What Works in Treating Reactive Attachment Disorder - Families in ...

REACTIVE ATTACHMENT DISORDER

What Works in Treating Reactive Attachment Disorder: Parents’ Perspectives James W. Drisko & Karen Zilberstein

ABSTRACT Reactive attachment disorder (RAD) is a relatively recent diagnosis that draws attention to the effects of early pathogenic caregiving. There is no evidence-based approach to treating RAD. Two different approaches, relationship-based attachment therapy and holding therapy, are widely mentioned in the literature. This qualitative study sought to identify a treatment package based on the views of parents whose children with RAD had made and sustained considerable progress. Parental commitment and availability, ability to find strengths, strong environmental structure, and emotional attunement are key sources of change, according to these parents. Findings also indicate children can make and sustain considerable progress in making attachments and improving social behavior without the use of therapeutic holding, the core feature of holding therapy.

Overview of Reactive Attachment Disorder

familiarity with relative strangers or lack of selectivity in choice of attachment figures” (American Psychiatric Association, 2000, p. 130). The inhibited subtype of RAD is evidenced by “persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions” (p. 130). Such inhibition is manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses such as responding to “caregivers with mixed approach and avoidance, resistance to comforting or frozen watchfulness” (p. 130). A diagnosis of RAD requires that the disorder originate in pathogenic care prior to age 5 but does not address the age range to which the diagnosis is applicable. This leaves many clinicians believing that RAD is not an appropriate diagnosis for school-age children or teenagers. It also leaves open the question of how RAD symptoms will manifest in older children and what distinguishes children who “outgrow” RAD as teenagers and adults from those who do not.

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eactive attachment disorder (RAD) was first included in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1980. The 1994 DSM-IV revision was the first to include the current definition of two subtypes of RAD, both characterized by inappropriate social behavior across situations. DSM requires that all RAD behavior must stem from “pathogenic care” before age 5 (American Psychiatric Association, 2000, p. 130). Pathogenic care includes (a) persistent disregard for the child’s emotional needs, (b) disregard of basic physical needs, or (c) repeated changes of caregivers that prevent formation of a stable attachment. The disinhibited subtype of RAD is evidenced by diffuse attachments, manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments. Such behavior might include “excessive Families in Society: The Journal of Contemporary Social Services ©2008 Alliance for Children and Families

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DOI: 10.1606/1044-3894.3773

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Families in Society | Volume 89, No. 3

Limitations to the DSM Diagnosis DSM’s key criterion for the disinhibited subtype of RAD is empirically supported by reports of specific behavior manifest by institutionally raised children (Chisholm, Carter, Ames, & Morison, 1995; Rutter, Kreppner, & O’Connor, 2001; Zeanah, Smyke, & Dumitrescu, 2002). However, research indicates that indiscriminate social behavior does not always stop when an attachment is formed, so it may not be an optimal criterion for diagnosis (Rutter et al., 2001). Children may also show different types of behavior to different adults (Boris & Zeanah, 1999). The criterion of inhibited or ambivalent behavior is not well documented for inhibited type RAD (Minde, 2003; O’Connor & Zeanah, 2003). Such behavior is reported but is neither necessarily frequent nor consistent, raising concern about its suitability as a diagnostic criterion for RAD. The DSM diagnosis locates the disorder within the child, despite attachments being widely understood as interactions between specific people. The DSM diagnoses emphasize the child’s general social behavior, but do not target attachment behavior specific to primary caregivers. Notably, attachment quality with a specific caregiver is not included in the DSM diagnostic criteria. This may be because the DSM seeks to be atheoretical and descriptive. However, attachment theory drawing on the work of Bowlby (1979) is often used by researchers and clinicians to examine RAD and related attachment behaviors. Based on Bowlby’s work, Ainsworth, Blehar, Waters, and Wall (1978) empirically identified several types of attachment. Their work evolved into the current typology of core attachment categories that include secure, anxious-avoidant, anxious-ambivalent, and disorganized attachment in which contradictory attachment behaviors are found (Carlson, 1998; Sroufe, 2000). The BowlbyAinsworth attachment categories do not easily integrate with DSM’s two RAD subtypes (Zilberstein, 2006). This may be in part because the attachment theory work is derived from experimental conditions applied mainly to nonclinical populations. Yet another alternate vision of reactive attachment disorder is offered by “holding” therapists. Holding therapists emphasize aggressive behavior and attention problems as key aspects of RAD, not as comorbid disorders (Reber, 1996). This broader image of RAD is often linked to treatment by “holding therapy.” Holding therapy refers to a technique of planned physical restraint of the child by caregivers, which is believed pivotal to opening the child up to making attachments. This approach is not derived from the Bowlby-Ainsworth attachment theory. Holding therapy is most often applied to a target population of older school-age children and teenagers. Byrne (2003) points out that children are rarely referred for mental health services because of attachment problems

