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In-home treatment of reactive attachment disorder in a therapeutic foster care system: a case example. (Practice).

When trauma precedes a child's placement in the foster care system, it can lead to lasting mental health difficulties. Often, children who experience extreme, chronic trauma prior to age 5 develop Reactive Attachment Disorder (RAD). However, the diagnosis of RAD is often overlooked. This article discusses the characteristics of RAD as well as diagnostic criteria and possible etiology. We present the case example of an adolescent diagnosed with RAD as an example of treatment from an in-home perspective.

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Nearly 1 million children enter the foster care system each year. If trauma places them there, it can create negative mental effects (Children in foster care have more SA/MH needs, 2001). Although children can overcome the results of abuse and neglect with an appropriate support system, supportive resources are not always available. What happens to children who never had a support system? How can they develop into productive adults? Often these children are perpetual clients in the mental health system, and they present with a multitude of symptoms and diagnoses (Milan & Pinderhughes, 2000). Some evidence suggests that children in foster care are more likely to receive behavioral health care services than any other group of Medicaid eligible children (Children in foster care). Often these services are related to the effects of pathogenic care resulting in a disruption of healthy attachment patterns.

Chronic disruption of early childhood attachment patterns may result in Reactive Attachment Disorder (RAD), a commonly misunderstood and under-diagnosed disorder. RAD begins in early childhood, and the symptoms can become pervasive throughout an individual's life (Doane & Diamond, 1994; Leick & Davidsen-Neilson, 1990; Levy & Orlans, 1998). We address issues related to the treatment of RAD from an in-home treatment approach within a therapeutic foster care (TFC) system. We examine the basic elements of RAD, and use a case example to further illustrate the concepts.

REACTIVE ATTACHMENT DISORDER

Our review of the literature produced more than 2,000 articles relating to attachment, encompassing many disciplines and describing attachment throughout the human lifespan. However, there is limited research regarding the treatment of adolescents with RAD. The majority of authors have focused on infants and young children or discussed attachment issues in the general population (Boris, Zeanah, Larrieu, Scheeringa, & Heller, 1998; Richters & Vilkmar, 1994; Zeanah, 1996; Zeanah et al., 2001). Few authors have empirically examined RAD, and fewer authors examined adolescents diagnosed with RAD. Thus, we review information related to the characteristics of RAD and the etiology of the disorder.

In order to understand RAD, it is important to discuss the nature and development of attachment in healthy human relationships. Bowlby (1969) posited that attachment is a four-stage evolutionary process that functions as an instinctual drive toward survival of the species. The attachment process begins with infants' communication of the need for proximity and physical contact through vocal and behavioral cues (e.g., crying, latching on, and grasping). Between 8 and 12 weeks of age, infants begin the second stage of the attachment process by establishing indicators of caregiver preference through behavioral cues such as reaching and scooting. The third stage of attachment, according to Bowlby, occurs from 12 weeks of age through the second birthday. This is the stage that Ainsworth, Blehar, Waters, and Wall (1978) believed to be the true process of attachment. In this stage, infants and toddlers begin to anticipate caregiver actions and adjust their own behavior in accordance with these anticipated events. Thus, primary caregiver consistency in the display of affection and attention to needs of the child are critical components in the formation of healthy adjustments on the part of the child. An understanding of caregiver independence and the development of reciprocity in the infant-caregiver relationship characterize Bowlby's fourth stage of attachment development, thus moving into a more sophisticated aspect of the process. The key facet across all of these stages is consistency in the provision of behavioral reinforcement to infant and toddler basic emotional and physical needs, which, in essence, is a method of conditioning the child to utilize human relationships as a sense of security and comfort (Wilson, 2001).

