15 Reactive Attachment Disorder

INTRODUCTION

“Unattached children…have an uncanny ability to appear attractive, bright, loving . . . helpless, hopeless, lost . . . or promising, creative, and intelligent, as may suit their needs at the time. Therefore, strangers, helpful neighbors, even therapists, often see the parents as the problem and believe the winsome child is ‘beautiful’. . .” (Foster Cline, 1979)

As a relatively new diagnosis to the DSM-IV manual, Reactive Attachment Disorder (RAD), also known as Attachment Disorder (AD) is often misunderstood, and relatively unknown. Expertise is lacking and normal behavior interventions can very easily add to the symptoms if following instinctive patterns. Experts in RAD estimate that this disorder has been misdiagnosed as Bi-Polar Disorder or Attention Deficit Disorder in 40 to 70 percent of the cases.

The DSM-IV (1994) defines Reactive Attachment Disorder (RAD) as markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age five, as evidenced by either:

1. Inhibited Type: persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hyper vigilant, or highly ambivalent and contradictory responses (e.g. responds to caregivers with approach, avoidance, and resistance to comforting, or frozen watchfulness)

If caregivers 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 caregivers. The child then uses psychological defenses (e.g., avoidance or ambivalence) to avoid disappointments with the caregiver. This is thought to contribute to a negative working model of relationships that leads to insecurity for the rest of the child’s life.

In inhibited RAD, the child 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 infant to establish a new attachment with a primary caregiver. Also, a nonattachment disorder may develop because the baby never had the opportunity to develop at least one attachment with a reliable caregiver who was continuously present in the baby’s life.

Indicators

• Failure to thrive
• Poor hygienic condition
• Underdevelopment of motor coordination and a pattern of muscular hypertonicity because of diminished holding
• May appear bewildered, unfocused, and understimulated
• Blank expression, with eyes lacking the luster and joy that is usually observed
• No evidence of the usual responses to interpersonal exchanges
• Appearance of not knowing body language
• Does not pursue, initiate, or follow up on cues for an exchange or interaction.
• No exploration of another person’s face or facial expression
• Does not approach or withdraw from another person
• May avoid eye contact and protest or fuss if a person 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)

2. Disinhibited Type: diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g. excessive familiarity with relative strangers or lack of selectability of attachment figures) (313.89, p. 116).

Young children exposed to multiple caregivers 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 person because past relationships were interrupted, disrupted, or consistently unreliable. Children with disinhibited 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 person, any sense of fear or loneliness is inhibited and the children develop a pseudocomfort with whoever is available. The child is thought to suppress the conscious experience of fear only as a result of a psychological defense. The child is afraid of trusting anyone and being further disappointed.

In disinhibited RAD, the child participates in diffuse attachments, indiscriminate sociability, and excessive familiarity with strangers. The child has repeatedly lost attachment figures or has had multiple caregivers and has never had the chance to develop a continuous and consistent attachment to at least one caregiver. Disruption of one attachment relationship after another causes the infant to renounce attachments. The usual anxiety and concern with strangers is not present, and the infant or child superficially accepts anyone as a caregiver (as though people were interchangeable) and acts as if the relationship had been intimate and life-long.

Indicators

• Instead of caution, excessive familiarity or psychological promiscuousness with unknown persons
• Can give hugs to anyone who approaches them and go with that person if asked
• 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:

• Signs of physical maltreatment, such as old fractures or bruises
• Effects of undernutrition and rashes because of not changing diapers frequently
• A syndrome characterized by excessive appetite in children who have been in several foster homes
• Excessive appetite and excessive thirst in children who experience severe stress
• Flattened back of the head because left in bed much of the time in cases of non-attachment
• If severe, growth retardation

Attachment disorders independent of DSM-IV

It should be fairly obvious that attachment or nonattachment is not simply not digital or quantitative as an either/or situation, but that qualitatively [analogically] the child can attach at any number of degrees. Martin Maldonado-Dun, MD & Linda Helmig, PhD, give indication of other degrees of attachment problems. These attachment difficulties do not have the certification of DSM, but may be helpful concepts for assessment specialists.

• In reversed attachment, the child becomes the source of comfort to the parent, who is insecure and vulnerable; the relationship is inverted and the infant, although unable to reassure the parent completely, provides the security.
• In angry attachment, a strong relationship exists between parent and infant 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 people around them.

In addition, Mary Ainsworth has developed an attachment classification based on the behavior of infants (typically aged 10-13 mo) in the presence of a stranger during and after a short separation from their primary caregivers.

• Behavioral patterns associated with secure attachments include some distress at separation, preference for mother over stranger, and a search for comfort from mother upon reunion.
• 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.

It is suggested that approximately 65% of American middle-class children are thought to have secure attachments with primary caregivers, whereas 35% exhibit an insecure attachment style. Not all children who show an insecure attachment to primary caregivers 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 child 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 child. It is not a diagnostic tool for attachment disorders. The critical issue to be addressed in all degrees of insecure attachment is the issue of ‘right brain’ or visceral thought development and the inability of traditional interventions to address these issues.

All to often the children with severe RAD grow up without appropriate intervention and can become sociopaths without conscience and without concern for anyone but themselves. Such children have learned that the world is unsafe, and have developed unhealthy protective shells that isolate them from the pain of attachment and dependency to adult caregivers. Their credo for survival becomes, “All for me, and me for me”.

These protective shells become very difficult to remove, as they are relied upon by the child as their sole means of coping and surviving with the world. In essence they become the providers of their own protection, and they see anyone else wanting to remove this protective barrier as a threat. Hence, they turn against the very ones who want to help them the most – the parental care givers.

Although many of those diagnosed with RAD are considered as very intelligent, this is primarily from environmental conditioning. Many of those with RAD do not let anyone of a parental or authoritative nature have any control over their lives. Consequently, they constantly exercise their intellect at manipulating their environment and people in their environment. If this happens in a classroom, they may experience learning lags.

Lack of a conscience appears to be caused by their lacking trust in anyone. They become so dependent upon themselves, that they ignore the needs of others to the point that they will steal, damage, and destroy anything that they believe hinders their control. In short, they do not trust any caregiver or person in authority.

Due to their charming behaviors around adults as they attempt to control them, other children are often the first to express any problems existing in the AD environment.

At the core of Reactive Attachment Disorder is trauma caused by significant and substantial experiences of neglect, abuse, or prolonged and unresolved pain in the first two years to three years of life. These experiences disrupt the normal attachment process so that the child’s capacity to form a secure attachment with a caregiver is distorted or absent. The child lacks trust, safety, and security. The child develops a negative working model of the world in which:

• Adults are experienced as inconsistent or hurtful.
• The world is viewed as chaotic.
• The child experiences no effective influence on the world.
• The child attempts to rely only on him/her self.
• The child feels an overwhelming sense of shame, the child feels defective, bad, unlovable, and evil.

Attachment is a survival mechanism. Children who do not attach fail to thrive. Failure to attach is fatal! It is the child who must attach and several epigenetic rules such as sucking, clinging and following are innate directives to attach. Bonding or attachment refers to the emotional connection or the strength of the relationship between one person and another.

Attachment disorder is transmitted intergenerationally. Children lacking secure attachments with caregivers commonly grow up to be parents who are incapable of establishing this crucial foundation with their own children. Instead of following the instinct to protect, nurture and love their children, they abuse, neglect and abandon. The situation is out of control.

Two major principles are apparent in the process of corrective intervention: As with all children,

1. RAD children need love, and
2. RAD children need limits.

The parents need to manage the child in a loving, kind, caring, and compassionate way while at the same time setting clear, necessary and appropriate limits. RAD children need their parents to be in control of them so they can have a normal dependent relationship that provides for their needs. Parents should not exercise this control through threats, punishment, deprivation, or by inducing fear. These methods are counter-productive for any child and actually create more rebellion than obedience. Although control is an essential ingredient in attaching and healing the RAD child, control alone is insufficient to produce change. A deeply, loving, compassionate, and understanding relationship is also essential.

THE DEVELOPMENTAL PROCESS

There is an instinct to attach: babies instinctively reach out for the safety and security of the “secure base” with caregivers; parents instinctively protect and nurture their offspring. Attachment is a physiological, emotional, cognitive and social phenomenon. Instinctual attachment behaviors in the baby are activated by cues or signals from the caregiver (social releasers). Thus, the attachment process is defined as a “mutual regulatory system” – the baby and the caregiver influencing one another over time. Kim Cross

For our purposes, it is the relationship between a child and his/her mother that is the critical issue. Under normal circumstances, the fetus and the mother interact to begin the attachment process in utero. Even before a child is born, the critical nine-months within the womb are a time where s/he must receive sufficient nutrition, and be free from drugs and alcohol, if the child is to have a chance at a normal healthy life.

When the baby is born, the olfactory sense is very powerful and visceral. Three days after birth the baby can discriminate the mother’s breath and milk. Thus, simple imprinting as might occur with other animals, does not occur with human children. Human children recognize and relate to the visceral sensory clues that they learned in the uterus and seek those visceral clues when separated by birth. Any interruption in this attachment process can create some degree of problem.

The first year is a year of needs. When the infant has a need, it initiates attachment behavior in order to summon a nurturing response from the attachment figure. The need-gratifying response usually includes touch, eye contact, movement, smiles and lactose. When gratification occurs, trust is built. This cycle occurs hundreds of times a week and thousands of times in the first year. From this relationship, a synchronicity develops between parent and child. The caregiver develops a greater awareness of the child and learns just how to respond. The child develops good cause-and-effect thinking, feels powerful, trusts others, shows exploratory behavior and develops empathy and a conscience. Weidman

Consider a child in the first days, weeks and months of life. The child is hungry, or wet. What does the child do? S/he screams out for attention, and in the rage s/he expresses, the mother comes to the child’s aid and feeds or changes the child.

Day after day, week after week, the closeness of eye contact, touch, movements, and smiles creates a bond of trust between the child and its mother. But what happens if this cycle is broken or interrupted? What if the mother doesn’t want to respond to the demanding needs of the child? What if there was an un-assessed condition in the child, that was never appropriately responded to and comforted?

In these instances, the child does not learn to trust, does not learn to bond, and proceeds on with the next lesson to learn in life. The neural paths for bonding have been ignored.

When the baby has a need, s/he seeks gratification and upon receiving that gratification is able to build trust with another. Thus, there is a cycle of:

NEED → arousal [discomfort] → attendance [gratification] → TRUST

Arousal, which is experienced as discomfort, will cause the baby to seek attachment to its mother. Under normal circumstances, the mother will attend to the neonate – not only providing for basic nourishment and elimination, but also cuddle, rock, and coo at the child. This process is quite gratifying for the newborn and leads to what we would call trust.

If, for any reason, the neonate is aroused and there is no attendance, the discomfort from the arousal can last up to about five [05] hours and then dissipates as self gratification occurs. If this happens, the baby has a first learning experience of trusting only him/herself. Movement is quite central to gratification, and self-gratification often includes movement.

Over time, s/he will have learned to trust him/herself, and no one else. S/he has also learned that s/he has the power to arouse anger in others, and s/he can cause them to act in anger. Given time, s/he may become a master of control, manipulation, and anger – feeling comfortable and secure, in anger and abuse; highly agitated and insecure when dependent upon others.

The baby attaches first with the mother, then father and then the world. Survival and failure to attach to the mother promotes a failure to attach [or trust] anyone but one’s own self. The child’s interpretation of the failure to attach can create some very difficult relationship issues throughout life. The very foundations of interpersonal relations are inhibited and no amount of repair work on the windows and roof are going to repair this foundation. The traditional reward/punishment systems of behavior change often make things much worse.

In this material, we will refer to attachment as the capacity of an infant or child to form a close, trusting, and loving relationship with his/her mother. In professional circles, when a child or baby has a severe problem attaching or bonding to his/her parents, it is called a Reactive Attachment Disorder (RAD). As the name implies, difficulty with bonding is a reaction to something that child has experienced. Reactive attachment disorder then, since it applies to living children, indicates that the child is having a reaction to the attachment process – possibly neglect or abuse as the cause – and the child is no longer seeking to attach. But since the child has survived, s/he has reached some level of congruence with other people although trust of others is lacking in any great degree. In fact, one may find varying levels of trust in kids with reactive attachment as there are a range of difficulties that can arise; the severity of the disorder relating to the timing and the intensity of the interruption in attachment.

