Parents as Partners in the Treatment of Attachment Disordered Children
Attachment disordered children present a unique challenge to the adoptive parents that attempt to love and parent them. Children who have experienced abuse and neglect in their original families, tend to develop a mental representation that anticipates similar treatment in other attachment relationships. This article describes a therapeutic partnership, combining nurturing parent narrative and therapist generated EMDR, that concentrates on shifting the child's destructive representation about self and others. Success is measured over a five year time period.
Parents as Partners in the Treatment of Attachment Disordered Children
In recent years, the customary role of therapist as the expert in diagnosing and treating pathology, has been challenged by the emerging influence of narrative and resilience based models of partnership therapy (O'Hanlon, & Weiner-Davis, 1989, Minuchin, 1992, White & Epston, 1990, Walsh, 1998).
In 1995, parallel thinking provided the foundation for the establishment of a program designed to treat children that were having difficulty accepting the love and direction of their adoptive families. Most of these troubled children experienced abuse and neglect while living with their biological families. Behavior was frequently characterized by violent threats and action, defiance, lying, stealing, impaired cause and effect thinking and conscience development. Referral information commonly suggested diagnoses of Reactive Attachment Disorder (RAD), Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), Post Traumatic Stress Disorder (PTSD), and Attention Deficit Hyperactivity Disorder (ADHD).
The adoptive parents of these children were often angry and exhausted by years of living with parent directed, rage and violence. Without exception, all of the children and their families had experienced a variety of failed therapeutic efforts including individual "talk" or play therapy, behavior modification, parent education and traditional family therapy. Many of these defeated families were considering adoption disruption as a final option.
Our partnership with parents was based on the belief that the parent and child would possess the most valid information on the meaning of individual behavior while the therapist(s) could be expected to contribute relevant theoretical data that wold enhance understanding of these children as a group and provide the rational for treatment methodology.
The underpinning, for understanding the difficulty these families were experiencing, was the attachment theory of John Bowlby, (1969/1982, 1973, 1980);. Most relevant was Bowlby's (1969/1982) conceptualization of the child's, experience based, mental representation of the attachment figure, the self and the environment.
The child whose first relationship is with a caring, loving parent is likely to develop a mental representation of self as loveable, and attachment figures as responsive and available. In contrast, when the attachment relationship has been compromised by abuse and neglect, the child views the world and the people in it as unpredictable and unavailable. This mental representation or internal working model tends to be accompanied by a negative self view and can be predictive of a response of aggression or withdrawal (Bowlby, 1969/1982).
Bowlby (1973) further postulated that the child's chronic maladaptive anger is a response to the perceived unavailability of the caregiver. When the expectation of being disappointed is applied to new relationships, the anxious infant becomes an angry, aggressive child.
Bowlby's (1969/1982) concept of mental representation or internal working model has also described as perspective, a concept attributed to symbolic interaction theory (Mead, 1934).
Central to symbolic interaction theory is the belief that human action is guided by individual perspective, defined as a conceptual framework made up of a set of assumptions, values and ideas, that influence perception and ultimately action. Perspectives are developed through the sharing of words. It is by the use of words that humans are able to establish objects such as love, freedom, truth, good and evil. As the child develops verbal language, a perspective is shared and often internalized through interaction with significant people such as parents (Charon, 1985). When the child internalizes a perspective of the original parent as being unavailable, abusive and rejecting, it is a viewpoint that is likely to be applied to parents in general.
This concept is reminiscent of Post Traumatic Stress Disorder (Pynoos, Steinberg & Goejian, 1996; Rutter & O'Connor, 1999) and complements the EMDR theory of blocked information processing.
Eye Movement Desensitization and Reprocessing (EMDR) was developed by Francine Shapiro in 1987 and has been used with children, adolescents and adults with a variety of presenting symptoms and issues including depression, anxiety, phobias and Post Traumatic Stress (Shapiro, 1995, 1997). EMDR has also shown to be helpful in working with children of divorce, and victims of childhood emotional, physical, and sexual abuse and generalized parental neglect and rejection (Lovett, 1999).
The most relevant segment of Shapiro's (1995; 1997) theory is her hypothesis that trauma results in a blockage of the information processing system. This neurological obstruction causes the incident, or series of incidences, to remain in its anxiety producing form, complete with the originally perceived pictures, emotions, sensations and negative self assessments. This means that the conclusions formed during a time of trauma are frozen.
The experience of trauma can also impact critical developmental transitions (Pynoos, Steinberg & Goenjian, 1996). Typically, attachment disordered children do not display emotional behavior that is congruent with chronological age. It can be usual for an intellectually bright 12 year old to display emotional and behavioral reactions typical of a 18-month old.
