Effective Treatment for Complex Trauma and Disorders of Attachment By Meds Reactive Attachment Disorder is a severe developmental disorder caused by a chronic history of maltreatment during the first couple of years of life. Reactive Attachment Disorder is frequently misdiagnosed by mental health professionals who do not have the appropriate training and experience evaluating and treating such children and adults. Often, children in the child welfare system have a variety of previous diagnoses. The behaviors and symptoms that are the basis for these previous diagnoses are better conceptualized as resulting from disordered attachment. Oppositional Defiant Disorder behaviors are subsumed under Reactive Attachment Disorder. Post Traumatic Stress Disorder symptoms are the result of a significant history of abuse and neglect and are another dimension of attachment disorder. Attention problems, and even Psychotic Disorder symptoms are often seen in children with disorganized attachment 1. Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms[2]. Many of these children are violent[3] and aggressive[4] and as adults are at risk of developing a variety of psychological problems[5] and personality disorders, including antisocial personality disorder[6], narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder[7]. Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence[8]. Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults[9]. Children who have been sexually abused are at significant risk of developing anxiety disorders (2.0 times the average), major depressive disorders (3.4 times average), alcohol abuse (2.5 times average), drug abuse (3.8 times average), and antisocial behavior (4.3 times average)[10] (MacMillian, 2001). The effective treatment of such children is a public health concern (Walker, Goodwin, & Warren, 1992). Left untreated, children who have been abused and neglected and who have an attachment disorder become adults whose ability to develop and maintain healthy relationships is deeply damaged. Without placement in an appropriate permanent home and effective treatment, the condition will worsen. Many children with attachment disorders develop borderline personality disorder or anti-social personality disorder as adults[11]. So, what is a person to do? Is there effective treatment for disorders of attachment? The answer is yes; there is an effective treatment for disorders of attachment. Dyadic Developmental Psychotherapy[12] is an evidence-based treatment that has proven success treating attachment disorders[13]. Family therapy, individual therapy, play therapy, residential placements, and intensive outpatient treatment, among other treatments, are often used to treat attachment disorders. However, when compared with Dyadic Developmental Psychotherapy, these treatments proved to be ineffective. A follow-up study compared the effectiveness of Dyadic Developmental Psychotherapy and usual care, and found that Dyadic Developmental Psychotherapy produced clinically and statistically significant
improvements one year after treatment ended. The study was composed of 34 families receiving Dyadic Developmental Psychotherapy and 30 families receiving usual care. Before treatment/evaluation in both the treatment and control groups, Randolph Attachment Disorder Questionnaire scores and Child Behavior Checklist scale scores were elevated and in clinically significant ranges (more than two standard deviations above the mean for the CBCL). The extent and severity of these children s disorder is underscored by the fact that 82% of the treatment group and 83% of the control-group subjects had received prior treatment using other methods. The average number of previous treatment episodes was 3.2 for the treatment group and 2.7 for the control group. The results for the treatment-group were achieved among children aged six to fifteen years, averaging 9.4 years, who received an average of twenty-three sessions over eleven months. Results presented in Table 1 show clinically and statistically significant reductions in scores for the treatment group and Table 2 shows no change for the control group. TABLE 1 Dyadic Developmental Psychotherapy N=34, df=33 measure mean Pre-test SD Pre-test mean Post-test sd Post-test t-value p value CBCL Syndrome Scale Scores Withdrawn 65
11.8 54 6.0 4.897 <.0001 Anxious/Depressed 62 10.5 58 8.1 2.665.006 Social Problems 67 9.7 59 5.5 4.376 <.0001 Thought Problems 68 9.5 56 3.9 6.133
<.0001 Attention Problems 72 12.5 57 6.1 5.836 <.0001 Rule-Breaking Behavior 69 6.9 53 3.8 12.181 <.0001 Aggressive Behavior 71 9.1 55 4.5 10.576 <.0001 TABLE 2 USUAL CARE GROUP N=30, df=29
measure mean Pre-test SD Pre-test mean Post-test sd Post-test t-value p value CBCL Syndrome Scale Scores Withdrawn 65 10.5 63 9.4 1.427.16 Anxious/Depressed 62 10.6 60 10.3 1.060
.30 Social Problems 64 11.1 65 11.2-0.854.40 Thought Problems 63 8.6 62 8.1 0.984.33 Attention Problems 68 11.9 66 1O.8 0.927.36 Rule-Breaking Behavior 67 7.4
