When Children Don’t Bond
By Tori DeAngelis
Psychologists are providing a controversial treatment for reactive attachment disorder.
Shuffled from one relative to another from the age of 2, José* by age 9 had became embroiled in one horrible misdeed after another. He had sexually molested 13 children in one foster home he lived in, and killed several family pets.
For two years, José had lived in a therapeutic foster home with Nancy Thomas, a therapeutic foster parent trained to help him with issues of attachment. In therapy also attended by Thomas, José was learning to reveal his dark childhood secrets one by one, and feel some remorse for them, Thomas says.
One day during this time, José seemed unusually agitated, and so did the family pet, a small Welsh Corgy with deep brown eyes whom José had learned to treat as his own. It took two weeks before José could say what went on: He had tried to kill the dog in the Thomas’ bathroom by crawling down a laundry chute to get a knife, and returning to the bathroom where the dog was locked in.
“He said he looked into the dog’s eyes and couldn’t do it,” said Thomas. “Telling me that was a big step for him,” says homas, who has since helped José, 18, find a permanent home. “Trust is a huge issue for these kids, and talking about what he’d really done was a move toward helping him create a real relationship.”
José is one of a growing number of children—especially those who were adopted or in foster-care—diagnosed with “reactive attachment disorder,” a condition psychologists say stems from a purely environmental influence: the absence of a nurturing caregiver in the earliest, most vulnerable stage of life. Because of severe neglect or abuse, these youngsters can’t form healthy attachments and fail to develop a conscience, resulting in such “bad seed” behaviors as pulling off the heads of baby animals and setting houses on fire.
“If you’ve never formed a connection to another person, there’s no reason to believe you would develop empathy for anyone,” explains Nancy Colletta, PhD, an Arlington, Va., psychologist with a federal grant from the Administration for Children and Families to train psychologists and parents to treat the disorder.
“These youngsters view the world as a scary and distrustful place to live,” adds Mary Owen, a social work professor at Catholic University who treats attachment-disordered children. Because as infants they were never able to express their rage and have their needs met, they internalize that rage and take it out on themselves and others, she says.
At least two social conditions make reactive attachment disorder more common, according to psychologist Gregory Keck, PhD, founder of the Attachment and Bonding Center of Ohio: Families are splintering apart as never before, so abuse and neglect are on the rise; and people are adopting more foreign children who have been severely neglected in overseas orphanages.
The result is tragic for the youngsters and for society. Studies in England and the United States estimate that 60 percent to 80 percent of felons emerged from the foster-care system, says Keck, who wrote “Adopting the Hurt Child: Hope for Families with Special-Needs Kids” (Pinon Press, 1995). If these children don’t receive intensive treatment early on, they’ll never be able to adequately attach with anyone, and will be at grave risk for developing later psychopathology, he says.
To help these youngsters, psychologists, social workers and lay people like Nancy Thomas are developing therapy techniques based on the tenets of attachment theory. Developed by British researcher John Bowlby in the 1950s, the theory holds that infants are born with a survival-based drive to attach and relate to others. If the need is not met, babies won’t develop a “positive working model” of relationships, and as children, never learn to trust.
The treatments themselves contain some controversial elements—in particular, “holding therapy,” designed to invoke youngsters’ infantile emotions, including rage, frustration, anger and the need for nurturing—and they are largely unevaluated. Yet conventional treatments don’t work with these youngsters, which is why psychologists and others have turned to the new methods, they say.
“Traditional therapy is predicated on the idea that a child can build trust with someone,” says Colletta. “But it became clear to me that these kids were unable to trust adults, to relax enough to give adults power over them.”
“This kind of attachment therapy—especially holding therapy—really provides the ultimate corrective emotional experience,” adds Keck. “It repairs a child’s disturbed development more fully than any other therapy I have been exposed to, or that I do.”
Nonetheless, practitioners doing more general work in attachment advise psychologists to keep some caveats in mind with these newer therapies.
Any treatment done with these children must account for the child’s unique personality and needs, and the specific emotional climate between child and caretaker, says Alicia Lieberman, PhD, professor of psychology at the University of California–San Francisco.
Therapists must also tease out behaviors that may result from early environmental deprivation such as malnutrition, from those that are specifically related to attachment problems, she says.
Another problem is that some practitioners apply concepts such as ‘bonding’ too literally, believes Joan Luby, MD, a child psychiatrist at Washington University School of Medicine.
“Simple holding and setting firm limits are not going to address a child’s psychopathology comprehensively,” she says. “It’s a big assumption that having physical contact with a child is attachment.”
How it works
The therapy typically begins with two weeks of intensive, three-hour-a-day treatment that uses cognitive, behavioral and psychodynamic techniques to evoke a child’s early rage at having been abandoned or abused. The adoptive or foster parents—often the target of the child’s present anger—are present to help the child build a sense of trust.
Part of the treatment involves “holding therapy,” where the child lies across the laps of two adults, typically the therapist and a foster parent. A boy, for example, wraps his right arm around the back of the adult closest to his face, and looks into that adult’s face. Both adults hold the boy tightly.
According to Thomas, the technique aims at getting the boy to relinquish control, which has been his vehicle for surviving in the world. The deep compression of the hold invokes a sense of panic and rage in the child that causes him to scream as he would have as an infant, she says. But Keck notes that the holding can also create a sense of calmness, contentment and safety in the child.
