Secure Attachment

What happens when the mother reassigns a different motive to the child's cry and decides not to be responsive?

A youngster cries for a reason - not to manipulate his parent, not to be mean, or nasty, or to be a "pain in the neck." When, instead of trying to discern what her youngster needs, a mother simply says - "oh, he's just tired," or "he has to deal with sleeping by himself now" - she has given her baby the idea that expressing his inner-self is wrong or bad. A baby is like someone who is quadriplegic. He can't do very much for himself - but that doesn't mean that he isn't thinking and feeling. When the baby cries and his mother responds, the youngster learns to have trust in the world around him and to have trust in himself. When the baby cries and his mother listens, the two join together in a moment of oneness that transcends the separateness, the aloneness, which the baby knows all too well.

If the youngster has not been responded to, if he has not been attuned to or empathized with, he begins to feel more and more powerless, alienated, and detached. You know, sometimes the best you can do is to simply empathize with your child - "I know, you are angry because . . ." or "You want to get out of this car seat right away!" Saying something like that is much better than ignoring your youngster. The less empathy that is developed between mother and baby, the less understood the youngster feels, and from there, the disconnection between the two just grows and grows.

Parenting Defiant RAD Teens

PARENTING CHILDREN & TEENS WITH REACTIVE ATTACHMENT DISORDER


What doesn't work:

1. Attempting to persuade the RAD youngster to change his mind by presenting “logical, reasonable, or “practical information”. RAD kids are highly unlikely to be influenced by reasonableness. Adult efforts to do so look “stupid” to a RAD youngster an can intensify his lack of feeling safe.

2. Emotional reactivity. RAD kids experience parents' frustration and anger as proof that the youngster is effectively controlling his parents' emotions. This only inflates their grandiose sense of power.

3. Negotiating with a RAD youngster.

4. Rescuing the youngster from the consequences of her behavior and / or attempting to solve the RAD youngster's problems for her.

Philosophy—

While love and parental common sense are necessary ingredients to successfully parent a youngster with attachment difficulties, they are rarely sufficient. This is due to the fact that most kids with attachment problems are too guarded and too distrustful to receive the love and support that moms & dads may be offering. The foundational issue for RAD kids is not love, but safety. In the absence of safety, love becomes an unaffordable luxury.

It is the pursuit of safety that leads RAD kids to be as strategic and controlling as they are. “Control” has become a prominent word in the attachment world as though it were the problem itself. This leads to conceptualizing parenting RAD kids as too often a “battle for control” which the moms & dads must win by wresting control from the youngster. While there is some truth here, this thinking mistakenly defines “control” as the problem whereas it is really only a symptom. “The problem” is a lack of feeling safe in the world, and “control” is no more than a compensatory attempt to make up for the sense of safety that is missing. It is important that moms & dads remember that they are aiming to create a feeling of physical and emotional safety that their youngster has not known previously, not simply to win a “war for control”.

With safety in place, a bridge develops across which love can flow. Think of safety as converting an “un-teachable student” into a teachable one who can now start to learn the lessons of love. Safety makes love “affordable” for the RAD youngster. Parenting a RAD youngster at this point begins to resemble the more conventional, common sense parenting of a youngster without attachment difficulties.

The specialized parenting techniques outlined below are all aimed at gradually creating safety for the youngster and removing the youngster’s blocks to receiving the love that the moms & dads have to give. Many of these techniques are somewhat counterintuitive and reflect the fact that if everything that typically makes sense has been tried without success, than anything else will seem at first not to make sense.

The parental qualities that are most successful with RAD kids are: sense of humor, curiosity about how things will develop vs. an exclusive focus on the end result, ability to meet the youngster where he is vs. where the moms & dads want him to be, and emotional availability and responsiveness. Even when parents have most of these qualities, kids with attachment problems can be very exhausting whether the parents are adoptive, foster, or biological. RAD kids have a sixth sense for finding every button a parent has and pushing them all. If you have reached the point of feeling ineffective and discouraged, that is a warning signal that professional assistance should be considered.

A word or two about brain growth and change. The brain adapts to experience, not to information. In this digital age, the tendency to overvalue the impact of information itself, disconnected from experience, has mushroomed. As H.L. Mencken put it, “For every problem there is a solution which is neat, believable, and wrong.” Information is not useless, but by itself, it does not fundamentally lead to change in kids, or adults, for that matter. If it did, you probably would not be reading this right now. The mental health of kids in the United States has been declining gradually, but steadily, since the 1950’s. All of our digital abundance has done nothing to reverse that trend. So, the message is, to facilitate growth in your kids, give them new experience, not simply new information.

A final word / warning: do not care about your youngster’s problems more than she does. RAD kids are quite content to allow the adults to carry the worry while they continue the behavior. Nothing is likely to change as long as you are more anxious about your youngster’s behavior than she is. So, moms & dads need to be careful not to take on anxiety that truly belongs to your youngster. Moms & dads cannot make their youngster better. Parents cannot make their youngster do the work they need to do to grow. Parents cannot make their youngster be successful. In the spirit of counter intuitiveness, acknowledging that your youngster has the freedom and the power to make a mess of her life increases the chances that she won’t.

Teaching / Learning—

1. Behavior: RAD kids tend to see only the payoff of their strategic behaviors as that is what’s immediately relevant. Consequently, they rarely have much understanding of what their behaviors may be costing them. It is useful for moms & dads to point out these costs to teach that behavior doesn’t come “free”. Setting up experiences to make those costs real can be very effective. (Example: A youngster who lies has almost never given any thought to the fact that this behavior costs him his believability. Besides pointing this out to the youngster, moms & dads can warn him that the time will come when he will really want to be believed about something ((the boy who cried wolf)), but the parents won't be able to. Then just wait for that opportunity to arrive- that's when the learning will begin to set in).

2. Choice: Because of disconnected thinking, RAD kids commonly lack any real concept of personal choice in their world view. They must first recognize connections between things before they can grasp how their choices affect the connections. Remedial education is in order here. RAD kids need to have connections of all kinds made for them repeatedly before the concept begins to take hold. Connections between triggers and feelings, between feelings and behavior, between behavior and its results, connections across time, and connections across situations are all examples. Visual aids (drawing) are useful supplements to verbal explanations.

3. Emotions: RAD kids usually need to be taught about their feelings. Some of them are so disconnected from their bodies that not only don’t they experience their feelings, they are often unaware of physiological sensations like cold, warmth, pain, hunger, tiredness, etc. They need help with just identifying that they are having a feeling or sensation. In addition, they need to be taught the language of feelings and to apply the correct word to the correct feeling state {much like would be done with a pre-school youngster}. This task is usually best accomplished if feeling words are limited to the following choices: happy, disappointed/sad, mad/angry, embarrassed/ashamed, and worried/nervous/afraid/scared,. RAD kids need help learning to read physical sensations {knot in stomach} as signals of feelings {nervousness} happening at the same time. Making photo flip cards can be a useful tool here. The youngster is asked to make faces representing different feelings. If the faces are accurate representations, photograph them and put them on cards. These can then be used to help identify feelings when they are running strong.

4. Eye contact: As long as a RAD youngster does not have consistently good eye contact, working on eye contact should be a priority. Good eye contact is the basis for the youngster learning to "take the parent in emotionally”. Without this "taking in", a RAD youngster is less likely to develop an emotional connection to moms & dads. If a verbal cue is not sufficient to restore eye contact, parents can: 1} gently place their hands on either side of the youngster's head and turn it or, 2} tap the youngster lightly on the cheek until her head is pointed towards the parent. Some judgment needs to be exercised here. “Getting eye contact” in any given situation, is not one of those battles to be “won” at all costs. This only contaminates eye contact with tension and conflict, like physical touch above. In addition, remember that extended eye contact in a relationship with a power differential (parent-youngster) tends to make the one with less power feel defensive. This is unlikely to lead to emotional connection. Do express pleasure and appreciation when eye contact is given.

5. Physical touch: RAD kids are often touch avoidant. Moms & dads should not let this intimidate them into rarely touching their youngster as touch is a cornerstone of attachment. Therefore look for opportunities for physical contact during calmer moments. Scheduling time for nurturant holding is another option. However, it is not recommended that physical contact be imposed over a youngster’s oppositionalism should that occur. To attempt to do so only contaminates the notion of physical affection with more conflict and tension which “poisons the well”. It may be better to look for a more propitious moment at another time. RAD kids also often need to be taught how to relax into being touched as they frequently develop an almost reflexive stiffening or bracing in response to touch.

6. Thinking connectedly: Because their early histories usually lack reliable, predictable caretaking, RAD kids tend to perceive the world as a fragmented place in which things are discrete and separate rather than connected. They are apt to see feelings and behavior as just “happening” without influencing each other. RAD kids need to be taught, over and over, that behavior is connected to triggers on the front end, to choices in the middle, and to consequences on the back end. The same is true of feelings; they need to learn that feelings are connected to triggers on the front end, to some form of expression (bodily, behavioral, or verbal) in the middle, and to outcomes on the back end.

7. Time: Because RAD kids typically have a distorted sense of time that lacks reliable continuity running from the past, through the present, and out into the future, they import things from the past into the present, believing those things belong in the present. These misplaced imports in time usually compromise the youngster’s present functioning. To prevent this, RAD kids literally have to be taught a sense of linear time and this involves repeated instruction in the difference between then and now. Much of this can be done by reiterating the concrete differences between “then vs. now” and the use of a visual time line.

Guidelines—

1. Access to Things: Prohibit access to any item that is not used for its appropriate purpose (Example: using toys to ignore the parent). The youngster’s misuse of the item is explained as a lack of knowledge (Example: “Toys are for playing with- not for ignoring your parents. So it seems that you are confused about the purpose of toys. Therefore, it wouldn’t be good for you to keep using things you are confused about”). Access is allowed again only after the RAD youngster has: 1) behaviorally demonstrated responsible behavior with things for some significant time period, and, 2) given a verbal promise to use the item in the proper fashion in the future. This promise must be restated in full, by the youngster. Just agreeing with the adult's rendition of the promise is insufficient.