66 9.6 1.869.07 Aggressive Behavior 70 10.2 68 9.4 0.919.37 Dyadic Developmental Psychotherapy is effective because of its reliance on and development of affective attunement between therapist and child, caregiver and child, and therapist and caregiver. The process of maintaining affective attunement allows for dyadic regulation of affect between child and therapist so that the child feels a sense of safety and security and can experience the affect associated with past traumas, allowing for integration of these experiences rather than dissociation of the affect and memory. Furthermore, Dyadic Developmental Psychotherapy s significant involvement of caregivers in treatment facilitates the development of an affectively attuned relationship between the child and caregiver. An affectively attuned relationship may be described as a relationship in which the two persons are experiencing the same affect and that their affect co-varies. Within the safety of the attuned relationship the shame of past trauma and current misbehaviors are explored, experienced, and integrated. The caregiver-child interactions build on a dyadic affect regulation process that normally occurs during infancy and the toddler years. The child s past traumatic history of abuse and neglect strongly suggests that such interaction, which facilitates a health attachment and a trusting and safe relationship, did not occur or occurred in an inadequate manner. Dyadic Developmental Psychotherapy facilitates the development of a healthy attachment between child and caregiver, enables the child to affectively trust the caregiver, and allows the child to secure comfort and safety from the caregiver. This study examined the effects of Dyadic Developmental Psychotherapy on children with trauma-attachment disorders who meet the DSM IV criteria for Reactive Attachment Disorder, all of whom were either adopted or in foster care. A treatment group composed of thirty-four subjects and a usual care group composed of thirty subjects was compared. All children were between the ages of five and sixteen when the study began. Seven hypotheses were explored. It was hypothesized that Dyadic Developmental Psychotherapy would reduce the symptoms of attachment disorder, aggressive and delinquent behaviors, social problems and withdrawal, anxiety and depressive problems, thought problems, and attention problems among children who received Dyadic Developmental Psychotherapy. Significant reductions
were achieved in all measures studied. The results were achieved in an average of twentythree sessions over eleven months. These findings continued for an average of 1.1 years after treatment ended for children between the ages of six and fifteen years. There were no changes in the usual care-group subjects, who were re-tested an average of 1.3 years after the evaluation was completed. The results are particularly salient since 82% of the treatmentgroup subjects and 83% of the usual care-group subjects had previously received treatment with an average of 3.2 prior treatment episodes. This past history of unsuccessful treatment further underscores the importance of these results in demonstrating the effectiveness and efficacy of Dyadic Developmental Psychotherapy as a treatment for children with traumaattachment problems. In addition, 53% of the usual care-group subjects received usual care but without any measurable change in the outcome variables measured. Children with trauma-attachment problems are at significant risk of developing severe disorders in adulthood such as Post Traumatic Stress Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, and other personality disorders. This study supports several of O Connor & Zeanah s[14] conclusions and recommendations concerning treatment. They state (p. 241), treatments for children with attachment disorders should be promoted only when they are evidence-based. The results of this study are a beginning toward that end. While there are a number of limitations to this study, given the severity of the disorders in question, the paucity of effective treatments, and the desperation of caregivers seeking help, it is a step in the right direction. Dyadic Developmental Psychotherapy is not a coercive therapy, which can be dangerous. Dyadic Developmental Psychotherapy provides caregiver support as an integral part of its treatment methodologies. Finally, Dyadic Developmental Psychotherapy uses a multimodal approach built around affect attunement. Arthur Becker-Weidman, Ph.D. Director Center For Family Development 5820 Main Street, suite 406 Williamsville, NY 14221 [1] Lyons-Ruth, K., & Jacobvitz, D., Attachment disorganization: unresolved loss, relational violence and lapses in behavioral and attentional strategies. In Cassidy, J. & Shaver, P., (Eds.) Handbook of Attachment. pp 520-554, NY: Guilford Press, 1999. Solomon, J. & George, C. (Eds.). Attachment Disorganization. NY: Guilford Press, 1999. Main, M. & Hesse, E. Parents Unresolved Traumatic Experiences are related to infant disorganized attachment status. In Greenberg, M.T., Ciccehetti, D., & Cummings, E.M. (Eds.) Attachment in the Preschool Years: Theory, Research, and Intervention, pp.161-182, Chicago: University of Chicago Press, 1990. Carlson, E.A. (1988). A prospective longitudinal study of disorganized/disoriented attachment. Child Development 69, 1107-1128.
