Chris Kerno, Field Education Director
In my last article, in the October 2005 issue of The Scholar-Practitioner, I wrote about a 14-year-old male client called Joe, who has a diagnosis of Reactive Attachment Disorder (RAD).
This psychiatric diagnosis begins before the age of 5 in which a child who has experienced extremely poor care or abuse exhibits very disturbed and inappropriate social relatedness for his or her age. For example, the child may exhibit contradictory or disorganized responses to caregivers such as alternatively approaching, avoiding, or resisting the caregiver’s efforts to comfort or care for the child. Or, the child may not adequately distinguish between his or her primary caregiver and strangers, exhibiting excessive familiarity with people the child has never met. (http://dcfswebresource.prairienet.org/resources/rad.php)
Joe’s diagnosis resulted in his coming to my special education school for children with emotional/behavioral disorders (EBD). Joe had bounced from school to school and from foster home to foster home for quite a while, a pattern not unusual for children with this disorder.
Level of Knowledge about RAD
At the time, the way we dealt with Joe did not seem particularly innovative, but after reviewing the literature, I could not find one single article that mentioned our treatment approach with adolescents like Joe. The approach seemed to work, but as O’Connor and Zeanah (2003) observed, for children with these attachment disorders, existing treatment methods were not usually effective.
Joe’s Perspective
So how did we work with Joe and why has this approach not been researched? To answer the first question, it is necessary to try to see the world from Joe’s perspective. The following scenario is fictitious, but attempts to demonstrate how Joe saw the world and how we worked with that view.
“Yeah, I really love it here. It is not like my last school, where people did not care much about me and were always ‘in my face.’ This place is OK. There is a woodshop here, and teachers and counselors who really care.”
The Role of the Counselor
His counselor looked at Joe passively and did not agree with his statements regarding the school or the people in it. He talked about Joe’s classes and the “expectations” and “code of conduct” that all students were required to abide by. He pointed out these expectations listed on the wall and emphasized how, as Joe’s counselor, his role would be to hold Joe accountable for his behavior while at the school. He said he was not all that interested in Joe’s life beyond how he did in school, but if Joe wanted to tell him something, he would always listen.
Joe’s Reaction to the Counselor
Joe left his counselor’s office and went back to class. This was the fourth special education school he had attended in the last two years. In all those schools, staff members had never told him that they did not care much about his life. “The guy was weird, but OK,” he thought.
The Role of the Teacher
In Joe’s next class, he looked around the room and settled in behind his desk. The teacher seemed OK, “not so pushy and all over his case,” he thought. Teachers who “crowded” his desk made him nervous and uneasy. In his last school, the teachers angered him by always trying to help him. “As if I needed their help!”
“Where are you from?” he could hear the teacher ask the other new student in the class. Joe was a bit uneasy, knowing he would be next, but he also craved the teacher’s attention.
Joe’s Reaction to the Teacher
When the teacher got to Joe, he seemed to blurt out his whole life’s story: all the foster homes, the social workers, and the schools. When he was done, the teacher just smiled and moved on to the lesson—no prying questions or any effort to get to know him better. Joe was not used to this kind of approach, but it kind of put him at ease.
Key Point
Joe’s counselor and teacher made no attempt to get to know him. They asked no questions and even attempted to distance themselves psychologically from Joe.
Treatment Center Staff Strategy
We found that the closer we attempted to get to these children, the farther away it pushed them. Eventually, we learned that for Joe safety was created, with individuals and with the school as a whole, when staff consciously refrained from trying to “build a relationship” with him.
In fact, the more we told Joe that his life was his own business and that all we really cared about was how he did in school, the more Joe came to us. As a result, Joe did fine. His grades improved, and he became stable in our program. He even began to build some relationships, completely on his own terms.
The Hard Lesson for Mental Health Professionals
Unfortunately, it is extremely difficult for most mental health professionals and county or state case workers to approach these kids in this way. Most professionals, along with the system itself, seem to be biased in favor of adoption and long-term foster care.
The consensus seems to be that these children need to learn how to have a “healthy relationship”; that if we offer a stable and loving environment, then they will somehow be “loved” into mental health.
A New Concept
We found the opposite. We found that we had to “not care” them into mental health. This did not mean that we in fact did not care. We actually cared enough to let go of our own needs and put the needs of the child first. For lack of a better description, this approach is best known as “paradox.”
Literature Limits
So why could I find no journal articles or studies on this approach to treating RAD? The closest I could find was this recognition by O’Connor and Zeanah (2003):
A more puzzling case is that of an adoptive/foster caregiver who is “adequately” sensitive, but the child exhibits attachment disorder behavior; it would seem unlikely that improving parental sensitive responsiveness (in an already sensitive parent) would yield positive changes in the parent-child relationship. (p. 233)
They go on to say this:
Parent support, in the form of (in)formal networks or as part of ongoing clinical attention, may be an important kind of intervention for addressing parents’ feelings of frustration, distress, and incompetence. Education concerning what attachment disorders are may also be important, although there is as yet a limited consensus on the specific characteristics of attachment disorders or what kind of treatment is required. (p. 241)
These authors at least recognized that “being sensitive and loving” is not going to “attach” a child to a caregiver. They did not, however, take the next logical step and posit that perhaps just the opposite might work.
The Paradox Approach: The Heart of Treatment
In our experience, the paradox approach needs to be at the heart of treatment at school, at home, and in the community. These children seem to do well in structured environments that do not place too many emotional and psychological demands on them.
Perhaps it is difficult for those working in the system to consider the group home approach for these kids. A well-ordered, consistent and psychologically safe environment just might be what these kids need. Certainly, the idea warrants further study if we are truly concerned about the well-being of children with attachment disorders.
Resources
DCFS Web Resource on Reactive Attachment Disorder.
http://dcfswebresource.prairienet.org/resources/rad.php
Haugaard, J. J., & Hazan, C. (2004). Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: Reactive attachment disorder. Child Maltreatment: Journal of the American Professional Society on the Abuse of Children, 9, 154–160.
Wood, M. E. (n.d.) Reactive attachment disorder: A disorder of attachment or of temperament? (Rochester Institute of Technology). Paper retrieved January 10, 2006, from http://www.personalityresearch.org/papers/wood.html
Reference
O’Connor, T. G., & Zeanah, C. H. (2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment & Human Development, 5 (3), pp. 223–244.
|