2. Advice: Never offer a RAD youngster help or advice without first asking the youngster if he wants it. This question forces the RAD youngster to take some responsibility for stating what he wants in order to get it - this is priceless practice. Additionally, it helps moms & dads avoid the frustration of offering advice only to have it rejected out-of-hand because the youngster wasn't interested in solving the problem in the first place. If the youngster says he does not want advice or assistance, do not offer it anyway. Just drop the subject and move on. This holds the youngster accountable for his negative answer. When the youngster gives moms & dads orders, as RAD kids do, politely inform him that you did not ask for his advice and when you do want it, you will be sure to ask him ahead of time. This can work better than reprimanding the youngster for being rude or disrespectful.

3. Appreciation / Praise: After a RAD youngster reluctantly makes a cooperative choice, appreciation is often a better parental response than praise. Appreciation puts parent and youngster on the same level for that interaction. Praise, on the other hand, can suggest that the one offering the praise (parent) is the more powerful one, and therefore able to pass judgment on the less powerful one (youngster). Praise is, after all, every bit as much a judgment as is criticism. Praise can run the risk of the youngster feeling the parent is rubbing his face in "the parent having won". This can generate anger which may undo the cooperative decision right then, or may fuel oppositional behavior in the future. Appreciation can avoid those risks and can strengthen the parent-youngster relationship.

4. Consequences / Empathy: When imposing a consequence as part of discipline, offer emotional support (empathy) for the hardship that the consequence will cause the RAD youngster. Communicate your understanding that being disciplined probably feels like humiliation and this will lead your youngster to want to misbehave. Nonetheless, you expect that she will make a good choice even though she does not want to. This both preserves attachment while maintaining discipline. Let go of any anger that remains after imposing a consequence or you run the risk of sabotaging the effect of the consequence.

5. Consequences: When imposing what would typically be time-limited consequences, don’t automatically give the RAD youngster a definite amount of time that the consequence will last. Instead of making the consequence end after a certain amount of time has passed, base its ending on a behavioral change criteria. The consequence ends when the youngster changes the behavior that led to the consequence in the first place. That change should have occurred not just once or twice, but often enough and long enough that the parents have begun to expect it. This puts the responsibility for the consequence ending, totally on the youngster.

6. Discipline: In disciplining a RAD youngster, speak succinctly without defending or explaining the discipline. This minimizes the chances of either overwhelming the youngster with too much information or providing information that can be used for evasive, argumentative purposes. In addition, explanations undercut parental authority for they imply that the authority rests on the explanation rather than on the parent’s role. Discipline is best carried out in a matter-of-fact manner, in the style of: “Nothing personal- it’s just business”. Disciplinary interventions should not be emotionally driven. Emotionally charged behavioral interventions tend to be ineffective because they increase the youngster’s sense of being unsafe, and the youngster is apt to counter by repeating behaviors she knows will upset her moms & dads.

7. Emotional contagion: Emotions can be passed from one individual to another much like colds. This is emotional contagion. It is driven partly by rapid nonverbal mimicry, particularly of other’s facial expressions, and the associated internal sensations. This phenomenon occurs in infants only a few days old. Once individuals start mimicking facial stimuli, they often rapidly experience the emotions that are connected to these stimuli. Hence, it is important for moms & dads to monitor their facial expressions when interacting with their RAD youngster so their expressions don’t act as a source of unhelpful emotional contagion.

8. Giving / Receiving & Guilt: Avoid giving a RAD youngster much more than she can give back. Doing so reliably stirs a sense of guilt in the youngster as not deserving what has been given to her. Guilt in RAD kids practically guarantees behavioral deterioration soon afterwards. It is for this reason that gifts at birthdays and holidays should be moderate in amount.

9. Information: It is fine to withhold information from RAD kids, even information they directly ask for, when parents have a sense that that information will somehow be misused. It is instructive to tell your youngster that you are not providing the information requested because her past behavior (you are teaching connected thinking by doing this) has shown you that she is most likely to use the information poorly.

10. Love: Offering and expressing love is the parents’ responsibility. Receiving love (letting it in) is the youngster’s responsibility. Moms & dads too often take the responsibility completely onto themselves to find a way to “get their love in”. It is far more helpful to your youngster to challenge him (softly) about his methods for keeping their love out and to remind him it is his choice to remove those obstacles or not.

11. Rules: Behavioral rules need to be specific, clear, and phrased in behavioral language that states what the youngster needs to do vs. not do or stop doing. The rules need to be stated proactively because the unconscious mind does not process negatives. Thus, negatively stated rules actually increase subconscious focus on the behavior being prohibited. This increases the future chances that the undesirable behavior will reoccur. The rules need to be communicated with the expectation that they will be learned and followed. This is best conveyed with a matter-of-fact tone of voice that is free of any emotional edge. Example: “You will go to your room right after dinner and do your homework.” Thanking the youngster in advance for his cooperation can improve compliance. The interaction should be broken off after the parent expresses gratitude for expected compliance. In addition, establish the ground rule ahead of time and always in play, that the RAD youngster needs to ask what the rules might be for anything that has never been discussed before. This removes avoidance efforts by way of ignorance, from the RAD youngster's repertoire.

12. Safety: Maintaining the physical safety of individuals and property should always be parents’ top priority. This always takes precedence over doing something to promote attachment, to encourage better behavior, etc.

13. Unpredictability: An unpredictable range of parental responses and consequences is useful to keep the RAD youngster a bit off balance. This sounds counterintuitive because safety is so linked up with consistency in the common sense parenting world. RAD kids see consistency, not so much as indicating safety, but as making it easier to strategically protect themselves because they can reliably predict what the adults are going to do. So, the element of surprise is a powerful tool for moms & dads of RAD kids because being surprised interferes with RAD kids's efforts to strategically maneuver. In addition to unpredictability, being vague at times is also useful because RAD kids tend to scan situations very quickly in order to try to figure them out. Moms & dads being vague blocks this “hypervigilant radar” and this again can disrupt efforts at control. Parenting strategies also need to be switched over time, particularly if they are being successful, so as not to wear a strategy out by making it too predictable or routine.

Specific Interventions—

1. Attention: Since attention activates thoughts, feelings, and behavior, a useful question to ask your youngster from time to time is, “What are you paying attention to that is leading to this behavior?”.

2. Belief vs. truth: Explaining the difference between belief and truth is useful. The central ideas are that individuals frequently believe things that aren’t true and disbelieve things that are true. What someone believes and what is true don’t necessarily have anything to do with each other. This then becomes the basis for suggesting that the RAD youngster may be fooling herself into thinking that some things are true just because she believes them. This can further promote some self-reflection on the youngster’s part.

3. Cross-talking: If there are two adults available, cross-talking is a useful technique. Here, the adults talk to each other, with the youngster present, in order to convey information they want the youngster to hear. This makes it more difficult for the youngster to mount an argumentative response. The adults might simply be hypothesizing about what may possibly be going on with the youngster. Cross-talking should be kept fairly short or the RAD youngster may tune it out.

4. Demandingness: RAD kids can be demanding, and often so. Occasionally ask your youngster, when she makes a demand, “What is in it for me?”. This can be an effective reminder that relationships are reciprocal.

5. Distrust of self: Describe how everything the RAD youngster does that is not real (making up answers, fake emotion, playing dumb, fake laughter, “forgetting”, etc.) teaches him to be distrustful of himself while he thinks he is fooling everyone else. Point out how he will tell himself it is other individuals he can’t trust while he remains unaware of his extensive distrust of himself. Explain how he has become so skillful at fooling himself that sometimes he really doesn’t know what he is doing. Reframe “I don’t know” answers as “pretending not to know” and tell the youngster that he has been pretending not to know for so long, he can no longer tell the difference between pretending and really not knowing. Should the youngster disagree, just point out that time will make it clear whether he has fooled himself with his own pretending, or he really doesn’t know. This approach can be supplemented by suggesting that the RAD youngster doesn’t even believe himself when he takes extreme or absolute stances. The goal here is to create a split within the RAD youngster so he begins to question his snap judgments and strategic maneuvering. When challenging a RAD youngster’s thinking, it is helpful to tell the youngster up front that he probably won’t believe you. This creates a paradox the youngster cannot escape with simplistic control maneuvers.

6. Forgetfulness: Forgetfulness should never be accepted as a valid reason for avoiding responsibilities or consequences. Instead, forgetfulness is framed as an intentional choice and the RAD youngster has taught her brain to forget things she doesn’t want to remember. The solution that is presented to the youngster in this situation is to sharpen her memory in the future or find a way to help herself remember. The youngster is held accountable for the act of remembering.

7. Promises: When accepting a promise from a RAD youngster, remind her that should she choose to break it, she will really hurt herself because she won’t be able to use promises in the future as a way to obtain something she wants from her moms & dads. She will then have the added burden of having to figure out how she can earn the adults’ trust back. Never accept a promise from a RAD youngster who already has a track record of broken promises that has not been corrected sufficiently to have earned trust back.

8. Unintelligible speech: RAD kids frequently speak so that what they say cannot be clearly understood. Sometimes they mutter. Sometimes they speak very softly. Sometimes they make up words. Sometimes they scramble the order of words in a sentence. Sometimes they leave words out. While some RAD kids do have language disabilities, the majority of unintelligible speech used by RAD kids is a purposeful strategy. Like lying, unintelligible speech is another way to keep moms & dads in the position of “not knowing and trying to find out”. Thus, if asked to repeat what was said unclearly, the RAD youngster is likely to say it unclearly again, or refuse to repeat it, or blame the moms & dads for not listening, or tell the moms & dads that they had their chance and blew it. This follow-up frustrating of the moms & dads only adds to the youngster’s unhelpful sense of power. Therefore, assume that if it was said unclearly, it wasn’t important, and move right on as if your youngster never spoke. If she later says that she already told you something, just tell her it didn’t get through. Then instruct your youngster that, in the future, when she has something that she wants you to know, to check with you when she tells you to make sure that you understood. If she doesn’t double-check with you, then she runs the risk that you don’t know what she wants you to know. This shifts the responsibility for communicating clearly onto the youngster.

