorder

An emotional connection develops between a newborn child and parent/primary caretaker using simple touch, eye contact, smiles, movement, and the fulfillment of basic needs, such as food, shelter, clothing, and love. In this facilitation of attachment, the parents are influencing the child's ability to trust, learn, and form relationships. Imagine an infant crying from the bedroom, expressing through his behavior a communication of physical or emotional need. The infant's mother responds to these behavioral signs, conditioning the child to expect caregiver actions and amend his/her own behavior in response. An emotional attachment has formed between mother and child.

Imagine that same infant crying in the bedroom, without a responsible, loving caretaker to react to his/her needs. If the child survives through infancy, s/he soon adjusts to not having basic needs met. Very quickly, a false sense of self-reliance develops, resulting in generalized distrust of human relationships, unstable attachment patterns, and an impaired understanding of cause and effect. Several factors interrupt the process of attachment: poor prenatal care (In-Utero trauma, drugs, and alcohol), severe abuse or neglect, sudden separation from primary caretaker, constant moves/placements, or neurological procedures (Anderson, 2001; Kelly, 2003; ATTACh).

Reactive Attachment Disorder (RAD) is considered one of the "most severe forms of infant psychopathology in terms of attachment disturbances" (Wilson, 2001:42). Characterized by the incapability to establish normal relationships, children (with RAD) manifest sociopathic behaviors in early infancy through a wide range of behavioral, cognitive, physical, and affective signs and symptoms. Such symptoms include lack of empathy, lack of causal thinking or conscience, lying, stealing, cruelty to animals, incessant chatter, inappropriate sexual conduct, aggression towards others, and poor hygiene. Children diagnosed with RAD are often manipulative, superficially charming, and frequently exploit and victimize any social relationships. These children usually exhibit "self-destructive, suicidal, self-mutilative, and self-defeating" behaviors (Sheperis et al., 2003:79).

The Diagnostic and Statistical Manual of Mental Disorders (DMS-IV) defines two subtypes of RAD, inhibited and disinhibited (Wilson, 2001; Kelly, 2003; Sheperis et al., 2003). The inhibited RAD child demonstrates a constant failure to interact socially in an appropriate manner, with a varied relationship of reception and evasion of comfort, guidance, or affection. The disinhibited child is "characterized by social promiscuity; the child fails to discriminate attachment behaviors" (Wilson, 2001:43).

Reactive Attachment Disorder is consistently misdiagnosed or ignored (Sheperis, Renfro-Michel, & Doggett, 2003; Wilson, 2001, Ward, 2001), partly due to the resemblance in symptoms to conduct disorder, oppositional-defiance disorder, or attention-deficit hyperactivity disorder. Indeed, many therapists and researchers criticize the DSM-IV for its lack of elaboration on specific behavioral criteria and its failure to emphasize the child's interactions with the primary attachment figure, which are often markedly different then the child's interactions with everyone else. Even with the official listing by the American Psychiatric Association, "counselors, teachers, adoption agencies, support organizations, doctors, and social workers" fail to recognize RAD and its implications for the families and children (Ward, 2001).

Rehabilitation: Attachment Focused Treatments
The fundamentals of current attachment therapy concentrate on developing a child's sense of security, safety, and emotional connection to his/her primary caretaker. This begins with the primary caregiver demonstrating and experiencing attunement, in which s/he "recognizes, connects with, and shares the child's inner states" (Kelly, 2003:4), while actively supporting and understanding the child's self-protective strategies of avoidance and detachment. The numerous treatment techniques used within attachment-focused interventions include cognitive restructuring, developmental regression, psychodrama, bibliotherapy, etc. Attachment-focused therapy must change constantly in order to appropriately address the extensive personal histories of children receiving treatment and to respond to the changing stages of healing in each child while maintaining the goal building strong attachments.

I. Holding Therapy

Holding Therapy, an immensely controversial and unconventional intervention, is gaining momentum in the treatment of attachment disorder. First developed in the 1950-1960's, holding therapy emerged with the purpose of integrating attachment, connection, and peacefulness in Schizophrenic (Robert Zaslow) and autistic children (Martha Welsh). The intervention continued to develop into the 70s by Dr. Foster Cline and Evergreen Consultants (Anderson, 2001) by removing tactile stimulation and alternating the levels of intrusion (confrontation) for each therapeutic case. The technique, not to be confused with re-birthing therapy, involves the primary caretaker or therapist physically holding the child on his/her lap and restraining the child's hands and feet (performed by a third participating individual), while holding the child's head in place to maintain eye contact. Using confrontational discourse in tandem with positive comments, the therapist attempts to invoke the child's "inner rage" from earlier experiences (e.g. "Who has control?" and "I know you hate, but who ends up suffering?") (Wilson, 2001:47). The purpose of this atypical method is to re-establish the bonding cycle between the child and parent.

In a safe and protected environment, the child is given an opportunity to express his/her constrained, overwhelming emotions. The constant eye contact enables the child to see the sympathy, understanding, and love from the caregiver. Many parents, families, and therapists describe their increased attachment and positive emotional expressions following the Holding Therapy interventions. Indeed, Nancy Thomas (renowned for her therapeutic parenting work with RAD-children) and her adopted daughter, Beth, travel the globe speaking on the positive results of their experience with Holding Therapy.

Yet, the therapy is not without criticism. Wilson (2001) quotes a researcher labeling the method as "cruel, unethical, and potentially dangerous" (47). Many opponents argue that Holding Therapy forces fear and submission from a child by restraining and degrading him/her, declaring that it is a violation of a child's rights and free will. Still others, such as Mike Thompson, describe the method as a form of child abuse "in the guise of therapy" (Thalman, 2003). A few research reviews have supplied positive substantiation for Holding Therapy, yet the conclusive empirical studies on its validity are limited.

