Multiple diagnoses common with disorder


Vicki L. Moss, Ph.D., of Delta Consultants West in Johnston, R.I. is impressed by the degree of parental commitment she has witnessed while treating children with attachment disorder. (photo by Kathryn Hardy)

By Phyllis Hanlon

Reactive attachment disorder (RAD), one the most complex severe psychological problems affecting children, requires expertise to diagnose and treat effectively. And while it is considered a relatively rare disorder by the American Academy of Child and Adolescent Psychiatry, there are several treatment options available to care givers in the New England region.

In order to understand what attachment disorder is, psychologists first need to comprehend what it isn't, says Vicki L. Moss, Ph.D. of Delta Consultants West in Johnston, R.I. "A healthy attachment comes from those thousands of interactions every day in which the baby has some need - hunger, a wet diaper or a need to be held. In healthy situations, one or two people - the same two people - respond and take away that pain," she says. "After the cycle is repeated over and over thousands of times in the first two years of life, the child gets the idea that he can trust these people to take care of his needs."

While the precise causes of the disorder are not known, most children diagnosed with the illness suffer from severe disruption or abuse in their early years, including inadequate care as a result of adoption, foster care, multiple caregivers or geographic moves.

Suzanne Allen, Ph.D. of the Attachment Institute of New England in West Boylston, Mass., indicates that children who present with attachment disorder exhibit specific behavioral characteristics, particularly an absolute need for control whether in a direct, aggressive way or in an indirect, manipulative, passive-aggressive manner. "What drives [that behavior] is the lack of trust of adults to be able to meet their needs, care for them and keep them safe because of past histories of abuse and neglect or major trauma," she says.

In most cases, Allen adds, children present with more than one Axis 1 diagnosis, including post-traumatic stress disorder, bipolar disorder, attention deficit disorder, anxiety, depression or other psychological difficulties.

"There are some people who argue that we should call these children 'multi-diagnostic,'"says Allen. The presence of multiple diagnoses, as well as the interrelatedness between issues, complicates treatment. Allen says that pharmacological intervention, at least in the beginning, is advisable. "If we sense that a child would benefit from either an ADHD medication or an antidepressant, we try to get that started first," she says. "Then we address the attachment issues and see what's left."

The 10-week, intensive sessions at the Attachment Institute include cognitive restructuring, psychodrama and eye movement desensitization and reprocessing (EMDR). "We use the Carl Rogers approach (which emphasizes awareness and the patient's experience of the present) and try to connect with the child," Allen says. "We also use some of Dan Hughes's work, which shows the importance of being empathetic for the child."

Daniel A. Hughes, Ph.D. of South China, Maine, focuses his therapy on empathetic behavior. "Cognitive training is not enough. The treatment has to be experiential," he says. "A therapist must have empathy and actively communicate that empathy." His theory is based on the research model that finds a strong, healthy, empathetic bond between children and their parents. "It's reflected in their eyes and faces," says Hughes. He currently spends a significant amount of time criss-crossing the globe to offer training and consulting workshops relating to attachment disorder. At its recent annual conference, the national organization, ATTACh (www.attach.org), presented Hughes a lifetime achievement award for his contributions to this field.

Michael Pines, Ph.D. of Glastonbury, Conn. says that attachment problems of some nature are common in child development and that effective treatment methods vary according to the intensity and intrusiveness of the illness. "For mild attachment problems, more traditional relationship therapy with a cognitive/behavioral/reality basis would be effective," he says. Pines says that more serious issues necessitate more intensive treatment. "Moderate to severe problems with trauma, grief and loss may require a more direct, more verbally challenging approach, the use of narratives, psychodrama, nurturing, holding by the parents or some regression therapy," he says.

In addition to current treatment options, two newer methods have garnered some attention. Although not backed by clinical research, neurofeedback is gaining favor with some psychologists. After hearing anecdotal evidence to support this therapy, Moss has begun training in the technique. Admittedly not an expert, she cites the effectiveness of using electrodes to tap into a child's "fear places," inducing calm in these children who so often live in a fight or flight state.

Pines says the "rebirthing" method has come under attack and is not endorsed by ATTACh. "The organization issued a statement last year basically saying no form of physical restraint of any kind is acceptable," says Pines. "Holding a child for safety or nurturing is acceptable but restraining a child against his will, using physical force in a coercive manner, is not acceptable."

According to Hughes, re-birthing is a reenactment of the process of physical birth. The patient is wrapped inside a blanket (the womb) and others pushing on him/her simulates contractions. The patient has to fight his/her way out, just as a baby would emerge from his mother's body.

Just as treatment type differs, length of therapy varies from an intensive 10-week model to ongoing sessions lasting 12 to 18 months or longer. Foad Afshar, Psy.D. of Concord, N.H. recommends intermittent treatment for optimum results. Although the disorder cannot technically be cured, Afshar says, left untreated or under treated, social maladjustment and relationship difficulties could persist. He adds that emotional problems such as depression and anxiety could develop if attachment disorder is not adequately addressed.

In spite of the obstacles psychologists face in successfully treating this disorder, the rewards can be sizeable. In addition to personal gratification, Moss expresses amazement at the degree of parental commitment she has witnessed. "I'm just in awe of their ability to love - their willingness to go to the ends of the earth to get this child the help he needs," she says. During the process, both Moss and the parents make some interesting discoveries. "These parents will often tell us that these kids have forced them to reach and stretch within their own personal resources and find strengths within themselves that they never knew they had," Moss says. "That's a payoff in a way."

Multiple diagnoses common with disorder (November 2003 Issue)

Multiple diagnoses common with disorder
(November 2003 Issue)