[2] Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1995). Finding order in disorganization: Lessons from research on maltreated infants attachments to their caregivers. In D. Cicchetti & V. Carlson (Eds), Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 135-157). NY: Cambridge University Press. Cicchetti, D., Cummings, E.M., Greenberg, M.T., & Marvin, R.S. (1990). An organizational perspective on attachment beyond infancy. In M. Greenberg, D. Cicchetti, & M. Cummings (Eds), Attachment in the Preschool Years (pp. 3-50). Chicago: University of Chicago Press. [3] Robins, L.N. (1978) Longitudinal studies: Sturdy childhood predictors of adult antisocial behavior. Psychological Medicine,. 8, 611-622. [4] Prino, C.T. & Peyrot, M. (1994) The effect of child physical abuse and neglect on aggressive withdrawn, and prosocial behavior. Child Abuse and Neglect, 18, 871-884. [5] Schreiber, R. & Lyddon, W. J. (1998) Parental bonding and Current Psychological Functioning Among Childhood Sexual Abuse Survivors. Journal of Counseling Psychology, 45, 358-362. [6] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment Styles in Maltreated Children: A Comparative Study. Child Development and Human Development, 31, 113-128. [7] Dozier, M., Stovall, K.C., & Albus, K. (1999) Attachment and Psychopathology in Adulthood. In J. Cassidy & P. Shaver (Eds.). Handbook of Attachment (pp. 497-519). NY: Guilford Press. [8] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment Styles in Maltreated Children: A Comparative Study. Child Development and Human Development, 31, 113-128. [9] Allan, J. (2001). Traumatic Relationships and Serious Mental Disorders. NY: John Wiley. Andrews, B., Varewin, C.R., Rose, S., & Kirk (2000). Predicting PTSD symptoms in Victims of Violent Crime. Journal of Abnormal Psychology, 109, 69-73. [10] MacMillian, H.L. (2001). Childhood Abuse and Lifetime Psychopathology in a Community Sample. American Journal of Psychiatry, 158, 1878-1883. [11] Allan, J. Traumatic Relationships and Serious Mental Disorders, NY: Wiley, 2001. Andrews, B., Varewin, C.R., Rose, S. & Kirk. Predicting PTSD symptoms in Victims of Violent Crime. Journal of Abnormal Psychology, vol. 109, 69-73, 2000. [12] Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity for Attachment: Dyadic Developmental Psychotherapy in the Treatment of Trauma-Attachment Disorders. OK: Woods N Barnes publishing. [13] Becker-Weidman, A., (2005) Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. Vol. 12 #6, December.
[14] O Connor, T., & Zeanah, C., (2003) Attachment Disorders: Assessment strategies and treatment approaches. Attachment & Human Development, 5, 223-245. Arthur Becker-Weidman, Ph.D. received Ph.D. from the University of Maryland?s Institute for Child Study. He has achieved Diplomate Status in Child Psychology and Forensic Psychology from the American Board of Psychological Specialties. He is a Registered Clinician with the Association for the Treatment and Training in the Attachment of Children. Dr. Becker-Weidman consults with Department?s of Social Services, Residential Treatment Centers, and Mental Health Clinics throughout the US, Canada, and Internationally. Dr. Becker-Weidman?s work has focused on the evaluation and treatment of adopted and foster children and their families, Complex-Post Traumatic Stress Disorder, and Alcohol Related Neurological Dysfunction (Fetal Alcohol Spectrum Disorder or FAS). He provides training and workshops to parents and professionals across the U.S. and internationally. Dr. Becker-Weidman is on the Board of Directors of the Association for the Treatment and Training in the Attachment of Children, serves on the Research Committee and Training Committee, and chairs the Registration Committee. He is an adjunct Clinical Professor at the State University of New York at Buffalo. Dr. Becker-Weidman is the co-editor of the book, Creating Capacity for Attachment, published by Wood?N? Barnes in 2005. He is finishing work on a book about Attachment-Facilitating Parenting that is expected to be published in 2009.