9. Unresponsiveness: When attempting to talk with a RAD youngster who is not responding at all, one can try role-playing the youngster and speaking what you think the youngster would be saying and then shift back into the adult role such that you are carrying both sides of the conversation. RAD kids often respond to this. This needs be done in a matter-of-fact and not teasing way.

10. Victimhood & Responsibility: When self-pity, which usually takes the form of blaming others, while playing “victim”, is used by the RAD youngster to try to get moms & dads to lower their expectations, parents should simply tell the youngster that he is choosing to feel sorry for himself and that is an easy out which the parents will not support. Empathy is the last thing to offer the RAD youngster in such situations- that would essentially be enabling. Instead, the goal is to use the situation to promote personal responsibility for the RAD youngster. Holding a youngster accountable often involves making restitution to the individual negatively impacted by the youngster’s behavior- this is action and not simply a “pro forma” verbal apology. As part of role modeling responsibility, avoid the phrase, “You made me feel…”. This is a terrible phrase and one that is fundamentally inaccurate. It assigns responsibility for the speaker’s feelings to the other individual, leaving the speaker in the role of “victim” and demonstrating the opposite of responsibility. If you are not responsible for your feelings, your youngster will not learn to be responsible for his.

Questions parents should avoid asking your RAD youngster:

1. “ Did you…?” (The answer will most likely be “no”.)
2. “ Do you remember…?” (The answer will be “no”.)
3. “ Why did you…?” (The answer will likely be made up or “I don’t know.”)
4. ” What did you say?” (See unintelligible speech.)

Questions to ask:

1. How does it happen that…?
2. How is it that…?
3. How…?
4. What happened?
5. What…?

Should a question be asked that goes unanswered, it can be useful to tell the RAD youngster that if he doesn’t answer, you will make up the answer for him and count that as his answer and use it as the basis for any related decision you might have to make.

1. Tantrums / Meltdowns: Different kids require differing approaches in order to come out of a tantrum. Some kids will need direct confrontation, others will need a warm and supportive approach including affectionate holding, while still others will need to be left alone for a while as their psychological boundaries are weakened during an outburst. A mismatch will produce escalating panic and prolong the tantrum.

2. Something Will Happen (unpredictability): Rather than confronting the RAD kid with a specific consequence in the moment, it can be very effective to say something like: “You can make that choice. I don't think it's a good move and something will happen.” Moms & dads must be ready to follow through in some specific way should the kid make the poor choice. However, the follow through can come several days later. That intervening period of waiting for the other shoe to drop can have significant impact on the RAD kid (though not the first time around). At the time of imposing the consequence, reference the prior warning that “something will happen” and identify that this is that something to insure your kid gets the connection.

3. Rejecting the family: When a RAD kid voices a wish to not be part of the family, periodically removing the kid from some or all of normal family routines can be more useful than trying to include the kid, who then may ruin whatever is happening for everyone. Then, instead of the family experiencing activities being sabotaged, the kid experiences the natural consequences of his wish not to be involved. Physical removal, while possibly seeming a bit “harsh” at first, serves to make the kid's wish very concrete so he can really experience it. This can lead the kid to begin to rethink his choices.

4. Problematic Situations: With situations wherein there have been problems, before re-entering the situation, review what happened the previous time and explain what is expected this time. Get a firm commitment from the kid to follow the expectations. The commitment takes the form of repeating back to you the expectations, not just a single-word answer. If your kid won’t do this or does it incorrectly on purpose, don’t take her back into the situation. That simply invites history to repeat itself.

5. Point plans: Point plans come in many varieties that differ in multiple ways. One of the ways they differ is the time period of their cycling: hourly, daily, weekly, or monthly. For RAD kids, given their difficulties with temporal perception, daily-based plans are the best choice. A daily plan provides practice at learning to make connections across a 24-hour time period and it can contribute to safety by emphasizing the 24-hour rhythm of family life. One way to structure a daily plan is that each day’s privileges must be earned by meeting certain behavioral criteria the day before. Things that may have been givens, such as free time, can be redefined as privileges and incorporated into such a plan. If the criteria aren’t met, the relevant privileges are lost for the next day, but the the next day also brings another opportunity to earn them anew.

6. Planned Regressions: This involves setting aside specific time periods during which the kid is allowed to regress to whatever age he would like to be. This is set up as a special game or play-time between parent and kid. As part of these planned regressions, the parents actually handle the kid as if he were the younger age he's pretending to be. One common technique is feeding the kid with a baby bottle. Such planned time for “backing up” can help RAD kids pick up missed developmental pieces. This approach generally works better the younger the kid is, but can be effective even with early adolescents. It should be done without a sibling audience.

7. Paradoxical Interventions: Precisely because they are nonlinear and illogical and therefore are not undercut by direct oppositionalism, paradoxical interventions can be very effective with RAD kids. Two examples are: (1) Humorous, but not mocking agreement with the kid's critical views of the family. Example: Openly agreeing that the youngster has gotten a raw deal in having to live with such a stupid and boring family and she should be upset. (2) Predicting and implicitly giving permission for limited misbehavior. Example: I know that you are probably going to argue, complain, be rude, get silly, whine, ignore me, and have a tantrum about__________. Would you tell me how much time you need for your tantrum?”

8. Over-practice: After a youngster breaks or “forgets” a rule, she must practice following the rule. Example: Youngster orders parents around rather than making requests. Rather than correct the youngster and then grant the request after it is phrased respectfully, the parent has the youngster approach the parent several times in a row, repeating the same request each time. It might then be honored after 3-4 practice rounds. The whole exercise is defined as practicing the “skill of making requests” since the earlier behavior indicated that the youngster did not how to do this properly.

9. Orphanage behavior: When RAD kids have spent time in an orphanage, they frequently pick up behaviors that were useful in that context such as hoarding, stealing, lying, setting others up, physical aggression, and poor hygiene. When these behaviors show up in the family, label them “orphanage behavior” and define them as reflecting the youngster’s difficulty in perceiving changes across time. Therefore they are acting as if they are still “then and there” rather than “here and now”. The expectation is that they will learn to tell the difference between “then” and “now” and drop the behaviors that belong to “then”. In addition to impacting behavior, this intervention simultaneously helps improve temporal perception.

10. Forced Choice: With this strategy, moms & dads give the RAD youngster two choices, both of which are agreeable outcomes to the moms & dads. Example: choice one: go to bed on time tonight and you get to stay up until your regular bedtime tomorrow night; choice two: for each minute you are late getting in bed tonight, five minutes will be taken off your bedtime tomorrow night. The moms & dads then step back and allow the youngster's behavior to "tell the tale" of what will happen. The fact that both outcomes stem directly from the youngster’s behavior teaches the concepts of both choice and cause-effect and makes it more difficult for the youngster to frame the outcome as resulting from the parents' just being “mean”.

11. Accessing Anger: (This intervention should NOT be used with kids prone to angry outbursts, tantrums, aggression, etc. It can be useful for kids who express their anger indirectly through passive-aggressive or nuisance behaviors or are inordinately fearful of anger). Anger is essential to the defining and maintaining of appropriate boundaries between oneself and the world. RAD kids who cannot access their anger and use it as a boundary tool, tend to perceive the world as a chronic invasive threat and themselves as relatively helpless. This intervention can help address these factors. 1) Parent and youngster sit three feet apart, facing each other. 2) Each individual picks an angry phrase to use that is agreeable to both. Over time, the phrases used by the youngster should move towards ones that are more uncomfortable to say. 3) Decide on the voice volume both parent and youngster will use. Over time, this should get progressively louder. 4) Agree on a length of time from ten to thirty seconds. Use a timer to monitor. 5) Both parent and youngster begin saying their phrases at the same time at the agreed upon voice level. There is no listening involved. 6) Discuss the experience briefly afterwards as needed. This exercise is done only once in any given day. It can be practiced regularly, though not necessarily daily, until the most uncomfortable phrases can be repeated, with an elevated voice, for a full 30 seconds.

12. “Why” questions: "Why?” questions from RAD kids are almost always maneuvers to undercut parental authority by getting information the youngster can use to argue that the parents position is illegitimate. “Why?” questions are also usually false questions in that the youngster already knows the answer. The best responses to “Why?” questions are to either: 1) point out that the youngster already knows the answer, 2) ask the youngster to tell you the answer to his own question; or 3) a tongue-in-cheek, but not sarcastic, answer: (Example: youngster asks why he has to sit and eat dinner with the family- parent replies that it helps his body digest food to eat with other individuals and talk). Probably the least useful thing a parent can do with a “Why?” question is to take it as legitimate and to provide a meaningful answer.

Promoting Attachment in Very Young Kids Ages 0 to 5—

Regardless of the youngster’s age, it is optimal if one parent is home full-time for the first six months post-adoption, and there are no separations longer than a weekend during the first year. If there are still significant problems after the initial six months, that is a reliable indicator that professional help should be sought.

0 - 6 Months: Maximize physical contact with your infant during feeding, changing, bathing and by obtaining a front mounting pack for carrying. Rocking, stroking and lots of infant massages can help as well. Maximize face-to-face communication. Seek to match your youngster’s facial expressions and vocal qualities to promote bonding. Observe whether your infant responds to one sensory modality more than another. If so, draw on that sense more when interacting. Identify which sounds, types of touch, rhythms, positions, sights, and smells your infant enjoys. Pair these up with things that cause a startle reaction to lower anxiety. If your infant is primarily a self-soother, imitate his soothing activities (e.g., rocking) and add an additional element such as singing or comforting touch. Allow your infant to look away as this is often in the service of self-regulation and don’t force excessive eye contact. Sleep with the baby in your bed or next to it in the with crib with the side rail down.