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per se. Their behavior, moods, and social functioning are instead the immediate cause of referral. He also notes that in traditional clinical practice, pure RAD is quite rare because it often co-occurs with other disorders. Given the high incidence of abuse co-occurring with neglect and inconsistent care, trauma in many forms is often likely to coexist with RAD. James (1994) viewed attachment problems as frequently linked to trauma and severe neglect, raising the issue of comorbidity between RAD and posttraumatic stress disorder. In addition to early trauma and neglect, later experiences of neglect and/or less than optimal caregiving may interact with the impact of pathogenic care before age 5. Such experiences may be more frequent in foster children, especially among foster children with multiple placements. RAD also co-occurs with medical conditions, neurological problems, and learning difficulties. Differential diagnosis of the contribution of each factor, and their interactions, may be very difficult. Treatments for RAD There are very different perspectives on treatment for children with RAD. Because of the interactive nature of attachment, few treatments emphasize individual treatment for the child alone (Brisch, 1999). The best developed and most widely studied treatments are parent counseling and holding therapy. The parent–counseling approach centers on helping parents establish conditions similar to those in which infants and toddlers develop secure attachments with parents in “good enough” circumstances. The goal is to create conditions that foster attachment (James, 1994; Lieberman, 2003). The main interventions are parent counseling and parent supports. This work seeks to help parents become better attuned to their child and/or to help parents establish conditions that promote secure attachment. Parent–child treatment or individual treatment for the child may also be employed. James (1994) emphasized the following characteristics as necessary for children with RAD to progress. First, the environment must be safe. Second, both James (1994) and Lieberman (2003) noted that the placement must be stable and long-term. Third, both also agree the social environment must be psychologically supportive. Relatively low levels of stress and conflict are needed to foster the child’s exploration and growth. Building on a safe and consistent environment, another key component of parent counseling addresses interpersonal connections more directly: Therapeutic work with parents seeks to improve the attunement of parents to their child. Children with RAD signal their needs and feelings poorly, often sending confused, complex, and even contradictory cues to others (Marvin & Whelan, 2003). Dozier, Stovall, Albus, and Bates (2001); Lieberman (2003); and Hughes (2004) all viewed work to help parents interpret and understand the cues sent by their

Drisko & Zilberstein | What Works in Treating Reactive Attachment Disorder: Parents’ Perspectives

children as vital to building connection, social skills, and attachment. Hughes (2004) stated that parents need their own security of attachment and strong reflective abilities to parent children with RAD effectively. This is because parents need to engage the child and tolerate a wide range of behavior while staying tuned in to the child’s needs. Physical contact is a part of parenting, but is done in only a nurturing manner (James, 1994). The overall goal is to provide a setting in which the child can trust, expect relative stability, and become comfortable enough to try new behavior. Conditions are established to help facilitate the development of a stable attachment in a manner parallel to conditions understood as necessary for the development of a secure attachment in “normal” development during infancy (Lieberman, 2003). In contrast, another approach, holding therapy, assumes that a special, confrontational intervention is needed to help build attachments (Anderson, 1988; Hughes, 1998). Although holding therapists include parent supports and counseling as components of a treatment package, they emphasize the pivotal importance of the holding technique. “The child’s defenses have to be breached, which traditional therapy cannot accomplish” (Reber, 1996, p. 93). Holding therapists assume a child with RAD needs a specific intervention to release “locked in” emotions and memories developed in interaction with early pathogenic caregivers. These emotions block the formation of relationships with those worthy of trust and love (Cline, ND; Crawford, 1986; Zazlow & Menta, 1975). The child is physically held, sometimes while confined in a blanket, by parents and others (sometimes several adults). The timing of the holding is not based on the child’s initial level of arousal. The child may scream in rage or sob in grief. After the feelings are “spent,” a key moment occurs: In a state of relaxation, the child can accept the care and concern of others, especially parents. Having given out all the feelings within, without harm, the child can see that parents fully know him and can accept his worst. Gruen and Prekop (1986, p. 251, as cited in English translation by Reber, 1996) stated, “The experience of rage, hate, fear, and shame in the context of being held brings security.” This special intervention is needed to allow behavioral change and to facilitate other effective therapeutic efforts. The holding is viewed as a type of corrective emotional experience in which the child who has been abusively touched in the past needs new experiences of touch coupled with a positive resolution. The high state of arousal holding generates is linked to containment, not hurt. The child is thus retrained to experience touch as beneficial rather than hurtful. Beyond holding sessions, other interventions are also used to facilitate attachment. Many of these interventions overlap with the parent support approach. Thus, holding

