Building a Secure Base: Treatment of a Child with Disorganized Attachment
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- Zilberstein, K. & Messer, E.A. Clin Soc Work J (2010) 38: 85. doi:10.1007/s10615-007-0097-1
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Treatment strategies for children with disorganized attachments are not well established. This population exhibits a large array of difficulties in social relationships and self-regulation, as well as numerous other co-morbid conditions. As such, treatment of children with attachment problems is complex and requires a multi-faceted approach. This paper explores current research and theories about disorganized attachment and then examines how that research helped shape the treatment of an 8 year-old boy.
KeywordsDisorganized attachmentSelf-regulationReactive attachment disorderChild treatmentParent-child therapy
Attachment disorders in children is an area of growing clinical concern. While individuals with secure attachments tend to have the best developmental outcomes, including the best responses to treatment (Dozier and Sepulveda 2004; Stubenbort et al. 2002), those with disorganized attachments show the greatest rates of psychopathology (Carlson 1998; Green and Goldwyn 2002; Solomon and George 1999) and can be extremely difficult to treat (O’Connor and Zeanah 2003). Children with attachment disorders, by definition, have experienced inadequate early care and exhibit an inability to form relationships on which they can depend for security, care and as a base for safe exploration (APA 1994). Many of these children have also experienced abuse, neglect, or multiple placements causing a host of co-morbid symptoms. This layering of early adverse experience complicates the clinical picture in that numerous conditions—including PTSD, aggression, oppositional behavior, school difficulties, mood disorders and/or attentional problems—must be sorted out and addressed concordantly (Byrne 2003; Zilberstein 2006). As such, the treatment needs of these children are quite complex and serious, and have broad ranging implications for later functioning.
At present, researchers and clinicians studying attachment have developed measures of attachment and therapeutic techniques for treating attachment difficulties in infants and toddlers, but the literature on school age children is less coherent. Attachment research and theory have not been translated into an understanding of the clinical manifestations of attachment problems in older children or into widely accepted clinical interventions for that age group. Psychometric measures of attachment status have only recently been established for older children (Kerns and Richardson 2005; O’Connor and Zeanah 2003; Steele et al. 2003) and case reports on this population tend to vary in regards to children’s backgrounds and presenting problems (Zilberstein 2006). In fact, children with attachment disorders, while sharing some common difficulties and presentations, are not a homogenous group. Different types of early experience such as abuse, neglect, institutionalization, duration and extent of adverse experiences, different temperamental and genetic traits, IQ, cognitive ability and varying degrees of caretaker availability and behavior all influence a child’s presentation and suitability for different types of treatment. Because of this, and despite the fact that these children do share some common difficulties, treatment must be individualized.
This paper examines the extent to which attachment theory can help frame treatment tasks and strategies for school-age children with attachment disorders. It looks at the core problems of disorganized attachments in children and how an understanding of those difficulties in light of attachment theory and research can help organize and direct the treatment of this population. Those issues will be explored further through a discussion of the treatment of an 8 year-old boy.
Attachment and Development
Ever since Bowlby (1982) focused on the importance of a child’s ongoing attachment to a caretaker, that relationship has been increasingly recognized as important to development. Attachments are biologically driven relationships that are based on an infant’s or child’s needs for comfort, protection and nurturance. Attachments are considered to develop early and to manifest themselves by 6 or 7 months of age through the infant’s selective preference for a primary caretaker to whom the infant or child turns in times of distress. A child’s repeated experiences of soothing, protection, nurturance and attuned response by an attachment figure allows that child to internalize a sense of safety which, in turn, becomes a secure base from which he can more confidently explore the world. In this model, parental behaviors precede the emergence of an attachment and determine its type. Children who are able to internalize a sense of safety and attunement from their caretakers are considered securely attached. Those children show better overall development than children without secure attachments. This includes higher ratings on self-regulatory skills, cognitive ability, compliance, social functioning, school performance and resiliency (Atkinson and Zucker 1997; Solomon and George 1999). As such, optimal development occurs within the context of an affective relationship with a caretaker who offers attuned opportunities for emotional communication.
Other types of attachments in infants and young children have also been coded using a procedure known as the Strange Situation (Ainsworth et al. 1978). Insecure attachment—with subtypes of avoidant and resistant– results when a caregiver is emotionally unavailable or only intermittently responsive. Disorganized attachment, which will be explored further, occurs in approximately 80% of maltreated children (Solomon and George 1999), many of whom present for treatment because of co-morbid symptoms rather than underlying attachment problems, per se (Byrne 2003). This may be, in part, because attachment disorders are poorly understood. In fact, research on disorganized attachment far exceeds that on Reactive Attachment Disorder (RAD) as defined by DSM-IV (APA 1994). It is for that reason that the case discussion in this paper focuses on a child with disorganized attachment, although he would also qualify for a diagnosis of RAD. While the exact correspondence between RAD and disorganized attachment remains uncertain, some overlap does seem to occur between the two, particularly in cases of early maltreatment, such as will be presented here (Byrne 2003; van Ijzendoorn and Bakermans-Kranenburg 2003; Shilkret 2005). However, significant differences do exist and bear highlighting.
DSM-IV (APA 1994) defines RAD as a disorder of impaired social relationships across domains. Two types exist. In inhibited RAD, children exhibit emotional withdrawal. They do not seek out comfort or affection, even when distressed. In disinhibited RAD, the child presents shallow and superficial social behaviors such as clinging and/or indiscriminate friendliness, which may be directed towards strangers. In addition, DSM-IV requires that the behaviors stem from persistent pathogenic care, become manifest before the age of five, and do not derive from developmental deficits.