INTERRUPTIONS to attachment include:

• addiction in utero [alcohol creates permanent neurological damage – apparently drugs may not]
• neglect – the failure to attend to the arousal discomfort – this tends to lead to a child who trusts no one but themselves since the gratification is self induced
• abuse – which includes doing something to the child to make him/her stop responding to the discomfort – this behavior often contains elements of gratification such as movement and touch – this tends to lead to a child who only trusts him/herself, but has learned that s/he can affect other and continues to do so in very controlling ways.
• separation from mother [daycare, foster care, adoption, loss]
• unalleviated pain

Depending upon the timing of this interruption [the earlier the more severe] and intensity of the interruption, the child may range across differing levels of symptoms – some children have a few – while those most severely affected have a lot.

Risk factors include:

• age of trauma – the earlier it occurs the more impact it has
  • sensory memories (e.g., smell triggers)
  • lost reference points
• genetics – any genetic propensity can inhibit/influence the reaction – propensity for attention deficit or bi-polar is particularly difficult
• personality [temperament]
• quality of attachment before interruption

The worst place for neonates and infants is in multiple baby placement – caregivers with multiple babies – Gregory Keck

Potential intervention strategies for adolescents and young adults might include the Cognitive Behavior Protocol – #09 – Cognitive Restructuring, which provides a basic approach to the problem and the process of change. This restructuring protocol would also be appropriate for younger children except for a difficulty of imbalance between language [left brain] to intuitive [right brain] knowledge that occurs and, therefore, the material we are creating here is an effort to identify ways in which to modify the protocol to be more visceral than logical.

As a matter of definition, we will use the term neonatal or newborn period to define the first two weeks of life. The term baby refers to the first year of human life, which is by definition the first part of infancy. Infancy is commonly described as that time between the neonatal and the childhood period, which begins at approximately three years of age and lasts until the beginning of adolescence. It is during childhood that the truly social forms of play develop and become organized, and begin to operate as creative socializing forces.

BACKGROUND

UNDERSTAND THE LOVE SYSTEMS

In his definitive books on bonding, Learning To Love, Harry F. Harlow (1974), suggests at least five basic kinds of interactive, interpersonal love. Harlow defines love as affectional feelings for others, which rules out self-love or narcissism.

The first affectional system is maternal love, the second is infant love, the third is peer or age mate love, the fourth, heterosexual love is love in which age mate passion is augmented by sexual gain and the fifth love system is that of paternal or father love. The description of five separate and discrete love systems is not meant to imply that each system is physically and temporally separate. Actually, there is always an overlap, so that affectional motives are continuous as the different forms and facets of love evolve.

Each love system, with the exception of the mother – infant combination, prepares the individual for the one that follows, and the failure of any system to develop normally deprives the child of the proper foundation for subsequent increasingly complex adjustments. The ties formed during each of the affectional systems are so strong and binding that they may sometimes impede transition to the appropriate new system when it eventually matures.

When maturation fails we may have to resort to learning; ergo a cognitive behavior management system of training the child to re-establish his or her beliefs, attitudes and values in order to learn how to trust and to accept and give love. This process is made especially difficult because of the nature of the child’s belief system created before age four. In order to understand the nature of this, we will take, with the help of Paul Valent, a short excursion into the bicameral brain.

We all have some idea that the right and left-brains have different functions. The left-brain deals with verbal logical matters, the right with emotional intuitive ones. But if we look in more detail at the different hemispheric functions, we realize as the eminent neurologist Rhawn Joseph said, we live simultaneously in two separate complex mental worlds. The right and left-brains exist, literally side-by-side, using unique strategies for perceiving, processing, and expressing information. Further, these separate mental worlds may know little about each other, as indicated by the fact that even in young adults forty [40%] percent of the connection between the two sides is still incomplete.

It may be helpful in accepting this mental split if we note a corresponding physical split. Our voluntary nervous system consciously directs our external muscles in the environment and is analogous to the left-brain. The involuntary nervous system directs internal muscles and organs unconsciously, is associated with emotion and is analogous to the right brain. Just as we are unaware of our internal organs except when they are stressed or injured, we may not be aware of our right brains if all goes well.

What is most important for our purposes, is to understand that the right brain is fully dominant until the age of three [03] when the ‘visceral’ child first starts to think – at least as we generally think of as thinking. Communication between the hemispheres is exceedingly poor before the age of three [03], and limited until the age of five [05]. Verbal dominance of information and awareness is established only after age seven [07]. What this means, of course, is that the foundational thoughts about self and others [self and mother] are right brain thoughts – sensory symbols other than words including hunches, intuitions, emotions, dreams, slips of the tongue, nonverbal behavior, patterns of activity, psychosomatic symptoms, and use of metaphor.

These thoughts are generally ineffable (unsayable). It is comparing the knowledge of the brain and the heart, while the first is a knowledge that you can describe or define and the second is not, the second is somehow believed to be the deeper knowledge – it is visceral not factual.

Only after age seven can the left-brain speech area organize and categorize information into linguistic codes and narrative units within linear time. Before that time, including during the period of bonding, the right brain utilizes the limbic system and the right frontal cortex. Both have close connections with the autonomic nervous system and visceral responses. The right brain reads faces, inflection, nuances, pitch, melody, empathizes and intuits what persons feel about what they say, why and in what context. In time it provides gestalt, morals, motives, inferences and meanings. These develop silently throughout life.

The right brain remains dominant in regard to most, if not all, aspects of social-emotional functioning. When it is disturbed a myriad of affective psychosomatic and behavioral disturbances may result. For instance, when an ambivalent mother says ‘I love you’, a child’s left brain hears the words while the right brain discerns hate. The two parts cannot be assimilated. Later on hearing ‘I love you’ the adult may cringe without knowing why .

With increasing connection we develop an ever more stereoscopic and coherent view of ourselves and our history. However, in traumatic dissociation, which is characteristic of RAD, a functional split recurs or intensifies between the hemispheres. The lack of self-awareness of the right brain is now used to protect the left-brain and its linguistic consciousness from being overwhelmed. This is done by dissociation of traumatic information and storing it in nonverbal codes in the right brain. Joseph says, “.. our traumas [and] fears.. are mediated .. by the limbic system, [and] the non-linguistic, social-emotional right brain. And.. these experiences are stored in the memory banks of the right cerebrum”. Thus, when dealing with a child who has been psychotraumatized before the age of five, the process of change must include methods which enable the nonverbal messages to become conscious and put into words.

We will leave this for the moment to continue to review Harlow’s five affectional systems.

MATERNAL LOVE

Freud conceived of the mother-child relationship as encompassing all the forces that shape the adult personality, with maladjustments at this level being the sole cause of any later emotional catastrophes.

Although we would never discount the importance of mothers, it now appears that mother-child attachments are actually less critical to adult social and sexual relationships than the interactions arising from age mate or peer attachments. This fact should not be ignored in the clinical process of change, since enabling the child to connect to peers; particularly in the ages between six [06] and twelve [12], is a critical part of the process of helping the child learn to love. Yet this is an area that tends to be completely ignored in traditional clinical intervention.

Be that as it may, it is meaningless and even misleading to judge the importance of one affectional systems over another. However, since each system evolves from the one that precedes it, there becomes a power of precedence and the mother/child bonding is the first to occur. The faulty development of any system, or the faulty transition from one system to another, may arise from any number of variables. Nonetheless, deprived of their mothers, Harlow’s monkeys were at times apathetic, at times hyperactive, and given to outbursts of violence. When raised in isolation, they were socially inept: they often held themselves and rocked like autistic children.

Maternal love differs from the other love systems in that the full sequence is normally recurrent. With maternal love, the advent of each infant initiates the entire sequence anew. In its early stages, maternal behavior is based almost entirely on the mother’s responses to the infant. In fact, the mother/infant relationship is as complex as the chicken and egg paradox. As the infant matures and develops his/her own responses, the maternal responses are modified by the interaction between mother and child. Thus, the mother’s expression of love for her infant changes and in fact appears to follow some type of development pattern.

There appear to be three stages of mother love: 1) a stage of care and comfort, 2) a stage of maternal ambivalence, and 3) a stage of relative separation. These stages are not discrete and all-or-none in character; rather, each merges into the next. It is impossible to define exact temporal periods for any maternal affectional stage, since there are large individual differences and variables of experience play an increasing role in the later stages.

Care And Comfort

The response of a mother to her newborn depends on many personality and cultural variables and reveals a complexity of concern. Many mothers have little maternal feeling until their infants have matured to the point that they can interact with their mothers by means of vocal and facial responses. This is important as noted in our original definition of bonding and attachment: the capacity of an infant or child to form a close, trusting, and loving relationship with his/her mother. While the mother starts the process and sets the foundation, it is the child’s ability to bond that is the focus of attention.

Nonetheless, it is important that the mother meet her obligations to the child. During the stage of care and comfort a primary function or obligation of the mother is to provide her infant with intimate bodily contact, which is the basic mechanism in eliciting love from the neonate and infant.

Until the infant is four to six weeks old the mother often perceives it as an anonymous asocial object and reports only impersonal feelings of affection. In the infant’s second month of life, when it begins to exhibit visual fixation and following, smiling responses and eye contact, her maternal feelings intensify. She now begins to view the infant as a person with unique characteristics and believes that it recognizes her. By the end of the third month, the maternal attachment is usually sufficiently strong that the infant’s absence is experienced as unpleasant and the imagined loss of the infant becomes an intolerable prospect.

A second primary obligation of mothers during the stage of care and comfort is that of satisfying the infant’s biological homeostatic needs, particularly those of hunger and thirst.

Many surrogate mothers may be relieved to know that it is possible for them to elicit and maintain infant love when they are using nothing but a bottle. As long as the bottle at each feeding is supplemented by tender loving care, the bottle-fed baby will achieve the same pervading love for the mother.

Along with feeding comes the task of controlling the infant’s eliminative functions. Most studies show that eliminative functions cannot be trained reliably and effectively until the child has reached a certain level of maturation. The more severe the training procedures and the earlier it is initiated, the more the child is upset by training, with severity being the more important variable.

The third and obvious essential function of the mother at the maternal stage of care and comfort is that of protection, and this is dispensed by good mothers at a level of vigor and violence appropriate or more than appropriate to the situation. Aggression matures less rapidly in females than in males, but aggression in both sexes reaches a similar frequency and ferocity of expression when the females become mature. This would make good evolutionary sense, since mature maternal females must exhibit aggressive responses to external animate objects that threaten their young. It should be noted that this same aggressive power also demonstrates to the young child that the mother could, if she chose, kill them, and this visceral thought is an important one for the development of a conscience.

The maternal protective function appears early in the initial maternal stage and usually continues long after this stage has passed. The protective function is commonly elicited during the stage of transition and ambivalence, with little or no decrease in belligerence. Actually, maternal protection response exists long after the infant has reached a state of relative physiological and psychological separation from the mother.

The protection of the infant, and to a lesser degree the juvenile and adolescent, is not an exclusive maternal function. In many primate species protection is, in fact, a prime obligation of the adult males and it is a basic component of the paternal affectional system. However, the psychological feeling of the child/adolescent that the mother is not protective, particularly of the female child, is overwhelming to many. One often sees the child take obvious risks in the hopes of forcing the mother to step in and control the behavior, thereby, protecting the child. Failure of the mother to act, or to act appropriately to protect, causes not only psychological trauma, but often results in physical trauma as well as the child is unprotected in risk situations.

What must be remembered in regard to all of these obligations of mother, is the message that her behavior carries to the infant. Remember that the infant is not taking in these messages in a logical or verbal manner, but is interpreting these behaviors nonverbally and viscerally, creating in the process an instinctive interpretation of the mother’s behavior. The mother can carry out all of these functions perfectly, but without passion, and leave an ambivalent message for the child which leaves the child ambivalent and anxious. On the other hand, the mother may carry out the functions less well, but with great passion and make a strong message of love to the child, which the child accepts.

This connection is further complicated by the need to separate.