6 -10 months: Maintain a consistent routine to promote physiological regulation. Allow your infant her full range of feelings. Crying now may just signal a feeling and not a call for help. This kind of cry need not be immediately soothed, but attachment can be promoted by staying with your infant while she's distressed, for your physical presence validates her feeling. Attachment problems make an infant prone to backslide or regress developmentally. Allow some degree of this. Interacting with your infant at a temporarily regressed level can help fill in any earlier gaps in the attachment process. Imitate any constructive self-soothing behaviors to reinforce them. If you adopt an infant at this age, transfer as many elements from the previous placement as possible, into your home. If your infant attached to his previous caretaker, expect a grief reaction. This can sound like a more despairing cry than other infant cries. Offer physical comfort, but know that this grief can be inconsolable. If your infant doesn't relax, then remain with him so that his grief becomes part of his relationship with you. This will facilitate bonding and attachment.

10 - 18 months: Many of the techniques for younger infants also apply now. Allowing regression, and interacting with your infant while she is regressed can become more important, as a method of filling in the previous attachment gaps, as the youngster gets older. If your youngster moves away from you to explore, but does not return to check in, you can encourage checking-in by placing some favorite objects near you after she has moved away and calling her attention to them. Praise your youngster for returning.

15 - 24 months: When your youngster's wooing becomes coercion, limit the attention available and redirect your toddler to another activity. Firm limits are important to complete the bonding cycle of trusting limits. If this isn't done, there is a risk of unraveling the attachment gains made to this point. Overindulgence, though well intended, will bear no good fruit. Watch for opportunities to use language to assist your youngster to understand and express feelings and ideas. To the degree things can be expressed verbally, they won't be acted out behaviorally.

If you adopt a youngster of this age, record all the details of placement day and of the previous caretakers. Maintain contact with those caregivers, including visits, and later phone calls and cards. The frequency of contact should lessen over time. Allow open discussion about previous caretakers. This will facilitate the transfer of bonding and attachment from them to you.

24 - 36 months: Regressions are likely during this period as well if attachment is poor. Allowing for these and interacting with your toddler during them can strengthen weak spots from previous stages. Guard against any temptations to be overprotective as this will interfere with resolving separation anxiety. Build in planned absences as they can facilitate the resolution of separation anxiety. Keep expectations realistic. This is particularly important for moms & dads who adopt a two - three-year-old. Unrealistic expectations will block attachment from developing by creating a preponderance of disappointment.

3-5 Years: The weak reality testing characteristic of this age (egocentrism and magical thinking) makes the use of the word “real”, very tricky. It will probably get interpreted as real vs. pretend or fake and this can complicate attachment and identity. Therefore, avoid this word and use functionally descriptive labels such as “birth parents” or “the moms & dads who are raising you”. Avoid the use of “forever parents”; it is too abstract. If you have the information, making the birth mother concrete with photos, her name, and telling stories of the youngster’s pre-adoptive life, based on information that you do have, can reduce the distraction that comes from not knowing. It is useful to point out likenesses between your adopted youngster and the rest of the family (appearance, qualities, activities, interests, foods liked or disliked, etc.) in order to nourish belonging. By age 3.6, kids understand that different skin tones are differentially valued in society. Don’t deny this but instead, point out that it is not true within the family. Explain it as others’ deficit and not the youngster’s. Make up stories, with your adoptive youngster as a central figure, of your family’s life in the near and more distant future to nurture a sense of belonging going forward.

Parenting Defiant RAD Teens

Attachment and Adult Relationships

How the Attachment Bond Shapes Adult Relationships—

You were born pre-programmed to bond with one very significant person—your primary caretaker, probably your mother. Like all babies, you were a bundle of emotions—intensely experiencing fear, anger, sadness, and joy. The emotional attachment that grew between you and your caretaker was the first interactive relationship of your life, and it depended upon nonverbal communication. The bonding you experienced determined how you would relate to other human beings throughout your life, because it established the foundation for all verbal and nonverbal communication in your future interactions.

People who experience confusing, frightening, or broken emotional communications during their infancy often grow into grown-ups who have difficulty understanding their own emotions and the feelings of others. This limits their ability to build or maintain successful interactions. Attachment—the interaction between babies and their primary caretakers—is responsible for:

• the ability to rebound from disappointment, discouragement, and misfortune
• the ability to maintain emotional balance
• the ability to enjoy being ourselves and to find satisfaction in being with others
• shaping the success or failure of future intimate interactions

Scientific study of the brain—and the role attachment plays in shaping it—has given us a new basis for understanding why vast numbers of human beings have great difficulty communicating with the most important people in their work and love lives. Once, we could only use guesswork to try and determine why important interactions never evolved, developed chronic problems, or fell apart. Now, thanks to new insights into brain development, we can understand what it takes to help build and nurture productive and meaningful interactions at home and at work.

What is the attachment bond?

The mother–child bond is the primary force in infant development, according to the attachment bond theory pioneered by English psychiatrist John Bowlby and American psychologist Mary Ainsworth. The theory has gained strength through worldwide scientific studies and the use of brain imaging technology.

The attachment bond theory states that the interaction between babies and primary caretakers is responsible for:

• the ability to bounce back from misfortune
• strengthening or damaging our abilities to focus, be conscious of our feelings, and calm ourselves
• shaping all of our future relationships

Studies reveal the infant/adult interactions that result in a successful, secure attachment, where both people are aware of the other’s feelings and emotions. Studies also reveal troubled - or insecure attachment - in which the communication of feelings fails. Researchers found that successful adult interactions depend on the ability to:

• use communicative body language
• stay “tuned in” with emotions
• manage stress
• be readily forgiving, relinquishing grudges
• be playful in a mutually engaging manner

The same studies also found that an insecure attachment may be caused by abuse, but it is just as likely to be caused by isolation or loneliness.

These discoveries offer a new glimpse into successful love relationships, providing the keys to identifying and repairing a love relationship that is on the rocks.

The attachment bond shapes a baby’s brain—

For better or worse, the infant brain is profoundly influenced by the attachment bond—a baby’s first love relationship. When the primary caretaker can manage personal stress, calm the infant, communicate through emotion, share joy, and forgive easily, the young child’s nervous system becomes “securely attached.” The strong foundation of a secure attachment bond enables the youngster to be self-confident, trusting, hopeful, and comfortable in the face of conflict. As an adult, he or she will be flexible, creative, hopeful, and optimistic.

Our secure attachment bond shapes our abilities to:

• balance emotions
• create positive memories and expectations of relationships
• deal with stress
• develop meaningful connections with others
• experience comfort and security
• explore our world
• feel safe
• make sense of our lives

Attachment bonds are as unique as we are. Primary caretakers don’t have to be perfect. They do not have to always be in tune with their babies’ emotions, but it helps if they are emotionally available a majority of the time.

Insecure attachment affects adult relationships—

Insecurity can be a significant problem in our lives, and it takes root when a baby’s attachment bond fails to provide the youngster with sufficient structure, recognition, understanding, safety, and mutual accord. These insecurities may lead us to:

• Become disorganized, aggressive and angry—When our early needs for emotional closeness go unfulfilled, or when a parent's behavior is a source of disorienting terror, problems are sure to follow. As grown-ups, we may not love easily and may be insensitive to the needs of our partner.

• Develop slowly—Such delays manifest themselves as deficits and result in subsequent physical and mental health problems, and social and learning disabilities.

• Remain insecure—If we have a mom or dad who is inconsistent or intrusive, it’s likely we will become anxious and fearful, never knowing what to expect. As grown-ups, we may be available one moment and rejecting the next.

• Tune out and turn off—If our mom or dad is unavailable and self-absorbed, we may—as kids—get lost in our own inner world, avoiding any close, emotional connections. As grown-ups, we may become physically and emotionally distant in relationships.

Causes of insecure attachment—

Major causes of insecure attachments include:

• emotional neglect or emotional abuse—little attention paid to the youngster, little or no effort to understand the youngster’s feelings; verbal abuse
• frequent moves or placements— constantly changing environment; for example: kids who spend their early years in orphanages or who move from foster home to foster home
• inconsistency in primary caretaker—succession of nannies or staff at daycare centers
• maternal addiction to alcohol or other drugs—maternal responsiveness reduced by mind-altering substances
• maternal depression—withdrawal from maternal role due to isolation, lack of social support, hormonal problems
• physical neglect —poor nutrition, insufficient exercise, and neglect of medical issues
• physical or sexual abuse—physical injury or violation
• separation from primary caretaker—due to illness, death, divorce, adoption
• traumatic experiences— serious illnesses or accidents
• young or inexperienced mother—lacks parenting skills

The lessons of attachment help us heal adult relationships—

The powerful, life-altering lessons we learn from our attachment bond—our first love relationship—continue to teach us as grown-ups. The gut-level knowledge we gained then guides us in improving our adult interactions and making them secure.

Adult interactions depend for their success on nonverbal forms of communication. Newborn babies cannot talk, reason or plan, yet they are equipped to make sure their needs are met. Babies don’t know what they need, they feel what they need, and communicate accordingly. When a baby communicates with a caretaker who understands and meets their physical and emotional needs, something wonderful occurs.

Relationships in which the parties are tuned in to each other’s emotions are called attuned relationships, and attuned relationships teach us that:

• conflicts can build trust if we approach them without fear or a need to punish
• nonverbal cues deeply impact our love interactions
• play helps us smooth over the rough spots in love relationships

When we can recognize knee-jerk memories, expectations, attitudes, assumptions and behaviors as problems resulting from insecure attachment bonds, we can end their influence on our adult interactions. That recognition allows us to reconstruct the healthy nonverbal communication skills that produce an attuned attachment and successful interactions.

Parenting Defiant RAD Teens

Insecure Attachment and Attachment Disorders

Symptoms and Repair of Poor Attachment and Reactive Attachment Disorder—

When babies and young kids have a loving caregiver consistently responding to their needs, they build a secure attachment. This lifelong bond affects growth, development, trust and the ability to build relationships. However, severely confusing, frightening and isolating emotional experiences early in life disrupts this bond, creating insecure attachment. In extreme circumstances, this can result in attachment disorders. Problems with attachment limit a youngster’s ability to be emotionally present, flexible and able to communicate in ways that build satisfying and meaningful relationships. The earlier attachment disruptions are caught, the better. However, it is never too late to treat and repair attachment difficulties. With the right tools, and a healthy dose of time, patience and love, attachment repair can and does happen.