DSM-IV’s nosology thus concentrates on indiscriminate and inhibited social relationships across social domains, but does not specifically look at the child’s relationship with the attachment figure, as do the categories derived from the Strange Situation. As such, DSM-IV provides a less useful diagnosis in that it does not focus assessment on the reciprocal nature of attachment relationships. In addition, DSM-IV’s symptoms of RAD describe children who show little real affiliation with others at all (Boris and Zeanah 1999). It excludes children who have developed attachment relationships with caretakers, but whose relationships are pathological (Minde 1999). Disorganized attachments, on the other hand, specifically refer to the child’s relationship with the caretaker, and include that dynamic. In addition, research has better delineated the internal states of disorganized children and how those states are expressed behaviorally.
Disorganized attachment derives from an experience of the caregiver being frightened or frightening, which creates a paradoxical and irresolvable situation for the child. The child both craves and fears, both approaches and avoids the caregiver. The young child exhibits this dilemma by expressing contradictory and disorganized behavior towards the attachment figure. This includes behaviors such as freezing, stilling, apprehension, disorientation and even fear (Main and Solomon 1990). This response has been observed most often in samples of children who have suffered abuse and neglect, but has also been seen in children whose parents, themselves, exhibit unresolved loss or trauma (Solomon and George 1999). Both groups of parents, can be experienced as frightening, although in different ways. While abusive parents show frightening behavior and affect, those with unresolved loss or trauma may be prone to dissociation and to expressions of frightening and unresolved emotions. Both groups exhibit a lack of sensitivity to the distress of their children.
The frightening behavior of the parent elicits fear and a state of over-arousal in the child. Such a state would normally cause children to turn to an attachment figure for relief. However, without a soothing and available attachment figure, no reprieve is available (Howe and Fearnley 2003; Solomon and George 1999). Those children must therefore rely on their own nascent and insufficient coping skills to help them deal with an intolerable situation. This, in turn, inhibits their ability to learn emotional regulation, relational strategies, and internal organization (Carlson 1998; Streeck-Fischer and van der Kolk 2000). In fact, the deficits, while appearing to be social and emotional in nature, also become neurologically wired into the evolving structure of the brain (Allen 2001; Applegate and Shapiro 2005; Perry and Pollard 1998; Schore 1997). Because of this, treatment cannot just focus on helping individuals cognitively understand their condition or conflicts, but must include experiential and emotional learning that will help stimulate new internal structure, such as occurs in attachment relationships.
Children with disorganized attachments exhibit internal worlds that are overwhelmed by unresolved affect and fear. They tend to display either great inhibition in their play and representations of attachments or great disorganization marked by catastrophic fantasies. Their drawings and stories are likewise incoherent, spatially disoriented and disrupted by distractions (Gubman 2004; Solomon and George 1999). Those children are, in fact, internally disorganized. This may, in part, derive from the fact that, when under duress, disorganized children are the least capable of securing safety, soothing and affective attunement that would help them integrate such experiences, while being the most overwhelmed by affect and fear.
By the age of three, attachment representations have generally become internalized as the child’s working models (Bowlby 1982). Those models continue to influence both a child’s internal self-organization and the way in which he interacts with and experiences the world and other relationships (Kerns and Richardson 2005; Sroufe et al. 1999). In this way, interactions that emerge out of an attachment relationship evolve into individual behaviors and beliefs. Although the environment continues to effect and modify working models over time, aspects of those models may endure even when the environment changes (Milan and Pinderhughes 2000; O’Connor et al. 2000). Disorganized children, as they age, have working models of helplessness or coercive control (Kerns and Richardson 2005; Solomon and George 1999). By age six, peer problems tend to be evident. Although no consistent pattern emerges, typical patterns include aggressive, controlling or fearful and helpless behavior, or sometimes an odd and contradictory mix. Children may alternate between aggression and withdrawal in the same interaction. These children often exhibit social difficulties, as a result of misunderstanding social cues (Kim and Cicchetti 2003; Page 1999). Disorganized attachment in the older child can be recognized by the unstructured expression of inner distress and by the child’s inability to regulate that distress in attachment and other social relationships.
Thus in older children, attachment behavior and representations can be viewed as an interplay between both their own working models of attachment and the attachment opportunities available to them in the environment. Such opportunities primarily consist of parental ability to promote attachment and, secondarily, of other significant figures in the child’s life. Those figures can include teachers, friends and other relatives whom the child encounters along with his growing social world (Kerns and Richardson 2005).
Parental Contributions to a Child’s Attachment Style
Parental attunement to the child’s needs is considered the mechanism through which secure attachment grows. Attuned parents show insight into the underlying emotional communication of their children thus allowing them to more effectively respond to the child. In doing so, they moderate arousal, providing both stimulation and soothing as necessary. They provide affective communication through which children learn to conceptualize feelings and beliefs and organize experience (Fonagy and Target 2002). When misattunements inevitably arise, they are rapidly repaired so that the child is not left feeling overwhelmed or scared (Hughes 2004; Peck 2003). Parents thus encourage safe exploration by anchoring children in a stable relationship. Parents of infants, toddlers and preschoolers who, through treatment, increase their insight and attunement to their children, tend to create more secure attachments and decrease behavioral problems in those children (Lieberman 2003; Lieberman and Pawl 1990; Oppenheim et al. 2004).