The Stage Of Transition

The love of the infant for the mother [or the mother for the child] is often so anxiety producing, clinging and incomplete and/or the need to endure so powerful that the very survival of the species is dependent on multiple separation factors or forces. In view of the obvious strength of maternal ties, there must be even more powerful mechanisms that unshackle the child from maternal bondage at an appropriate age or stage, so that s/he can become an independently functioning individual. Obviously, where the bond has not developed, such mechanisms can be perceived as abandonment. This may happen because the mother begins the rejection process too early, or because the mother and child have just never made an appropriate attachment. The latter usually occurs in our society because of the mother’s preoccupation with her own childhood or absorption with substance abuse, but can occur with a mother who needs and does not receive reinforcement from the child either because of neurological or psychological difficulties.

There are at least three processes that operate to gradually weaken mother infant ties. Harlow treats these three processes as components of a single mother-infant separation mechanism. Certainly all of them operate toward a common goal – to free the child from the mother. The development of the transitional stage is indicated by changes in the nature and number of maternal responses, particularly restraining and retrieving. The transitional stage is best illustrated by the form and frequency with which the mother actively rejects her infant. Obviously, the frequency of active maternal rejection is a joint function of both infant and maternal variables. As the transitional stage reaches a peak, maternal punishment is sometimes made without regard to any observable aggravation of the mother and the baby.

However, except for the mother who has been disconnected throughout, s/he is usually ambivalent during the period. For example, if the infant appears to wander or stray beyond the maternal fold too quickly or too much, maternal responses appropriate to the stage of care and comfort reappear. Infantile independence during this transitional stage can be a source of frustration for the mother as she attempts simultaneously to protect and emancipate.

Nevertheless, on all occasions in which the cherished infant is exposed to dangers, real or only imagined, the mother usually provides defense and protection with no hesitation or delay. Failure to do so in these circumstance leads to psychological and physical trauma for the child.

While active rejection and punishment by the mother plays an important role in helping the infant to break the overwhelmingly strong maternal ties and freeing him/her to make his/her own place in the world, it also is a ‘double edged sword’. Maternal rejection during this period is truly one of many forms of mother love; a mother who loves her infant will emancipate him/her. However, if the mother does not love her infant or is ambivalent about such love, this message is apparent to the infant and separation or detachment becomes a traumatic process.

The Stage Of Relative Separation

It is obvious that the affectional ties between mother and child are eventually dissolved at least physically. The advent of a new baby is a variable of great importance, perhaps even primary importance, in establishing the stage of maternal separation. Normally, the mother has both love to share and love to spare and nestles and nurtures both, or even all, her offspring for a necessarily protracted time, thereby guaranteeing their survival. Again, there is the potential that the mother’s situation is such that she does not have the capacity for more than one child – either because of her own limitations or those imposed by her environment. Mothers can become overwhelmed by the number of children and the limited environmental supports.

Maternal separation may be either physical or psychological, and it may be achieved by either maternal choice or offspring choice. Separation is commonly a period of stress, fear and frustration even if the bond is a good one.

INFANT LOVE

Infant love, which is the love of the neonate, baby and young child for the mother, has often been confused with maternal love. Infant love is usually entirely indiscriminate at birth, and the neonate eagerly and equally attaches to any maternal object, animate or inanimate that is endowed with adequate physical properties. This differentiates animal imprinting from love; in love it is not the infant’s effort, but the mother’s that cements the affectional bond. This assumes, therefore, that the child has a natural tendency to love which must be consummated by the mother. This begs the question as to whether the mother has a natural tendency to love the infant as well.

What has already been noted is that mothers may or may not have such a tendency and that even if they do, the spark may need to be lit by the child. Motivation theory was once dominated by the thesis that the only important unlearned motives were such homeostatic biological drives as hunger, thirst, elimination and organic sex. All other motives were considered derived, learned or secondary. Observations suggest, however, that contact is actually the primary factor in the infant-mother relationship. This critical factor will play an important part in considering cognitive reconstruction.

There is seldom, if ever, any single cause for any behavior by any animal, particularly animals as complex as a human being. Multiple stimulus variables operate to elicit each and every response and there are commonly multiple antecedent variables, both maturational and learned. Hence, although contact comfort appears to be the primary factor in the formation of infant-mother affectional bonds, it is by no means the only variable.

According to Bowlby [1969], the first attachment shown by the infant to his/her mother is based on a number of primary, unlearned species-specific behavior patterns which he calls ‘instinctual response systems’. These response systems mature and develop at different times and rates during the first year. Bowlby has described three such instinctual response systems sucking, clinging and following as mechanisms through which the infant actively maintains contact with his mother.

Two other instinctual response systems, ones in which the mother plays an active role were mentioned as crying and smiling, which elicit maternal caretaking and strengthen the mother’s attachment to her infant. At first the various instinctual responses operate independently and lead the baby to attach him/herself to any mother figure; later, with development these response systems become integrated and focused on a single mother figure.

The sound of the normal maternal heartbeat, as compared against other sounds, exerts a distress-relieving effect on the infant and even facilitates physical development. Other observations also point up the significance of activity associated with the breast and nursing is a significant variable when the more powerful variable of comfort is held constant. Human babies are also soothed by rocking motion and demonstrate a significant preference for the warm mother during the early days of life.

The infant system proceeds through at least five stages – a stage of organic affection, security and solace, detachment and environmental exploration, and a stage of relative independence.

Organic Affection

The baby’s initial affectional force is not a love for the mother, since the neonate probably does not distinguish between his own body and the body of any outsider. Thus, the original love is an egoistic love – not of himself or the body image of himself, but simply of the organic sensations and satisfactions, initiated by the reflex act of nursing and maintained by the pleasures of food assimilation and the relief of organic tensions.

Comfort And Attachment

This stage begins as soon as the infant is able to attach to the maternal body and breast. For the first six months of life or longer, the human infant is totally dependent on the mother for contact and attachment, and human mothers vary greatly in the degree and amount of bodily contact given during nursing or through cuddling or simple play. Studies indicate that with relatively limited affection, if it is given readily and consistently, an infant adjusts successfully within each period of affectional development and proceeds to the next.

Another important behavior at this stage of infant development is primary object following – a powerful mechanism in attaching the infant to the mother, and possibly in producing security responses.

These behaviors enable infants to profit from maternal experience, so that their own exploratory behaviors will not be blind and the dangers inherent in untutored exploration are minimized.

Solace And Security

The state of solace and security in infant/mother affection develops at the time, or probably some time before, infants develop affection for their specific mothers. Security at this stage is expressed by the willingness of the infant to wander beyond the mother’s physical and functional confines to explore the strange new world of objects, playthings and playmates.

The nature and function of the stage of security and solace is clearly demonstrated by the infant’s bravery when the mother is present and his/her terror when the mother is removed.

Detachment And Environmental Exploration

As the infant matures, many factors arise that tend strongly toward maternal detachment. One variable is maternal punishment, but secure infants are also lured by natural forces from maternal charms. The primary mechanism is maturation in the infant of freedom of activity, curiosity and manipulatory needs concerning the external physical environment and later, social drives and interaction with age mates and other members of the species. The primary maternal contribution is neither maternal restraint nor punishment, but rather the positive factor of establishing the personal and social security that the infant must have to be able to leave the mother and the mother’s domain.

Social Independence

Detachment is normally an almost totally infant-guided process, with the mother’s role remaining passive unless disturbance or danger develops, whereas separation appears to be primarily mother-determined, and even the most resolute infant struggles against it in moments of apprehension and whenever daylight fades into dusk.

The Attitudes Of Success

Certainly it should be clear that successful bonding and attachment is primarily the responsibility of the mother although the child contributes to the process through reinforcement of the mother’s behaviors. It is clear that while the neonate has an innate drive toward bonding, the mother does not. The mother’s motivation to bond may be intrinsically connected to her own values and belief’s about self and others. It is easily determined that if the mother did not bond as a child, she is unlikely to be able to bond as an adult; unless significant repair work been completed beforehand. What this implies is that there is a critical cycle of incomplete bonding, if the child survives to adulthood. Because in this society, drugs and sex are available escapes for most incompletely bonded women, and in fact, often are the escapes of choice, pregnancy and the birth of an unwanted child are the norm provided the mother does not eliminate herself from the population through suicide.

Addressing the issue of RAD, one must first have a clear diagnosis of what has occurred and how it occurred. Most often the disorder is seen in children who have been released from the custody of their biological parents and placed in foster care or adoption, and an additional problem occurs since the adoptive parents are not prepared for the unusual behavior of a child who rejects closeness, which the adoptive parents are so desirous of giving. A secondary issue occurs when the adoptive parents, in being so rejected, struggle to maintain a caring relationship. Thus, a corrective protocol, must:

• identify whether the mother and/or the child was the rejecting component and address that rejection
• identify the child’s ‘thoughts’ about what has occurred and how s/he protects him/herself from love
• identify the current mother/child relationship and correct the misapprehensions of the parents so that they can effectively participate in change.

The corrective process is difficult even with adolescents and young adults. However, use of the cognitive restructuring protocol and the specific techniques involved should provides a basis for change. What we are concerned with her are children from six [06] to twelve [12] years of age, who are less prepared to deal with the verbal nature of the usual interventions. What we are seeking is a way to bring the intervention process into a more visceral, nonverbal arena as a way of helping the child identify his/her intuitive responses and change them.

The question of visceral, nonverbal ‘thoughts’ brings us to the question of the intervention called Holding Therapy, which ranges from ‘cradling’ through ‘rage reduction’ to ‘rebirthing’. As stated in the beginning by Harlow, intimate bodily contact is the basic mechanism in eliciting love from the neonate and infant. Peer love is also preceded by the two transitional mechanisms of contact acceptability and basic trust – the mutual acceptance of body contact with member of the same species. Thus, physical contact is a substantial component of learning to love. It should be noted, however, that contact and trust are two components of love and there is no indication that one creates the other.

The basic concept underlying holding therapy seems to be that if the child is forced to tolerate holding, s/he will learn to love. But the espoused theory does not seem to hold water.

First, there is the suggestion that compulsive holding will act as a catharsis so that the child can rid him/herself of rage. According to the Freudian position of catharsis, the individual posses a limited amount of ‘aggressive energy’, and if s/he views or participates in aggressive behavior in a model, s/he will ‘use up’ some of this limited supply and, hence, will be less likely to engage in aggressive behavior than one whose supply of aggressive energy is still untapped.

Many social learning theorists argue that the converse is true – observation of, or participation in, aggression is likely to increase rather than decrease the probability of aggressive behavior. Bandura’s model, for example, clearly shows that film models are extremely capable of eliciting substantial aggressive behavior from children viewing the film. If simply observing such behavior can generate anger and rage, it seems unlikely that participating – even on the weakest side, would not have the same meaning: that is it is alright to be aggressive and violent. In fact, Harlow indicates that although the antecedent conditions of anger in the adult usually involve psychological or social limitations or frustrations, the conditions leading to the arousal of anger in the very young are primarily physical. Restrictive clothing, confinement and denial of desirable play activities are all situations that can give rise to anger in the child. Restrictive holding seems to feed into this very concern.

A second component of the ‘holding theory’ is the belief that resistance by the child to this restrictive holding is merely an indication of the need for holding – ‘resistance is futile’. This unfortunate component of the medical model approach to psychological fitness is not only wrong, but ethically unsound as well. Professionals have no right to force clients to do something against their will, even if they believe that such force is helpful.

Holding the child is allowable by the parent or the counselor for the purpose of containment when the child is in a dysregulated, out-of-control state only when less active means of containment are not successful in helping him/her regain control, and only as long as the child remains in that state. The counselor/parent’s primary goal in such holding is to insure that the child is safe and feels safe. The goal is never rage reduction or to provoke a negative emotional response or to scold or discipline the child. The model for this type of holding is that of a parent who holds an overtired, over-stimulated, or frightened preschool child and helps him/her to regulate his distress through calm, comforting assurances and through the parent’s own accepting and confident manner.

Finally, in discussing holding or ‘touching’ there is a concern that the clinician is so focused on the mother/child love relationship, that they are ignoring another very important love system – peer love. Since we are talking about children under the age of twelve, who in all probability have not had the socialization of their peers, this is a factor of considerable substance.