therapy should be understood as a package of interventions, some quite unique and others shared across approaches. However, safety and stability in family life appear assumed in the holding therapy literature; they are portrayed as challenged solely by the child’s behavior toward parents. Further, parental empathy appears to be assumed as present by holding therapists. Thus, the child is the main focus of holding therapies and holding a necessary aspect of treatment. Demonstration of successful treatment is improved interaction with parents and others. If the logic of the holding therapists is correct, children must be held and must become emotionally aroused while being appropriately contained by caring adults to begin to make attachments and change their behavior. That is, without this specific intervention, holding therapists theorize that change is unlikely or impossible for children with RAD. Empirical Support for RAD Treatments According to O’Connor and Zeanah (2003, p. 233), “no treatment method has been shown to be effective for children with attachment disorders.” As of June 2007, there was no mention of RAD in either the Cochrane Collaboration or Campbell Collaboration databases of systematic reviews. At the same time, several approaches to parent supports have been developed, and some appear to be helpful (Lieberman, 2003), at least to certain subgroups of children with attachment disorders. However, even these treatments have not been rigorously assessed (O’Connor & Zeanah, 2003), and their effectiveness is largely founded on anecdotal evidence and clinical wisdom. The outcome literature on holding therapy is also minimal. Myeroff, Mertlich, and Gross (1999) found that 25 adolescents treated with holding therapy and parent supports had fewer problem behaviors and exhibited greater improvement in mood than did a waiting list control group as measured by the Child Behavior Checklist (CBCL). However, Kennedy, Mercer, Mohr, and Huffine (2002) pointed out several threats to the internal validity of this comparison. It is also clear that the CBCL is not intended as a measure of attachment. Randolph (2000) found parents involved in holding therapy viewed the interventions as helpful, and Lester (1997) reported behavioral improvement among 12 adolescents after holding therapy. In these studies of holding therapy, attachment per se was not assessed as a dependent variable. Given the preliminary state of research on RAD, further exploratory and descriptive research is needed to better define the disorder and components of its treatment (Steele, 2003). Specifically, this study seeks to better define how the interventions that led to improvement in children with RAD who made and sustained notable gains might point to interventions for use in future treatments. This study

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might also provide a test of the role of therapeutic holding as a necessary intervention. That is, if gains are made only or most often when holding is employed, such a result would support the importance of holding intervention. On the other hand, if gains are frequently made and sustained without the use of holding, such a result would suggest that parent supports alone are sufficient, and holding intervention is not pivotal. Examining the views of parents whose children with RAD have made and sustained substantial progress, this study will consider each of these questions.

Method Research Design A qualitative research design was selected for this exploratory study. The goal was to develop an empirically grounded description of parents’ views of “what works” in treating RAD and to learn about the role of therapeutic holding. Parents were viewed as having the most in-depth knowledge of effective aspects of their child’s treatments. They are both providers of care and therapeutic interventions, as well as key assessors of change. To enhance validity, parent views were cross-compared and triangulated with the views of closely involved professionals when possible. In addition, multiple interviews were employed to increase contact and reflection. All interviews were tape-recorded and transcribed. To find families whose children had made and sustained substantial progress a range of clinicians in western Massachusetts were contacted. These clinicians were asked to identify children with “substantial relationship difficulties,” due to poor early care, who had made significant and sustained improvement. The treating clinicians contacted the child’s parents; those parents who gave approval were asked to participate and given complete informed consent materials. Those children who appeared to warrant a RAD diagnosis at the time of adoption and who had made and sustained symptomatic improvement were included in the study. With parental consent, treating professionals were also interviewed. Sample The children. Five boys and four girls were the target children with RAD. Six were White, one was African American, one was Latina, and one was biracial. At the time of adoptive placement into the current family, four were between 2 and 3 years old, two were between 4 and 5, and three were between 6 and 12. At the time of interviews, four children had been in their homes for 6 years, and the other five children were in the current home for more than 10 years. All the children met the DSM criteria of persistent pathogenic care before age 5. All the children suffered

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maltreatment and placement changes prior to their adoptive placements. Eight of the children had histories of physical or sexual abuse, seven had suffered abuse or neglect in previous foster placements, and all had experienced between one and four prior placements. Co-occurring organic conditions were also evident: Three of the children were born with fetal substance effects, one had a genetic syndrome, and one had a traumatic brain injury. Drawing on contemporary or retrospective accounts of the children’s behavior at the time of placement, all nine of the children warranted a DSM diagnosis of RAD. However, their attachment difficulties took on varied forms. Three of the children showed indiscriminate behavior across social situations, consistent with the indiscriminant subtype of RAD. Three children showed clinginess to their caretakers. Six children were avoidant of physical or emotional closeness consistent with the avoidant subtype of RAD. For example, some of the children hid under beds to avoid contact, while others fled the room to avoid contact. Two children exhibited mixed behavior in which they were alternatively clingy and avoidant. Both younger and older children were described as avoidant and indiscriminant; both younger and older children were described as clingy. At time of placement these children also exhibited prominent behavioral difficulties and symptoms. All nine children had difficulty trusting, disbelieving that adults would consistently care for them, feed them, nurture them, or be available after separations. All nine children exhibited emotional constriction and great difficulty expressing feelings in an organized manner. Eight children had mood-related issues such as difficulty modulating sadness, rage, or anxiety. Seven children had symptoms of post-traumatic stress syndrome (PTSD) including flashbacks, dissociation, and sexually reactive behavior. Five of the nine children displayed fearfulness, particularly at night. Six children showed conduct problems including lying, stealing, and/or aggression. All nine children initially had peer relationship difficulties. Six children appeared controlling or provocative with others. Four children had continuing, unresolved issues concerning their birth family, such as problematic visitations or loyalty conflicts. Three children exhibited stereotypical behavior such as rocking and head banging. Several children appeared to warrant both a diagnosis of RAD and PTSD (consistent with their early pathogenic care); several children also appeared to warrant diagnoses of attention-deficit/hyperactivity disorder (ADHD), depression, or anxiety. Given the criteria for a RAD diagnosis, comorbid conditions are likely to be present. The families. Eight families were included in the study. All eight were two-parent families. Income was not formally assessed, but all appeared to be either working class