What is insecure attachment?

Attachment is the process of bonding between a baby’s primary caregiver, usually the mother, and the infant. Babies are helpless from birth, and need consistent, loving responses to their needs for food, sleep and comfort. As the infant grows, so does the bond of trust with the primary caregiver. Secure attachment has a lifelong effect on growth, development, trust and relationships.

If a youngster is not provided this consistent, loving care, insecure attachments form. Kids with insecure attachments have learned that the world is not a safe place. They don’t have the experiences they need to feel confident in themselves and trust in others. Because attachment is a fundamental part of kid’s development that affects the growing brain, insecure attachment shows itself in many different ways. Kids may have trouble with learning, may be aggressive and act out, be excessively clingy, have difficulty making friends, suffer anxiety or depression, or be developmentally delayed. In cases of severe deprivation, abuse or neglect, attachment disorders may form. Attachment disruptions and disorders often have similar symptoms of disorders such as ADHD or autism and may be misdiagnosed.

Causes of Insecure Attachment and Attachment Disorders—

• Abuse and neglect. If the primary caregiver is a source of pain and terror, as in physical or emotional abuse, a secure attachment cannot form. Moms & dads who abuse alcohol and drugs may have a lowered threshold for violence and are at increased risk for neglecting their kids.

• Child illness or disability. Babies with long hospital stays, where they have been isolated and alone, are also at risk. Moms & dads may also feel overwhelmed with a baby’s needs if the infant is constantly sick and in pain, withdrawing or lashing out at the youngster because they don’t know what to do.

• Kids in institutional care. Kids in institutional care have not only lost their primary caregiver but may have lived in conditions where they cannot form a secure bond. Kids in a succession of foster or group homes, or kids adopted from overseas who have lived in orphanages, are at risk.

• Constantly changing caregivers. Insecure attachment can also occur if the youngster has very little interaction with a primary caregiver, but instead has a succession of childcare providers that are not attuned to the youngster and do not stay in the youngster’s life.

• The caregiver is unable to provide for the child. Sometimes, moms & dads may love and intend the best for their kids, but not know themselves how to provide the care the kids need. They may have a history of abuse, depression, trauma or be overwhelmed by work and childcare responsibilities. A medical emergency may have occurred in the parent, making care very difficult. A death or trauma in the family can also have enormous impact.

Signs and symptoms of attachment disorders—

Insecure attachments influence the developing brain, which leads to a variety of symptoms. Interactions with others, self-esteem, self-control, learning, and optimum mental and physical health are affected. Symptoms of insecure attachment may be similar to common developmental and mental problems including ADHD, spectrum autism, depression, and anxiety disorders.

Insecure attachment patterns:

Although the signs of insecure attachment are many, they are really the youngster’s attempt to make sense out of an unpredictable world. Some symptoms of attachment disruption can be traced back to what the parent did not provide.

• Ambivalent attachment. An ambivalently attached youngster experiences the parents’ communication as inconsistent. Sometimes their needs are met, sometimes not, and sometimes the communication can be overly intrusive. Because these kids cannot reliably depend on the parent for attunement and connection, they may be insecure and anxious. They may also display excessive clinginess and dependence, on the unconscious hope that their needs will be met some of the time.

• Avoidant attachment. When a parent is emotionally unavailable, rejecting, or prematurely forcing independence, a youngster may become avoidantly attached. These kids adapt by avoiding closeness and emotional connection. On the surface, this youngster may appear to be very independent, but their self reliance is a cover for insecurity. Avoidant kids may have difficulty forming relationships, be aggressive and bully other kids.

• Disorganized attachment. Disorganized attachment occurs when the youngster’s’ need for emotional closeness remains unseen or ignored, and the moms & dads behavior is a source of disorientation or terror. When kids have experiences with moms & dads that leave them overwhelmed, traumatized, and frightened, they become disorganized and chaotic. Coping mechanisms may include dissociation, withdrawal, extreme passivity or aggression in getting needs met.

Reactive Attachment Disorder (RAD)—

Reactive Attachment Disorder (RAD) is a clinically recognized form of extreme insecure attachment. Common causes of RAD include severe child abuse and neglect. Kids may have been removed from the home and placed in the foster care system. RAD also frequently occurs in internationally adopted kids who were living in orphanages.

Signs and Symptoms of RAD:

Kids with RAD are so neurologically disrupted that they have extreme difficulty attaching to a primary caregiver, attaining normal developmental milestones or establishing normal relationships with other people. They show strong symptoms of attachment disruption. These kids may be difficult or impossible to soothe, accepting comfort from no one, even the primary caregiver, and preferring to play alone. On the other hand, they may seem superficially friendly to everyone, inappropriately approaching and interacting with strangers as if they were the primary caregiver. What can be especially hard to bear for those who care for these kids is that the youngster might not seem to be bonded to them at all, despite their attempts to show love and affection. Many of these kids may be incorrectly diagnosed with severe emotional and behavioral disturbances ranging from bipolar disorder to depression. Families caring for kids with RAD will benefit from treatment and therapeutic parenting skills. In time and with patience, even severe attachment disorders can be repaired.

Repairing insecure attachments and attachment disorders—

Sadly, insecure attachment can be a vicious cycle. Due to problems with social relationships, insecurely attached kids may become even more isolated and withdrawn from their primary caregivers, family and friends. They may be seen as “bratty” or “bullies”, making it hard for them to form relationships that may mitigate the effects of insecure attachment. However, it is never too late to work on forming secure attachments. While the brain is most pliable in infancy and early childhood, it is responsive to changes all of our lives. Relationships with relatives, teachers and childcare providers can also supply an important source of connection and strength for a youngster’s developing mind.

Here are some tips on repairing an insecure attachment:

• Help the youngster express his or her needs. Kids with attachment problems will need extra help in learning to express their needs. They may have learned not to cry if in pain or frightened, for example, or not associate touch with being soothed. They may revert to developmentally inappropriate behaviors if stressed or scared. It might take extra creativity and diligence on the caregiver’s part to help the youngster express needs safely and appropriately.

• Learn what creates a secure attachment. Attachment is an interactive process that requires both verbal and nonverbal skills. Emotional intelligence is critical to building a secure attachment, since even verbal kids are sensing our moods and watching everything we do. Every youngster is unique and will have different ways to be soothed.

• Provide support for the primary caregiver. The primary caregiver needs to be emotionally healthy, have adequate time, and the right skills to be attuned and responsive to the youngster’s needs. In some cases, the caregiver may simply be overwhelmed, and help with household or work responsibilities allows them to focus. Other caregivers may need more help, such as parenting classes, alcohol or drug treatment, or therapy for mental disorders such as emotional trauma or depression.

• Time, consistency and predictability is key. Problems in attachment result from problems with trust. By this very definition, repairing an attachment disruption takes time, consistency and patience. It will take time for a youngster to realize that they can trust and rely on their primary caregiver and other important people in their lives. Kids with attachment disruptions may be more sensitive to life changes and situations like travel, returning to school or holidays. Caregivers should be aware and as attuned to this as possible, helping to keep a normal schedule during unpredictable times.

Conflict, boundaries, and repair in secure attachment:

No matter how much we love our kids, there comes a point where we are not in agreement with them, a point when we have to set limits, and say “no.” This conflict temporally ruptures the relationship as the youngster angrily protests. Such protest is to be expected. The key to strengthening the attachment bond of trust is to be consistently available when the youngster is ready to reconnect. It is also important to initiate repair when we have done something to hurt, disrespect, or shame a youngster. Moms & dads aren’t perfect. From time to time, we are the cause of the disconnection. Again, our willingness to initiate repair can strengthen the attachment bond.

For kids with insecure attachments and attachment disorders, this conflict can be especially disturbing and scary—for both the kids and the primary caregiver. The youngster may overreact, having a wild tantrum, or rapidly withdraw. They may temporarily show developmentally regressive behaviors, like rocking or trouble with toileting. Don’t be afraid to set limits and boundaries with insecurely attached kids. Consistent, loving boundaries will help them develop the sense of trust they need that their caregiver will be with them through thick and thin. These kids also need to learn that no matter what they do, they will be loved and respected.

Professional treatment:

Kids with severe attachment difficulties and their caregivers can benefit from professional treatment as well. Caregivers can learn tips and techniques for coping with their youngster and helping to repair the attachment. Therapists can help caregivers learn how their youngster communicates through play, for example, which allows many kids to express feelings and desires they cannot verbalize. Attachment therapy should never be coercive or shaming to the youngster.

Adoptive and foster parents:

Adoptive and foster parents open their hearts and homes to kids who have sometimes been severely abused and neglected. These parents might not have expected the challenges that come with kids with attachment difficulties. Even if these challenges are known, anger, lashing out and difficult behaviors can be frustrating and hard to handle. Remember that the youngster is not acting out because of lack of love for you. They are acting out because their brain development has actually progressed differently. Your stability in the youngster’s life is giving him or her a tremendous chance to repair insecure attachments and have a much better start in life. Be sure to seek support from organizations and support groups that specialize in your situation, and don’t be afraid to seek help for yourself if you are feeling overwhelmed and frustrated.

Parenting Defiant RAD Teens

Dr. Ann Corwin: Attachment Theory



Parenting Defiant RAD Teens

Secure Attachment

The research in the field of attachment opens up a whole new world for all of us in understanding the problems of parents and kids. Attachment is the emotional connection between any two people. However, life's first attachments are by far the most important, as they set a template for all later relationships. Attachment between young ones and parents evolved naturally eons ago, as the infants and kids who developed a strong need to remain near their moms & dads were the ones who were most likely to survive - both physically and psychologically. Kids who feel the most secure in their early relationships with moms & dads have tremendous advantages in life. They tend to grow up feeling good about themselves and others. They cope well with life's ups and downs, and they have a strong capacity for empathy. These young ones naturally form other healthy, close relationships as they go out into the world. Young ones who have not developed a healthy, secure attachment with moms & dads tend to grow up feeling more insecure, disconnected, and angry.