Yet ‘touching’ and body contact are important requirements of both mother/child love and of peer socialization, both of which have importance to the detached child. It would seem that the use of occupational therapists to design a sensory program which is individualized for each child, but includes the present parents as significant implementers of the regimen offers considerable merit.

In addition, the clinician should not overlook the importance of peer socialization in the present moment for six to twelve years olds. This is probably the most pervading and important of all the affectional systems in terms of long-range personal-social adjustment and has been cited as the single most determining factor of future social adjustment.

Among the most significant developmental goals of childhood is peer acceptance. Positive interactions with peers provide opportunities for socialization and promotes a child’s sense of self-worth and belonging. Social rejection has been correlated with other indicators of maladjustment, such as impaired academic performance, behavior problems, and emotional disorders. Psychologists, therefore, should become increasingly concerned with the detection and treatment of children who have few friends and are disliked by their peers.

Investigation of the problem depends on accurate identification of the personality and behavioral characteristics of peer-rejected children. It is important to clarify the distinction between peer-rejected and peer neglected children. According to French and Waas, rejected children “have few friends and are actively disliked by others” while neglected children “have few friends, but are not disliked by their peers”. Neglected children are simply ignored. In essence, rejected children tend to be isolated by the peer group, while neglected children appear to be isolated from their peers.

Regardless of whether the target child is rejected or neglected or even rejecting, which is quite probable with the unattached child, the need to overcome the isolation from the peer group is every bit as important as learning to participate effectively in mother/child love. Play in all its complete forms is impossible if bodily contact is looked upon as undesirable or loathsome. We simply accept reasonable basic security as an essential social antecedent to the formation of peer love. The age mate affectional system is of superordinate importance for normal social and sexual development.

AGE MATE OR PEER LOVE

The peer affectional system begins at about three years of age, peaks between the ages of nine and eleven, and wanes with the onset of adolescence, when peer relations become hopelessly entangled with heterosexual affection. Thus, for children, particularly on the younger end of this scale, involvement with peers is an essential aspect of learning to love.

This system develops through the transient social interactions among babies, crystalizes with the formation of social relationships among children and then progressively expands during childhood, preadolescence, adolescence and adulthood. Individual age mate or peer affectional relationships may exist between members of the same or opposite sex. Because of the importance of this interaction, it is suggested that the clinical team start with the development of sociometric measures to determine the status of the child with his or her peers and then specifically seek to determine the levels of interaction in which the child is proficient or deficit. From that analysis, the team can develop strategies to address the concerns.

The primary positive variable pervading peer love is that of play, which progresses from the asocial exploratory play characterizing early infancy to parallel play and subsequently to the multifaceted forms of social, interactive play achieved by the child, the adolescent or the adult. Because of its importance, we will take a short excursion into the mechanisms to be considered.

Presocial Play

Developmentally and functionally, play progresses according to a definite maturation pattern. Play with inanimate objects precedes play with animate objects, so that presocial play by definition precedes social play of comparable complexity. Three types of nonsocial or presocial play occur, the first is exploration, the second form is that of parallel play, in which two or more individuals play simultaneously and in close proximity, but without any apparent interaction, and the final presocial play form is investigative play. In this case the activity initiated by one child serves as a model to another, who immediately accepts the challenge and attempts the chosen chore.

Social Play

As important as presocial play is in preparing the child for more social involvement, the more complex and more socially demanding forms of play comprise the categories of social play. Social play, as its name indicates provides the basis for social interplay on the adult level and is therefore an extremely important training ground for interpersonal relationships. Clinicians should be specifically aware of what areas of social play the child participates in and which s/he does not, and then develop strategies to increase levels of play which are in deficit. It is important to note that we are not talking about Play Therapy, but actual play with peers without the interference of adults.

Social play may properly be divided into three major forms – free play, creative play and formal play.

Free Play

Free play can be conducted without recourse to rules and may be physically vigorous and even violent, or sedately satiating. Either physical or cognitive factors may predominate, but the outcome of the activity is not pre-determined and there is no prescribed process.

Physical play is the easiest for the child and the most disturbing for the parent. This form plays a predominant role in the socialization process, for it is here that social ordering and even social roles develop, the rules of social intercourse are shaped, and eventually the control of immediate demand and aggression is established. Frequency and finesse of social interaction in such play determines social status. Such contact play also shapes and shifts social roles.

Creative Play

Creative play begins when the child becomes the master, the creature becomes the creator and all reality becomes subservient to the child’s whimsical whirlwind of wishes. Creative play differs from free and formal play in many ways.

In creative play the child uses as raw materials things which to adults are finished products – s/he personalizes such objects to serve a unique basis.

Formal Play

Formal play is conducted within the limits of prescribed rules and, therefore, functions as the basis for all formal relationships in which protocol and rules must be followed. One is given rules, bylaws and a credit system, and for each move or alternative the consequences are predetermined.

From a developmental standpoint there appears to be irony in this ritualistic recreation. As physical and mental independence increase, we tend to favor forms of play which have increased restrictions. Our recreational preoccupations are transformed from artistic adventures to scientific solutions.

The Functions Of Peer Play

The primary basis of aggression control is the formation of strong, generalized bonds of peer love or affection. All humans are born with aggressive potential, but aggression itself is a relatively later-maturing variable. Thus, the primary functions of peer play is the discovery and utilization of social and cultural patterns. The child is enabled to discover not the individual reality principle, which the infant discovers through interaction with its mother, but the social reality principle discovered through interaction with peers. Familiarity with the established social and cultural patterns offers the child the reward of social acceptance, the freedom to engage in play of challenging complexity, and guardianship against social failure and rejection.

The moral support supplied by the group diminishes the fear of real objective danger and intensifies the fear of age mate rejection. This is a particularly important foundation for the basis of love relationship with a member of the opposite sex.

HETEROSEXUAL LOVE

The heterosexual affectional system typically emerges at puberty, reaches full expression by late adolescence and operates throughout most of adult life. The context of male and female gender roles is required before romantic love can have any content or consequences.

The need for close social bonds, the formation of gender identification as male or female, along with acceptance and adoption of sex roles and of the cultural reproductive model, are relatively permanent characteristics of human adolescents which operate with the strength of basic moral obligation.

References

Harlow, H. F. (1974) Learning To Love, New York, Jason Aronson.

Joseph, R. (1996). Neuropsychiatry, Neuropsychology, and Clinical Neuroscience. New York: Lippincott, Williams & Wilkins.

Schore, A. (1994). Affect Regulation and the Origin of the Self. Hillsdale, NJ: Lawrence Erlbaum.

Valent, P. (1998). From Survival to Fulfillment: a framework for the life-trauma dialectic. Philadelphia: Brunner/Mazel.

SYMPTOMS

The nature of the disorder is that the child won’t have many symptoms or will have a lot.

Infant [from birth to approximately age three]

Generally infants present with sleeping problems, eating problems, a resistance to being comforted.

Child [from approximately age three to age thirteen]

Overall, there seem to be several areas of symptomatology – the first area concerns the child’s need for control of other people and includes a variety of attempts to make the adults ‘seem crazy’, which can be categorized as follows:

• superficially engaging and charming [stalking the prey]

Often, teachers, dentists, doctors and others who occasionally meet the child believe that it is the mother’s problem [see the last symptom] and can’t believe that the child is or has a problem. Teachers, because of the length of time they are involved, may come to ‘see’ the child differently.

• not affectionate on parental terms – WANT CONTROL

The discrepancy between the mother and the child often appears most obvious around the attempts of the mother to cuddle or comfort the child. At the time that the mother most wants reciprocal behavior, she is most vulnerable to being disappointed. However, the child may want to cuddle when the mother is angry or when other people can see it – in order to confuse the mother and the others as to what is really happening.

• destructive to self, others and things

As part of the ‘crazy making’ activities carried on, these children can be abnormally destructive.

• persistent nonsense questions

While such questioning is normal for infants, it is not normal for children but is another ‘crazy making tool for controlling adults, particularly mothers.

• inappropriate demanding/clinging

While generally unwilling to accept cuddling, these children may choose inappropriate times to demand or cling.

• stealing

Again, this is a ‘crazy making’ activity. RAD children typically steal things that they could have if they asked. They will also make obvious choices that indicate that they want to get CAUGHT.

• primary process lying

This is described as blaming things on, for example, an imaginary friend. The lying is often a baiting process in the ‘crazy making’. Never ask “Do you think I am stupid?” – for the answer is YES!

• no impulse control

The RAD child may ‘ACT’ hyperactive. While ADHD is a possible additive to RAD, it is difficult sometime to tell because many of these kids ACT hyper to agitate [make crazy].

• acts dumber than dumb

Again, the difficulty is to determine if the child is attempting to make the adult crazy or s/he actually has a problem.

• idiosyncratic speech patterns

This ‘crazy making’ may be connected to the one above. These kids often seek to make the adult ask – what? – and the more times the better.

A second category is probably also connected to control, but is includes much more dangerous potential.

• preoccupation with fire

As with cruelty to animals, there is a tendency to escalate the fire setting issues.

• cruelty to animals

While typical boys may occasionally injure animals – they do not do so regularly nor do they escalate. The RAD child’s injury to animals is done almost ritually and always escalates to a next level of cruelty.

A third segment of symptoms occur because of deprivation, and include:

• lack of conscience

As startling as it might sound, the infant by age two or three must learn that the parent could KILL them – which also means s/he can PROTECT them. But this double edge sword enables a process within which the child can acquire a conscience.
– I want that
– I want that – she will kill me
– I want that – she will find out
– I want that – its not right

Failure to attach means that this process of initiating a conscience does not occur.

• eating problems

Particularly patterns in which the child might hide, gorge, or waste food – or eat unusual items – PICA plus – parents should not attempt to deny food, even if wasted, but should provide the child control over sufficient food that they can finally be secure that there is enough food.

• don’t get along with age mates

Often these kids will hang out with older or younger children – if it is SAFE – let them play with younger kids in order to gain the social skills that they lack.

• no stranger anxiety

Typical children will have some anxiety around strangers, particularly if their parents are not close at hand. Children with RAD are often peculiarly able to meet and greet strangers, sometime inappropriately so.

Finally, we have a grouping of symptoms that are difficult to place in a category:

• lack of eye contact [eyes are power] – except:
  • when they lie
  • when angry
  • they want something

Clearly, there are elements of control and ‘crazy making’ in this symptom. However, there is also a fear of making eye contact which derives from the ‘eye power’ that children perceive.

• lack of cause and effect thinking

Because the child has not had a grounding in cause/effect responses on a visceral level, s/he may be unable to make the connection on a logical level. S/he may be able to articulate the concept without ‘gut’ level understanding.

The final category of symptomatology is indicative of the strangeness of the RAD problem, but is outside of the child. The symptom is ultimately the result of the child’s ‘crazy making’ control behaviors.

• unreasonably angry parent

The primary caretaker, usually mom, is completed befuddled by the behavior of the child, while everyone else does not understand how the kid sets her up and then behaves so charmingly for others. While caution must be shown in making this determination, if the caretaker is [or has been] considered to be a functional and authentic person in every other area of his/her life, but is ‘out of control’ when s/he thinks or talks about the child – this is very symptomatic.

Needing to control their environment, the RAD child will quickly target the Mother as the one who has to be broken. This is because the mother is the one who instills discipline on a daily level, and ensures that chores and work are performed to standard. It may also be because, ‘a mother’ was the one who let them down in the past, and they target the mother in a sense of pay-back.

Father’s are often charmed into believing that this child is innocent of all accusations, and if the father allows any benefit of doubt to creep in, the child will work that against the rest of the family. Quite often the child will exhibit a “Dr. Jekyll, and Mr. Hyde,” disassociation between the family and the father in order to control, and, if necessary, split-up the family.

PARENTAL INTERVENTIONS

The parents need to be educated to the concept of attachment problems and to understand that the child’s behavior is not caused from their parenting, but from past traumas. From this base then, new parenting strategies can be designed from a cooperative relationship to fit a child with special needs, while enabling the parents to rid themselves of the emotionality that the child’s behavior would normally arouse.