Building on the combined theories of Attachment and loss, Symbolic Interaction and EMDR, we conceptualized a methodology that would shift the child's negative internal working model and provide a mechanism that would allow the child to "grow up" emotionally and behaviorally. In so doing, we postulated that the noted impaired cause and effect thinking and conscience development would improve as the child's emotional and chronological age became more congruent.
We proposed that the parent, rather than the therapist, would need to be the primary agent of healing. Instead of relying on the strength of the child-therapist relationship, or the expertise of therapist in shifting the family system, we conceptualized the role of the therapist as a facilitator of parental excellence.
Our first consideration was the child's preverbal trauma history. Although some of the children remembered traumatic events, others demonstrated evidence of somatic memories and the altered stress response noted by van der Kolk (1994). When early experience include fear, helplessness, unpredictability, anger, hunger and pain, the result can be affective lability, behavioral impulsivity, cardiovascular irregularities and increased anxiety (Perry, 1994). Based on this research, we assumed that it would be necessary to develop therapeutic techniques that would assist the parent in altering the child's most primitive conclusions.
REDOING THE NARRATIVE (A Parent Task)
Propelled by the desire to provide the parent with a healing technique, we initiated a procedure termed Redoing the Narrative. Following education, informed consent and contracting with the child, we ask the parent(s) to sit on a rocking loveseat and cradle the child in a position resembling the way an infant would be held. Generally, the mother begins the narrative with "if I had been there the day you were born." Eventually, narratives are introduced to address the child's trauma history, problem solving, developmental education and the teaching of empathy and moral behavior. Parents also use narratives to impart family values, faith, history and rituals.
The support for Redoing the Narrative is based on the research noting that it is a normal developmental task for a child to organize the life narrative into a beginning, middle and end. In contrast, children exposed to disruption or familial violence typically construct a chaotic life narrative (Osofsky, 1993). Acknowledging symbolic interaction theory, we speculated that the parent narrative would provide the verbal definition necessary for the child to internalize a new life perspective.
Initially, therapists were fairly active in directing parent narratives. As it became apparent that the impact was consistently positive, parents were elevated to the position of leading the direction of the therapeutic effort. This shift requires therapists to relinquish their customary job as teacher and expert and enables parents to embrace the dual role of nurturing parent and objective professional.
Children whose early attachment relationships have been damaged by abuse and neglect often have difficulty with the loving, reciprocal relationship rewarding to parents. The shift in status enables parents to view the child's difficult, violent behavior with the objective eyes of a professional, while simultaneously initiating the corrective, unconditional love of a parent. The result is that parents are rewarded by being part of the child's process rather than expecting immediate, mutual love and appreciation as a measure of parental competence.
As we now evaluate parent narratives, there are some common themes. Narratives always represent the ideal in parenting and convey the conviction that "from the moment of conception, you were a child that deserved to be wanted, cherished, celebrated, loved and cared for by responsible parents." Narratives never attempt to alter the child's actual history. Instead, the child is introduced to new possibilities for positive beliefs about self and others.
EMDR (A Therapist Task)
In concert with the parent narrative, the therapist employs EMDR. It is hypothesized that the eye movements, or alternative stimuli such as tapping, used in EMDR initiates a physiological mechanism that activates the information processing system. This process seems to impact the verbal definition that accompanies the event. Instead of being forever locked in the cognition that accompanied the trauma, a new more adaptive conclusion is spontaneously achieved (Shapiro, 1995).
The application of EMDR consists of alternative stimuli (tapping) as the parent introduces the positive, loving narrative. This process is theoretically consistent with the EMDR concept of cognitive interweave which is used to assist the client in assimilating new, positive life conclusion (Shapiro, 1995). In our methodology, nurturing parent narratives provide the map for a fresh, beneficial inner working model, while EMDR accomplishes assimilation at the neurological level.
EMDR is also used to assist the child in working through cognitive memories of abuse, neglect and abandonment and the feelings of fear, anxiety and rage that often accompany such trauma.
DISCOVERING THE MEANING OF BEHAVIOR
The therapeutic partnership with the parent(s) includes discovering the meaning of the child's problem behavior. Consistent with the foundation theories, this journey concentrates on identifying the child's inner working model or perspective.
All of the children we work with begin therapy with the expected negative representation described by Bowlby (1969/1982). Most have a similar belief system which resembles the following: "I must be bad or evil to deserve the treatment I received in my biological family; It is not safe to trust adults or those in authority; The only way I can survive is to be in control; I am bad and evil and my bad behavior is who I am; There is nothing I can do that is right; I deserve to be hated; Others deserve my hate."
