Parents as Co-therapists: Treating Traumatised and Attachment Disordered Children

- Debbie Jeffrey, Australian Families for Children

27 October 2004

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Abstract

How can a therapist engage and establish trust with a child who is unattached - profoundly unable to form an intimate relationship? Reactive Attachment Disorder develops in children who fail to develop an attachment to their caregiver before about three, because of trauma, abuse, neglect, or separation (Levy & Orlans, 1998). Healthy parents who adopt or foster, struggle and often fail to connect with an unattached child. In this framework, the clinician works indirectly by engaging the parents as co-therapists, acknowledging that (a) the essential foundation for change is the child's developing attachment to a parent (Hughes, 1998) and (b) the parents are not at fault, but are resourceful and capable people (Hart & Thomas, 2000). The clinician uses elements of psychodynamic, educational, and problem-solving therapies to assist the parents to become empowered and form a secure, nurturing parental base which facilitates attachment and assists in healing.

Introduction

In traditional child therapy, the child's relationship with the therapist is the critical foundation for change. However, with a child who has a profound lack of experiences of trust, there is a great deal of difficulty on his part in beginning to trust the therapist. The child perceives the therapist's acceptance and nondirectiveness as qualities that are easy to control and which result from his successful manipulations.  The child's goal is often only to maintain control of the therapy session. (Hughes, 1997, p. 7).

The children to whom Hughes is referring are those who never learned to trust because they missed an essential developmental experience - attachment to their mothers, or to a primary caregiver. That's an essential foundation of human development. In order to treat these children effectively, we need to help them attach to their parents first and foremost. To do otherwise is to try to build on cracked foundations.

And where you have parents who are reasonably well-adjusted and motivated, as you do in adoption and foster situations, then it makes a lot of sense to work directly with the parents rather than with the child.

Reactive Attachment Disorder

In this paper, the term "Reactive Attachment Disorder" is used synonymously with Attachment Disorder. The term "mother figure" is used to mean the child's primary caregiver.

Attachment is an essential developmental task. In evolutionary terms, it is essential to our survival. Children's brains have been programmed in such a way that they are born seeking to be close to one, primary caregiver - usually, but not necessarily - their mother. Children expect their mother to feed them, to keep them warm and, most importantly, keep them close and safe. This experience activates important events in children's brains that cause them to grow and develop, to learn to trust. Further it aids in the development of their self-concept and identity, and in their ability to regulate their emotions.

The mother figure becomes the secure base from which children explore the world, and the safe haven to which they return when things become too stressful. Once children have formed this relationship with their mother figure, they generalise this experience of trust to the rest of the world, and to other attachment figures.

So how does the attachment relationship become disrupted?

• Separation from birthmother: For some children, separation from birthmother, as happens in adoption, can be experienced as extremely traumatic. (though most children, as we know, manage this pretty well)
• Abuse
• Neglect
• Trauma
• Chronic painful illness
• Multiple placements
• Multiple caregivers

Being unable to trust, children who have undergone one or most of the abovementioned experiences, are profoundly frightened, yet often manifest their fear as toughness, and "untouchability". For children who can not trust anybody, the world becomes a frightening place, one in which they can only trust yourself. They only feel safe when they they are in control. So their life becomes a huge battle for control.

Most writers and researchers don't use the DSM- IV (American Psychiatric Association, 2000, p.130) or ICD-10 (WHO, 2003, F94.1-2) criteria for Reactive Attachment Disorder, because these criteria are fairly limited, and refer only to disturbances in the child's social relatedness believed to have been caused by pathogenic care. Most of the developmental descriptions and research, such as that of Cicchetti (1989,1995), Schore (2001, 2003) and Perry (1997, 2001) refer additionally to problems in the areas of relationships, emotional development, behavioural control, and cognitive development.

ATTACh, the American Association for Treatment and Training in the Attachment of Children, uses the following to describe children who have developed Reactive Attachment Disorder :

• Superficially engaging and charming
• Lack of eye contact
• Indiscriminately affectionate with strangers
• Lack of ability to give and receive affection on parents' terms - not cuddly
• Inappropriately demanding and clingy
• Persistent nonsense questions and incessant chatter
• Poor peer relationships
• Low self-esteem
• Extreme control problems
• Difficulty learning from mistakes
• Learning problems - disabilities, delays
• Poor impulse control
• Abnormal speech patterns
• Abnormal eating patterns
• Chronic "crazy" lying
• Stealing
• Destructive to self, others, property
• Cruel to animals
• Preoccupied with fire, blood, and gore

(ATTACh, 2004, par.1)

Because they've missed some of the important affect modulation experiences which are part of mother-infant attachment, the brains of these children are hyperaroused and they have difficulty with affect regulation. They seem always angry.