Attachment is the base upon which emotional health, social relationships, and one’s world view are built. The ability to trust and form reciprocal relationships will affect the emotional health, security and safety of the child, as well as the child’s development and future interpersonal relationships. The attachment-disordered child does whatever she feels like, with no regard for others. She is unable to feel remorse for wrongdoing, mainly because she is unable to internalize right and wrong. This child may be savvy enough to speak knowledgeably about standards and values, but cannot truly understand or believe what she is saying. The child may tell you that something is wrong, but that will not stop her from doing it.

Normal attachment takes a couple of years of cycling through mutually positive interactions. The child learns that s/he is loved, and can love in return. The parents give love, and learn that the child loves them. The child learns to trust that his/her needs will be met in a consistent and nurturing manner, and that s/he is safe and secure and ‘belongs’ to this family, and they to him/her. Positive interaction. Trust. Claiming. Reciprocity is the mutual meeting of needs, a give and take. These must be consistently present for an extended period of time for healthy, secure attachment to take place. It is through these elements that a child learns how to love and how to accept love.

Beyond the basic function of secure attachment – providing safety and protection for the vulnerable young via closeness to a caregiver – there are several other important functional improvement for these children:

1. learn basic trust and reciprocity, which serves as a template for all future emotional relationships.
2. explore the environment with feelings of safety and security (‘secure base’), which leads to healthy cognitive and social development.
3. develop the ability to self-regulate, which results in effective management of impulses and emotions.
4. create a foundation for the formation of identity, which includes a sense of competency, self-worth, and a balance between dependence and autonomy.
5. establish a prosocial moral framework, which involves empathy, compassion and conscience.
6. generate the core belief system, which comprises cognitive appraisals of self, caregivers, others, and life in general.
7. provide a defense against stress and trauma, which incorporates resourcefulness and resilience.

If we remember that it is the child’s responsibility to attach to the mother, it is important that the mother build an appealing presence and becomes a magnet to the child. The child must come to you. the old cliché of “attracting more flies with honey than with vinegar” makes sense here. The goal is to provide security, not challenge.

Nonetheless, you will need a tough (not mean) parent. RAD kids will have difficulty internalizing a parent that they think they can control. A context to think about this may be found in the book, “How To Be a Dog’s Best Friend” which can be found at most book stores. In order to become psychologically fit, the child must learn to sit, stay, come, go, fetch. This may sound harsh and uncaring, but it is the attitude that must be taken by the parent if successful attachment is to ultimately occur.

Teaching the child to be compliant can lead to reciprocity, but that is only the beginning of trust and love. A good place to start is with having the child sit in a designated area (often called practicing ‘good sitting’). The goal of good sitting is not to degrade or control the child, but to teach the child positive self-control, and not institute a control battle.

Perhaps the most difficult area of parenting a RAD child is in knowing how to successfully parent this kid. Normal parenting skills are insufficient, and a parent cannot rely upon what they automatically would do in day-to-day situations. The RAD child does not tend to learn from past experiences, so what was done wrong yesterday, may be repeated today. And, the child will often expertly pit the parents against each other.

Rule #1: Take Care of Yourself First. This may sound selfish, but you must remember that in the extreme RAD, this kid is out to get you – as harsh as that sounds, you must maintain an equilibrium in order to help. The parent must be a solid foundation of emotional stability and never give in to anger and aggressiveness.

Rule #2: Never give the benefit of the doubt to the child! Their lies, or jumbled talk will convince expert after expert of their innocence or demand your attention as they seemingly stumble for a long time on trying to put their thoughts into words. While never giving the benefit of the doubt, the parent should always give the benefit of caring and security – recognizing that these behaviors are a symptom of the child’s hurting. While the symptom may hurt you – two wrongs do not make a right.

Rule #3: Do not enter into power struggles. AD kids will constantly struggle to control everything. But no one wins in control battles. Set up a scenario so that you’ll win in either situation. This is a highly potent skill – which will require a mindful parent who is always thinking about the situation from the perspective of the child’s pain and not their own. Humor is one positive way to avoid the assertion of power. Another is to articulate an understanding of the pain while maintaining the consequences.

Things That Are Not Going To Work

• cursing and anger
• depriving the child of something
• isolation
• physical punishment
• reward [externalization] DON’T PRAISE
• avoid power struggles – don’t make adamant statements unless you intend to back them up
• if you get in a power struggle you MUST WIN!

What Might Work

• Natural consequences – don’t check homework – let the kid pay the price
• Logical consequences – only when natural consequences are not available or acceptable
• be a consultant to the kid – don’t take responsibility
• reciprocity
• no reminders and no warnings
• be SAD with them not MAD at them

CREATING AN INDIVIDUALIZED PROTOCOL

How do you fix a broken child?

The Contract

In any successful approach to reducing the symptoms of AD, the child has to attempt to be a part of the fix.

1. An elementary approach to produce bonding is to get the child to agree to ask the parents’ assistance and permission for everything. The idea here is to restore the bonding of the parent in the first year cycle. The repeated request to the parent becomes the tool for repeated gratification/relief.
2. A second addition to this method is to require the child to make eye contact when asking for the things in step one. And, then asking him/her to reinforce the question with the terms ‘Mom’ or ‘Dad’ as necessary.

The child might struggle with these simple requests because of the release of control in their lives over to the parent. Releasing control is a very difficult process for a RAD child. They do not know why they feel and act as they do. They are operating in the only way they know how to survive. Remember that the child formulated their ‘inner logic’ before they were able to develop logical language to articulate their needs. Now they have hunches and intuition [strong ‘gut’ feelings] about the need to protect themselves, but do not know why this is so.

The overriding issue that the clinical staff will need to deal with is how to address the inner child, when the subject is still a child and not far removed from the creation of the traumatic and distressing cognitive structures, e.g., schemata of self and others. We expect that the clinician is dealing with a child between five and twelve years of age. For a child older than twelve years of age, and perhaps for some of the twelve year olds, the clinician can turn to the Cognitive Restructuring Protocol and perhaps use it more directly.

Create a Context for change

For the younger child, the first thing that is required is that the counselor needs to create a context that the child can understand and relate to. This context should perhaps have a mystical and spiritual quality. Native American [perhaps an animal spirit guide – a little work on the internet should give you a good mystical way to select this guide] and/or eastern orientations [Buddhist monk and Zen koan – give the child a mystical mantra in Sanskrit] and/or Druid mysticism – may be helpful. You can also, of course, consider Yoda and the Force.

Create a model parent – Aunt Bea from the Andy Griffith Show, would be an example. Must be culturally attuned. Show tapes or tell social stories of how the model would view childhood incidents. One of the things that may be useful when the child is stuck as to how the parent should act in a given situation is to have the child think about how this model parent [selected by them] would handle the given situation. This is drawing on the most positive nonconscious thoughts of the child to apply to a ‘sticky’ problem. What is really happening is that the child draws on some instinctive part of themselves to address the problem and then puts the onus on the ‘perfect parent’ to test out the instinct. This is the same process that occurs in CBT#22 – Six Step Reframing – which seems quite mystical or silly, because the client is asked to ‘talk’ to different parts of him/herself to seek clues to solve difficult problems. Six Step Reframing is an appropriately mystical technique that with adaptation can be used with young children. It is a process which enhances the ability to put instinctive or visceral thoughts into consciousness and logical thought.

As with ‘laddering’ and other such techniques, the process of asking someone to describe in words that which is un-describable drives the individual to bring these ‘hidden’ thoughts into consciousness.

Laddering is a way of analyzing your internal monologue statements by looking for more and more basic underlying assumptions and predictions until you arrive at statements of core belief. The technique is called laddering because it proceeds step by step. Laddering has only two rules. Rule number 1 is to question yourself with the following format, and Rule number 2 is don’t answer with a feeling. The format is to ask:

‘What if _________________? What does it mean to me?’

In the blank space the client writes a self-statement from his/her internal monologue. Then s/he writes the answer to the question. Having done that, have the client use the answer to fill in the blank and ask the question again. After using this sequence a few times, the client will arrive at a core belief. The answers must be confined to statements that express conclusions, beliefs or assumptions – not descriptions of feelings.

The same kind of issue arises when you ask the client “how do you know?” and get the answer “I just know!”. The client has an instinctive or gut knowledge that s/he cannot explain. This is the very kind of thought that you need to expose to the client’s own consciousness. By asking the question over and over, each response will lead the client closer to the truth. This process is difficult and frustrating for the client and kids will often shut down, because they don’t know how to respond. Using something like the ‘perfect parent’ or the Six Step Reframing takes the burden off the child responding directly, but only responding as they believe this other entity might respond. But where do they get these thoughts about how another part of themselves might respond – only from their own mind. Thus any such articulation is a step closer to bringing the intuitive to the conscious.

Create a respite care system

Unfortunately, there are few qualified RAD respite care facilities out there. Many of those that exist do not meet local social services requirements for financial assistance. Networking of care providers with other care providers not only provides resources for understanding RAD, but may also provide the best resource to the care provider of understanding respite care.

Tackling another RAD child is not always as difficult as it may sound. Keep in mind, that the respite care provider is NOT attempting to love the child, so the child does not feel threatened. And in many cases, the child has their best foot forward and is quite helpful and pleasant to have around.

As previously indicated, providing respite care for an RAD child, cannot become a reward, or a holiday, or a time for the child to regroup. It must be a time to realize what their life is like, and to understand that they can choose to make it better.

Create a structure for the counseling:

The structure in Dialectic Behavior Counseling provides a solid structure for both the client and the counselor. It also provides for the ability to use other strategies at the same time you are following the structure.

The dialectic that underpins the structure is to continue to ask for change while supporting the individual as s/he is. Linehan, in her work with adult women, reported three particularly troublesome issues:

1. Clients found the unrelenting focus on change invalidating. Clients responded by withdrawing from engagement, by becoming angry, or by vacillating between the two. This resulted in a high dropout rate.
2. Clients unintentionally reinforced their counselors for ineffective intervention while punishing their counselors for effective services. In other words, counselors were unwittingly under the control of consequences outside their awareness. For example, the research team noticed through its review of taped sessions that counselors would ‘back off’ pushing for change of behavior when the client’s response was one of anger, or emotional withdrawal, or shame, or threatened self-harm. Similarly, clients would reward the counselor with interpersonal warmth or engagement if the counselor allowed them to change the topic of the session from one they didn’t want to discuss to one they did want to discuss.
3. The sheer volume and severity of problems presented by clients made it impossible to use the standard format. Individual counselors simply did not have time to address both the problems presented by clients – suicide attempts, urges to self- harm, urges to quit treatment, noncompliance with homework assignments, untreated depression, anxiety disorders, etc, — AND have session time devoted to helping the client learn and apply more adaptive skills.

Each of these, to some degree, is likely to be a problem with a RAD child, although the intensity of suicidal ideation and implementation may not as yet have reached the same intensity.

In addition, Linehan hypothesizes that any comprehensive service must meet five critical functions. It must:

• enhance and maintain the client’s motivation to change,
• enhance the client’s capabilities,
• ensure that the client’s new capabilities are generalized to all relevant environments,
• enhance the counselor’s motivation to treat clients while also enhancing the counselor’s capabilities, and,
• structure the environment so that appropriate intervention can take place.

In order to accomplish these functions effectively, she organized the strategy by Functions and Modes and by Stages and Targets which is a suggested framework for clinicians working with RAD clients.

Create a conceptual framework for the counseling:

Schema Focused Counseling [See CBT#39] gives options which are appropriate – you don’t have to fit into a domain, but it helps to have an orientation to the kind of schema the child tends to use. The following is a short definition of Early Maladaptive Schema without the domains.

Emotional Deprivation: The belief and expectation that your primary needs will never be met. The sense that no one will nurture, care for, guide, protect or empathize with you.

Abandonment: The belief and expectation that others will leave, that others are unreliable, that relationships are fragile, that loss is inevitable, and that you will ultimately wind up alone.

Mistrust/Abuse: The belief that others are abusive, manipulative, selfish, or looking to hurt or use you. Others are not to be trusted.

Defectiveness: The belief that you are flawed, damaged or unlovable, and you will therefore be rejected.

Social Isolation: The pervasive sense of aloneness, coupled with a feeling of alienation.

Vulnerability: The sense that the world is a dangerous place, that disaster can happen at any time, and that you will be overwhelmed by the challenges that lie ahead.