or middle class. Seven of the parent pairs had previously parented birth children. In all seven cases, some birth children were still in the home at the time of the adoptive placement. Two families had adopted prior to this placement; two adopted subsequent to this placement. In all of the families, at least one of the parents spent substantial time at home caring for the child with RAD. Although mothers tended to be the primary caregivers, fathers were involved to a considerable extent both as supports to the mother and by providing care on their own. The professionals. With parental consent, eight professionals who had worked with the children and families in the sample were also interviewed. Of those professionals, five were therapists who had worked consistently with the children and families nearly from the time of placement. All were either still engaged in treating the children or had ongoing, intermittent contact. Three were adoption workers responsible for placing the children and providing substantial ongoing supportive services. Together, these professionals worked with six of the families in this study. For two of the families, consistent professional helpers were unavailable or never used. The contributions of professionals are not the main focus of this report, but will be noted briefly to provide a triangulating perspective. Data Analysis Transcribed interviews were “open coded” using Glaser and Strauss’s (1967) constant comparative method, organized using ATLAS.ti data analysis software (Muhr, 1994). More than 80 codes were defined. Axial coding was then used to develop a typology of diagnostic issues, situational characteristics, and interventions. Seven axial codes related to key aspects of developing attachments were identified. Intercoder comparison of each transcript and the developing coding structure were done by the authors to increase reliability and reduce bias. Efforts were made to identify contradictory evidence and to challenge the emerging typology.

Findings A consistent pattern of parental commitment, extensive availability, structured behavior management, and specific sensitivity to relationships and feelings emerged from the interviews. Parents were very able to stay closely attuned to their child. Parents were able to identify and value changes and to keep a positive outlook. Parents found, and made good use of, available social supports. Interviews conducted with parents, adoption workers, and therapists all support the same prominent parental behaviors and characteristics as being crucial to the children’s success in developing and maintaining social relationships.

Safety Although these parents and professionals did not specifically address the safety of the children in their adoptive homes, all of the families had been evaluated by social services and had passed criminal record checks. Nonetheless, the issue of safety was evident. The initial behaviors of some children raised concerns about prior abuse and neglect in these parents very quickly. For example, one child was “touch sensitive,” making routine diaper changes a difficult matter. In turn, the parents “narrated” what they were doing to the child, and tried to make sure the child understood necessary intrusive contact such as doctor’s appointments. Commitment and Persistence Parents demonstrated a solid, consistent commitment to the child over time. Difficulties were many, and testing was often severe. Nonetheless, these parents consistently indicated they did not consider giving up the child as an option. One parent said, “I initially gave up my life and committed it to her.” Another said, “I made a promise that I would be his parent.” Yet another parent stated, “You just keep trying … you make a commitment and that is it.” Still another said, “Families are forever.” Parental commitment was evident despite differences in how quickly they bonded to the child. One father said, “We each had concerns [about his behavior], but never about his staying.” They accepted the children “as is,” while believing in the child’s potential for growth and development. Some parental bonds developed very quickly, and others took much longer. One mother said, “I really thought that I would love him almost immediately, but it is not always so. Like any good relationship, it takes time.” One father noted a young child’s comfort as he took him out of a car seat for an early visit. The boy put his arms around the man’s neck and seemed relaxed, at ease. The father’s bond to the child was cemented then, though it proved to be followed by several years of anxieties and fears from the boy. He said about his wife, “I think she was totally attached right away!” Bonding—forming an initial emotional connection—was not described as the same as forming an attachment, using another person as a source of security. Ability to Recognize Strengths and Small Gains Parental ability to find and take pleasure in the child’s gains helped them persevere. These gains were often small and incremental, but seemed significant to these parents. One parent stated, “I saw flashes where it was wonderful, and I had enough good stuff going on that the horrible stuff, I could live with.” Parents noted various types of progress as gratifying. These included the child’s improved ability to relax, tolerate criticism, or accept dis-