Parental state of mind regarding attachment also predicts the child’s attachment status (Dozier and Sepulveda 2004; Dozier and Tyrell 1998). Parents whose own attachments are more organized, seem better able to promote secure attachments in their children. In research settings, adult internal working models of attachment is generally measured on the Adult Attachment Interview (AAI) (Main 2000) in which adults are asked to discuss their past attachment relationships with their own caregivers. Those who communicate about such topics during the interview in a coherent and consistent manner are termed “autonomous.” Those that devalue those relationships and speak of them in a limited fashion are termed “dismissing.” Dismissing individuals may idealize their early attachment relationships in a superficial way, often with few or inconsistent supporting memories or details. “Preoccupied” adults are overly focused on those relationships, often angry about them, but are unable to reflect upon those experiences in a coherent manner. They tend to ramble, show little perspective, and easily get off track. Individuals whose communication is disoriented in regards to topics of loss, trauma, or the traumatizing figure are labeled “unresolved as regards to loss or trauma.” These adults show lapses in the organization and coherence of their speech and narrative around such topics. Autonomous parents generally raise secure children, dismissing parents often rear insecure/avoidant children, preoccupied parents have insecure/resistant children, and unresolved parents tend to have disorganized children. A similar concordance has been found in adoptive children 3 months after placement (Steele et al. 2003) as well as in foster parents fostering infants or young children (Dozier and Sepulveda 2004).
Perhaps one of the most striking aspects of these attachment categories is the way in which attachment status impacts the ability to benefit from treatment. Adults deemed autonomous and children rated as secure are noted to be the most collaborative and to benefit most from treatment (Dozier and Sepulveda 2004: Stubenbort et al. 2002). Dismissing adults have been noted to minimize their need for help and may reject the overtures of others, including therapists. The challenge for therapists working with such clients is to recognize the underlying relational needs and attune to those desires despite overt, misleading cues and verbalizations to the contrary. Preoccupied individuals accept help, but often have difficulty staying focused on pertinent issues. In fact, their tendency towards dependence often impedes their ability to form and maintain an autonomous self in close relationships, which must be addressed in treatment. Those with unresolved states of mind lead more chaotic lives that require comprehensive and long-term interventions (Dozier and Tyrell 1998; Shilkret 2005). Such parents may have tremendous difficulties helping children form attachments, as well. Without the ability to reflect flexibly on attachment and emotional expressions, to recognize them and to resonate their meaning for the child, insecure parents tend to minimize the child’s experience (Fish and Dudas 1999). Ruptures in relationships are left unrepaired and safety, comfort and affective attunement not provided in a timely fashion. Parental capacity for attachment is thus important because it influences both the parents’ ability to help children form attachments and also to use therapeutic help to that end.
Beyond Attachment: The Older Child
As children age, they increasingly rely on both their internal working models of attachment and ongoing parental guidance to help them cope with new challenges. Attachments thus remain influential, even as children are required to demonstrate independent social and cognitive judgment in new arenas such as school, peers, and activities (Kerns and Richardson 2005). Navigating this environment can be particularly difficult for children who, because of poor early attachment and subsequent internal disorganization, have not developed trust in reciprocal relationships, an organized sense of self or adequate social and self-regulatory skills. These children are required to function more autonomously without a caregiver in close proximity, yet lack sufficient internal resources to cope with environmental demands. They have difficulty keeping up with expectations, thus confirming their working models of a chaotic and unfriendly world. Since they are unable to formulate an organized response to stress (Streeck-Fisher and Van der Kolk 2000), they continuously face situations that are overwhelming and that encourage further disorganization and catastrophic feelings. This often results in emotional and behavioral turmoil and acting out behavior. Containing and keeping safe the child who is not sufficiently restrained by a well-developed ability to self-regulate, who shows internal disorganization, and who no longer has a caretaker in close proximity to organize and regulate him, can be quite difficult.
Assessment of Attachment Problems in Children
The first task in conducting treatment is an assessment of the child’s attachment relationships and other needs. While psychometric measures such as the AAI and Strange Situation are too cumbersome for clinical settings and are not applicable to school age children, they can be modified for clinical use (O’Connor and Zeanah 2003; Shilkret 2005; Slade 2004). Clinicians must determine how the child uses the parent figure, particularly when in distress. Whereas in a younger child, distress can be observed clinically through evaluating and exploring how a child reacts to separations, such a situation is less likely to provoke distress in middle childhood (Kerns and Richardson 2005; O’Connor and Zeanah 2003). However, it is possible to ask the child and caregiver when and how that child seeks out proximity to a caregiver, what the child and caregiver do when the child is distressed, and to observe those responses in the therapeutic setting. Observations are important because parents often miss attachment cues or overlook other signs of anxiety or need for care (Lieberman 2003). Play and art can also help the therapist obtain a sense of the child’s inner structure and themes. The therapist notes how well organized is the play or construction and what themes emerge from it. In addition, a therapist can set up scenarios, which involve distressed, hungry or needy children and then observe how that child handles the situation and in what ways the caregivers are used to help resolve problems.
Likewise, parental capacity to reflect on attachment issues, speak coherently about relationships, and demonstrate insight and attunement towards the child’s underlying feelings are all important to assess as they give information about the parents’ attachment status (Hughes 2004; Slade 2004). Lastly, it is important to evaluate how the child and parent relate to and use the clinician. Assessment includes whether the parent or child possess a collaborative and open communication style, whether they are either dismissing of help or too preoccupied with their own concerns or need for dependence to engage mutually in therapy, or whether they are disorganized about attachment issues and show few coherent relational abilities. Different types of treatment are indicated for differing attachment skills. Parents may not be ready for dyadic work if they do not demonstrate reflective skills and internal representations associated with secure states of mind (Hughes 2004).
