Last spring one of our two adopted daughters (from Russia) was diagnosed with reactive attachment disorder (RAD). My wife and I read up on it a bit and, seeing some recognizable RAD symptoms in our other daughter, we decided that one of us needed to attend the annual conference sponsored by the Association for Treatment and Training in the Attachment of Children (ATTACh). I spent October 16th through 19th, 2002, in Costa Mesa, California. This was a conference of considerable size, some 500 people in attendance, with at least eight concurrent tracks (sessions) convening after each morning's keynote speaker, after lunch, and after a short mid-afternoon break.
I cannot hope to capture everything of significance that was said, but I will try to render accurately what the keynote speakers talked about and what I picked up from the sessions I attended. For those who like to "cut to the chase," my bottom line conclusions are
• Attachment disorders are still struggling to gain widespread recognition within the mental health community.
• Parents need to exercise their cognitive advantages in creative fashion to stay one step ahead of the child with attachment-related behavior disorders.
• Technology can address physiological aspects of brain functioning that can be a big help in both diagnostics and treatment.
For the record I am a layman with a completely useless degree in political science, but I was warmly welcomed by the multitude of mental health professionals (who significantly outnumbered "just plain parents" like myself) and found the level of discourse accessible to people with a fair general education and refreshingly free of jargon. I'll recommend up front that parents of children with RAD and related problems such as attention deficit disorder (ADD) ought to consider attending next year's conference in Pittsburgh, PA. The ATTACh website (www.attach.org) is a good place to learn about the conference and find many other resources.
Attachment disorders, broadly defined, reflect a rupture in the bonding process between children and their birth parents. This can occur in infancy if a child is immediately given up for adoption, or later in childhood when a family breaks apart for whatever reason or a child is physically or emotionally abused by one or both parents. Those of us with adopted children need to pay careful attention to their behavior and expression, because we know that such a rupture between child and parent did in fact occur. A common, generalized symptom of attachment disorder is a child's inability to trust parents or caregivers unconditionally. Often a child who has grown up in an orphanage or foster home learns to trust only him or herself, and most of the disruptive behavior we see in these children is related in some manner to the child's futile attempts to control his or her own environment. A memorable quote from Nancy Thomas, a foster parent and therapist, was that "a family is like a ship, and attachment disorder is 'man overboard'."
As noted above, a principal theme of the conference is that attachment therapy still faces an uphill battle to gain full acceptance within the mental health community as a recognized discipline. This was emphasized in the opening keynote address by Dr. Foster Cline, a well-known child psychologist who has become famous for his "Love and Logic" approach to dealing with troubled children. Cline commented that far too many mental health professionals "just don't get it" about attachment disorders. He surveyed his long experience with cases that have proven to his satisfaction (and ours) that disrupted infancy and childhood experiences are often at the root of later behavioral problems. He concluded, with strong agreement from the professional social workers in the audience, that research is underfunded, the diagnosis itself is underutilized, and treatment techniques – some proven over years and even decades – are marginalized. In passing, Cline paid tribute to the mid-20th century sociologist and anthropologist John Bowlby, whose groundbreaking research led to his recognition as the founding father of attachment between parent and child as a psychological issue.
Sharon Roszia, the keynote speaker on the second day of the conference, echoed Cline's conclusion that a vast body of research on attachment disorders goes untapped and underutilized by therapists, while many accepted therapy techniques, proven in a significant number of cases, are still regarded as "fringe" by mainstream health care professionals – to include holding therapy, EMDR, and reciprocal play ("theraplay"). Too many of these professionals still subscribe to the "clean break" theory, holding that an adoption or other custody change poses no inherent problems for young children. Roszia emphasized the need to accept the fact that raising a child from a disrupted background necessitates defining "family" in broader kinship terms – not "who does this child belong to?" but rather "who belongs to this child?" As Gregory Keck pointed out in his seminar ("Parenting the Hurt Child"), "adoption always involves loss." The child will have emotional connections with birth parents that may never completely be broken, and the problem is to bring the more recent and essential connection – with the adoptive or foster parents – into solid focus rather than attempt to erase relationships that make little sense in anyone's mind other than the child's. A corollary to this principle is the invariable need to tell the truth to the child. Another speaker, Regina Kupecky, quoted sociologist Ken Watson in this regard: "Fantasy flourishes where facts founder." Regina emphasized her belief that for a child, not knowing about his/her background is worse than knowing the worst. This can be a difficult issue for adoptive parents to face, particularly in cases where the child was given up for adoption immediately after birth. But that's why we go to conferences like this – to hear things that may strike us as counterintuitive or difficult to acknowledge.