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cipline; improved self-regulation; more appropriate use of parents as sources of comfort and security; and athletic, social, and academic gains. Positive Outlook Parents very quickly found strengths within their child. They emphasized the strengths over the child’s deficits. One mother said, “I think we were both actually surprised by how affectionate they were when in the right emotional space.” Parents maintained a generally positive outlook despite many prolonged challenges. This positive outlook was evident in daily interactions. Parents looked for opportunities to be nurturing even when the child pushed them aside. One mother said, “I think I had some unrealistic expectations about that—the speed with which I would be accepted as a parent. But you wouldn’t do it unless you had a high expectation that you were going to be rewarded with love and affection and adoration. You just wouldn’t do it.” Another parent closed the interview, which included descriptions of many significant challenges, with the summary comment: “It’s very rewarding.” Parental Availability and Supervision of the Child Parental commitment is also demonstrated in the great amount of time they spent with children each day. These children spent very little time in surrogate care, and, in fact, some parents rearranged their work and daily schedules to provide the availability they thought the child required. One mother stated it this way, “So I quit my job … because she was such a needy child …. It took 90% of my time …. And I would say 90% for 15 years.” Other parents echoed this commitment: We were with them all the time—all the time absolutely. Every night we did nothing around here except play with them, listen to music, play games, rough house, cuddle, whatever, play dress-up—there was nothing else, really … and it has continued until today. We are with them most of the time.

Supervision of the children by parents was substantial. Parents, in large part because the children’s behavior could be so changeable and difficult, remained in close proximity at home and in the community. One parent said, “The younger one was so needy … almost like a puppy. I couldn’t go down to the mailbox that he would get horrified.” Another parent said, “I had to restrict her more than I’d restrict a typical kid because she was so unpredictable … she would have gone with anybody.” Another noted, “His temper tantrums were really difficult. When he would rage, he would rage and rage and rage …. He would have to be contained.” Some of the children remained close to their parents in a regressive and needy manner. Parents always toler-

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ated such behavior. These children could be clingy and whiney. On the other hand, some children were kept near to prevent or contain extreme behavior. For example, a 3-year-old was carried on his mother’s hip to curb his often impulsive aggression, which included the breaking of the family television set. In all cases, these parents kept close supervision of their child. This supervision did not always involve physical presence, but included visual or aural monitoring of the child’s location and activities. One mother said she felt her teenage daughter sometimes needed time alone, but she always “kept the door open, kept within earshot.” It is important to bear in mind that such close supervision not only served to prevent or contain problem behavior but also simultaneously helped develop connection. Constant supervision reflected parental bonding to their child prior to the development of a true, interactive relationship. Such supervision and structure were continued outside of the home. Parents encouraged success in their children by maintaining a protective and supportive stance during recreational and social activities. Often they went with their children to activities and coached them through baseball or soccer games to ensure success. They avoided pulling away from their children, even in response to misbehavior, instead using such events as opportunities to get closer and provide structure and support. Structure and Behavior Management Parents provided a high level of daily routine for their children. The level of structure could be very intensive. One parent said, “What we are essentially doing is residential treatment in the home …. It is close to it.” The intensive effort was purposefully delivered within the home. Thus, it served to build consistency and security as well as connection with the child. Parents were clear about rules and consequences. As one parent stated, When he misbehaves, he is going to have a time-in. I would set the timer, but he would have to sit in my lap for a minute …. My husband and I were both very good about being consistent. No matter what … it would happen … even in the grocery store.

Note that this parent used a “time-in” technique, a time together in response to misbehavior rather than a time apart or “time-out.” She emphasized making connection even when strong feelings were present and a more common reaction would have been a “time-out” apart. Physical contact is made, and perhaps some modest restraint employed, but not prolonged holding. Behavioral management was based on the child’s developmental needs rather than expectations tied to the child’s