This set of beliefs, however, cannot be employed to understand the child's individual perspective about the meaning of their life story. Therapists are careful never to suggest to a child that we know their thoughts or conclusions. Direct confrontation of the child's thought process, by either parent or therapist, is not part of our methodology. Instead, the parent uses the narrative to touch the areas they intuitively know are a problem for the child.
One mother of a troubled, suicidal adolescent intuitively believed that her child had experienced prenatal trauma. Narratives of loving, cherishing and celebrating focused on the prenatal months. Finally, the teen blurted, "I was a mistake, I was supposed to die." Significant in understanding the power of this motivating perspective, is the research correlating unwanted pregnancy and abortion attempts with subsequent suicide and juvenile criminality (Janus, 1997)
LOOKING FOR HIDDEN ASSETS; The meaning of opposition
Perhaps the most common behavioral description of the children we serve is that they are oppositional. Verbal exchange with parents is often characterized by disrespect, blaming, and accusing. The temptation of parent(s) and therapist(s) is to conceptualize this opposition as a function of the child's need to be in control. Although attachment disordered children do exhibit control issues (Solomon, George & de Jong, 1995), oppositional behavior can also be an attempt to camouflage disability.
As noted above, it is common for attachment disordered children to exhibit frozen emotional development. We now routinely administer the Vineland Adaptive Behavior Scale (Sparrow, Balla & Cicchetti, 1984) which includes domains on receptive, expressive and written communication. Although quantitative research on this project is not complete, our scanning of the data suggests that most of the children we serve have substantial difficulties in ascertaining the meaning of what is said to them. Instead of admitting a lack of understanding, the child becomes oppositional.
As the therapeutic team considers this new way of looking at the child's opposition, a shift occurs in the way the parent evaluates the child's behavior. One very oppositional six year old became enthusiastically compliant when parents used concise, clear language to convey requests, rather than the lengthy, abstract explanations that had been their custom. This child is typical of many of the children. Behind the oppositional facade, is a child who really wants to be cooperative.
In the five years since inception, one hundred and eighty children and their parents have completed the intensive therapy program. Five adoptions disrupted and an additional six children have spent time in residential treatment facilities. The remainder are living with their adoptive parents.
The success of our methodology in changing the child's negative inner working model is frequently demonstrated by the child's report. Following the application of parent narrative and EMDR, it is common for the child to share the conclusion that the abuse they endured was not their fault and that their biological parent was not being responsible. Often, the child expresses a desire to love and trust their adoptive parent(s).
Illustrative of the shifting of the child's individual perspective, is the eight year old who began therapy with a goal of becoming a mass murderer and now hopes to be an art teacher.
Based on parent report and clinical observation, most of the children demonstrate vastly improved attachment to their adoptive parents. The reciprocal loving relationship, longed for by parents, is regularly evidenced in child initiated, spontaneous hugs and expressions of love.
Placements that were in danger of disrupting have stabilized. In most cases, problem behaviors have diminished or ceased so that, frequently, the child's behavior no longer meets the criteria for psychiatric diagnoses. Improved school performance is common. Violent, aggressive children no longer display the behavior that originally defined them.
We initially hypothesized that the combination of EMDR and developmentally instructive parent narrative would be successful in growing the child up. Quantitative research is in process which appears to confirm our hypothesis. Clinical observation and parent report demonstrate improvement in emotional maturity, cause and effect thinking and conscience development. As one mother of a ten year old stated, "I started the program with a 11 month old. I watched him grow to two, four and six. Now, at least half of the time, I have a moral, empathetic, responsible ten year old."
In developing a methodology based on credible theory and research, we anticipated a positive outcome for the child. We did not foresee the effect the combination of parent narrative and EMDR would have on the parent.
Parents entering the program often display hurt and anger directed at the child. Initially, we were tempted to treat the parent prior to beginning therapy. As we have progressed, it has become evident that the parent narrative, concentrating on what every baby deserves, allows the mother to experience the natural empathy and bonding of mother and newborn infant and provides the basis for healing of the parent-child relationship. We speculate that the auditory tapping of EMDR also contributes to the shifting of the parental perspective.
We were also concerned about the parent's ability to nurture when their own attachment relationships were damaged. Parent report suggests that these affiliations are symbolically healed as the narrative concentrates on the positive ideal every child deserves.
The sophistication of therapeutic techniques employed in the parent narrative has been a humbling experience. It is common to observe professionally uneducated parents using techniques such as paradox, reframing, restructuring and going with the resistance.
It is usual for parents to self correct unhelpful styles and to model their parenting on the ideal presented in the narrative.
ADDITIONAL CLINICAL APPLICATIONS
With some modifications, the program has expanded to include adolescents and adults with unresolved issues of attachment.