Three Ingredients of Attachment—

There are three main ingredients to a secure attachment relationship. The first is physical connection, which means plenty of touch and eye contact. Such things as cradling an infant while feeding, cuddling with a toddler before bedtime, and hugging a teenager increase the sense of physical connection, especially if touch and eye contact take place on a daily basis throughout the childhood years.

The second ingredient is emotional connection. Kids sense their moms & dads are connected on an emotional level when their parents are tuned into their feelings. Infants feel their parents' attunement when moms & dads respond accurately to their infants' cries or when they share their infants' delight in new discoveries. Kids sense the emotional connection when their parents empathize with their feelings or provide them with comfort or reassurance. Even discipline, when carried out with empathy, can increase the emotional connection.

Finally, kids need an environment that is consistent, predictable, and safe in order to develop a quality attachment. Kids need to know that if their feelings or behaviors get out of control, their moms & dads will remain steady and calm. They need to be able to depend on a consistent schedule, consistent limits, and consistent parental responses. Without this kind of safe, dependable environment a child will develop emotional walls which will prevent a secure attachment.

Obstacles to a Secure Attachment—

All babies and kids are biologically programmed to attach to their moms & dads, but not all kids develop quality attachments. There are several situations that can interfere with a good attachment. For example, kids with a difficult temperament may be so highly active or so extreme in their emotions that their parents naturally have difficulty connecting with them either physically or emotionally. Kids who endured an abusive or chaotic early life and who are later placed with an adoptive family may have emotional walls that are difficult to penetrate.

Moms & dads who live in stressful circumstances may have difficulty creating secure attachments. Out of necessity they may be so preoccupied with solving the problems of living and coping that they are unable to tune into their kid's feelings and needs. Moms & dads with addictions are unable to stay attuned to their kids or provide a consistent, safe environment because they are preoccupied with the addictive substance or behavior, and the whole family may be on the addictions roller coaster together.

Finally, parents who grew up without secure attachment relationships themselves often have difficulty providing the ingredients of a secure attachment relationship with their own kids. Moms & dads who did not experience nurturing and closeness growing up may feel uncomfortable with closeness, and may subsequently distance themselves from their young ones. Parents who were mistreated as kids may have a strong need to be in control in order to avoid feeling vulnerable, and may therefore become excessively controlling with their kids. Moms & dads who were mistreated may perceive normal child misbehaviors as attempts to mistreat or hurt them, and may overreact in these situations. Moms & dads who feel unlovable may fear their kids don't love them, and may attempt to placate their kids or give them things to get them to love them more. Parents who were not securely attached in childhood may be disconnected from their own painful feelings, or they may be overwhelmed by painful feelings. Parents who experienced poor attachments are also more vulnerable to the use of addictive substances or behaviors to cope.

Parenting Defiant RAD Teens

Preventing Reactive Attachment Disorder (RAD)


While it's not known if reactive attachment disorder can be prevented with certainty, there may be ways to reduce the risk of its development:
  1. Be actively engaged with babies and kids in your care by playing with them, talking to them, making eye contact or smiling at them, for example.
  2. Don't miss opportunities to provide warm, nurturing interaction with your baby or youngster, such as during feeding, bathing or diapering.
  3. If you lack experience or skill with babies or kids, take classes or volunteer with kids so that you can learn how to interact in a nurturing manner.
  4. If your baby or youngster has a background that includes orphanages or foster care, educate yourself about attachment and develop specific skills to help your youngster bond.
  5. If you're an adult with attachment problems, it's not too late to get professional help. Getting help may prevent you from having attachment problems with your kids, who otherwise may also be at risk.
  6. Learn to interpret your baby's cues, such as different types of cries, so that you can meet his or her needs quickly and effectively.
  7. Teach kids how to express feelings and emotions with words. Lead by example, and offer both verbal and nonverbal responses to the youngster's feelings through touch, facial expressions and tone of voice.

Coping With RAD—

If you're a parent or caregiver whose baby or youngster has reactive attachment disorder, it's easy to become angry, frustrated and distressed. You may feel like your youngster doesn't love you — or that it's hard to like your youngster sometimes.

You may find it helpful to:
  • Acknowledge that the strong or ambivalent feelings you may have about your youngster are natural
  • Be willing to call for emergency help if your youngster becomes violent
  • Continue friendships and social engagements
  • Find respite care so that you can periodically have downtime if caring for your youngster is particularly troublesome
  • If your youngster was adopted, reach out to your adoption agency for attachment resources
  • Join a support group to connect with others facing the same issues
  • Practice stress management skills
  • Take time for yourself through hobbies or exercise

Parenting Defiant RAD Teens

Risk Factors for Reactive Attachment Disorder

Reactive attachment disorder is considered uncommon. It can affect kids of any race or either sex. By definition, reactive attachment disorder begins before age 5, although its roots start in infancy.

Several risk factors can contribute to the occurrence of reactive attachment disorder.

Parental or caregiver related risk factors:
  • Aggressive behavior towards kids when they request comfort
  • Being abused, neglect, and abandonment by primary caregivers
  • Being raised by parents with different psychological conditions (such as unipolar or bipolar disorder, postpartum depression, substance abuse, anger management problems, or attachment disorder)
  • Forced removal from a neglectful home
  • Frequent changes in foster care or caregivers
  • Inexperienced parents that provide inconsistent or inappropriate care
  • Maternal ambivalence toward pregnancy

Child related risk factors:
  • Being separated from parents/caregivers due to prolong hospitalization
  • Difficult temperament
  • Premature birth
  • Suffering a birth or prenatal trauma
  • Suffering from painful or undiagnosed illnesses

Environment related risk factors:
  • Being separated from birth parents as the result of divorce, death, or serious illnesses
  • Extreme poverty
  • Frequent changes in foster care or caregivers
  • Living in orphanages
  • Significant family trauma, such as death or divorce

Complications:

Without treatment for reactive attachment disorder, a kid's social and emotional development may be permanently affected.

Complications and related conditions may include:
  • Academic problems
  • Aggression
  • Anxiety
  • Bullying or being bullied
  • Depression
  • Developmental delays
  • Drug and alcohol addiction
  • Eating problems
  • Growth delays
  • Inappropriate sexual behavior
  • Lack of empathy
  • Malnutrition
  • Relationship problems in adulthood
  • Temper or anger problems
  • Trouble relating to classmates or peers
  • Unemployment or frequent job changes

Parenting Defiant RAD Teens

All About Attachment Disorder: An Overview

Attachment disorders are the psychological result of negative experiences with caretakers, usually since infancy, that disrupt the exclusive and unique relationship between kids and their primary caretaker(s). Oppositional and defiant behaviors may be the result of disruptions in attachment.

Many kids experience the loss of primary caretakers either because they are physically separated from them or because the caretaker is incapable of providing adequate care. Removal from primary caretakers can cause serious problems by breaking primary attachments, even if alternate caretakers are competent.

Attachment disorders have been described in the psychological and psychiatric literature for approximately 50 years. The condition Rene Spitz called anaclitic depression is now considered an attachment disorder. Spitz observed young kids in an orphanage who were fed and kept clean and were initially in good physical condition but who received no consistent affection from a sole caretaker. The long-standing absence of emotional warmth took an enormous toll on the kids, primarily on their emotional development but also on their physical growth and development condition. Spitz concluded that providing only for a baby's physical needs is not sufficient for normal development.

A short while later, John Bowlby, a psychoanalyst interested in the parallels between human babies and animal babies, incorporated Harlow's research on rhesus monkeys into his study of the youngster's tie to its mother. He concluded that separations during the first few months of life negatively impact a baby's psychic organization and that separation from a parental figure causes separation anxiety.

In a film entitled A-Two-Year-Old Goes to Hospital, Bowlby shows that a baby goes through several phases in reaction to separation. The baby goes from protest to crying to a sad state and, finally, to a more desolate state of resignation regarding the loss.

Bowlby, the father of attachment theory, produced a report for the World Health Organization (WHO) highlighting the importance of parental sensitivity in adequate child development. Parental sensitivity refers to the ability of a mom or dad to read internal states and emotions in his or her baby and to respond to them in a positive and supportive manner.

Attachment refers to a set of behaviors and inferred emotions that can be observed in babies. Humans need attachments with others for their psychological and emotional development as well as for their survival. Early manifestations of attachment include the unique and exclusive relationship between a baby and its moms & dads. Moms & dads and babies establish a continuous relationship that has specific features. The quality of this relationship colors the individual's relationships for the rest of his or her life.

Both caretaker and baby have biological preprogrammed instinctive equipment to foster their relationship. Most individuals have a strong attraction and desire to care for babies. In addition, a baby's crying and clinging (signaling behaviors) reinforce the baby's efforts to obtain care and attention. Moms & dads also has instinctive behaviors, such as soothing the crying baby, caressing it, making sounds that are appealing to the baby, and mirroring the baby (i.e., playfully imitating the baby's facial expressions), all of which trigger tenderness and a maternal instinct.

Attachment develops through repeatedly being looked after and appropriately responded to by the caretaker. This convinces the baby and young child that an individual is available to soothe, console, and comfort. Babies may develop attachments to other individuals who are consistent in their lives; however, the relationship with the primary caretaker(s) plays the most critical role in determining the youngster's basis for future attachments. The attachment figure(s) cannot suddenly be replaced by any other caretaker because that relationship is unique and stable.

Based on the nature and quality of early attachments, kids develop an internal working model of relationships that serves as a template for future relationships. These working models of relationships can be positive (i.e., individuals can be trusted, confided in, helpful in distress) or negative (i.e., no one can be trusted, individuals are not caring, one is all alone in the world). Babies internalize their moms & dads (and other attachment figures) as a secure base. This allows babies to feel internally safe and to confidently explore the world around them. It also allows them to experience positive interpersonal exchanges with other kids. The baby can come back to the caretaker to refuel emotionally before proceeding with further explorations.