Throughout the holding, the therapist looks softly into the child’s eyes and provides a nurturing embrace. The idea is to simulate good mothering, and allow the child a chance to experience missed bonding, says Keck.
Occasionally, a more radical version called “compression holding” is used. In this version, the therapist literally lies on top of the child, says Thomas. The hold is only used if a child is psychotic and needs help getting back in touch with his body, she says.
Back at home
In the next stage of treatment, the psychologist provides 90-minute therapy sessions that are conducted regularly over the next year. The sessions involve both parents and children, and are geared to improve the child’s emotional functioning and to iron out problems between the child and parent. If the child is still severely acting out, he or she may live with a therapeutic foster parent during this time.
Parents are urged to maintain firm control over their children’s environment. Parents stay with the children while they brush their teeth, perform chores, eat, play and read to keep them out of trouble and to deal directly with their lies, which are habitual in many of these children, Thomas says.
“We also do holding, cuddling, eating ice cream, telling stories and singing nursery rhymes,” she said. “And we do funny, silly things together, like making mud-pies and having snowball fights.”
The children also play with toys and do exercises that help them build sensory and motor skills, which are often severely impaired in children who live fearfully and hypervigilantly, says Thomas.
As the youngsters attach more fully with their parents, they’re allowed more independence. They attend regular school and develop their own friendships.
While little research has been conducted on these methods, those using them claim a high success rate. Thomas says that 85 percent of the younger children she’s helped treat attach healthily with their adoptive or foster parents, and go on to succeed in school, form stable relationships and acquire and stay in jobs.
Keck, who specializes in treating teenagers with the disorder, says most of the teens he sees also attach healthily enough to be considered healed. Thomas has had less success with that population: Only 5 percent of the teens she’s treated have navigated attachment successfully, partly because they’re at a developmental stage marked by separation, she thinks.
The only quantitative study to date on the treatment is by Robin Myeroff, a psychology doctoral candidate who conducted research on therapy at The Attachment Center in Evergreen, Colo.
In her dissertation at Union Institute, Myeroff found that 12 children who received the center’s treatment scored somewhat lower on aggression and delinquency after treatment; the scores were clinically significant, she said. Eleven attachment-disordered children who did not receive therapy showed no change.
Until more data emerges, the field must rely on anecdotal evidence. But that doesn’t daunt Keck, who believes the treatment works because it addresses the most basic issue of human development.
“What’s exciting is that there’s now hope for kids who before were written off,” says Keck. “Before, we thought that kids who had poor attachment would never experience normal development. This treatment kicks the kid back into a normal developmental process.
Reactive attachment disorder defined too narrowly
The official definition of reactive attachment disorder is too narrow and too vague, critics charge. Reactive attachment disorder is considered a rare diagnosis that manifests in infants or young children in two forms: an “inhibited type” and an “uninhibited type,” according to the American Psychiatric Association (ApA) Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). The manual links both types to poor early care that results in developmentally inappropriate ways of relating to others.
The inhibited child shows excessively withdrawn, hypervigilant or ambivalent responses to others, such as “frozen watchfulness” and resistance to being comforted, says the DSM-IV. The uninhibited child exhibits indiscriminate friendliness and a tendency to attach to anyone.
While the description has expanded since the prior version of the DSM, which only contained the inhibited type, the fourth edition’s expanded description fails to address the full spectrum of the disorder, say practitioners who treat children with attachment disorders.
“The DSM diagnoses are still way too limited—they only allow you to make diagnoses in the most extreme cases,” says Joan Luby, MD, a child psychiatrist and assistant professor of psychiatry at Washington University School of Medicine.
Instead, she favors a proposal by psychologists Alicia Lieberman, PhD, and Charles Zeanah, PhD, to include subtypes of attachment disorders that recognize less severe types of the condition. The proposal, notes Luby, is clinically sound but needs empirical validation.
The DSM’s list of symptoms does not reflect practitioners’ knowledge of the condition, says Gregory Keck, PhD, who treats attachment-disordered children and teens and is founder of the Attachment and Bonding Center of Ohio. Practitioners see a cluster of more serious, even dangerous, symptoms in older children with the disorder, including destructive behavior, cruelty to animals, chronic lying, a lack of conscience, poor peer relations, demanding and clingy behavior, and impulsivity.
In fact, many of these symptoms are listed in the DSM-IV under the diagnoses of conduct disorder and oppositional defiant disorder (ODD), but Keck is concerned they do not address etiology.
“While someone may be labeled ODD as an older child, what preceded that could have been reactive attachment disorder,” says Keck, who is also president of a parent-and-professional advocacy organization called ATTACh (Association for Treatment & Training in the Attachment of Children). ATTACh board members are now gathering consensus on a new description of the disorder to present to ApA’s DSM committee for review.
Luby, however, believes that children with conduct disorder or ODD may indeed have had attachment disorders earlier, but have additional problems that should be included as separate diagnoses. She says labeling older children with reactive attachment disorder does not address the fact that these youngsters now have major social and moral development problems that result in antisocial behaviors.
Both parties have time to hone their views: The next revision of the DSM—to which practitioners will submit proposals for change—is not planned until at least 2000, according to ApA officials.