Attachment disordered children are frequently misdiagnosed as having ADHD, when what they really have is the hypervigilance that comes with post-traumatic stress. They often have specific learning difficulties, and as a result may be misdiagnosed as having low IQs.

In common with other children who experience early trauma, their brains often develop abnormally. Their brains are often smaller in volume, and frequently there is significant underdevelopment of the cortex and of the corpus callosum. Perry describes how, because she has a baseline of low-level fear, the cognition and behaviour of such a child is mediated by brainstem and midbrain areas - "... she will be more reactive, reflexive and will have a very difficult time pulling cognitive solutions from her cortex" (Perry, 1997, p. 134). These difficulties with cognitive organization, in which the child tends to focus on non-verbal, physical information, contribute to a more primitive, less mature style of problem-solving. The calm child, however, using her neocortex, is able to engage in abstract cognition and more sophisticated problem-solving.

Therapy: Parents as Co-Therapists

Conventional therapies just aren't very effective for children with Reactive Attachment Disorder, and parents report finding such therapy extremely frustrating and disempowering:

These kids aren't reachable dynamically because there is no relational template, no 'other' in the psychic system, and unreachable behaviourally because they lack cause and effect thinking and can not generalize. They are profoundly over aroused at the level of the CNS and although they do not, actually cannot, talk of being terrified, they are. They have no capacity for empathy or remorse. (Fisher, 2000).

So in therapy they refuse (or are unable) to engage, they lie and manipulate, and they perceive the therapist's non-directiveness as permission to control. Because of cognitive deficits and poor cortical control, "they have difficulty working at a cognitive level and great difficulty learning from experience" (Perry, 1997, p. 134). They will often work hard at triangulating the therapist and parents.

The parents of these children already feel overwhelmed by the multitude of issues, powerless in the face of their inability to change anything, deskilled by their child's lack of responsiveness, and angry in response to the constant anger and manipulative ploys from their child. These parents need a lot of support, and they need to be believed.

"If we know diagnostically that the roots of the child's psychological problems lie in disrupted and/or distorted attachments, then we need techniques that will facilitate the child's ability to form new attachments to caring and competent caregivers" (Hughes, 1997, p. 24-25).

Beliefs and Assumptions Underlying the Model

• The "identified client" is the relationship between the parent and child.
• When we're working with parents who are adoptive or foster parents, we're assuming that we're working with people who weren't implicated in the development of the child's attachment disorder. This also applies to some biological families. The framework I'm going to describe assumes that the parents are reasonably well-balanced and motivated people.
• It is based on the belief that in order to fix the root cause of the child's difficulties, we need to help her to attach to her parents before addressing any other issues.
• It is also based on the belief that "... excessive child-professional contact, particularly in the absence of a secure parental base, has the potential to impede children's primary attachments" (Hart & Thomas, p. 309).

Principles

Two major principles in using parents as co-therapists are: Parent Education, and Parent Support and Validation.

Parent education. The primary goal is for the parent to create a connection with the child, via a corrective emotional experience. It is important that parents learn about the attachment process and just what it provides to the child, because what they are asked to provide is a kind of re-parenting experience. I believe that some of these principles are very useful even for children who aren't attachment disordered. In times of stress all children regress, and the safe haven provided by the parent is reassuring and stabilising.

The poster from the Circle of Security Project illustrates the attachment process beautifully (Figure 1). Especially relevant are the words at the bottom:

• Always be: Bigger, stronger, wiser, and kind
• Whenever possible: Follow my child's lead
• Whenever necessary: Take charge

Figure 1. Circle of Security: Secure Base and Haven of Safety (© Cooper, Hoffman, Marvin, & Powell, 2000) (Marvin, Cooper, Hoffman, & Powell, 2002, p. 110).

Many healthy parents seem to know intuitively how to engage in this process with their normal children. However, "Because foster children enter the dyad with problematic care-giving histories we suspect that foster parents need to be not only sensitive but 'therapeutic' as well" (Chase, Stovall, & Dozier 1998, p. 80).

Three essential elements of a healthy attachment experience with which parents need to become familiar in order to have a therapeutic focus with these difficult children, are: attunement, interactive repair, and nurturing and structuring.