Assessment of Co-morbid Conditions
Careful assessment of a child’s co-morbid conditions must also occur. Environments that are maltreating or neglectful and that create attachment disorders also carry risks for other problems as well. Some of these children will have traumatic memories and reactions, others may have mood disorders, others problems with attention, still others may have difficulty with cognition and learning (Byrne 2003; Howe and Fearnly 2003; O’Connor et al. 2000). Often it is difficult to sort out the child’s symptomology and make a differential diagnosis. For instance, confusion often occurs between symptoms of ADHD, bipolar disorder and attachment problems (Alston 2000). While children with all three disorders do tend to show difficulties with behavioral control, including, in some instances, poor frustration tolerance, aggression and irritability (Post et al. 2006), many differences exist. Symptoms unique to bipolar disorders, but not to ADHD or RAD, include decreased sleep, delusions and hallucinations, hypersexuality when no history of sexual abuse exists, periods of elevated mood, and suicidal or homicidal ideation (Post et al. 2006). These groups may also be differentiated by their relationships with attachment figures. Children with ADHD or bipolar disorder do not necessarily exhibit poor attachments or difficulty accepting soothing from those attachment figures. Unlike children with disorganized attachments, they do not become more disordered when faced with attachment tasks, but, in fact, often find the attachment figure to be an organizing force. However, it should be noted that these various conditions are not mutually exclusive and that any given child may exhibit one or more of them together. As such, evaluations must be comprehensive and should include assessments in various social, behavioral, cognitive, self-regulatory, and affective domains.
In addition, research shows that many co-morbid conditions such as poor social skills and attentional difficulties do not necessarily abate once a secure attachment is formed (O’Connor and Zeanah 2003; Zilberstein 2006), thus rendering it important that such conditions be recognized and treated separately. Specialized school services, medication and behavioral interventions may be required. Understanding how these conditions both interrelate and require attention in their own right is important, although beyond the scope of this paper. However, clinicians should be aware that traumatic triggers and emotional instability might add to a child’s sense of fear and instability and interfere with the establishment of a secure base. As such, caution must be employed in combining treatments. For instance, many traditional treatments that seek to uncover and explore trauma or other emotionally disturbing material are counterproductive in the early stages of treatment. Exploring such material could overwhelm the child’s fragile resources and disorganize him further (Allen 2001; Hopkins 2000; Streeck-Fisher and van der Kolk 2000). For this reason, it is our belief that some co-morbid conditions cannot be tackled until attachment issues have been addressed and a secure base formed.
No evidence-based treatment for attachment disorders exists, although a number of different techniques are discussed in the literature. While some case studies discuss individual therapies that aim at increasing relational abilities and emotional regulation through non-directive play (Benedict and Mongoven 1997; Hopkins 2000; Ryan 2004), others focus on eliciting change through the parent-child relationship. A growing consensus in the field suggests that incorporating the caregiver into the child’s therapy is the most effective form of treatment for this population (Heller et al. 2006; Hughes 2004; Kinniburgh et al. 2005; Lieberman 2003). This is because a child who is internally disorganized rarely has the capacity to internalize and generalize gains made in a therapeutic relationship into his broader social sphere. Very dysregulated children require containment of their affect and behavior in their everyday environments as they slowly integrate the skills and experiences learned in therapy. Caregivers also need help to more accurately understand the roots of the child’s behaviors and effective interventions for addressing them. In fact, case studies suggest that when a suitable attachment figure is not available to participate in treatment, outcomes tend to be less successful (Heller et al. 2006; Ryan 2004).
In general, attachment-based treatments are much more prevalent for infants and young children than for the older child. In fact, a number of early intervention models now exist that aim at enhancing early child-parent attachments. Although these programs vary in terms of populations and services, a few core features pervade the literature. Interventions aim primarily at changing the internal working models of attachment of the caregiver (Applegate and Shapiro 2005; Lieberman and Pawl 1990), at increasing the capacity of the caregiver to reflect upon and understand the child’s behavior (Cooper et al. 2005; Dozier et al. 2005; Slade et al. 2005), and at helping the caregiver cue more effectively to the child’s needs and meet those needs with behavioral interventions and emotional attunement (Applegate and Shapiro 2005; Cooper et al. 2005; Dozier et al. 2005; Lieberman and Paul 1990; Zeanah and Smyke 2005). This work often has a didactic component (Cooper et al. 2005; Dozier et al. 2005; Zeanah and Smyke 2005) that educates caregivers about the child’s relational needs, about how to read the child’s affects and enhance his emotional regulation, about picking up on children’s cues and miscues, and about how parents can reflect on their own states to better help their children. Some programs use videotaping to give parents perspective on their interactions with their children and the cues that child presents (Cooper et al. 2005; Dozier et al. 2005). Provision of parental support is also a key component of these programs. Although some of these interventions specifically target children who are in foster care and/or have histories of early maltreatment (Dozier et al. 2005; Lieberman and Pawl 1990; Zeanah and Smyke 2005), a number concentrate more broadly on children with insecure attachments or do not specify the attachment status of the child (Cooper et al. 2005; Oppenheim et al. 2004; Slade et al. 2005).
Only a few attachment-based interventions exist for the older child. Hughes (2004) provides a comprehensive description of how he conducts parent-child therapy. In his model, the therapist works to model relational skills and facilitate the growth of the parent-child bond. Key elements of therapy involve attunement to the child, the therapist and parent’s emotional communication of the child’s affective states, which leads to co-regulation of affect within the child, followed by helping the child construct meaning out of his affect, behavior and experience and thus enabling him to work through past maltreatment experiences. Such tasks are accomplished both verbally and non-verbally. Empathy and understanding are expressed through verbal interpretation of the child’s inner life and through facial expressions, gestures and vocal tones that communicate attunement. The parent is coached to respond to the child with comfort and to aid with affect regulation. Conflicts are promptly addressed and repaired. These therapeutic techniques provide a sophisticated method for facilitating attachment behaviors and affective communication between parent and child. However, given the complex needs of these children, it is not clear whether they address the full range of difficulties encountered in this population.