chronological age. A 16-year-old was thus allowed to sit on a parent’s lap during church, though the parent found this awkward. As mentioned, a 3-year-old was carried on his mother’s hip like a younger child. One boy was allowed to ride his bike in circles around the house immediately upon arriving home from school, before entering the house. His parents saw this as a necessary transition for the boy despite its unusual nature. His parents said, “We have allowed him to do things on his own time and stages.” These behavioral techniques were administered with positive regard for the child and with measured parental self-control. One key issue was how much arousal the child could tolerate. Parents found techniques to match the child’s level of comfort, rather than confronting it. Parents showed strong sensitivity despite confusing and variable messages these children sent. Therapists and child welfare workers made comments about these parents, such as, “She has good intuition; know what I mean? And the instincts are there.” Parents described holding or use of touch as a response to what they saw as the immediate need of the child. That is, holding was employed to help the child gain composure and to assist self-regulation. It was not imposed to increase arousal or to challenge defenses; rather it was used to reduce the child’s level of arousal and to show concern and affection. Intersubjective Attunement In spite of confusing cues and communication, parents showed attunement and sensitivity to the child, also known as intersubjective attunement. Daily structure and behavioral management provided consistency in the children’s lives, whereas the attuned quality of the parent– child relationship added emotional safety and stability over time. Empathy and attunement to the child’s often obscure needs and feelings guided the development of parenting strategies. One mother said, “I think about how hard it was for her to be touched, and I really looked at ways to touch her that didn’t feel like holding her exactly. I put on a lot of lotion and sunscreen that first summer and brushed her hair a lot.” One therapist said the parents did a lot of detective work, sorting out mysteries of communication and need, demonstrating “how could they get around something, and how could they essentially help her turn to them for comfort.” Because of the confusing signals sent by the children, and their idiosyncratic understandings of everyday actions, parents often had to articulate to the child why they took specific actions. Limits and routines were upheld consistently; the child’s thoughts and feelings were put into words and affirmed. One parent said, “Frequently we would know that she was going through an emotional trauma and she could not figure out what it was. … I had this power of

giving her choices, saying the things out loud, and letting her nod her head or using a puppet or something, to figure out what it was.” Discipline was often misunderstood and required explanation. Via discussion of its purpose, discipline became a way to help the child understand the meaning of his behavior as it related to needs, feelings, and history, as well as to explain the parents’ purposes in intervening. Parents were well able to appraise the success of their interventions. This allowed them to continue those that worked and to let go of those that did not. One parent said, It is interesting … the degree to which testing is a part of attachment. And your response to it is the piece that matters. … For example, every time there was acting out and we put a limit or a container on it, it felt awful, like this isn’t the kind of parenting we wanted to be doing. And the next day, the children were so happy, and then we would know that it was working.

Similarly, when misattunement arose, it was repaired immediately, or as soon as the parents could identify what had led to the miscommunication. Over time and with support, parents understood more clearly the children’s cues about anxieties and fears, reactions to losses, need for care, expressions of trauma-specific behavior, and regulation of arousal. Yet they maintained a balanced appraisal of their child, noting successes as well as challenges. Challenges were many: learning difficulties, trauma reactions, moodiness, attachment difficulties, provocative behavior, and medical conditions. The combination of intersubjective attunement and structure served to provide the children with safety, predictability, and recognition of their internal feelings, even when confusion predominated. The foundation of attachment was provided through empathic appraisal of the child and affirmation from parents. Use of Social Supports and Advocacy These parents were able to locate social supports and were also able to make good use of available supports. They actively sought out supports both for themselves and for their children. Strikingly, these parents used social supports very effectively. One therapist said about a mother: “[She] is a great example of someone who would say, ‘I did what you told me … it worked like a dream … and I added this, this, and this. And it worked even better.’” This mother used supports, recognized their value, and collaborated to make their impact even more helpful. Supports were of varied types. They came from family members, friends, other adoptive families, church, recreational activities, and professionals. Almost all families

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found either an adoption worker or therapist whom they consulted up to a few times a week during the early months of placement. In addition, parents educated themselves through reading, going to conferences, and seeking out others in similar circumstances. Two fathers noted they made use of Internet contact with other adoptive parents. Parents felt professionals generally supported them, but when they did not, the parents actively intervened to remedy the situation. Parents found needed resources and advocated for their timely provision. Such advocacy included educating others about their child’s needs. One parent told her daughter to return items to people from whom she had “begged” them (in an indiscriminate manner). She was careful to point out it was her role to care for her daughter. Another parent served as an informal educator to her son’s little league team, helping coaches understand his needs and unusual behavior. Therapeutic Holding None of the children had been in holding therapy or had received therapeutic holding as described by Reber (1996) or Gruen and Prekop (1986). Bear in mind that selection criteria for the study sample required that the child had made and sustained substantial progress: All the children had improved markedly in their capacity for self-regulation and ability to make attachments. There was, however, no effort to include or exclude any form of therapy in the selection criteria for the study, nor was it inherent in the philosophies of the referring agencies. Other children served by the agencies involved in the study had received holding therapy. Parents in the study noted that physical contact was important and sometimes useful to help calm or contain the child. Still, none mentioned prolonged holding or emotional release through holding as described by holding therapists. Many noted the importance of contact with their child. Some, at times, physically restrained the child in response to dangerous behavior or tantrums. More typically, parents emphasized the role of everyday touch as an aspect of building relatedness. Another mother noted that nurturing her avoidant child through a sickness helped melt some of his physical defensiveness. Other parents noted the importance of backrubs and allowing the child to sit on their laps (even in church, and when the child was a teen). Contact mattered but was consistently done in ways that reduced arousal and increased engagement with the child, rather than externally inducing arousal while the child was held. Other Forms of Touch and Holding The most direct description of holding offered by any of these parents is this one, which took place during an early preadoptive visit:

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When she came, she was adorable—because all 3-yearolds are. But the very first weekend she came home on a preadoptive overnight visit, she had a terror and this glazed-over look. And I am thinking, I didn’t touch her, what happened? And all I could do was go and hold her; what else can I do? As soon as I touched, she started flaying, and I thought, just hold her tight. And that helped …. The tighter I held her, the more comfortable she seemed.