Dependence/Incompetence: The belief that you are unable to effectively make your own decisions, that your judgment is questionable, and that you need to rely on others to help get you through day-to-day responsibilities.

Enmeshment/Undeveloped Self: The sense that you do not have an identity or ‘individuated self’ that is separate from one or more significant others.

Failure: The expectation that you will fail, or belief that you cannot perform well enough.

Subjugation: The belief that you must submit to the control of others, or else punishment or rejection will be forthcoming.

Self-Sacrifice: The belief that you should voluntarily give up your own needs for the sake of others, usually to a point that is excessive.

Approval-Seeking/Recognition-Seeking: The sense that approval, attention and recognition are far more important than genuine self-expression and being true to oneself.

Emotional Inhibition: The belief that you must control your self-expression or others will reject or criticize you.

Negativity/Pessimism: The pervasive belief that the negative aspects of life outweigh the positive, along with negative expectations for the future.

Unrelenting Standards: The belief that you need to be the best, always striving for perfection or to avoid mistakes.

Punitiveness: The belief that people should be harshly punished for their mistakes or shortcomings.

Entitlement/Grandiosity: The sense that you are special or more important than others, and that you do not have to follow the rules like other people even though it may have a negative effect on others. Also can manifest in an exaggerated focus on superiority for the purpose of having power or control.

Insufficient Self-Control/Self-Discipline: The sense that you cannot accomplish your goals, especially if the process contains boring, repetitive, or frustrating aspects. Also, that you cannot resist acting upon impulses that lead to detrimental results.

The concepts alone should help you become better able to describe and discuss the characteristics of the individual child. Just as the child has visceral intuitions which s/he has difficulty describing, so do you. These concepts provide some language, which perhaps will help you to better understand what you are dealing with. NOTE: the flaw in this process when working with the client is that the availability of language may suffice, but not satisfy the essence of the notion. Therefore, you may want to review CBT#37 Metaphor Counseling with Clean Language to explore ways of avoiding placing too many alien ideas into the client’s mind.

Psychoeducation:

This is a process of ensuring that the child understands the concepts necessary to carry out the techniques. The child needs a solid counseling educational component in order for the child to understand what force is driving his/her feelings and controlling his/her behavior. Just as the conceptualizations of schema help the counselor to articulate the issues more specifically, so too the child must learn the concepts of both the disorder and the corrective protocol to help them feel more in control of the learning process. Nothing in any cognitive behavior management process is kept secret from the client because each intervention is a training process which enables the client to use the techniques for themselves in the future.

Concepts the child must learn include:

• that there is no meaning in an event – except as s/he gives it meaning.
• that things turn out best for those who make the best of the way things turn out
• to view their own behavior as a WITNESS not a JUDGE
• to be a detective and seek evidence [avoiding traditional bias]
• to be mindful of their own thought/emotion

When we say there is no meaning in an event, we mean no inherent meaning. When an athlete ‘celebrates’ after scoring a touchdown, is it taunting or not? It is not taunting, until the referee decides it is taunting. The basis for that decision is idiosyncratic based on the referee’s prior experiences and interpretations. There is a general ‘consensus’ of meaning for most people that will narrow the meaning down to a ‘margin of error’ aspect. It ‘could have been taunting’, but I didn’t think it rose to that level. On the other hand, people often give meaning to an event which is startling to bystanders, since no one else gave the same meaning.

As the philosopher Epictetus said almost 2,000 years ago: “The thing that upsets people is not what happens but what they think it means.” And the attribution of meaning in the infant is a nontrivial task as the difference between ‘sensation’ and ‘perception’ might demonstrate.

A first and seemingly immediate awareness, which more or less corresponds to the energy stimulation patterns, is referred to as ‘sensation’. ‘Perception’ can be distinguished from sensation in that it refers to a process that requires more organization than sensation, is more heavily dependent on learning than sensation, and requires more time for completion than sensation. When the learning is only beginning the perception or cognitive organization is based upon the construct of utility [e.g., pleasure and pain], meaning that the infant has a visceral reaction to the sensation and determines it to be pleasurable or painful. Neglect and abuse are perceived as painful, even though the infant is unable to connect these painful experiences to anything else in his/her memory. Over time, these visceral experiences are connected to the caregiver, or perhaps even to adults in general. The child may then come to ‘fear’ adults even though s/he cannot indicate why. Or, s/he may attribute these painful experiences to his/her own inadequacies – it is s/he who is undeserving of care – it is not the fault of the caregiver. S/he then has a next level of cognition – to determine how to handle these fearful concerns.

Kids with attachment difficulties often give meaning that is far more emotional and powerful than observers believe it warrants. That is because a child’s ‘inner logic’ sets the stage for the observation. Therefore, when a substitute teacher hands out a ‘pop quiz’ in math and the child screams obscenities and threatens to hit the teacher – it makes no sense until you understand a schema that might go something like: everyone hates me because I am so stupid. My parents and teachers always set me up to humiliate me. This test is specifically directed at my dumb math and this teacher was told to make me look stupid in front of the class. Yes it is an irrational and distressing thought process, but remember, this kid never learned to love and trust. S/he was never hugged and told that everything would be all right and that s/he was okay. Instead, she was invalidated at every turn and punished for mistakes with humiliation and perhaps more. Until the inner logic changes, his/her responses to events may continue to be out of the ordinary.

EXPLANATIONS AND ATTRIBUTIONS

One of the most amazing features of human beings is that they can explain anything. No matter what the cause, we have a strong need to understand and explain what is going on in our world. When we offer explanations about why things happened, we can give one of two types. One, we can make an external attribution. Two, we can make an internal attribution. An external attribution assigns the cause to an outside agent or force. Or as kids would say, “The devil made me do it”. By contrast, an internal attribution assigns causality to factors within the person. Or as the sinner would say, “I’m guilty, grant me forgiveness”. An internal attribution claims that the person was directly responsible for the event.

Under normal circumstances, an internal attribution that is unstable and controllable is the most beneficial attribution – I can do better if I try harder [effort]. When an internal attribution of cause is tied to repeated failure and is seen as stable and uncontrollable, this is a seriously flawed attribution.

Now one the things the child with RAD is struggling with is why things happened? Why was s/he traumatized by his/her mother? Most often the explanation the child has will be contained in a belief about him/herself and others. It is my fault – AND I have no control over it [or attempts to control require perfection, which as we all know, is impossible] OR I must control everything because the only one I can trust is myself – they don’t care. but, remember, these ‘thoughts’ are contained in intuitions, hunches and visceral reactions which are often ineffable, or can be said only in metaphors or generalities.

Look again at the early maladaptive schema listed above and identify how many are explanations about why things happened the way they do. This is the critical issue. If the child blames the mother for the way things turned out, the critical edge is probably anger – if s/he blames him/herself, the critical edge is probably sadness, hopelessness and helplessness.

Yet, remember, the child’s formation of these beliefs occurred predominantly before the age of three years of age, a time when the symbolic memory had nothing to do with logic and words. Since you want to reactivate those nonverbal beliefs into consciousness, you may have to do it indirectly.

One suggestion is to line up a series of social stories and explanations. These can be used to indirectly approach the question of responsibility and performance skill.

e.g.,

Many people know the story about the elephants who are tied to very small stakes in India. The western visitor usually asks why they don’t pull up the stakes and walk away.

Why indeed? Why do you suppose?

The local people reply that when the elephants are babies, they are tied to the stakes and learn they can’t walk away from them. Even when they grow up to be big and powerful, and could easily walk away, they don’t because they have accepted the idea that they can’t.

Ask the child whether s/he does or does not do anything because s/he believes s/he can’t do anything else?

On the other hand, you might want to use optical illusions to demonstrate that there is more than one way to look at things.

e.g.,

Ask the child whether s/he sees the cubes or the star? Being able to see both things at once is impossible – but once learned, the child can see either the star or the cubes at will. Suggest that illusions occur in our thinking as well. One can see blame where another person sees none. Which side of this illusion would be better to see – which one does the child wish to see?

Kids are filled with wonder – if you can do any magic tricks – do them. They don’t have to be very fancy or expert. Make a quarter disappear.

Ask the kid to tell you how it was done. Don’t tell him/her, but indicate that you are going to teach them magic – how to change their own distressing thoughts – and if they work hard at it – you will teach them other magic as well.

You need to get the child to suspend his/her own beliefs about themselves and others in order to heal the inner child and create a new schema and the context of magic is probably an appealing way to involve them.

SANCTION TO HELP

BUT you also need to be AUTHORIZED to help – you must ask the child whether s/he wants to change – does s/he want the torment to stop?

If so, is s/he willing to trust (obviously within the limits of RAD) you to help them change? What are the requirements that they need to feel safe and secure?

This will be HARD WORK – it took 6,7,8 years to create the thoughts, attitudes and beliefs that you have now and we are going to try to make those thoughts, attitudes and beliefs less distressing and more supportive in the next 9 – to 12 months.

Are you with me? If you are – we CAN do this!

INTERVENTIONS

No pharmacologic treatment specifically for attachment disorders exists and individual counseling alone is largely ineffective with RAD children. Therefore, the use of family and parent counseling along with individual and social interventions is likely to be the most productive approach. Parents should almost always be present [either in person or though technology] when the counselor is working with the RAD child on current issues since counselors who treat RAD children without parent input can be manipulated by the RAD child’s deception. Parents give the counselor the most reliable access to what is true about the RAD child, and after all, it is the parents that we want the child to attach to. Counseling must be reality based and focused on current, specific problems. The child is not given a choice about the subject or allowed to avoid issues. As the child becomes attached through the process, genuine talk about past trauma occurs more often.

Parent education is an integral part of the intervention. Most people learn how to parent by being parented as a child but this training rarely prepares them to parent the RAD child successfully. People learn to parent children who want parents and to give love to children who want to be loved. Parents need special skills because RAD children do not want parents and reject their parent’s love. The fear of being hurt by someone you love is much too powerful to allow love to happen. In the psychoeducational component, parents will need to learn how to give love to a child who does not want love and how to parent children who do not want parents. Parents will also learn the inner logic of the RAD child, why the child thinks, feels, and acts the way s/he does. Increased understanding leads to increased competence, as well as, helping the parents to regain compassion for their child. Another purpose of the parent education is to teach parents to protect themselves from their child’s pain and help stop them from being hurt by their child’s emotions and behaviors. This skill helps parents continue to have loving feelings toward their child while their child is learning to attach.

Intervention always involves a child and the parents. Sometimes the clinician may need to involve siblings as the child has often abused them and corrective work is needed for these relationships. The parents are involved in all counseling. They are either in the room directly or are watching clinician work with the child from an observation room.

SPECIFIC TECHNIQUES

RELAXATION

No matter what distresses the child has, relaxation techniques can be used to alleviate the distress. It is highly recommended that the full Relaxation Technique [CBT#04] be followed. It may be quite difficult for the child who is anxious and restless. But if s/he gave you authorization and you have developed an appropriate mystical/spiritual context – s/he will work at it. If s/he succeeds, even once, in completing each segment, s/he will have attained a skill that s/he can always use. Too often, it is the counselor who believes that the child can’t relax or believes that this is nonsense and we don’t need to do the whole thing. This is destructive to the helping process. One cannot be relaxed and distressed at the same time. If the child can learn to relax occasionally, s/he will have a respite.

NARRATIVE COUNSELING

Stories are our habitation. We live in and through stories. They conjure worlds. We do not know the world other than as a story world. Stories inform life. They hold us together and keep us apart. We inhabit great stories of our culture. We live through stories. We are lived by the stories of our race and place. [Mair – 1988]

Counselors are collaborating with children and families in ways that allow counselors, children, and parents alike to be lighthearted, humorous, and creative – and yet surprisingly effective in resolving many of the presenting problems. The developments, collectively known as narrative counseling, offer some unique and helpful perspectives to the field of child and family counseling.

The term narrative implies listening to and telling or retelling stories about people and the problems in their lives. In the face of serious and sometimes potentially deadly problems, the idea of hearing or telling stories may seem a trivial pursuit. It is hard to believe that conversations can shape new realities. But they do. The bridges of meaning we build with children help healing developments flourish instead of wither and be forgotten. Language can shape events into narratives of hope.

