Interventions with Reactive Attachment Disorder David Zidar, LISW-S [email protected] Davezidar.com

Why attachment is important         

Attain his full intellectual potential * Sort out what he perceives * Think logically * Develop a conscience * Become self-reliant * Cope with stress and frustration * Handle fear and worry * Develop future relationships * Reduce jealousy

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Two types of Reactive Attachment Disorder (RAD) 

Inhibited: Turning Inward

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Disinhibited: Turning outward

Symptoms               

1 Superficially charming and engaging. 2. Affectionate with strangers or attempts to leave with strangers. 3. Refuses, resists, or is uncomfortable with affection on parental terms. 4. Hyperactive, over-active, or attention deficit. 5. Destructive to self or others. 6. Significant learning problems or lags. 7. Fire setting, fire play, or fascination with fire. 8. Hoarding, gorging, eating abnormalities, or hiding food. 9. Intense control battles. 10. Incessant chatter or nonsense questions. 11. Cruelty to animals, siblings, or others. 12. Poor, underdeveloped, or no conscience. 13. Fascination with weapons, blood, or gore. 14. Daily lying or lying in the face of the obvious (crazy lying). 15. Parents who feel like giving up or feel hostile toward the child.

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Common mistaken DXʼs ADD/ADHD  PTSD  Axis II  Mood disorders  Others? 

Normal Attachment 

Attachment is defined as the affectional tie between two people. It begins with the bond between the infant and mother. This bond becomes internally representative of how the child will form relationships with the world. Bowlby stated "the initial relationship between self and others serves as blueprints for all future relationships." (Bowlby, 1975)

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Causes          

Any of the following conditions occurring to a child during the first 36 months of life puts them at risk: * Unwanted pregnancy * Pre-birth exposure to trauma, drugs or alcohol * Abuse (physical, emotional, sexual) * Neglect (not answering the baby’s cries for help) * Separation from primary caregiver (i.e. Illness or death of mother or severe illness or hospitalization of the baby, or adoption * On-going pain such as colic, hernia or many ear infections * Changing day cares or using providers who don’t do bonding * Moms with chronic depression * Several moves or placements (foster care, failed adoptions) • Caring for baby on a timed schedule or other self-centered parenting

What can a worker do? Limit moves  Consistent people in life: therapist, worker, foster parent, GAL or mentor  Same places 

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What else?

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What is the role of Trauma? Traumaʼs impact is huge on children  The process of placement is part of this trauma  What does it do to the brain? 

mad glad sad afraid Teach feeling Words

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Bruce Perry’s Model of Trauma Memory

Tape: A Child’s view of Adoption.

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Tape Questions 1. Do you see your kids in this tape?  2. What things does the tape bring to light regarding the thoughts, feelings and behaviors of the children in your care?  3. How do you create an environment in which these children can grow to their fullest potential? 

More tape Questions    

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4. What are some of the systems issues do you see in this tape? 5. What does the tape mean when it say’s It is at that point that my spirit started to die? 6. How does trauma effect the behavior of the children? When they act out who is it that they are attacking? 7. What role does the creation of chaos have in these children’s behavior, or to put it another way; what has been the norm for these children before foster care? 8. What things can you do to help the parent or child to better understand their behavior? 9. Who can be a model for these children to follow? 10. When do you know that these children have begun to improve?

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Internal Working Models Self is no good  Care givers are no good  The future is no good 

Behavioral: The concept of “reciprocity” is central to any intervention with these children. The is ue of balance and fairnes wil be central to any intervention with these children. Rewards and consequences are tools that the parent wil need to use in order to manage and developed these children. 9

The goal of the Parent is 

Firm

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Fair

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Consistent

Toxic Reaction Toxic reaction Often, these children will react with closeness with a toxic or allergic reaction. Like with other allergic reactions, we need to gradually build up a tolerance to closeness. The mistake that many make is to push to fast and the child becomes toxic. The therapist needs to help the parents and family to work up to healthily closeness. It literally needs to be a written down plan in clear behavioral terms that they work toward.