There was abundant testimony from frustrated parents and mental health professionals alike about adopted or foster children with behavioral problems who had made little or no progress after years of struggle and pain, until they came under the care of a psychiatrist or therapist knowledgeable about attachment issues and conversant in the various methods of therapy. One parent, Kelly Frey, presenting her firsthand experience in a session called "Slipping Through the Cracks," emphasized the non-recognition or belated recognition of RAD among the therapists and other medical professionals with whom she dealt in trying to get help for her out-of-control adopted son, and outright bureaucratic resistance to RAD therapy. She commented on the familiar sensation of being "held hostage" by a child, with the need for both parents to stay engaged and united – to avoid letting the child gain an advantage by "triangulation" or playing one parent against the other. Eventually her family found an attachment therapist who proved effective, and their story is working its way toward a happy ending. Parenting techniques they adopted include frequent evaluation of behavior with small and specific praise offset by realistic penalties. The awarding or withholding of "points" will usually engage the child; an alternative penalty might be the obligation to practice good behavior for a specified interval.
A second major theme of the conference was that parenting children with behavior problems stemming from attachment disorders requires a great deal of intellectual discipline. As adults we must at all times take full advantage of our cognitive edge over our children and be highly rational in responding to negative behavior. Psychologist Gregory Keck proposed that we view attachment as a cycle, with frustrated needs leading to anger and arousal, which in turn should bring about gratification which then leads to trust – and growing trust creates, in the child, new needs. For children with attachment disorders the cycle is closed: they trust only themselves, thereby impairing their ability to trust others. Adoptive and foster parents must work to reopen this cycle with the parents providing the gratification to replace the child's self-gratification (which is seldom effective). As the child moves through this cycle with the parents – new authority figures with whom the child has not yet bonded – there are intersections where this relationship will be tested, and one thing psychologists have noted is the ease with which most children learn which "buttons to push" to trigger an emotional response from parents. It is critical, therefore, to avoid letting children know what's valuable or important to you. When you see a child approaching a critical intersection with a collision likely, turn in another direction. You must at all costs avoid control battles, or make sure you can win those you take on – which means picking and choosing battles very carefully. Keck had some other useful observations: children with attachment disorders are likely to have a gap between their chronological age and their "developmental" age. (This is also true of children with fetal alcohol syndrome [FAS] or effects [FAE].) Therefore, you should treat a child at his or her development age, which is why "holding therapy" and even bottle nurturing are appropriate with older children. Consistent with this approach, Keck noted that nurturing after confrontation encourages emotional growth.
A popular speaker was Nancy Thomas, who titled her presentation "I'm NOT Going to Do It And You Can't Make Me!" (Sound familiar to many of us?) Nancy runs a foster home for troubled kids of the more extreme variety, and her talk was on practical ways of dealing with oppositional behavior. This is, invariably, a process of testing the foster or adoptive parents, in which children look for someone who's strong enough to make them do what almost all of them, deep down, know they should do. The bottom line on handling kids in an oppositional mode is to shift gears at critical junctures, respond in an unanticipated manner, keep them off-guard. Answer a question with a question. Consequences of bad behavior should be prompt, calm, and non-hostile. She emphasized "using opposition to overcome opposition" – i.e., reverse psychology. Nancy also takes for granted what many adoptive and foster parents have long ago learned, that you need respite and everyone should find a "respite provider," someone who can assume temporary responsibility for the child while the parent recovers for a day or so, or even for a few hours.
A counterpoint of sorts to Nancy Thomas was offered by Deborah Hage, who talked about the use of "paradoxical techniques" in dealing with misbehavior, bad speech, and other variations on the theme of oppositional behavior. She began with a physiological refresher, noting that in most people sensory input normally passes through the prefrontal cortex of the brain, which is the seat of judgment. In children who, because of attachment disorder or other psychological stresses, are in a state of "hyper-arousal" and prone to disruptive or oppositional behavior, sensory input signals may be intercepted by the amygdala and not reach the prefrontal cortex. The amygdala's principal task, according to a brain tutorial available on the Internet, is to "filter and interpret sophisticated incoming sensory information in the context of our survival and emotional needs." The emphasis is apparently on "sophisticated" signals and an appropriate sense of "survival and emotional needs." Children in a state of high arousal will trap these signals in the amygdala and not allow them to proceed to the prefrontal cortex. The problem, therefore, is how to circumvent the amygdala and defuse the arousal cycle.
Paradoxical Techniques involves short-circuiting resistance, attempting to circumvent anger and fear, thus minimizing or eliminating "control" battles that (for the most part) can't be won anyway. Parents must strive to remain free of resentment and anger, offer no buttons to push, and present their children with choices that are true choices. Honesty really is the best policy – sarcasm loses ground with RAD children. The whole thrust of parenting and therapy should be to train the children to behave in a manner that brings about a new way of thinking, not attempt to get them to think their way into a new way of behaving. (Of course this smacks of behaviorism, which is a contrary notion to some therapists today.) Dr. Hage also had some counterintuitive thoughts about therapy. It need not be a "comfort zone" for the child; rather, it should be an ordeal, requiring of a child what he/she cannot require of him/herself. The therapist's key relationship is with the parents, not the child. What the child needs is motivation to get well in order to avoid therapy.
