Reactive Attachment Disorder is a severe developmental disorder caused by a chronic history of maltreatment during the first couple of years of life. Reactive Attachment Disorder is frequently misdiagnosed by mental health professionals who do not have the appropriate training and experience evaluating and treating such children and adults. Often, children in the child welfare system have a variety of previous diagnoses. The behaviors and symptoms that are the basis for these previous diagnoses are better conceptualized as resulting from disordered attachment. Oppositional Defiant Disorder behaviors are subsumed under Reactive Attachment Disorder. Post Traumatic Stress Disorder symptoms are the result of a significant history of abuse and neglect and are another dimension of attachment disorder. Attention problems, and even Psychotic Disorder symptoms are often seen in children with disorganized attachment 1.

Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms[2]. Many of these children are violent[3] and aggressive[4] and as adults are at risk of developing a variety of psychological problems[5] and personality disorders, including antisocial personality disorder[6], narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder[7]. Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence[8]. Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults[9]. Children who have been sexually abused are at significant risk of developing anxiety disorders (2.0 times the average), major depressive disorders (3.4 times average), alcohol abuse (2.5 times average), drug abuse (3.8 times average), and antisocial behavior (4.3 times average)[10] (MacMillian, 2001). The effective treatment of such children is a public health concern (Walker, Goodwin, & Warren, 1992).

Left untreated, children who have been abused and neglected and who have an attachment disorder become adults whose ability to develop and maintain healthy relationships is deeply damaged. Without placement in an appropriate permanent home and effective treatment, the condition will worsen. Many children with attachment disorders develop borderline personality disorder or anti-social personality disorder as adults[11].

So, what is a person to do? Is there effective treatment for disorders of attachment? The answer is yes; there is an effective treatment for disorders of attachment. Dyadic Developmental Psychotherapy[12] is an evidence-based treatment that has proven success treating attachment disorders[13]. Family therapy, individual therapy, play therapy, residential placements, and intensive outpatient treatment, among other treatments, are often used to treat attachment disorders. However, when compared with Dyadic Developmental Psychotherapy, these treatments proved to be ineffective. A follow-up study compared the effectiveness of Dyadic Developmental Psychotherapy and “usual care,” and found that Dyadic Developmental Psychotherapy produced clinically and statistically significant improvements one year after treatment ended. The study was composed of 34 families receiving Dyadic Developmental Psychotherapy and 30 families receiving “usual care.”

Before treatment/evaluation in both the treatment and control groups, Randolph Attachment Disorder Questionnaire scores and Child Behavior Checklist scale scores were elevated and in clinically significant ranges (more than two standard deviations above the mean for the CBCL). The extent and severity of these children’s disorder is underscored by the fact that 82% of the treatment group and 83% of the control-group subjects had received prior treatment using other methods. The average number of previous treatment episodes was 3.2 for the treatment group and 2.7 for the control group.

The results for the treatment-group were achieved among children aged six to fifteen years, averaging 9.4 years, who received an average of twenty-three sessions over eleven months. Results presented in Table 1 show clinically and statistically significant reductions in scores for the treatment group and Table 2 shows no change for the control group.