These parents employed several forms of holding and made widespread use of physical contact. No holding was particularly prolonged. The purpose of holding was consistently to reduce arousal. Changes following holding were modest rather than dramatic. For some, similar results were achieved by sharing a chore with a child, generating an opportunity for discussion. The Parent’s Comments on the Role of Professionals Parents said that professional supports helped them attune to their child despite the child’s misleading cues and mysterious or off-putting behaviors. They said professional support helped them stay affirming and consistent with their child. Most parents described the roles of professional supports as crucial to their child’s progress and to rebounding after periods of regression. Professional supports aided parents in developing and enhancing attachments with their child and in improving the child’s social behavior. Professionals were described as attuned helpers to parents, who, in turn, were attuned caregivers to their child over time. The consistency of these parents’ relationships with their professionals—over many years—was parallel to the parents’ consistent, committed relationships to their children. Parents emphasized professionals affirmed the importance of their roles as parents. They also noted that professionals offered perspective on behaviors and interactions—that they “gave” both children and families a language to talk about issues more effectively. Professionals also offered help with the parenting role and techniques to manage behaviors. Professionals allowed parents to express their concerns and feelings safely. Parents stated professionals helped them identify progress (even when change was small) and to “hang in there” through challenging times. Parents noted these professionals helped with referrals to additional resources and services. It is important to bear in mind that while parents sought out and made use of supports of many kinds, the availability of such services supported parents and child alike.


In the direct treatment of the child, parents emphasized how professionals helped the children understand why their parents did what they did. Professionals conveyed respect for what the parents knew about their child and their commitment and effort. They reinforced that the parents were doing the right thing. Treatment sessions with children often included parents and continued, with varying frequency and intensity, over many years.

Discussion The children in this study all made and sustained substantial progress without therapeutic holding. This suggests that holding therapy is not necessary for all children with RAD. Instead, the findings of this study indicate that sustained and intensive efforts by parents to provide caring, structure, and emotional attunement can lead to improvement without therapeutic holding. This does not mean that holding therapy cannot be potentially helpful, but it does indicate that therapeutic holding is not necessary for therapeutic change by children with RAD. The children in this study presented widely varying behaviors. All did meet criteria for a DSM diagnosis of RAD. These children did not, however, consistently fit into either the DSM’s inhibited or disinhibited subtypes of RAD. They appeared to present a variable and confusing mixture of behaviors reflecting problems with attachment and social relationships due to poor early care. As demonstrated by the wide range of behaviors, thoughts, and anxieties present in the children in this study, RAD and other disorders or behavioral problems often coexist. Comorbid conditions, most often PTSD, are likely to be present along with RAD. Thus parents and professionals must often work on several fronts at once. Components of a Treatment Package for RAD First, the description of parents suggests they worked extremely hard to provide a “secure base” for child development (Bowlby, 1988). This consists of physical safety, a predictable home environment, clear daily structure, and consistent behavior management (James, 1994). Oddly, assessment of the child’s safety and the consistency of both parental availability and daily routines are not often emphasized in descriptions of RAD treatment. The current findings are consistent with the recommendation of James (1994), who viewed safety and consistency as central to building attachment. Safety warrants close, ongoing attention, given the backgrounds of children with RAD. Consistent with the views of Lieberman (2003), Hughes (2004), and Minnis, Marwick, Arthur, and McLaughlin (2006), intersubjective attunement between parent and child appears vital to progress. Their view is supported