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Example: First Year Abuse Cycle Child’ Child’s Adaptation: (a) Ignores Others (b) Self Abuse (c) lack of Trust

4. Self-Gratification

Model Provided: (a) Ignoring (b) Neglect (c) Physical Abuse (d) Reciprocal Rage

1. Need

First Year Abuse Cycle 2. Rage Reaction

3. Child is Silenced

Conscience Development

6 yo 5 yo 4 yo 3 yo

Self Control With Verbal Instruction

Parent Present and Able to Act Parent Present and Initiates

•Interruption

in the

conscience development of the AD child will evidence itself in the cessation of maturing in conscience and responsibility at that stage of development.

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Factors that influence Moral Development        

Heredity Early childhood experiences. Modeling by important adults and older youth. Peer influence. The general physical and social environments. The communications media. What is taught in the schools and other institutions? Specific situations and roles that elicit corresponding moral behavior.

Thoughts+Feeling=behavior 

As children (all people) think will lead to feelings and behaviors.

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A WARNING: When in therapy with these children, we must set the stage for them to be willing to be in therapy. The best example of how to get them ready for therapy is to let them know that it is going to be like cleaning a cut. It will hurt some but will help them not to get infected. These children tend to do an approach vs. avoidance. Remember the issues of toxic reactions.

Comorbidity with other pathology       

Depression Anxiety disorders Thought disorders Sexual issues (offending and reactivity) Conduct disorder ADD/ADHD Axis II issues

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Increasing Eye Contact

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• Write an an I love you message in soap on a mirror. Stand behind the child when he reads it. You may get a glance in the mirror. If not, you still said I love you. • Pick or buy daffodils and put them in a case with some food coloring in the water. Watch with you child what happen overnight. Get a small glass of ginger ale. (A tall glass won’t work.) Put a raisin in the glass and watch what happens. ] Dress the same. Match. Wear blue jeans and a red shirt. Tan shorts and a blue T-shirt. Get a family photo taken with everyone dressed the same. Hang it prominently in the home and frame one for each child’s room. If your child is young (not a teen), buy a key chain in which to insert the picture and attach it to his backpack or belt.

Maximizing Touch • Put a delightfully smelling lotion on your child and have him reciprocate. Talk about how you smell alike. • Get matching temporary tattoos. And put them on each other. • Comb, braid, or braid your child’s hair. • Scratch his back. • Hold hands while walking. • Get your hair cut the same way. Touch it frequently as a reminder. • Hold and cuddle your child every day, even when you’re tired and busy. • Give him a back rub or foot rub. • Let him stay up an extra fifteen minutes past his bedtime, but make sure he spends the time in your lap. • Allow him to watch television only if he sits beside you and a part of his body touches a part of yours. Hold hands while saying grace before a meal.

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Teaching Calming skills Foot breathing  Belly breathing  Teeth clicking  Other calming skills 

Bibliography for Interventions with Reactive Attachment Disorder A Presentation in Person by David A. Zidar

American Psychological Association. (2001). Publication Manual of the American Psychological Association (5th ed.). Washington, DC: Author.) Lenore Terr, (1990) Too Scared to Cry. Basic Books. New York Levy, Terry M. & Orlans, Michael. (1989) Attachment, Trauma and Healing: Understanding and Treating Attachment Disorder in Children and Families. Child Welfare League of America. Washington D.C. Keck, Gregory & Kupecky, Regina (2002) Parenting the Hurt Child: Helping Adoptive Families to Heal and Grow. Pinon Press. Colorado Springs, Co. Perry, Bruce, D. (2007) Adapted in part from: "Maltreated Children: Experience, Brain Development and the Next Generation" (W.W. Norton & Company, New York, in preparation) http://members.tripod.com/~radclass/slide13.html

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