A slightly different approach is presented by the ARC model (Kinniburgh et al. 2005). The ARC model focuses on building attachment, self-regulation and competency through caregiver attunement, skill-building, self-regulation capacities and developmental and interpersonal competency. Interventions occur on the individual, familial and systemic levels. This approach aims to provide a framework that can be individualized to each child. As such, it does not outline specific strategies for treatment, although it does suggest goals and possible interventions. ARC, like some of the more recent treatments for adults suffering from early maltreatment, emphasizes a phase oriented approach to treatment in that affect regulation and relational issues are addressed prior to trauma treatment so as not to overwhelm highly vulnerable and dysregulated individuals with affects they cannot integrate (Allen 2001; Cloitre et al. 2002; Ford 2005).
Therapy with attachment disordered children is thus quite complex given that the population is diverse and the needs many. Basic deficits in this population appear to occur in the areas of relationships and self-regulation, although other problems are also common. Hughes (2004), the ARC model (Kinniburgh et al. 2005), and attachment-based early intervention techniques all offer helpful frameworks for treatment and components of each are utilized in the case presented below, as well as other interventions.
In our therapeutic experience, treatment, though not completely linear, should follow the developmental trajectory of first building attachments, then developing self-regulation skills within the attachment relationship, then enhancing the child’s ability to represent thoughts and feelings, and finally encouraging exploration and competency in the greater environment. Furthermore, building attachment and self-regulation in the older child, whose social, emotional and neurological development has already progressed in maladaptive ways, is both similar and different from the growth of attachment and self-regulation in infants and young children. While such elements of early attachment as caregiver availability and protection, attunement, emotional communication, and repair remain necessary components in any attachment relationship, the older child also brings certain cognitive and developmental traits that both hinder and help in the process. Treatment must challenge and change previously formed working models of attachment and methods of handling stress and emotions (Page 1999). But older children, even those who are developmentally behind, do have varying capacities to participate in cognitive, symbolic and other therapeutic procedures. With careful assessment of the child’s capacities in those areas such arenas can provide additional tools for treatment. In addition, whereas a secure attachment in early childhood helps immunize children from some later difficulties, establishing a secure attachment later in life does not necessarily remit all of the social and emotional problems that emerge from poor early attachments. As such, therapy must be multi-faceted.
The following case vignette demonstrates how the elements of attachment, self-regulation and reworking of past experience can be organized into therapeutic interventions. Names and details that might permit identification of individuals have been disguised. While in many ways this case typifies the intensive treatment strategies necessary for working with children with disorganized attachments and the people that care for them, individual differences are such that techniques often need to be modified according to clinical presentation.
Rafael, an 8 year-old European American boy, was referred for therapy due to physical aggression, hour-long temper tantrums that included screaming, kicking and throwing objects and night terrors. His pre-adoptive parents reported that Rafael exhibited poor relational qualities and little self-control. He rarely made eye contact with others, attempted to monopolize parental attention, especially when they were engaged in other activities, demanded constant satisfaction of concrete needs, but showed little ability to share inner thoughts or feelings. With peers, he was bossy, controlling and often angry.
As detailed by his DSS worker, Rafael’s early history was one of severe neglect. Sexual and physical abuse were not reported, but given the chaotic environment in which he lived, could not be ruled out. His birth mother was described as cognitively and emotionally limited, with a history of childhood sexual abuse and later illegal drug use. At the time of Rafael’s removal, she appeared overwhelmed by the demands of childrearing and maintaining a home. The apartment in which they lived was filthy and cluttered, food was sparse and a constant flow of men and women, perhaps connected to her drug use, filtered through the house. Rafael was at times left with other caretakers, some of whom were only casual acquaintances of mother, for periods of up to a month.
DSS involvement began when Rafael began preschool at Headstart at age 3. The school noted that Rafael appeared unkempt, often arrived ravenously hungry, exhibited clingy behaviors towards the staff, acted aggressively towards other children and had trouble maintaining focus on activities. The DSS worker noted that interactions between Rafael and his mother were awkward. When Rafael was upset, mother tended to ignore his screams and cries to the extent that the worker wondered if mother dissociated. Eventually, his piercing cries would rouse her and she would respond in an angry manner, telling him to “shut up” or go to his room. During one such incident, the worker observed Rafael clinging to his mother, to which she responded by pushing him harshly away. Services were provided to mother to help her with parenting, but she did not follow through. Rafael was removed from his birth mother at age 4 and subsequently lived in five separate foster homes before placement in the current pre-adoptive home 6 months prior to the start of treatment. While some of those placements offered good quality of care, some housed so many children that Rafael got little attention, acted out vigorously and was asked to leave. Placement lengths varied from 1 month to 1 year. The longest placement ended because of parental divorce.
When the therapist met initially with Rafael’s pre-adoptive parents, both of whom were also European American, they expressed concern and confusion about his behaviors. They felt surprised at his small response to and appreciation of their attention and nurturing. His rejection of their warmth produced some ambivalence in them and they wondered about their own efficacy as parents. They also felt exhausted by the length and depth of his emotional outbursts. Time-outs and other contingencies seemed to do little to diminish the intensity of those tantrums and their onset was often unpredictable.