We have also treated some children living with biological parents. The protocol for working with biological parents can be quite similar providing the parent is no longer living or participating in the environmental that allowed the child to experience the original abuse and neglect.
Experienced therapists that come for two weeks of intensive training, have been able to implement the methodology in their home states with comparable success.
Children that complete the program do not, of course, demonstrate uniform success or a standard of perfection. Some are compromised by prenatal exposure to alcohol. Others have genetically influenced temperament and psychiatric issues or permanent neurological impairment, caused by early life trauma. Although all of these influences do effect the level of functioning, they do not necessarily compromise the child's capacity for responding to life and their adoptive parent(s) in a meaningful manner.
In conclusion, progress is measured by the extent of change in the child's internal working model. This shift in perspective really describes a new attitude of resilience. The successful child's life narrative now includes confidence in the availability of the new attachment figures(s) and plans for a meaningful future. This is congruent with the research finding that resilience is a process rather than an inherent trait (Egeland, Carlson & Stroufe, 1993, Stroufe, 1997). We believe that our partnership with parents is descriptive of the healing process needed for a new, resilient life perspective.
Joanne May, Ph.D., L.P., L.M.F.T.
The Family Attachment and Counseling Center of Minnesota, Inc.
18322-C Minnetonka Blvd.
Deephaven, Minnesota 55391
(952) 475-3356 fax
Bowlby, J. (1969/1982). Attachment and loss: Vol. 1. Attachment. New York: Basic Books.
Bowlby, J. (1973). Attachment and loss: Vol. 2. Separation. New York: Basic Books.
Bowlby, J. (1980). Attachment and loss: Vol. 3. Loss. New York: Basic Books.
Charon, J.M. (1985). Symbolic interactionism: An introduction, interpretation, and integration. Englewood Cliffs, NJ: Prentice-Hall.
Egeland, B., Carlson, E., & Stroufe, L.A. (1993). Resilience as a process. Development and Psycopathology, 5, 517-528.
Janus, L. (1997). Echoes from the womb. New York: Jason Aronson, Livingston.
Lovett, J. (1999). Small wonders: Healing childhood trauma with EMDR. New York: Free Press.
Mead, G.H. (1934). Mind, self and society. Chicago: University of Chicago.
Minuichin, S. (1992). Family healing: Strategies for hope and understanding. New York: Macmillan.
O'Hanlon, W.H., & Weiner-Davis, M. (1989). In search of solutions: A new direction in psychotherapy. New York: Norton.
Osofsky, J.D. (1993). Applied psychoanalysis: How research with infants and Adolescents at high psychosocial risk informs psychoanalysis. Journal of the American Psychoanalytic Association, 41, 193-207.
Perry, B.D. (1994). Neurobiological sequelae of childhood trauma: Post-Traumatic stress disorders in children. In M. Murberg (Ed.), Catecholamine Function in post traumatic stress disorder: Emerging concepts, 233-255. Washington, DC: American Psychiatric Press.
Pynoos, R.S., Steinberg, A.M., Goenjian, A. (1996). Traumatic stress in childhood and adolescence: Recent developments and current controversies. In B.A. van der Kolk, A.C. McFarlane (Eds.), Traumatic Stress, New York: The Guilford Press.
Rutter, M & O'Connor, T. (1999). Implications of attachment theory for child care policies. In J. Cassidy & P.R. Shaver, (Eds.), Handbook of Attachment: Theory and Clinical Applications, New York: The Guilford Press.
Shapiro, F. (1995). Eye movement desensitization and reprocessing: Basic principles, protocols, and procedures. New York: Guilford Press.
Shapiro, F. (1997). EMDR, the breakthrough therapy for overcoming anxiety, stress and trauma. New York: Harper Collins.
Smith, C. (1997). Comparing traditional therapies with narrative approaches. In C. Smith & D. Nylund (Eds.) Narrative therapies with children and adolescents. New York: The Guilford Press.
Solomon, J. George, C., & De Jong, A. (1995). Children classified as controlling at age six: Evidence of disorganized representational strategies and aggression at home and school. Development and Psychopathology, 7, 447-464.
Sparrow, S.S., Balla, D.A., & Cicchetti, D.V. (1984). Vineland adaptive behavior scales. Circle Pines, MN: American Guidance Service, Inc.
Stroufe, L.A. (1997). Psychopathology as an outcome of development. Development and Psychopathology, 9, 251-268.
Van der Kolk, B.A. (1994). The body keeps the score: Memory and the evolving psychobiology of PTSD. Harvard Review of Psychiatry, 1, 253-265.
Walsh, F. (1998). Strengthening family resilience. New York: Guilford Press.
White, M., & Epston, D. (1990). Narrative means to therapeutic ends. New York: Norton.