1. Attunement:Jernberg (1993) believes that the optimal conditions of a parent-child interaction are when the parent is engaged with the child and finely attuned to the child's every internal experience. These are "recurring moments of interpersonal communion that rest on affect" (Hughes 1997, p. 12). Many writers believe these moments to be critical events because they "represent a fundamental opportunity to practice the interpersonal coordination of biological rhythms" (Schore 1993, pp. 140-142). It's in these moments of affect attunement that the mother figure regulates the child's arousal state; in time this becomes an interactive regulation which in turn becomes the basis for the child's development of self-regulation.
2. Interactive repair: Mother figures aren't always so good at attunement. However, when the "good enough" mother induces a stress response in her baby through a misattunement, she will usually manage to repair, to change the negative back into positive emotion with comfort, and reattunement. It is now recognised that this repair interaction is a positive experience, one which teaches the child that distress can be endured and conquered.

   (Figure 2: Process of Interactive Repair)

3. Nurturing and Structuring Activities:Parents need to welcome regression in their child, and to treat it as an excuse for reparenting. The child needs to be treated according to his emotional age at any given hour of the day. Because attachment disordered children are so often defiant, oppositional and controlling, by the time parents get to see a therapist, they have often become caught up in a thousand control battles. Of course, it's very important that parents maintain control of the family and establish safe and secure limits. However, they are often struggling so hard to get that control that they can lose sight of their child's need for nurturing. They need to strike at a balance between nurturing and structuring experiences, or else their over-zealous structuring behaviour will cause the child to view the parent as "mean", and interfere with the attachment process. Nurturing may involve the following:
   • Smell - mother's perfume, home aromas
   • Taste - sweet foods associated with mothering
   • Speech - singing (especially nursery rhymes), talking
   • Motion - rocking, swinging, dancing
   • Warmth - bedtime stories
   • Eye contact - have the child associate it with a reward.

"Asking these childrento give up control and hand it over is very difficult, because to them, it is a matter of life and death" (Keck & Kupecky, 2002, p. 63). Structuring experiences need to reduce the child's opportunities to be self-destructive, oppositional, or disruptive. These may involve:

• Avoid control battlesby choosing battles, and pruning back on all but the most essential, and those that can be won.
• Keep boundaries firm and fair.
• Natural or Logical Consequences: children with Attachment Disorder don't understand arbitrary consequences such as grounding. Using natural consequences wherever possible will ultimately be more effective and will help develop cause-and-effect thinking.
• Time-ininstead of time-out. Sending a child to her room adds to her level of arousal and is very isolating. The parent can instead keep the child by the parent's side, sitting quietly or helping with a quiet, calming task. This contact is very calming and strengthens the attachment process.
• Limit TV, computer and video games
• Limit toys and possessionsuntil the child shows he can look after them.
• Provide calming activitiesfor the hyperactive, hyper-aroused child, preferably within sight of the mother figure. For example, play dough, jigsaws, baking. Limit stimulating activities such as unstructured gross physical play.
• Lower parental expectations
• Be in charge. Don't permit argument or questioning. Insist on respect.

Parents can help to develop their child's sense of belonging by ensuring that their family has a strong sense of identity and connectedness. Things that will foster this are family habits, songs, jokes, rituals, funny anecdotes, and stories of memorable family moments. It's important that the family does things together, for example, taking holidays and going on outings together.

Supporting and validating parents.

Whoever carries the emotion and pain over the child's behaviour is the one who will make the most lasting change. If the parents carry the grief/anger/fear then they will change in order to avoid the pain of such deep emotions. When the parent gets overtly angry and upset over the child's behaviours then the child often says internally, "No point in both of us worrying about this" and steps back.. (Hage, 2003).

Professionals who are familiar with families like this may be aghast at parenting strategies listed above. Parents of attachment disordered children are usually overwhelmed, hurt, stressed, and angry. They are traumatised themselves. How on earth can they undertake this kind of therapeutic parenting? Yet, as Hage suggests, unless they step out of the battle with their child, they risk losing perspective, losing their own sense of compassion and causing psychic harm to themselves as well as to their child.

Parents need a lot of support and compassion in order to do this. The therapist needs, first and foremost to listen and to believe. The therapist needs to work on a sense of attachment (i.e., secure base and safe haven) with the parents, and to trust them to reflect honestly on the child's behaviour, and on their own responses. Parents need help to connect again to their ability to be tender and to nurture their child in the face of the child's tremendous hostility and resistance. It is important that the parent's intuitive actions are validated wherever possible, and their confidence and resilience in parenting are facilitated and maintained.

