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Opinion & Essays - Jun, 2000 Issue #70 

Understanding and Treating Attachment Disorder
By Linda Zimmerman
Clinical Consultant, Rancho Valmora Treatment Center 

[Linda Zimmerman, MA., LPCC, is Clinical Consultant for Rancho Valmora treatment center for adolescent boys and girls in Valmora, New Mexico. Previously she served as Chief Clinical Officer at Villa Santa Maria, an attachment-based residential program in Cedar Crest, NM. She is the Founder and former Director of Namaste Child Development Center. Linda currently offers ten-day intensive in-home consultation, education, and intervention strategy development throughout the country for parents of children with attachment disorder who need assistance to avert out-of-home placement.]

Children with attachment issues generally do not respond well to traditional therapy or parenting methods. In fact, traditional treatment approaches are notoriously unsuccessful with attachment disorder, particularly the approaches that aim to change or modify specific behaviors. The difficulty arises because these processes are relationship-based, and these children by definition lack the capacity for genuine relationships.

When I began specializing in Attachment Disorder twelve years ago, it was still rare to find a clinician who could define it. It wasn’t that children with attachment disorder did not abound; they were (literally) on almost every street corner! Who among us had not struggled with these controlling, demanding, “treatment resistant” kids who routinely bounced out of placements, confounded their therapists, angered legions of parents, and drove their teachers out of the profession? The lack of a clinical definition was not due to an absence of the population. The kids were there, all right; but we, the mental health professionals, did not have a handle on the problem.

Fortunately, times have changed. We are indebted to the likes of John Bowlby and Rene Spitz, who showed us the critical importance of the relationships that develop between children and caregivers. Many of us in the less esoteric, attachment-treatment trenches, are beholden to the innovative pioneers at Forest Heights Lodge. They were the ones who applied talent, uncommon sense, and unequaled commitment to the task of developing a unique residential treatment model, at last offering hope for these seriously troubled children and their families. What is Attachment?

Current theories of attachment describe it as the reciprocal process by which an emotional connection develops between an infant and caregiver, typically the parent. It is also believed that this emotional connection, or its absence, is the foundation for a basic attitude of either trust or mistrust in relationships; a basic attitude that will tend to persist throughout one’s life.

The attachment process can be disrupted in a number of ways, including:
· separation from the primary caregiver
· trauma
· abuse
· prenatal exposure to drugs or alcohol
· unalleviated childhood illness or pain
· divorce or loss · multiple caregivers
· chronic maternal depression
· neurological problems

In many cases, a thorough history will reveal a reason for disrupted attachment. In other cases, the reasons are less clear, but the deficit in basic trust is unmistakable.

Issues of problematic attachment are suspect when a child shows these types of symptoms:
· unable to comfortably tolerate closeness with caregivers,
· motivated by material rewards but not by the intrinsic satisfaction available in healthy relationships,
· reported by parents as having “a behavior problem ever since s/he was a baby.”
· superficiality
· indiscriminate affection
· clingy behaviors
· annoyingly incessant chatter
· lack of eye contact
· dishonesty
· cruelty
· poor peer relationships
· inappropriate demands (sometimes to the point of tantrums)
· physical aggression
· poor impulse control
· poor conscience development
· low self-esteem

Accurate diagnosis is crucial because some neurological syndromes masquerading as attachment disorder, carry quite different implications for treatment. Fortunately the diagnostic process has been aided in recent years by various assessment tools, behavioral checklists, and brain scan techniques.

Treatment: What Works, What Doesn’t

Because these children lack the capacity for genuine relationships, relationship-based processes such as traditional therapy and parenting methods often are ineffective. The stress the children with attachment disorder create in the home environment is so great, often they require out-of-home placement.

Since traditional treatment approaches that aim to change or modify specific behaviors are notoriously unsuccessful with children with attachment disorder, it is more effective to deflect attention away from specific negative behaviors. It is more helpful to view the problem behavior as the child’s way of keeping others at a distance, and recognize that the true problem is fear of intimacy. It is usually more useful to emphasize closeness as non-negotiable.

What does it mean to say closeness is not negotiable? It means that when the child is having a hard time, s/he needs to be close so that the caregiver can help, and, if the child is having a good day, the caregiver needs to be close so as not to miss out on the fun! Non-negotiable closeness implies substituting nurture and supportive control techniques in place of punishment. Common interventions such as isolation, seclusion, or the familiar “go to your room” are counterproductive in the treatment of attachment disorder, because these children have what is called a “reversal of learning” in which closeness is scary and distance is safe. Therefore, isolation has exactly the opposite of its intended effect: it is gratifying or rewarding to the child.

This ‘reversal of learning’ phenomenon is a primary reason why traditional treatment models generally fail to benefit children with attachment disorder. The same contingencies that will extinguish a behavior in an adequately attached child may reinforce the behavior in a child with attachment disorder. In addition, programs that rely on “point” or “level systems” are seldom effective, because children with attachment disorder show a remarkable ability to “work the system” to get rewards, without internalizing any meaningful changes. Such children do better in treatment programs that minimize systems or rules, while maximizing human interaction. The needed human interaction can be maximized by requiring the child to negotiate needs and privileges directly with the caregivers.

Programs utilizing nurture and non-negotiable closeness, such as the treatment model originally developed at Forest Heights Lodge, can provide the corrective emotional experiences that help make up for the deprivations and deviations in nurture that alter attachment and subsequent development. These kinds of programs are helpful for younger children. As children reach later stages of adolescence, developing trust is still a crucial issue when working with issues of attachment. However, it becomes complicated because part of the ‘normal’ process of adolescence involves moving beyond one’s initial attachment to parents and caregivers. Yet, the development of trust is still a critical need in order to build healthy attachments. As adolescents move toward adulthood, their peers become their most important relationships. Often substance abuse becomes their way of dealing with the pain of attachment disorder. Another way adolescents try to cope with attachment disorder is to build a sense of trust and relationship with their peers through the strong bonds formed within a gang.

Older adolescents with attachment issues are benefited by experiential therapy, such as wilderness programs, which foster and depend upon the building of trust between peers. Programs with positive peer culture can also be an important way to use the influence of attachments in a constructive way.

Providing a nurturing environment and helping the child learn how to trust within a healthy relationship plays a key role in working with attachment disorder. With younger children, this trusting relationship is built through non-negotiable closeness with the care-giver. In older adolescents, the trusting relationship is built through experiential therapeutic activities within a positive peer culture.

Regardless of their age, children with attachment disorder can develop the ability to have healthier attachments as a result of being in an environment where they are nurtured and allowed to develop trusting relationships through non-negotiable closeness.

Copyright © 2000, Woodbury Reports, Inc. (This article may be reproduced without prior approval if the copyright notice and proper publication and author attribution accompanies the copy.)

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