The third major theme I took away from the conference is that the physiological component of the RAD problem deserves serious attention, and technology can provide some valuable diagnostic and treatment tools. The keynote speaker at the "Pre-Conference" on October 16th and on the final day of the regular conference (October 19th) was Dr. Daniel Amen, an advocate and practitioner of SPECT (single photon emission computed tomography) imaging of the brain to aid diagnosis and medication prescription. Another technological tool, which has been around for many years but is only now gaining widespread acceptance, is EEG neurofeedback (sometimes called biofeedback).
Dr. Amen is a psychiatrist who has become the leading practitioner and evangelist of SPECT brain imaging. SPECT imaging is a branch of nuclear medicine that uses injection of an extremely low dose of radioactive trace particles to measure blood flow in the various regions of the brain. This procedure shows every promise of providing solid physiological and quantitative support to the treatment of virtually every type of mental disorder. Dr. Amen noted that until quite recently few psychiatrists were interested in images of the brain. This struck him as puzzling and counterintuitive – he pointed out to his colleagues that psychiatrists were the only medical specialists who never viewed the organ they treated. Most psychiatrists complacently prescribe chemicals affecting brain function without looking at the brain for direct evidence of what those chemicals are doing. The importance of blood flow activity in various parts of the brain appears self-evident when comparing images of well-adjusted people with those of people with serious pathologies, whether diagnosed or discerned through violent antisocial behavior. Even a layman could see the significant difference in brain activity revealed by SPECT images of a "normal" person and (for example) a deranged murderer, as shown on one of Dr. Amen's slides.
The brain's bio-electrical complexity is well known. Its 100 billion neurons have some 10 trillion synaptic connections – more than the number of stars in the known universe - and the brain accordingly absorbs 20 to 30 percent of all calories consumed. Disorders occur when regions of the brain are underactive or overactive, and measurement of blood flow by SPECT imaging appears at present to be the best way to measure these levels of activity. Dr. Amen reviewed what the different areas of the brain do, starting with the prefrontal cortex that controls a person's "executive functions." These include judgment, attention span, impulse control, organization, forward thinking, and empathy. This section, he noted, is not fully developed until at least age 25. The temporal (or deep limbic) lobes are the seat of memory, language, temperament, social cues, listening/reading, rhythm, and spiritual experience. The anterior cingulate gyrus and basal ganglia are associated with cognitive flexibility – overstimulation in these areas leads to anxiety, inflexibility, and oppositional behavior.
Dr. Amen has used SPECT imagery to treat a number of behavioral disorders referred to as attention deficit disorder, which he noted was becoming the most commonly diagnosed psychiatric ailment in America, with an expanding definition that included several disorders with unique proximate causes lumped together as ADD. Analysis of blood flow patterns in various regions of the brain enables him to prescribe medication with a higher degree of confidence than he would otherwise have.
The other technical tool that attracted great interest was biofeedback, or neurofeedback as it is more commonly referred to within the attachment therapy community today. This involves attaching EEG leads to the head and prompting the patient with images on a computer screen that can be manipulated by electrochemical activity in selected regions of the brain. The authoritative presentation on this topic was by Sebern F. Fisher, whose theme was "train the brain, and the child will follow," echoing the main point made by Dr. Amen that psychology follows physiology.
Ms. Fisher commented that the paradigm shift within the field of psychology is leading away from a broad focus on the mind and toward a closer focus on the brain, and within the brain less emphasis on biochemistry than on the bio-electrical functions mentioned above. Most of what the brain does is in the category of self-regulation, and attachment, she emphasized, is "hardwired" in our brains – this capacity does not disappear. It is encoded in the synaptic firing within the right hemisphere and can be accessed, even long after it has been muted by a traumatic disruption experience characteristic of attachment disorders. The brain has a "functional plasticity" that makes it possible to improve through exercise, much as we do with other parts of the body. She addressed what she termed "co-morbid disorders" to include ADHD, explosive and oppositional-defiant conduct, anti-social personality, and learning disabilities – all of which called for training in the right hemisphere of the brain. She outlined a number of case studies where EEG neurofeedback training achieved significant results on varying time scales. Fisher believes that children with learning disabilities can achieve an average 10 point shift in IQ using EEG neurofeedback.
In summary, we as adoptive parents need to understand that adoption always involves loss. For our children the normal bonding process was broken at some point, and sooner or later attachment issues are likely to surface. While I was heartened by Gregory Keck's comment that parents are the best therapists for children, too often we will need professional help. This report has necessarily been a condensed and somewhat idiosyncratic overview of an interesting conference. It was a challenging experience for a layman seeking a better understanding of attachment therapy. For further information, you should start with the Association for Treatment and Training in the Attachment of Children, at their website www.attach.org. For information on SPECT imaging of the brain, see Dr. Amen's website www.amenclinic.com, or www.brainplace.com. For information on EEG neurofeedback training, you can try www.EEGSpectrum.com. There are many other websites with more information about both of these technologies.
Finally, I encourage anyone with questions to contact me by e-mail, firstname.lastname@example.org. As adoptive parents we are all in this together!