by Madigan et al., (2006), who found unresolved states of mind in parents led to anomalous and unhelpful parenting behavior. Parents must stay involved with, and attuned to, their child’s inner states. They must engage with confusion. They must articulate their own feelings and motives, as well as help puzzle out and articulate what they believe the child is feeling. Such efforts appear to help reduce externalizing behaviors and enhance attachment (Guttmann-Steinmetz & Crowell, 2006). Parent descriptions make clear that consistent parental behavior occurs prior to, and is viewed as a prerequisite for, improved attachment behavior by a child with RAD. Parents were committed to the care of these challenging children. Commitment might waiver at times (Barth, Crea, John, Thoburn, & Quinton, 2005), requiring parents to seek their own supports, but it did not break. Beyond commitment, these parents were extensively available and constantly present for their child. Presence and availability provided the setting for bonding and attachment. Bonding by parents to their child generally took place rapidly, although parents and children differed in how long it took to connect. True attachment—the child’s view that parents would be emotionally supportive—took much longer and could be tempered by significant trials or built on consistency over time. Recognition of attachment often was most clear at times of trial or separation. It was often evident through a simple statement or action. For example, one child said, “This is the first time I had a family to come home to.” Structured rules and routines were also seen as very important (James, 1994; O’Connor & Zeanah, 2003). Routines were sometimes broadly understood: A routine might include reading and singing with the child each night before bedtime or regularly allowing time alone before the child entered the house after school. Loving care was a key part of structure; discipline was used to provide order to life (Lieberman, 2003). Less commonly noted in the literature was the importance of parental recognition and acknowledgment of their child’s strengths and small gains. Being able to appreciate these small steps helped parents track progress and sense the value of their actions. The descriptions of these parents make clear the importance of a positive outlook to children with RAD, to siblings, and to the parents’ own sense of well-being. Consistent with the treatment recommendations of Lieberman (2003) and Hughes (2004), these parents addressed episodes of problematic behavior in an engaged manner. In addition, these parents proved very adept at “tuning in” and staying attuned to their child. Nonetheless, they were often confused by the messages and communications sent by their child (Dozier et al., 2001; Hughes, 2004). However, these parents were able to empathically attune with the child even in confusing moments. They engaged with

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confusing messages sent by their child and were often able to “see through” the confusion to sense the child’s need for help in emotional or behavioral self-regulation. These parents also demonstrated a strong ability to be self-observing and self-reflective. Parents demonstrated their own strong attachments to their child, a capacity Hughes (2004) viewed as vital to building attachments for children with RAD. These parents acted in ways that built connection, limited the child’s level of arousal, and acknowledged the child’s feelings. In discipline, time-in replaced time-out. Intersubjective attunement guided discipline. Such engagement and attunement by parents were supported by considerable work with therapists and child welfare workers, especially during the early years. Parents need to have their own supports available. However, current findings indicate that parents must also make use of these supports to sustain the demands of caring for a child with RAD. This capacity appears minimally emphasized in the prior literature, yet is vital to a parent’s ability to stay attuned to their child over many years. The ability of parents to both find and make use of supports is an important area warranting further investigation. In contrast to the findings of Kerker and Dore (2006) regarding foster youth, professionals actively encouraged and supported parents in using mental health services. Holding and touch were widely used. Most of the contact was of the everyday parent–child type: backrubs, hair brushing, grooming. This positive use of touch and contact was noted by James (1994), but is not widely discussed in the literature on RAD treatment. Holding as physical restraint was used when needed but with the goal of containing the child and helping to reduce arousal and increase the child’s self-regulation (Drisko, 1976). Holding was not done at a time chosen by the adult, and it did not have the goal of building arousal or the effect of achieving a breakthrough to allow more emotional access. Holding and touch were important aspects of building attachment, but not central to it, in the words and views of these parents. The demands of adopting a child with RAD and other disorders were significant. Families rearranged their lives, careers, and daily priorities to be consistently available to their child. The work of family life was very difficult over an extended period of time, frequently very stressful, but ultimately successful. These children improved markedly in social functioning as appraised by parents, involved professionals, extended family members, and community social contacts. Adoptive parents need to be made aware of the level of demand required in caring for a child with RAD.

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Implications for Treatment Children with RAD vary widely and do not constitute a simple, homogeneous group (Zilberstein, 2006). Comorbid disorders, such as ADHD or PTSD, are often present, as are a wide range of organic conditions. Both RAD and comorbid disorders shape the challenges of treatment. As a result, clinicians and social services workers are advised to consider each child with RAD as a unique individual who may have multiple challenges and needs. Treatments for children with RAD should begin with the foundation of a solid, consistent adoptive family placement. Families need to understand the work involved is considerable, challenging, and likely to be prolonged. Selection of families able to provide empathic attunement and to be present consistently—nearly constantly—maximizes opportunities for connection and attachment over time. Families must be flexible and able to meet the child at a developmentally appropriate level rather than on a chronological age basis. Maintaining a positive outlook and the ability to identify and celebrate even small gains are both important. Families who find social supports, and are able to make good use of them, are likely to be better sustained in this hard journey. Therapists and child welfare workers need to be available to families on a frequent and steady basis during the first year of placement. Families need their guidance and affirmation to help understand the confusing and sometimes contradictory messages children with RAD and comorbid disorders send. Families also need multiple sources of support. Holding and physical contact are important to children with RAD and are often areas of some initial discomfort. Parents may need to use brief physical restraint to help protect, organize, and calm children with RAD. However, extended holding, used purposefully to increase arousal and allow emotional release, was not a part of any work done with these children. This finding is consistent with the recent practice guideline for RAD treatment published by the American Academy of Child and Adolescent Psychiatry (2005), which states that holding therapies “have no empirical support and have been associated with serious harm, including death.” Without therapeutic holding, all these children made and sustained considerable progress in improving social relationships and developing attachments. Committed parental care, subjective attunement, and behavioral supports appeared key to the sustained changes these children made.


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