Father described his own upbringing in a strict family setting in which showing disrespect to parents was unacceptable. He felt shocked, angry and undermined by Rafael’s challenging stance toward him. He believed that a stricter, more heavy-handed approach towards Rafael was necessary. Mother, on the other hand, tended to respond more permissively towards Rafael. She was the eldest of five children in a family in which the mother suffered from intermittent depression. She began, early on, to assume responsibility for her younger siblings and many household chores. Though proud of how she helped her family, she also felt pained by her own lost childhood and the inconsistent nurturing she received. As such, she believed that children should be allowed to be children, and primarily be given warmth and care. However, Rafael’s bottomless pit, that took and took without giving back, had begun to exhaust her. As such, his pre-adoptive parents wavered between strict and permissive behavior towards Rafael, between viewing Rafael’s behavior as normal or manipulative and between feeling nurturing in their interactions with him or undermined and depleted. Despite these issues, it was clear in the initial meeting that the parents showed a strong ability to reflect upon Rafael’s behaviors, a robust desire to understand him better and an ability to attune to his needs once they grasped his dynamics. Their home was structured and nurturing, and despite Rafael’s provocative behavior, his pre-adoptive parents were able to control their reactions and emotions to his conduct and generally respond in his best interest.
After the initial parent session, Rafael was seen together with his pre-adoptive parents. The therapist explained that they were coming because Rafael was new to this family and just getting used to it. He had lived in lots of families and some of them had been nice homes for him but in others he had not always felt safe and cared about. He probably wondered what these parents would be like and whether he really could stay forever. The therapist would help them become a family that loved each other, helped each other, was safe together and stayed together. Rafael listened intensely to this description, but did not look at his parents or acknowledge them.
The therapist played with Rafael with the purpose of assessing him developmentally, engaging him in a fun manner and appraising his internal representations. Rafael appeared cognitively intact with an ability to understand and answer questions, although he often ignored the communications of others. He could play symbolically, but his play was often disrupted by terrifying creatures and events, at which times he would either leave those toys and find others or become physically agitated, himself. At other times, he simply appeared distracted by other toys or sounds from outside the office. At one point, as Rafael created a scene of a child being chased by a monster, the therapist suggested that the child might feel safer and less scared if a mother or father doll came to help and she provided him with the doll. He responded by telling the therapist to be quiet. At another point in the play, when Rafael’s behavior became agitated and he threw the doll out of the dollhouse, the therapist suggested that he was feeling somewhat disturbed and that it might help him to sit with his parents for a bit and let them try to make him feel better. The mother warmly invited him to cuddle on her lap. With prompting from the therapist, he was able to do so and to allow some soothing from her.
After these sessions, the therapist devised a preliminary formulation. Rafael appeared to have significant social impairments in all domains, little ability to use his pre-adoptive parents for security or comfort when in distress, little interest in allowing others into his emotional world and little capacity to self-regulate and organize emotions and behavior. All of those areas should have been fairly well developed by the age of 8, and thus Rafael was well behind age norms. It was unclear to what extent the distracted behavior he showed resulted from anxiety or attentional difficulties or both, which would require more assessment and monitoring over time. Rafael clearly showed difficulties with attachment as his behavior most closely resembled that of a child with a disorganized attachment. He alternated between clingy and withdrawn behavior with caregivers, resorted to bossy and controlling strategies in his peer relationships and showed little ability to organize his emotional and behavioral responses in play or with others. This behavior was consistent with what would be expected from his early history. His mother, according to DSS accounts, was not only neglectful but also interacted with him in ways that were, themselves, disorganized and at times frightening and unpredictable.
His current parents, on the other hand, presented in a more coherent, organized and thoughtful manner. They showed an ability to control their own reactions, to reflect on their own histories and how they affected their conduct and attitudes, to think flexibly about Rafael’s behaviors and needs and to maintain a structured and nurturing response to him. They thus appeared autonomous in their own working models of attachments. As such, parent-child therapy was initiated with the goal of strengthening the relationship between Rafael and his parents, helping Rafael and his parents address and contain Rafael’s emotional and behavioral dysregulation and aiding Rafael in resolving issues from his past. Parental doubts about their own abilities and effectiveness as parents and their fears for the future were addressed in separate, collateral sessions, which occurred bi-weekly. Those sessions were extremely important in helping the parents remain committed, in helping them better understand Rafael’s behaviors and needs, in easing their exhaustion by aiding them in finding ways to nurture themselves and in allowing them to reflect upon the small gains they had made so as to obtain some feeling of success.
Rafael came with his mother for weekly sessions and father joined when available. Therapy focused initially on helping Rafael with relational issues and reciprocal communication. Within weeks, he reliably made eye contact and would respond when addressed. He was encouraged to seek out his parents for comfort when hurt or distressed, and they, in turn, to initiate such responses when he did not. The therapist worked hard to help him view shared play as fun, rather than threatening, and he slowly began to tolerate the therapist’s joining and intervening in his play.
The circumstances around Rafael’s aggressive behavior were probed. Rafael often became dysregulated when he felt wronged, angry or overwhelmed with emotion. Rafael was particularly sensitive to situations he interpreted as rejecting or confusing, as he did not have the skills to sort out or contain his feelings. Helping Rafael learn self-regulation skills thus seemed critical to reducing his aggression.