The parents must be placed in the lead role as the agents of change. The therapist becomes the parent coach and treatment catalyst.

Conclusion

When children experience significant maltreatment at the hands of their parents, they experience a dual trauma. First, they experience the overt experience of maltreatment, which may result in symptoms of PTSD. Second, these children experience the loss of a parent as secure base and the critical security it affords. They become stuck in the paradox of needing closeness, yet fearing closeness, because the parent is the source of fear.(Kelly, 2003, p. 6)

It's really only the child's parent who can affect that dynamic, not a third party such as a professional, no matter how skilled or empathic. That's why I suggest that we challenge more orthodox treatment methods when working with such traumatised children, that we elevate the status of parents and move them into a central position therapeutically when working with attachment disordered children.

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References

American Psychiatric Association ( 2000). Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington DC, American Psychiatric Association, 2000.

ATTACh - Association for treatment and training in the attachment of children. (n.d.) Reactive attachment disorder: signs & symptoms. Retrieved June 20, 2004, from http://www.attach.org/signssymp.htm

Chase Stovall, K. & Dozier, M. (1998). Infants in foster care: An attachment theory perspective. Adoption Quarterly, 2(1), 55-58.

Cicchetti, D. (1989). How research on child maltreatment has informed the study of child development: perspectives from developmental psychopathology. In D. Cicchetti & V. K. Carlson (Eds.) Child Maltreatment: Theory and Research on the Causes and Consequences of Child Abuse and Neglect. Cambridge: Cambridge University Press. 

Cicchetti, D., Toth, S.L. & Lynch, M. (1995). Bowlby's dream comes full circle: the application of attachment theory to risk and psychopathology. In T.H. Ollendick & R.J. Prinz (Eds.), Advances in clinical child psychology (Vol. 17, pp. 1-75). New York: Plenum Press.

Fisher, S.F. (2001). Neurofeedback: A treatment for reactive attachment disorder. EEG Spectrum International. Retrieved August 20, 2004, from http://www.eegspectrum.com/Articles/Articles/InHouseArticles/RAD/

Hart, A. & Thomas, H. (2000). Controversial attachments: the indirect treatment of fostered and adopted children via parent co therapy. Attachment & Human Development, 2(3), 306-327.

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Hughes, D. (1997) Facilitating developmental attachment. Northvale, NJ: Jason Aronson.

Jernberg, A. & Jernberg, E. (1993). Family Theraplay for the Family Tyrant. In T. Kottman & C. Schaefer (Eds.), Playtherapy in action: a casebook for practitioners (pp. 45-96). Northvale, NJ: Jason Aronson Inc.

Keck, G. & Kupecky, R. (2002) Parenting the hurt child. Colorado Springs, Co.: Pinon Press.

Kelly, V. (2003). Back to the basics - post-traumatic stress disorders vs. attachment disorders. Connections, June 2003, pp6-7.

Marvin, R., Cooper, G., Hoffman, K. & Powell, B. (2002). The circle of security project. Attachment & Human Development. 4, 107-124.

Perry, B.D. (1997). Incubated in terror: neurodevelopmental factors in the 'cycle of violence'. In J. Osofsky (Ed.), Children, Youth and Violence: The Search for Solutions (pp 124-148). New York: Guilford Press.

Perry, B.(2001). Maltreated Children: Experience, Brain Development and the Next Generation. New York: W.W. Norton & Co.

Schore, A. (2003). Affect regulation and the repair of self. New York: W.W. Norton & Co.

Schore, A. (2001). The Effects of Early Relational Trauma on Right Brain Development, Affect Regulation and Infant Mental Health. Infant Mental Health Journal, 22, 201-269.

World Health Organisation (2003), International Statistical Classification of Diseases and Related Health Problems. 10^th Revision. Retrieved September 9, 2004 from http://www3.who.int/icd/currentversion/fr-icd.htm

Figure 1: Process of interactive repair


Author Note

Debbie Jeffrey is the parent of three children, two by adoption and one by birth. She is a mental health nurse and counsellor, runs an adoptive parents' support group in Sydney and is a Board Member of the intercountry adoption organisation, Australian Families for Children (AFC). She has a special interest in Reactive Attachment Disorder.

Correspondence concerning this article should be addressed to her at Queenscliff Health Centre, P.O. Box 605, Brookvale NSW 2100, Australia. Email: dpj1@optushome.com.au