Reactive attachment disorder—

Reactive attachment disorder (RAD), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), requires etiologic factors, such as gross deprivation of care or successive multiple caretakers, for diagnosis.
  • In dis-inhibited RAD, the youngster participates in diffuse attachments, indiscriminate sociability, and excessive familiarity with strangers. The youngster has repeatedly lost attachment figures or has had multiple caretakers and has never had the chance to develop a continuous and consistent attachment to at least one caretaker. Disruption of one attachment relationship after another causes the baby to renounce attachments. The usual anxiety and concern with strangers is not present, and the baby or youngster superficially accepts anyone as a caretaker (as though individuals were interchangeable) and acts as if the relationship had been intimate and life-long.
  • In inhibited RAD, the youngster does not initiate and respond to social interactions in a developmentally appropriate manner. It is a disorder of nonattachment and is related to the loss of the primary attachment figure and the lack of opportunity for the baby to establish a new attachment with a primary caretaker. Also, a nonattachment disorder may develop because the baby never had the opportunity to develop at least one attachment with a reliable caretaker who was continuously present in the baby's life.

Attachment disorders independent of DSM-IV –
  • In angry attachment, a strong relationship exists between mom or dad and baby that is unique and exclusive; however, the relationship is marked by angry features and exchanges. The dyad members are angry with each other but not with other individuals around them.
  • In reversed attachment, the youngster becomes the source of comfort to the mom or dad, who is insecure and vulnerable; the relationship is inverted and the baby, although unable to reassure the parent completely, provides the security.

Mary Ainsworth developed an attachment classification based on the behavior of babies (typically aged 10-13 mo) in the presence of a stranger during and after a short separation from their primary caretakers.
  • Approximately 65% of American middle-class kids are thought to have secure attachments with primary caretakers, whereas 35% exhibit an insecure attachment style. Not all kids who show an insecure attachment to primary caretakers are diagnosed with RAD, either because they did not receive pathological care or because their insecure attachment is not severe. The lack of a secure attachment style affects the youngster throughout life; however, an insecure attachment should not be confused with a disorder. The Ainsworth attachment study is only a suggestion of an internal state of the youngster. It is not a diagnostic tool for attachment disorders.
  • Behavioral patterns associated with insecure attachments, such as avoidant and ambivalent styles, include lack of distress upon separation and avoidance of, or anger toward, mother upon reunion.
  • Behavioral patterns associated with secure attachments include some distress at separation, preference for a mom or dad over a stranger, and a search for comfort from the mom or dad upon reunion.

Pathophysiology—

Inhibited RAD:

If caretakers are not reliably or consistently present or if they respond in an unpredictable and uncertain way, babies are not able to establish a pattern of confident expectation. One result is insecure attachment, or a less than optimal internal sense of confidence and trust in others, beginning with caretakers. The kid then uses psychological defenses (e.g., avoidance or ambivalence) to avoid disappointments with the caretaker. This is thought to contribute to a negative working model of relationships that leads to insecurity for the rest of the youngster's life.

Dis-inhibited RAD:

Young kids exposed to multiple caretakers simultaneously or sequentially do not easily experience the sense of security associated with unique and exclusive long-standing relationships. No opportunity exists to trust one individual because past relationships were interrupted, disrupted, or consistently unreliable. Kids with dis-inhibited attachment resort to psychological defense mechanisms (e.g., relying only on themselves and not expecting to be soothed, cared for, or consoled by adults) to survive. Instead of relying on one individual, any sense of fear or loneliness is inhibited and the kids develop a pseudo-comfort with whoever is available. The youngster is thought to suppress the conscious experience of fear only as a result of a psychological defense. The youngster is afraid of trusting anyone and being further disappointed. This pattern can continue into adult life and adversely affect adult relationships.

Frequency—

United States:

No epidemiologic studies of frequency or prevalence of attachment disorders in kids exist; however, statistical data regarding adoptions and foster care placement are available. One might estimate, based on the number of foster care placements and disruptions in relationships, approximately how many kids can have attachment disorders.

International:

Many kids, examples being certain kids from Romania and China, have lived in orphanages and have had little opportunity for attachment or they have lived in bleak conditions with multiple caretakers and are emotionally and cognitively deprived. In the midst of such deprivation and so many disruptions in relationships, determining exactly what causes a youngster to have difficulties in relating and communicating, in development of trust, and in linguistic and cognitive development can be difficult.

Race:

No evidence suggests greater prevalence of attachment disorders in a particular racial or ethnic group unless as noted above in specific countries with unusual youngster care practices.

Sex:

No information in the scientific literature suggests a sex predilection exists.

Age:

Onset of attachment disorders is in kids younger than 5 years. Typically, the disorder has its roots in infancy. The more serious effects of disruptions in attachment relationships tend to persist and manifest themselves in the preschool and school years. In more muted forms (e.g., mistrust and difficulties in establishing supportive, sensitive, and intimate relationships), they last into adolescence and adulthood.

Clinical—

History:

Rene Spitz noted that the kids in the orphanage were prone to physical illness and had decreased appetites. They exhibited some stereotyped movements, self-stimulation, and an empty look in their eyes. They lacked normal responses of interest when individuals came close. They cried vaguely or softly many times a day and seemed unhappy. Many of these kids seemed depressed and unresponsive to initiatives for interaction, as if they were resigned to their situation of affective deprivation. These kids also had a much higher mortality rate than non-institutionalized pediatric populations.

A history of gross neglect, lack of contingent responses, and little or no attention, interaction, and affection are required to establish a diagnosis of inhibited RAD. For a diagnosis of dis-inhibited RAD, a history of multiple caretakers, sequential changes in caretaker, disruptions in relationships, and placement with different individuals for considerable periods must exist. The youngster does not develop preferential attachments and secure base behavior toward a specific individual but instead develops an undifferentiated closeness with anyone who approaches the youngster.

1. Inhibited RAD-
  • Blank expression, with eyes lacking the luster and joy that is usually observed
  • Failure to thrive
  • May appear bewildered, unfocused, and under-stimulated
  • No evidence of the usual responses to interpersonal exchanges
  • Poor hygienic condition
  • Underdevelopment of motor coordination and a pattern of muscular hyper-tonicity because of diminished holding
  • Appearance of not knowing body language
  • Does not approach or withdraw from another individual
  • Does not pursue, initiate, or follow up on cues for an exchange or interaction.
  • May avoid eye contact and protest or fuss if an individual comes too close or attempts to touch or hold them (have developed avoidant behaviors because they do not expect interaction and have learned not to interact when an adult approaches)
  • No exploration of another individual's face or facial expression

2. Dis-inhibited RAD-
  • Can give hugs to anyone who approaches them and go with that individual if asked
  • Instead of caution, excessive familiarity or psychological promiscuousness with unknown individuals
  • May approach a complete stranger for comfort, food, to be picked up, or to receive a toy

Physical—

No specific physical signs of attachment disorder exist. Nevertheless, indirect indicators may be present, such as the following:
  • A syndrome characterized by excessive appetite in kids who have been in several foster homes
  • Effects of under-nutrition and rashes because of not changing diapers frequently
  • Excessive appetite and excessive thirst in kids who experience severe stress
  • Flattened back of the head because left in bed much of the time in cases of nonattachment
  • If severe, growth retardation
  • Signs of physical maltreatment, such as old fractures or bruises

Causes—

Multiple situations can lead to attachment disorders.

1. Inhibited RAD: Young kids who are exposed to multiple caretakers simultaneously or sequentially do not easily experience the sense of security associated with unique and exclusive long-standing relationships. No opportunity exists to trust one individual because past relationships were interrupted, disrupted, or consistently unreliable.
  • Abandonment by caretaker at the peak of attachment needs (end of first year of life)
  • Gross insensitivity in the caretaker
  • Gross neglect
  • Repeated abandonment by caretaker

2. Dis-inhibited RAD: Promiscuous or dis-inhibited attachment disorders have a phenomenology opposite that of inhibited attachment disorders. This is the most common type of attachment disturbance in clinical settings. Many kids with this condition have been placed in multiple foster homes or have lived with different relatives; their moms & dads are unable to create a sense of permanency in their lives. Many of the moms & dads experience legal problems, engage in illegal drug use, abuse alcohol, or have personality disturbances, which make them unable to provide stability for the youngster.
  • Multiple caretakers sequentially or concurrently
  • Multiple disruptions in attachment relationships
  • Several changes in foster home placement

3. Risk factors: Risk factors are the same as those associated with poor parenting, maltreatment, and neglect. A number of psychosocial factors place some kids at particular risk, such as caretakers who abuse drugs, have multiple unmanageable stressors, or have been maltreated or have experienced multiple attachment disruptions themselves.

Workup—

Laboratory Studies:
  • Studies related to neglect and nutritional deprivation (e.g., anemia caused by iron deficiency, high level of lead caused by pica) exist.
  • No directly related laboratory studies exist.

Imaging Studies:
  • No imaging studies are used to diagnose this condition.

Histologic Findings:
  • No histologic findings are related to attachment disorders.

Treatment—

Medical Care:

An appropriate treatment program for a youngster with multiple challenges requires the participation of several specialists. Most of the treatment is provided by primary caretakers, such as moms & dads or substitute moms & dads, in their everyday interactions with the youngster. Hopefully, these caretakers can rely on the expertise and advice of a mental health professional who is aware of the emotional needs of kids, the phenomenology of attachment disruptions, and the need to repair and recreate the sense of security in the youngster. Referral to a mental health professional may be critical.

Play therapy with a youngster psychotherapist, particularly in the presence of the primary caretakers, may help the youngster and the caretakers to express the emotional needs, fears, and anxieties of the youngster in the context of play. Caretakers may become more sensitive to the issues (e.g., anger about having been abandoned, maltreated, left alone, or locked up) faced by their youngster. Also, kids may be able to express their dependency needs (e.g., to be a baby, to be looked after, to be soothed) through play.