II. TheraPlay

TheraPlay, a form of play therapy, is built around activities that provide high levels of stimulation that utilize the brain structures involved in the development of the affect regulatory systems. Developed in the 1960's by Dr. Ann Jernberg, Theraplay is used effectively with children diagnosed with autism, pervasive developmental disorders, attention-deficit/hyperactivity disorders, attachment disorders, adjustment disorders, anxiety disorders, behavioral problems, and depression. Therapists who advocate this form of rehabilitation recognize that the interaction between infant and caregiver is "psychobiological in nature" (Buckwalter & Schneider, 2002:5). During an ideal infancy, the caregiver provides sensory feedback (touch, sight, sound, and scent) that allow neurobiological organization to occur, increasing the child's ability to infer meanings from the environment and fostering attachment with the primary caretaker.

When a child is neglected or abused, s/he does not experience the dependable environmental stimulus necessary to develop an effectual system for emotional control. TheraPlay attempts to influence the right hemisphere of the brain through eye contact, close physical proximity, touch, and activities involving rhythmic movements (e.g. Patty-Cake) shared with the primary caregiver. The method is used short-term, considered to be fun and engaging for both parent and child, and has been used in day care centers, special education classrooms, parenting programs, and residential and out-patient treatment centers.

III. Therapeutic Parenting

Though not widely acclaimed as an attachment-focused treatment, Therapeutic Parenting, restorative programs for the benefit of parents, deserves credence in its own ability to provide structure, love, support, and strength to children diagnosed with RAD and especially their parents. The programs, such as Nancy Thomas Parenting and Love & Logic, stress warm and caring relationship values with a goal of maintaining the strength of the family unit, all while teaching parents to raise children to be capable of solving problems.

Most parents of attachment-disordered children experience extreme frustration, worry, doubt, anger, sadness, and fear. They are kicked or bitten when hugging their child, they are reacted to with hate when trying to talk, they are unable to predict when or where the next angry outburst will occur, and they cannot even leave their child alone with other people to get temporary relief. Nancy Thomas, a therapeutic parenting specialist, often proclaims that she works with "abused parents." Therapeutic Parenting programs help normalize the parent's experiences, address their grief and frustration, and help parents accept the reality of living with a RAD child. These programs also outline ideas and suggestions for behavior modification, techniques and natural consequences for parents to use in the home, with strong emphasis on nurture and structure.

Conclusion

There are "one million substantiated cases of serious abuse and neglect in the U.S. each year" (Attachment, 2003) and current statistics reveal nearly 800,000 children with severe attachment disorder entering the child welfare system each year (Attachment, 2003). There are thousands of other children going undiagnosed and many others entering the United States through adoption from other countries. Research on Reactive Attachment Disorder, its corresponding treatments and its relationship to juvenile crime is significantly minimal, a fact that stands in sharp contrast to the ruthless acts of pain and transgression perpetrated by RAD children. As mental health and juvenile departments are only beginning to understand and recognize RAD, these establishments are less able to effectively respond to increasing numbers of RAD cases due to the massive funding cuts in mental health care, removal of beds at residential treatment facilities, and lack of cooperation from state insurance companies.
There is hope, however, in the healing of children with Reactive Attachment Disorder. As parents, teachers, counselors, and social workers become aware of the risks, symptoms, and treatments, focus can shift towards identifying populations of children at jeopardy of developing RAD and prevention programs. The treatments for RAD are many, varied, and sometimes unconventional, yet they continue to provide hope not only for RAD kids, but also for all mentally ill children and adolescents at risk of entering the juvenile justice system due to mental health disorders.

References

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Presentation: Mountain Pathways Counseling. July 12, 2001.

Attachment Treatment and Training Institute, PLLC home page. Retrieved 5 November

2003. http://www.attachmentexperts.com/attachmentdisorder.htm

Buckwalter, Karen D., Schneider, Michael. May 2002. "Why Theraplay Works."

Connections Newsletter. May: 5

Kelly, Victoria J. 2003. "Theoretical Rationale for the Treatment of Disorders of

Attachment." Association for the Treatment and Training in the Attachment of Children (ATTACh). Retrieved 1 November 2003. http://www.attach.org/Research/research1.htm

Markowitz, Sara; Cuellar, Allison Evans; Libby, Anne M. 2002. "Juvenile Crime and

Mental Health and Substance Abuse Treatment: A Study of Foster Care Children in Urban Areas of Colorado" CornwallCenter for Metropolitan Studies. Retrieved 3 November 2003. http://www.cornwall.rutgers.edu/pdf/markowit.pdf

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Treatment of Reactive Attachment Disorder in a Therpeutic Foster Care System: A Case Example." Journal of Mental Health Counseling. 25:76-88

Thalman, James. January 31, 2003. "House Rejects Holding Therapy." Desert News.

Retrieved 5 November 2003. http://deseretnews.com/dn/view/0,1249,455028752,00.html

Thomas, Nancy. Nancy Thomas Parenting. 5 November 2003.

www.nancythomasparenting.com

Ward, Susan M. 2001. "WNC Awakening to Reality of Reactive Attachment Disorder."

Older Child Adoption. Retrieved 1 November 2003. www.olderchildadoption.com/rad/WNCawareness.htm

Wilson, Samantha L. 2001. "Attachment Disorders: Review and Current Status." The

Journal of Psychology. 135:37-52.

[1] Name and some events changed to protect confidentiality.