This occurred in a number of ways. The parents were educated about the role of attachment relationships in regulating emotions and behavior. They were encouraged to view Rafael as an emotionally younger child who had not learned soothing and needed to do so in the context of a parental relationship. Rafael had a tendency at times to try to fend for himself when distraught. He could be prematurely emotionally independent. If he scraped or bruised himself, he denied hurt and dismissed nurturing responses. At first the parents found this independence welcome, but learned to view it as maladaptive behavior that interfered with Rafael’s attachment to them. They learned to nurture even when he did not seek it. Behaviors that father interpreted as manipulative were reframed to emphasize Rafael’s attachment needs. For instance, when the parents raised their voices, sent Rafael to his room or gave him a consequence, Rafael would scream and cling to them. The parents were taught that when Rafael felt his relationship with them was ruptured, his fears of rejection activated his attachment system and caused him to cling as a way of maintaining the relationship. It became important for the parents to handle such incidences in structured and supportive ways that did not provoke attachment fears. These understandings increased their investment in the relationship and they concentrated on providing positive relational experiences when possible. When Rafael was agitated, a timely hug or expression of concern could sometimes ward off a full tantrum. At other times, the tantrum could not be deflected, but the parents learned to stay in proximity and re-establish a positive relationship as quickly as possible when it ended.
Rafael’s parents maintained tight supervision at home and were careful to modulate the arousal and stimulation Rafael experienced and to keep it at a tolerable level. Both at home and in therapy, an emphasis on cuing to Rafael’s inner experience through words, tones and gestures was maintained. New experiences were gradually introduced and processed so as not to overwhelm him. Expectations were geared towards his developmental rather than chronological age.
In therapy, Rafael and his parents learned various fun games and exercises that require children to attend to external stimuli and regulate behavior accordingly. These were then practiced at home. They played Red-light Green-light, Simon Says, performed mirroring exercises and moved to the varying paces and intensity of a drum. Rafael was also taught to pay attention to physical manifestations of emotions—tight muscles, butterflies in his stomach, restless hands—and to begin to label them as nervousness, fright, excitement etc. An emotional thermostat was placed in his room, color coded green, yellow and red that helped him signal the degree of distress he was feeling at various times so that he and his parents could catch and address those feelings before they exploded. This began to provide the family with a concrete language to discuss feelings and to begin to reflect upon them. At first the parents had to cue Rafael to signal his feelings through the thermostat. After about 9 months, Rafael gained the skills to contain himself enough that he could begin to discuss those feelings verbally.
Mother: We had a rather difficult week. My sister was coming over for dinner on Tuesday and I asked Rafael to help clean up the house. He told me I was just bossing him around and that he never got to do what he wanted. My husband told him that everyone who lives in this house has to respect each other and help each other out and that he was not being nice to me–given how much work I had to do to get ready. When Rafael heard that, he blew his top. He kicked at his toys, screamed and started swearing. It took about an hour before he calmed down.
Therapist (to mother): Sounds like you weren’t expecting that reaction.
Mother: Absolutely not. When I was his age, I helped out much more than he does. And I wasn’t even asking him to do that much.
Therapist: So why do you think he had such a hard time with it? Do you have any sense of what was going on with him?
Mother: Not really.
Therapist: Let’s ask him. Rafael, when you do things like kick toys and swear, you are telling your parents about something going on inside of you. It could be a feeling or a thought that you haven’t put into words. Do you have any idea what you were telling them that day?
Rafael: I don’t know.
Therapist (to mother): Do you have a sense of what he was feeling inside?
Mother: He was probably angry.
Therapist: He might have been. Generally when kids do something fairly aggressive they are angry or scared. What might he have been angry about?
Mother: I guess he didn’t want to clean up.
Therapist (to Rafael): How did you feel about being asked to clean up?
Rafael: I just wanted to play. I had a game that I was planning to do with her, but I couldn’t do it because I had to clean up and then her sister was coming and there wasn’t going to be time.
Therapist: So you had planned something special that got interrupted. And you felt just totally helpless like you were going to miss out on things and maybe even not get special time with your mom. And since you got so upset, you must have felt that you couldn’t do anything about it.
Therapist (to mother): Did you know that he was feeling that way?
Mother: Well, I knew he was upset, but not all the rest.
Therapist: Would it have made a difference if you had known the rest?
Mother: Absolutely. We might have been able to work something out differently.
Therapist (to Rafael): You know, kids and grown-ups get upset about stuff all the time. And it’s just fine to have those feelings. It’s the way you handle them that makes the difference. And when you scream and kick and do things that aren’t safe, usually you just get in trouble, which makes you feel more upset rather than working out the problem. I am wondering, when you feel that way, what else can you do that wouldn’t get you in trouble?
Rafael: I don’t know.
Therapist (to mother): Has there ever been a time when Rafael got really upset about something and he handled it without exploding?
As the conversation proceed, Rafael and his parents worked out ways in which the parents could help Rafael to handle such events in the future. This included having the parents ask Rafael at difficult moments, “how can I help you handle this?” and to have some agreed upon silly code words that would help Rafael signal his inner state. Such words bring playfulness and humor to the situation, thus helping to transform it.
Rafael was educated about family relationships. He learned that children never get non-stop attention, that when parents set limits they do so for children’s best interests and safety rather than for selfish reasons, and that even when children make mistakes or their parents feel crabby or tired, they still love their children and would neither hurt them nor send them away. He learned that cuddling and talking with a parent could help him calm down and feel better when upset. He slowly began to tolerate his parents’ and therapist’s reflections upon his feelings and joined with them in becoming a feeling detective who could figure them out, himself.
As Rafael grew closer to his parents, regressive behaviors emerged. He followed them around the house, even to the bathroom door, and craved constant attention. He wanted to cuddle and pretended to be a baby. These younger relational behaviors were seen as an opportunity for Rafael to rework his early attachments and experience a more positive parental relationship. They cooed over him, told him how much they loved him and assured him that they would take care of him and keep him safe. With the therapist’s support, they were able to tolerate his regression.