Several therapeutic ingredients seem important in treating inhibited RAD and dis-inhibited RAD. When caretakers provide the ingredients described below, the youngster may experience healthy dependency, rely on someone, and trust a new individual. That is to say, the youngster may become attached.
  • Security, or a sense of psychological safety, helps promote the development of a new attachment relationship. Constant or intense stress and anxiety do not facilitate a sense of security but, rather, promote guarding behavior. To correct the scars or sequelae of attachment disruption, the clinician, parent, or caretaker must have time and be ready, without judging, to listen to the youngster. Limits must be set for the youngster, but these should be set in the context of empathy and compassion. Only when the verbal kids feel emotionally secure will they begin talking about what has happened to them and, likely, to their siblings and gradually develop trust in the new caretaker.
  • Stability refers to the permanence of the attachment figure. The youngster needs time to develop trust in a new primary caretaker. After disruption(s), these kids need to learn to recognize their needs and to learn that these needs can be met repeatedly by the same individual.
  1. Separations and disruptions may reactivate a defensive isolation on the part of the youngster.
  2. Some kids take a long time (more than a year) to trust a caretaker again; others trust a caretaker after receiving just a few months of sensitive care. This may be a temperamental feature (e.g., orientation toward others versus inwardness) or a reflection of the quality of the match between the youngster and the new caretaker.
  3. The youngster might fear that the caretaker will disappear, die, or go away, thus leading to another disruption.
  • Sensitivity, or emotional availability, refers to attentiveness to the youngster's needs and is crucial in care taking. Inform substitute caretakers that, although the youngster may or may not be mature cognitively, the youngster's emotional development is frequently delayed in areas such as emotional expression, attachment, and age-appropriate independence. Hopefully, during the course of treatment, the youngster will gradually begin to develop feelings of dependency toward the primary caretaker because the youngster learns to expect the caretaker will be physically and emotionally available at times of crisis. During this process, caution moms & dads to expect and tolerate occasional regressive behaviors and to view them as signs that the youngster is psychologically working through earlier phases in development.
  1. For instance, a youngster who typically is independent and suspicious of others may suddenly express needs for dependency, report fears, want to sleep in the moms & dads' bed, and wish to be mommy's little boy or girl. Recommend that the moms & dads, in a sensitive way, allow the youngster to express and experience that dependency. Encourage moms & dads to think of the youngster as emotionally younger and as having legitimate emotional needs appropriate for his or her emotional age.
  2. Some kids are almost frozen emotionally because, with multiple placements and relationships, expressing age-appropriate emotions has not been safe. These kids might at first appear to be obedient because they do not express anger and are not prone to emotional outbursts. As time goes by, expressing emotions, such as anger, jealousy, and neediness, becomes safe. The caretaker may observe the appearance of temper outbursts, jealousy, and anger toward him or her upon separation. Things that previously did not seem to matter to the youngster (eg, if the caretaker comes or goes) may suddenly be upsetting. For example, a youngster who never seemed to mind separations may strongly protest the parent's leaving by clinging or going to the mom or dad for comfort. Encourage caretakers to see these behaviors as positive signs that a new attachment and a deeper level of trust have formed because the youngster feels safe to express these developmentally appropriate dependency needs.

Surgical Care:
  • No surgical procedures to treat this condition exist.

Consultations:

Consult specialists about particular problems that may be associated with experiences of detachment and neglect, such as excessive eating and drinking.
  • Pediatric gastroenterologist to rule out gastroenterological problems
  • Endocrinologist or nutritionist for short stature and malnourishment

Diet—

No specific diet is indicated; however, many kids who have experienced disruptions and early neglect also have feeding disorders and may require treatment. Also, some kids may have excessive appetite and thirst.

Medication—

No pharmacologic treatment specifically for attachment disorders exists. Psychopharmacologic agents may be used to address problems such as explosive anger, hyperactivity, and difficulty focusing or sleeping. These agents are used at similar doses and with the same objectives as described in other articles. Treat ancillary problems in order to promote the optimal psychosocial functioning of the youngster; however, these treatments are not addressed specifically to the attachment disorder.

Follow-up—

Further Inpatient Care:
  • Unfortunately, intermediate or longer-term hospitalization is no longer available in today's economic climate. Day hospital, partial hospital, or residential care in a placement skilled in treating very disruptive, poorly attached kids may be a suitable alternative to prevent further foster care placement failures.
  • No specific indication exists for treatment of attachment disorders with inpatient hospitalization; however, occasionally, some kids and, particularly, teenagers may require a period of inpatient hospitalization to address issues such as mistrust or lack of emotional involvement with others. For instance, with the teenager who has had multiple placements, foster homes, or group homes, a period of inpatient treatment may be beneficial in helping the youngster face fears of becoming close to any individual. Also, therapy during hospitalization may help the youngster work on overcoming the fear of acknowledging dependency needs and the fear of acknowledging desires for attention and affection.

Further Outpatient Care:
  • Child therapy and relational therapy (e.g., parent-child, parent-baby) may be useful for many kids and caretakers. Caretakers may struggle with disciplining the youngster while trying to foster the youngster's ability to relate and trust. Establishing a positively oriented and developmentally appropriate behavioral management program is very important to avoid further punishment or prolonged abandonment in excessive time outs. In the context of relational play, or narrative therapy, the youngster can develop a theme that describes what is in the youngster's mind. New caretakers may need considerable emotional support to deal with challenging and difficult behaviors in their kids.

Inpatient & Outpatient Medications:
  • No pharmacologic treatments specifically indicated for attachment disorders exist; however, kids with this condition may exhibit complications in their behavior, such as aggression, defiance, or attention deficit. Medications may be geared toward those symptoms. The treatment of these problems is covered in the respective articles.

Complications:
  • Disruptions in attachment tend not to occur as isolated events but coexist with a number of adverse psychosocial circumstances known to cause psychologic disturbance. These circumstances impede adequate parenting and care…giving and often result in the loss of the primary caretakers, possibly causing posttraumatic stress symptoms. They include the following:
  1. Exposure to drugs in utero
  2. Multiple stressors, such as economic hardship, family conflict or violence (e.g., physical abuse of the baby), and crowding in the house
  3. Neglect of the needs of the baby because of parental substance abuse
  • Because of the attachment disorder, kids who have experienced multiple losses tend to engage in defiant behavior, are non-cooperative with adults, experience pervasive anger and resentment, and develop an exploitative attitude toward other individuals.
  • Persistence of the nonattachment or the superficial exploitation of individuals, with fear of closeness and intimacy, is a major complication. When kids become moms & dads, they may transmit difficulties in attachment (i.e., the moms & dads may be insensitive emotionally and may be unavailable) to their own kids.
  • The youngster with disruptions of attachments faces academic difficulties related to maltreatment and to mistrust of adults. Academic difficulties may also be related to attentional problems and hyper-arousal associated with posttraumatic stress. Additionally, the youngster may have learning disabilities and language difficulties if exposed to drugs in utero or because of a genetic loading. These disabilities may have led to the difficulties the moms & dads had in caring for their youngster in the first place. Even without all of those challenges, kids with multiple placements and disruptions in their living situations are at risk of experiencing academic problems. A specific educational program designed to address those needs is necessary. If the youngster is a ward of the state and the school system does not promptly and appropriately respond, state-supported legal assistance is usually available to enforce compliance with federally mandated educational assessment and management.
  • When the youngster has experienced multiple disruptions in placements and has witnessed violence, he or she may develop conduct disorder, experience difficulties in social settings, and/or be prone to antisocial behavior because he or she lacks empathy and appropriate models of coping and caring behavior.

Prognosis:
  • Without treatment and new attachments, the chance for normal emotional development, building trusting relationships, and experiencing and tolerating intimacy and closeness with other human beings is very poor.

Miscellaneous—

Medicolegal Pitfalls:
  • Reserve diagnosis of attachment disorders for cases clearly related to nonattachment (e.g., gross neglect, separation, loss of the caretaker) or dis-inhibited superficial attachments (e.g., multiple caretakers).
  1. Many babies seem to be oblivious to their caretakers; they do not exhibit fear and are very dis-inhibited. They might not have an attachment disorder but, instead, be focused on a particular stimulus and be unaware of their surroundings. This tendency to be impulsive, focused on a stimulus, and to be somewhat oblivious to danger is not necessarily a sign of an attachment disturbance but is more a sign of attentional deficit and impulsivity. The history of disruptions in relationships with caretakers guides the diagnosis.
  2. Many kids experience disruptions in their relationships with caretakers, and many kids become aggressive, hyper-vigilant, or defiant. However, these kids do not necessarily have attachment disorders. Aggressive behavior, explosions of temper, and defiance are characteristics of several disturbances in childhood; do not assume all of these are attachment disorders.
  3. In some facilities, clinicians have become very interested in attachment disturbances. As a result, they may view practically any behavioral disturbance in a youngster as caused by disruptions in attachment and, therefore, diagnose the behavior as an attachment disorder. This may create problems for the clinician because the current definition of the disorder implies pathogenic care (e.g., neglect or multiple caretakers in rapid succession).
  4. In kids who are non-relational and unresponsive to others, rule out the presence of a pervasive developmental disorder or an autistic condition. The differential diagnosis is facilitated by the history of neglect or multiple caretakers and by the development of imaginative play and communicational intent (which are absent or grossly impaired in the youngster with a developmental disorder).

Special Concerns:
  • A frequent concern of potential adoptive moms & dads or caretakers is deciding when the youngster is unable to develop a new attachment or to warm up to new caretakers after multiple past disruptions. After the first few months of life, the concern exists of whether or not forming an attachment to a new individual as well as the old one is possible. During the school years, establishing a close and intimate bond with a new caretaker or family seems possible. Of course, the new attachment is a complex phenomenon determined by multiple factors, such as the youngster's temperament, previous experiences with caretakers, the nature of the new moms & dads, and how sensitively the new caretakers deal with the problem.


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