TABLE 1

Dyadic Developmental Psychotherapy

N=34, df=33

measure

mean

Pre-test

SD

Pre-test

mean

Post-test

sd

Post-test

t-value

p value

CBCL Syndrome Scale Scores

Withdrawn

65

11.8

54

6.0

4.897

<.0001

Anxious/Depressed

62

10.5

58

8.1

2.665

.006

Social Problems

67

9.7

59

5.5

4.376

<.0001

Thought Problems

68

9.5

56

3.9

6.133

<.0001

Attention Problems

72

12.5

57

6.1

5.836

<.0001

Rule-Breaking Behavior

69

6.9

53

3.8

12.181

<.0001

Aggressive Behavior

71

9.1

55

4.5

10.576

<.0001

TABLE 2

“USUAL CARE” GROUP

N=30, df=29

measure

mean

Pre-test

SD

Pre-test

mean

Post-test

sd

Post-test

t-value

p value

CBCL Syndrome Scale Scores

Withdrawn

65

10.5

63

9.4

1.427

.16

Anxious/Depressed

62

10.6

60

10.3

1.060

.30

Social Problems

64

11.1

65

11.2

-0.854

.40

Thought Problems

63

8.6

62

8.1

0.984

.33

Attention Problems

68

11.9

66

1O.8

0.927

.36

Rule-Breaking Behavior

67

7.4

66

9.6

1.869

.07

Aggressive Behavior

70

10.2

68

9.4

0.919

.37

Dyadic Developmental Psychotherapy is effective because of its reliance on and development of affective attunement between therapist and child, caregiver and child, and therapist and caregiver. The process of maintaining affective attunement allows for dyadic regulation of affect between child and therapist so that the child feels a sense of safety and security and can experience the affect associated with past traumas, allowing for integration of these experiences rather than dissociation of the affect and memory. Furthermore, Dyadic Developmental Psychotherapy’s significant involvement of caregivers in treatment facilitates the development of an affectively attuned relationship between the child and caregiver. An affectively attuned relationship may be described as a relationship in which the two persons are experiencing the same affect and that their affect co-varies. Within the safety of the attuned relationship the shame of past trauma and current misbehaviors are explored, experienced, and integrated. The caregiver-child interactions build on a dyadic affect regulation process that normally occurs during infancy and the toddler years. The child’s past traumatic history of abuse and neglect strongly suggests that such interaction, which facilitates a health attachment and a trusting and safe relationship, did not occur or occurred in an inadequate manner. Dyadic Developmental Psychotherapy facilitates the development of a healthy attachment between child and caregiver, enables the child to affectively trust the caregiver, and allows the child to secure comfort and safety from the caregiver.

This study examined the effects of Dyadic Developmental Psychotherapy on children with trauma-attachment disorders who meet the DSM IV criteria for Reactive Attachment Disorder, all of whom were either adopted or in foster care. A treatment group composed of thirty-four subjects and a usual care group composed of thirty subjects was compared. All children were between the ages of five and sixteen when the study began. Seven hypotheses were explored. It was hypothesized that Dyadic Developmental Psychotherapy would reduce the symptoms of attachment disorder, aggressive and delinquent behaviors, social problems and withdrawal, anxiety and depressive problems, thought problems, and attention problems among children who received Dyadic Developmental Psychotherapy. Significant reductions were achieved in all measures studied. The results were achieved in an average of twenty-three sessions over eleven months. These findings continued for an average of 1.1 years after treatment ended for children between the ages of six and fifteen years. There were no changes in the usual care-group subjects, who were re-tested an average of 1.3 years after the evaluation was completed. The results are particularly salient since 82% of the treatment-group subjects and 83% of the usual care-group subjects had previously received treatment with an average of 3.2 prior treatment episodes. This past history of unsuccessful treatment further underscores the importance of these results in demonstrating the effectiveness and efficacy of Dyadic Developmental Psychotherapy as a treatment for children with trauma-attachment problems. In addition, 53% of the usual care-group subjects received “usual care” but without any measurable change in the outcome variables measured. Children with trauma-attachment problems are at significant risk of developing severe disorders in adulthood such as Post Traumatic Stress Disorder, Borderline Personality Disorder, Narcissistic Personality Disorder, and other personality disorders.

This study supports several of O’Connor & Zeanah’s[14] conclusions and recommendations concerning treatment. They state (p. 241), “treatments for children with attachment disorders should be promoted only when they are evidence-based.” The results of this study are a beginning toward that end. While there are a number of limitations to this study, given the severity of the disorders in question, the paucity of effective treatments, and the desperation of caregivers seeking help, it is a step in the right direction. Dyadic Developmental Psychotherapy is not a coercive therapy, which can be dangerous. Dyadic Developmental Psychotherapy provides caregiver support as an integral part of its treatment methodologies. Finally, Dyadic Developmental Psychotherapy uses a multimodal approach built around affect attunement.

Arthur Becker-Weidman, Ph.D.

Director

Center For Family Development

5820 Main Street, suite 406

Williamsville, NY 14221

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[7] Dozier, M., Stovall, K.C., & Albus, K. (1999) Attachment and Psychopathology in Adulthood. In J. Cassidy & P. Shaver (Eds.).Handbook of Attachment(pp. 497-519). NY: Guilford Press.

[8] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000). Attachment Styles in Maltreated Children: A Comparative Study.Child Development and Human Development,31, 113-128.

[9] Allan, J. (2001). Traumatic Relationships and Serious Mental Disorders. NY: John Wiley.

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[11] Allan, J. Traumatic Relationships and Serious Mental Disorders, NY: Wiley, 2001.

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[12] Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity for Attachment: Dyadic Developmental Psychotherapy in the Treatment of Trauma-Attachment Disorders. OK: Woods N Barnes publishing.

[13] Becker-Weidman, A., (2005) Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,Child and Adolescent Social Work Journal.Vol. 12 #6, December.

[14] O’Connor, T., & Zeanah, C., (2003) Attachment Disorders: Assessment strategies and treatment approaches.Attachment & Human Development,5, 223-245.