We humans have evolved as a species to use mental narratives to organize, predict, and understand the complexities of our lived experiences. Our choices are shaped largely by the meanings we attribute to events and to the options we are considering. A problem may have personal, psychological, sociocultural, or biological roots–or, more likely, a complex mix of the above. Moreover, young people and their families may not have control over whether a certain problem is in their life. But even then, how they live with it is still within their choice. As Aldous Huxley once said, “Experience is not what happens to you. It is what you do with what happens to you”.

A Playful Approach

It is sometimes amazing how resourceful, responsible, and effective children can be in facing problems! Externalizing language separates children from their problems and allows a lighthearted approach to what is usually considered serious business. Playfulness enters into family counseling when we narrate the relationship between a child and a problem.

When adults and children collaborate actively play is a mutual friend. It inspires children to bring their resources to bear on problems and make their own unique contributions to family therapy. Playful approaches in narrative counseling direct the focus away from the child as a problem and onto the child-problem relationship in a way that is meaningful for adults as well as intriguing, not heavy-handed or boring, for children.

Externalization

“The problem is the problem, the person is not the problem” is an oft quoted maxim of narrative therapy. The linguistic practice of externalization, which separates persons from problems, is a playful way to motivate children to face and diminish difficulties.

In a family, blame and shame about a problem tend to have a silencing and immobilizing effect. Moreover, when persons think of a problem as an integral part of their character or the nature of their relationships, it is difficult for them to change, as it seems so “close to home”. Separating the problem from the person in an externalizing conversation relieves the pressure of blame and defensiveness. No longer defined as inherently being the problem, a young person can have a relationship with the externalized problem. This practice lets a person or group of persons enter into a more reflective and critical position vis-à-vis the problem. With some distance established between self and problem, family members can consider the effects of the problem on their lives and bring their own resources to bear in revising their relationship with it. In the space between person and problem, responsibility, choice, and personal agency tend to expand.

This practice also tends to create a lighter atmosphere wherein children are invited to be inventive in dealing with their problem, instead of being so immobilized by blame, guilt, or shame that their parents are required to carry the full burden of problem-solving. Externalizing conversation “frees persons to take a lighter, more effective and less stressed approach to ‘deadly serious’ problems”.

Soiling was one of the first problems to be externalized by Michael White in Narrative Counseling. In a straightforward externalization, encopresis was renamed “Sneaky Poo”. Encopresis is a medical diagnostic term; in itself there is nothing wrong with it. However, the grammar that we use in speaking with and about young people has certain effects. To say that “Tom is encopretic” is to imply something about his identity. To say that “Tom’s problem is that he soils his pants” is accurate, but it may be adding shame to an already humiliating situation. To say that “Sneaky Poo has been stinking up Tom’s life by sneaking out in his pants” is a more gamesome way to describe Tom’s relationship with the problem of soiling. It is more likely to invite Tom’s participation in the discussion of his problem. It can also evoke a more sportive stance for Tom vis-à-vis the problem, as we can now talk about how “Tom can outsneak Sneaky Poo and stop it from sneaking out on him.” Tom no longer has to be a different kind of person from the one he understands himself to be. In fact, revising his relation with such a problem as “Sneaky Poo” may very well confirm him as being just the right kind of person for the job at hand–“outsneaking Sneaky Poo.”

Standing as an alternative to the diagnosis and treatment of pathology, the focus in an externalizing conversation is on expanding choice and possibility in the relationship between persons and problems.

In contrast to the common cultural and professional practice of identifying the person as the problem or the problem as within the person, this work depicts the problem as external to the person. It does so not in the conviction that the problem is objectively separate, but as a linguistic counter-practice that makes more freeing constructions available. [Roth and Epston]

When they enter counseling overwhelmed by a problem, members of the family may expect that the clinician will discover further underlying conflicts in their minds or relationships. Counselors take an active role in shaping the attributions that are used to describe young persons and families and to explain their problematic situations, and when a counselor listens to, accepts, and then furthers the investigation of a pathological description of a child, the child’s identity may suffer.

When a problem is externalized, the attitude of young people in counseling usually shifts. When they realize that the problem, instead of them, is going to be put on the spot or under scrutiny they enthusiastically join in the conversation. Relief shows on their faces. Their eyes light up, as if to say, “Yeah, that’s it, that’s how I look at it. It’s not my fault.” They are then in a position to acknowledge that the “problem” happens to be making them and others miserable and to discuss matters with, at times, remarkable candor.

Although in one sense it is a serious pursuit, we find this practice to be inherently playful and appealing to children. Jenna, a nine-year-old once wrote in relation to a mask she had made of “The Trickster Fear”: ‘You’re no longer nothing . . . being nothing made it hard to know you. Once you’re named, you can be known and conquered!”.

Externalization And Children’s Identity Formation

Aside from their understandable opposition to being blamed or shamed, perhaps children are showing common sense in resisting being defined by descriptions that imply that their identities are limited or fixed. Even adults do not find rigid negative descriptions of themselves particularly motivating toward change. Why shouldn’t children resist a fixed adult-imposed definition or a normative characterization? After all, identity remains exploratory and relatively fluid well into adolescence.

Viewing the child as facing, rather than being, a problem is a helpful start to preserving the fluidity of identity formation. Externalization seems a natural fit for many children. It is compatible with the way they typically approach difficulties in the dynamic learning environment of play. In play, along with hats, costumes, and accents, multiple perspectives and roles are tried on during “dress up” and other games. This fluidity allows the child to explore variations of attitude, identity and behavior – to try out the emotional flavor of the moment or day. In fact, when a child’s play is repetitive, ritualistic, or confined in its range of roles and behaviors, we may wonder about abuse or other severe interruptions to developing identity.

For the child, externalization is like playing a game of ‘pretend’. Implicitly, or sometimes even explicitly, we are saying to the child, “Let’s pretend the problem is outside yourself and we’ll play with it from there.” “‘Pretend’ often confuses the adult but it is the child’s real and serious world, the stage upon which any identity is possible and secret thoughts can be safely revealed.”

As counselors, we have been especially trained in the use of words. But practicing the language of externalizing conversations is for us, as for many others, not so much about learning a technique as about developing a particular way of seeing things.

We do not see externalizing as a technical operation or as a method. It is a language practice that shows, invites, and evokes generative and respectful ways of thinking about and being with people struggling to develop the kinds of relationships they would prefer to have with the problems that discomfort them. [Roth and Epston]

When focusing attention on values, hopes, and preferences, rather than on pathology, counselors often find ourselves less fatigued by the weight of the difficulties encountered. Since they can now put the problem in the spotlight, they can be more forthright in our questions and comments. As well as allowing the counselor to connect with children “where they live”, the externalizing narrative practice stimulates our creativity as well.

This approach is distinct from most open, unstructured play therapy, in that the counselor collaborates closely with children in play that is actively focused on facing a problem. Children’s sense of effectiveness as agents of change clearly increases when they experiment with possibilities in relationship to an externalized problem. In counseling with families the play is mainly with words, using humor wherever possible! But an externalizing conversation is easily enhanced with other forms of expression favored by children, such as play and expressive arts therapy.

CIRCULAR QUESTIONING

Another method of externalization occurs within the Systems Theory of Circular Questioning. Circular questioning is the centerpiece of a group of family counselors known as the Milan Group. Their experiences with families of people with schizophrenia led them to question and discard structural approaches and to incorporate systems theory, which draws heavily on the work of Gregory Bateson, into their work. For Bateson, mental processes are a form of cybernetic feedback, and ‘mind’ consists of components connected in circular patterns. For people such as Karl Tomm, circularity means “the capacity of the therapist to conduct his [sic] investigation on the basis of feedback from the family in response to the information he solicits about relationships”. Tomm also regards circularity as “a bridge connecting systemic hypothesizing and neutrality by means of the therapists’ activity”.

Systemic counselors attempt to understand the system and to facilitate therapeutic change. To achieve these goals, they use two types of Circular Questions: descriptive and reflexive. They use the former to elicit information to help them understand how the ‘problem’ is systemically connected, while they use the latter to attempt to precipitate a change in that particular system. In general, using circular questioning in therapeutic intervention not only demonstrates respect for the autonomy of the system, but also provides more possibilities for transformation than does offering opinions, prescriptions, directives, or instructions. In family counseling, the method has three key aspects: circularity, neutrality, and hypothesizing.

In circularity, the usual rule for groups that “Each person speaks only for him or herself”, is broken by asking each family member in turn about particular aspects of relationship between two or more of the other family members. For example, the counselor asks a teenager, “Who intervenes more in the arguments between your parents, your grandfather or your grandmother?”. Similarly, persons not present and hypothetical situations are also talked about – such as: “If one of the children were never to leave home and never to marry, which of you would probably be best for your father? And which for your mother?”.

It is also important that many of the contributions made by individual persons are now examined carefully to detect their possible communicative function. Let us assume that the mother begins to cry. While counselors might traditionally ask something like: “How do you feel?”, “What are you experiencing now?” or “What is going on inside of you?”, the circular question directed at the son could be, for example: “how do you think your father feels when he sees your mother crying like that?”.

The circularity results from asking questions in such a way that the family can make new connections and think in new ways about certain events and acts. This requires shifting person-positions from first-person actor to third-person observer. For example, when a mother describes her son’s perception of his father, the father faces a new image of himself. Instead of asking the son linear questions, such as “Do you love your father?” the therapists ask the mother circular questions, such as “How does your son show his love for his father?”

Neutrality, the second aspect of Circular Questioning, protects counselors from being forcibly incorporated into a family’s system. Normally, neutrality implies a lack of bias or involvement. In the case of Circular Questioning, Systemic counselors expect to be drawn into the conflicting patterns of the family, so they match this expectation in unexpected ways: they intervene by joining the family’s system of knowledge in order to help change the very same patterns of meaning and action that have brought the family to counseling. Counselors using Circular Questioning work in teams to take the side of the entire family and not the side of any one particular family member. They do this by asking each other circular questions in the family’s presence. For example, one counselor might ask another, “What do you think is the biggest challenge this family faces together?” Besides performing a person-shift, this question indicates to family members that they have to work together and that the counselor see them as a unit.

The third aspect of Circular Questioning, hypothesizing, is used to guide the family to make connections among elements of the stories told by family members and the actions associated with those stories. Counselors create a flurry of hypotheses, all of which suggest different patterns of connections. They may hypothesize that a person being treated for depression has been and will be through periods of being ‘not depressed’. Instead of asking that person, “Why are you depressed?” they might ask, “When you are not depressed, what do you enjoy the most about not being depressed?” In searching for systemic connections, the counselors may ask the group, “Who is most affected by X’s depression?” They might also give a positive connotation to a symptom. For example, they may praise the depressed person’s behavior, hypothesizing that this depression is what holds the family together. From this point, they hypothesize that when the depressed person is ready to let others share the burden of holding the family together, s/he might find it easier not to be depressed.

Once a team of counselors joins a family system to explore how persons, actions, and ideas are inter(in)dependent, they use circular questioning to help the family become aware of how they engage with their “problems” by thinking and acting in certain patterns, and to guide them in creating alternate patterns. Rejecting the notion that problems are “caused” by meanings inside a person’s head, counselors use circular questioning to help people conceive of things like “family problems” as socially constructed achievements. Ultimately, circular questioning helps counselors probe for the ways families describe their relationships; in essence, it helps counselors discover a ‘grammar’ of meaning and action within relationships in order to transform painful patterns of interaction.

REPARENTING/ INNER CHILD

These concepts seem to be two sides of the same coin – at least in some descriptions. It is a metapercetion process of imagining an earlier stage of childhood and ‘seeing’ the traumatizing experiences from the observer position. By commenting on the role of the child and the parent, the child can nurture his/her earlier self from this new position – reparenting him/herself.

An outline for this process can be found in CBT#15 Changing Core Beliefs with Visualization.

Another definition of re-parenting provides that the counselor play the reparenting role, if the child is not able to comfort his/her younger self, the counselor can become the ‘good parent’ in the metaperceptive process and provide the appropriate supports.