Through therapy, Rafael learned to verbalize and communicate his thoughts and feelings better and to depend on his parents to help him handle emotional issues. His parents gained a better sense of his inner life leading to greater attunement, emotional understanding and connection. Over time, this allowed an exploration of Rafael’s past, through both play and discussion. Initially, the therapist and Rafael explored these play themes together with the therapist interpreting the play to his parents. The therapist provided containment by limiting this exploration to doses that Rafael could tolerate. Over time, and with coaching, the parents participated with Rafael, as well, in this endeavor. Through very vivid dollhouse play, Rafael worked on issues about the neglect and fear he experienced in his birth family and about his various losses and how those experiences influenced his expectations of others. He allowed the therapist to introduce nurturing and protective figures into his play and eventually began to do so himself.
Rafael made improvements over time. After approximately 2 years, he expressed a firm commitment to his new family and an ability to use them reliably for comfort and nurturance when upset. A secure attachment had been formed. Aggressive behavior diminished noticeably as he used his parents and the skills they learned together to help regulate himself. He continued to show some difficulties with organization and attention, becoming distracted at school and home, even at times when he did not appear anxious or upset. An assessment for ADHD was conducted and he began on medication for that condition.
Peer relationships remained problematic for some time and social skills training was needed to help improve those skills. He began partaking in structured activities such as sports teams with other children in which the social demands were somewhat less than in individual or group free play. The parents at first stayed close on the sidelines during games, discreetly coaching his social behavior throughout. Sports became an important outlet for him to develop athletic skill, a sense of competence and peer approval. This helped fuel gains in self-esteem and peer interactions.
Rafael’s secure attachment to his parents though not, in itself, remedying all his problems, increasingly allowed him to reflect on his behaviors, follow their suggestions and thus acquire new skills. Despite these gains, stressful circumstances often brought a return of dysregulated behavior, but not aggression. Rafael and his family continue to be seen intermittently to address issues as they arise. He remains quite vulnerable to situations that provoke feelings of loss, rejection or fear.
Conclusion and Future Directions
This case explores the various diagnostic and treatment elements of one child who exhibits a disorganized attachment and other difficulties with relationships, self-regulation and attention. Though a number of treatments for young children have been developed, few exist for older children. The methods of treatment described here share some common traits with those other treatments, but also diverge in important ways. Like many treatments based on attachment principles (Cooper et al. 2005; Dozier et al. 2005; Hughes 2004; Lieberman and Pawl 1990; Kinniburg et al. 2005; Slade et al. 2005), the case here concentrates heavily on the attachment relationship and the ways in which parental insight and behavior impacts the child. The parent is aided in reflecting upon and more accurately interpreting the child’s cues and miscues as well as the parent’s own reactions to those indicators. Provision of extensive parental support is also a key component (Dozier et al. 2005; Drisko and Zilberstein, in press; Zeanah and Smyke 2005). Additionally, an emphasis on emotional communication and affect regulation pervades the treatment, although the methods for achieving this goal differs somewhat from other interventions.
Those differences in part result from the fact that middle childhood is a very different developmental stage than early childhood, thus creating new challenges and opportunities for intervention. Internal working models of attachment are more internalized and generalized and less easy to modify simply by changed parental behavior, itself. As such, the older child must be more actively engaged in the treatment. In addition, older children are required to cope more independently with a larger number of environments and expectations outside of the attachment relationship making it important that some autonomous social and regulatory skills be learned. As maturation allows for increased cognitive and reflective skills, those skills can be more directly taught and practiced in treatment. The child, as well as the parent, is taught to reflect upon emotion and behavior and to take some responsibility for learning techniques to enhance emotional regulation. Emphasis is placed upon learning those techniques within the attachment relationship, as the child will initially have trouble cuing himself and recognizing his own internal states.
In addition, as discussed here, therapeutic assessment and intervention must focus both on attachment issues and also the myriad of other co-morbid conditions that result from poor early care. Those co-morbid issues vary from child to child, as do the strengths and vulnerabilities that both the child and family bring to treatment. Only a few discussions of treatments for this population focus on the myriad of co-morbid concerns that often accompany disorganized attachment (Kinniburg et al. 2005; Zeanah and Smyke 2005). This may, in part, be due to the fact that differential diagnosis, in many cases, only becomes possible as the child ages and different syndromes become clearer.
This case focuses on a child with adequate cognitive ability and autonomous parents, both crucial strengths that aided in his treatment. In fact, the availability of an adequate attachment figure was most likely the single most important factor in propelling his gains. Forming a secure attachment to a parental figure allowed this child to rely on that attachment figure for soothing, relief of distress and guidance. He was able to internalize a safe base, which became the foundation of other gains. However, it is important to recognize that while forming the attachment relationship was a crucial first step in the therapeutic process, it did not, in itself, prove sufficient for abating all of the child’s difficulties and comorbid problems. Treatment also needed to focus, in a step-by-step process, on addressing the various other issues that emerged. This aspect of treatment is more similar to recently developed phase-based treatments for trauma (Cloitre et al. 2002; Kinniburgh et al. 2005) than treatments that look more singularly at attachment. However, given the high rates of comorbidity in this population, which necessitates a combination of interventions, a phase-based approach seems warranted.
Only a few case studies currently exist that explore the various difficulties and treatment dilemmas for this population. Treatment needs may be quite different for children with varying types of maltreatment or experiences of early institutionalization and deprivation. More case studies and research is needed on these populations so that a more comprehensive model of their treatment needs can be established. In addition, the quandary of how to treat children who do not live with caretakers who can help them establish secure attachment relationships remains. That domain requires further exploration.