Frankly, it seems more powerful to teach the parent how to play this role, since then the parent can continue being the ‘good parent’ in an ongoing pattern. There is the opportunity to use these clinical metaperception experiences to identify guidelines to teach the parent how to parent, since the child is providing some direction on what s/he thinks a ‘good parent’ is, or should be – although one should not share the child’s perspective of specific incidents without the child’s OKAY.

By taking the child back to his/her childhood in imagination, the counselor must recognize that the memory is not REAL, except in the mind of the child. The child gave meaning to the experience at the time, and that is what is coming out now. A sibling or a parent may have an entirely different meaning for the incident. Do not be concerned with the difference between these perspectives of reality, except to a) help the child find a better thought:emotion for the experience, and b) to help the parent find better ways to articulate their intent. Adoptive parents and the child need to understand how the child’s ‘tunnel vision’ based upon their perception of the critical incidents COLORS their understanding of the adoptive parents motives and intents.

Walking backwards and forwards through the previous childhood – correcting miscommunication – comforting distressing situations – and reinterpreting the beliefs about self and others that were generated is required for the child to reconstruct his/her ‘inner logic’.

You may also want to insert some ‘wishful’ scenarios – how would the child visualize a perfect childhood? This may give a great deal of insight into his/her reality and expectations – and how rational and balanced they are. Where the expectations are unrealistic, the clinician can help to work them out; if they are realistic, the clinician can help the parents address the expectations.

All of this should be done within the context of magic that you set up at the beginning. If the child is (pretending to be) a Native American, s/he might revisit earlier childhood with the help of the animal spirit guide. The wolf spirit may add an additional feeling of ‘safety’ in revisiting such traumatic events.

PSYCHODRAMA

You can ask the child and the (adoptive) parents to role play a scene that was visualized as distressing. The roles could be either way [child as the child or as the parent] – but the outcome should be different. However, if the child is again the child, s/he may experience trauma as though it were happening and the parent will need to seek ways to reduce the distress.

If the psychodrama is not well thought out, it can raise distress in ways that are not obvious and give no real insight as to what went wrong. The counselor should try to think of all aspects of possible outcome before implementation if s/he wants the outcome to be beneficial.

EYE MOVEMENT DESENSITIZATION REPROCESSING

This is controversial, but benign – the research indicates that it works in relieving distress, but no one is sure why. Since it is not likely to be harmful and is a recommended technique for the disorder – there is no reason why it should not be tried [See CBT#36].

SENSORY INTEGRATION

It is difficult to accept ‘holding therapy’ on either end of the spectrum as was discussed earlier. An alternative is to ask an Occupational Therapist to design a sensory regimen that will help the child accept touching and ultimately hugging. I am inclined also to suggest that the counselor and the parents ‘touch’ [hold hands, arm around the shoulder, tousled hair, etc. as a scheduled part of the process. No hour should go by without some positive touching.

SOCIAL INTEGRATION

We have spent substantial time discussing the importance of a child having a peer group relationship. If we assume, by diagnosis, that the RAD child has not had an adequate foundation of mother/child love to support and adequate transition to peer or age mate relations, we must try to ensure that it occurs now. It is not necessary to await a mother/child love to address this issue. It is strongly recommended that the clinical team review CBAT#02 – Sociometry and use this as a basis for the development of satisfactory peer relations.

CONCLUSIONS

Philosophy: Attachment is the fundamental building block of cognitive, neurological, social and emotional development therefore healthy attachment is of critical importance to human development. The family system is essential to the success of the child developing healthy attachment relationships and healing from attachment difficulties. The primary goal of intervention with children with attachment problems is to enable them to form healthy attachment relationships with significant others and to resolve dysfunctional feelings and behaviors. The majority of healing attachment difficulties occurs at home, between the parent and child therefore a family systems approach is crucial to the healing process.

Reactive Attachment Disorder is a label whose time seems to have come. Diagnoses come in and out of popularity and, as a result, many children may be given the label, who do not fully meet the criteria. For those who do, life is exceedingly difficult as their thoughts about themselves and others are excessively negative and also well hidden. The child will not easily be able to articulate ‘what is bothering them’. The child has not learned to trust and, therefore, will present problems for the clinician whose whole process starts with a trusting relationship. This is the child who belies the ‘I love children’ rationale for coming into the field. This child does not give the reciprocal feedback so necessary for maintaining relationships and is not pleased to have his/her feelings move toward the positive. The child does not want to like/trust you or anyone else. Such feelings evoke danger – “If I care about you – you can hurt me!’. It is, therefore, downright masochistic to care about anyone and self protective to not care. And if I get too close to caring, I will need to test the relationship by doing things that are so atrocious that you assuredly will go away!

What’s a parent or clinician to do? You will need to operate in a manner that ensures that you will do exactly what you say you will do and nothing else. The child can learn to trust you, even if s/he is unwilling to like you, provided you do what you say you will do. S/he can come to believe in you up to a point, but then will probably deteriorate to a higher level of testing. Such children try your patience and tax your own belief of self. This is why Linehan requires clinician support and why you will need your own ‘loving critic’ to hold your hands to the fire.

Principles of an appropriate Counseling and Parenting Model

This model was adapted from Dan Hughes. The creation of the model is based on the premise that the development of children is dependent upon and highly influenced by the nature of the parent-child relationship. Such a relationship, especially with regard to the child’s attachment security and emotional development, requires ongoing, dyadic (reciprocal) experiences between parent and child.

Such experiences are affectively and cognitively matched to the developmental, age-appropriate needs of the child. The parent must be attuned to the child’s subjective experience, make sense of those experiences, and communicate them back to the child. This is done nonverbally as well as verbally. It is done with playfulness, acceptance, curiosity, and empathy. These interactions are contingent, i.e., when the parent initiates an interaction, the child’s response determines the parent’s subsequent action based on the feedback of the child’s subjective experience of the first action. In that way, the parent constantly fine-tunes his/her interactions to best fit the needs of the child. The primary context in which such dyadic interchanges occur is one of real and felt safety. Without such actual and perceived safety, the child’s neurological, emotional, cognitive, and behavioral functioning is compromised.

When a child’s early attachment history consists of abuse, neglect, and/or multiple placements, s/he has failed to experience the dyadic interactions that are necessary for normal development and s/he often has a reduced readiness and ability to participate in such experiences. Many children, when placed in a foster or adoptive home that provides appropriate parenting, are able to learn, day by day, how to engage in and benefit from the dyadic experiences provided by the new parent. Other children, having been much more traumatized and compromised in those aspects of their development that require these dyadic experiences, have much greater difficulty responding to their new parents. For these children, specialized parenting and counseling intervention is often required.

For counseling and parenting to be effective, it is strongly believed that they must be based on parenting principles that facilitate security of attachments and incorporate an attitude based on playfulness, acceptance, curiosity, and empathy. The foundation of these interventions – both in home and in counseling – must incorporate the above principles and never involve coercion, threat, intimidation, and the use of power to force submission.

The following represents a list of general principles that are characteristic of the appropriate counseling and parenting model:

1. Eye contact, voice tone, touch (including nurturing-holding), movement, and gestures are actively employed to communicate safety, acceptance, curiosity, playfulness, and empathy, and never threat or coercion. These interactions are reciprocal, not coerced.
2. Opportunities for enjoyment and laughter, play and fun, are provided unconditionally throughout every day with the child.
3. Decisions are made for the purpose of providing success, not failure.
4. Successes become the basis for the development of age- appropriate skills.
5. The child’s symptoms or problems are accepted and contained. The child is shown how these simply reflect his/her history and how they need not be experienced as shameful.
6. The child’s resistance to parenting and counseling interventions is also accepted and contained and is not made to be shameful by the adults.
7. Skills are developed in a patient manner, accepting and celebrating “baby-steps” as well as developmental plateaus.
8. The adult’s emotional self-regulation abilities must serve as a model for the child.
9. The child needs to be able to make sense of his/her history and current functioning. The understood reasons are not excuses, but rather they are realities necessary to understand the developing self and current struggles.
10. The adults must constantly strive to have empathy for the child and to never forget that, given his/her history, s/he is doing the best s/he can.
11. The child’s avoidance and controlling behaviors are survival skills developed under conditions of overwhelming trauma. They will decrease as a sense of safety increases, and while they may need to be addressed, this is not done with anger, withdrawal of love, or shame.
12. The child may be held at home or in counseling for the purpose of containment when the child is in a dysregulated, out-of- control state only when less active means of containment are not successful in helping him/her regain control, and only as long as the child remains in that state. The counselor/parent’s primary goal is to ensure that the child is safe and feels safe. The goal is never to provoke a negative emotional response or to scold or discipline the child. The model for this type of holding is that of a parent who holds an overtired, over-stimulated, or frightened preschool child and helps him/her to regulate his distress through calm, comforting assurances and through the parent’s own accepting and confident manner.

It is almost bizarre to need to list interventions that should NEVER be used in counseling nor recommend that a parent use at home. Yet the literature lists such interventions as ‘rage reduction’ and ‘rebirthing’ that not only have resulted in terrible abuse, but have actually resulted in homicide. Given this background, the following interventions are NOT found within appropriate counseling and parenting model:

1. Holding a child and confronting him/her with anger.
2. Holding a child to provoke a negative emotional response.
3. Holding a child until s/he complies with a demand.
4. Hitting a child.
5. Poking a child on any part of his/her body to get a response.
6. Pressing against ‘pressure points’ to get a response.
7. Covering a child’s mouth/nose with one’s hand to get a response.
8. Making a child repeatedly kick with his/her legs until s/he responds.
9. Wrapping a child in a blanket and lying on top of him/her.
10. Any actions based on power/submission, done repeatedly, until the child complies.
11. Any actions that utilize shame and fear to elicit compliance.
12. Dismissing a child from counseling because s/he is not compliant.
13. Punishing a child at home for being dismissed from treatment.
14. Sarcasm, such as saying ‘sad for you’, when the adult actually feels no empathy.
15. Laughing at a child over the consequences that are being given for his behavior.
16. Labeling the child as a ‘boarder’ rather than as one’s child.
17. Depriving a child of any of the basic necessities, for example, food or sleep.
18. Blaming the child for one’s own rage at the child.
19. Interpreting the child’s behaviors as meaning that “s/he does not want to be part of the family”, which then elicits consequences such as:
    1. Being sent away to live until s/he complies.
    2. Being put in a tent in the yard until s/he complies.
    3. Having to live in his/her bedroom until s/he complies.
    4. Having to eat in the basement/on the floor until s/he complies.
    5. Having ‘peanut butter’ meals until s/he complies.
    6. Having to sit motionless until s/he complies.

Giving the above consequences in a ‘loving, friendly tone’ does not make them appropriate. That tone may actually cause greater confusion about the meaning of love, parenting, and safety that we want children to understand.

A rule of thumb is always that the intervention is something that is congruent with how secure attachments are formed and how traumas are resolved.

This model requires confidence that the parents are no longer engaged in such actions of abuse and neglect, that they have acknowledged and accepted responsibility for their actions, and that they are able to actively work to assist their child in resolving the effects of the abuse in a manner that is in the best interests of the child.

Finally, while the above represents the basic premises of this intervention model that have been constant over the past twelve years, there are three areas where the model has gradually changed:

A parent being ‘in control’ of the child’s behavior only when necessary for safety as an immediate response to a given situation. Obedience is not the foundation of a secure attachment nor is it the foundation of effective long-term counseling and parenting.

Increased focus on the child’s adoptive or foster parents’ own attachment histories. A child’s serious attachment and trauma problems may well elicit unresolved issues in the parents’ histories which then make it difficult for the parent to assist the child in regulating and integrating areas of him/herself that are unresolved. This is not to suggest that adoptive and foster parents cause their child’s attachment difficulties. Rather, that a parent’s own coherence and resolution with respect to his/her attachment history is a necessary, though often not sufficient, factor in their child’s ability to resolve their own past issues.

This protocol addresses the areas that need to be addressed, but cannot really tell the clinician how to use the techniques. It will be simple, but exceedingly hard. If you cannot rely on your relationship, you will need to rely on your skills and consistency.

To adequately resolve some of the challenges presented by RAD, a local networking resource has to be developed, trained respite care and financial resources have to be established and acceptance of the interventions necessary to combat RAD have to be recognized.