When the provision of infant and toddler basic needs is not conducted in a consistent fashion, attachment becomes disrupted, causing difficulty in the conditioned response to rely on human relationships and also resulting in insecure attachment patterns. Chronic inconsistency in meeting infant and toddler needs as well as the introduction of early childhood trauma (i.e., abuse) may result in the formation of RAD. In research, attachment insecurity or disturbances have been linked to psychiatric syndromes, criminal behavior, and drug use (Allen, Hauser & Borman-Spurrell, 1996; Rosenstein & Horowitz, 1996).

The Diagnostic and Statistical Manual of Mental Disorders: Text Revision (American Psychiatric Association, 2000) criteria for RAD includes: (a) "evidence of a clearly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5" (p. 130), (b) evidence of pathogenic care, and (c) a presumption that the pathogenic care is responsible for the disturbed behavior. There are two types of RAD, Inhibited and Disinhibited, that relate to the presentation of behavioral problems.

Differential diagnosis is a critical issue when considering a diagnosis of Reactive Attachment Disorder. It is important to differentiate RAD from Autistic Disorder, Mental Retardation, and other pervasive developmental disorders (APA, 2000), as many RAD symptoms are characteristic of several other disorders in the DSM-IV-TR (e.g., depression, oppositional defiant disorder, and conduct disorder). Cognitively, these children often manifest both learning and language disorders, which may be receptive and expressive (Levy & Orlans, 1998). In a limited study related to RAD and differential diagnosis, Muladdes, Bilge, Alyanak, and Kora (2000) reported 15 cases of RAD which were misdiagnosed as a pervasive developmental disorder. In addition to recognizing exclusionary criteria in arriving at an accurate diagnosis, it is also important to recognize that accurate diagnosis of RAD involves a combination of criteria. For example, although children diagnosed with RAD tend to be the victims of severe abuse and neglect, the presence of abuse and neglect does not necessarily indicate RAD. Inaccurate diagnosis can limit appropriate interventions, and thus compound the difficulties with RAD.

Symptomology

Because differential diagnosis is a key issue, it is important for mental health counselors to understand the etiology of RAD and the factors that are involved in accurate diagnosis. The symptoms of attachment disorder can confuse many mental health counselors and, as a result, RAD often goes undiagnosed. These symptoms include low self-esteem, lack of self-control, anti-social attitudes and behaviors, aggression and violence, and among other things, a lack of ability to trust, show affection, or develop intimacy (Levy & Orlans, 1998). Children diagnosed with RAD also have a lack of cause-and-effect thinking similar to that manifested by children with severe Attention Deficit Hyperactivity Disorder (ADHD). Symptoms of RAD are expressed in different domains including: (a) behavioral, (b) cognitive functioning, (c) affect modulation, (d) social, (e) physical/sense of self, and (f) spiritual/moral development. Attachment behaviors and symptoms exist on a continuum from mild to severe. Each child may experience symptoms from mild to severe within each of the domains.

Behaviorally, these children are often self-destructive, suicidal, self-mutilative, and self-defeating (Lyons-Ruth, 1996). Pathological lying is not uncommon, as is stealing both inside and outside the home (Levy & Orlans, 1998). Children with RAD may be overtly aggressive or passive-aggressive. Often, the children are ingeniously manipulative, fooling professionals who assume that the child's cooperative behavior is sincere, while in fact it is devious and controlling. It should be noted that these children are often sadistically cruel toward animals, and these behaviors can also be directed toward other humans (Levy & Orlans; Lynam, 1996; Rosenstein & Horowitz, 1996). Also, many children diagnosed with RAD have been physically and sexually abused. Although controversial in nature, some experts believe that children with a history of sexual abuse manifest abuse, reactive and predatory behaviors including sexualized attitudes, excessive masturbation, sexual grooming of other children and adults, and sexualized play (Lynam). It is important for mental health counselors, foster parents, and helping professionals to recognize that children diagnosed with RAD may display some or all of these reactive and sexual predatory behaviors. They may perceive themselves as perpetual victims even while victimizing others.

Self-regulation and affect modulation are two of the fundamental elements in the early stages of childhood development (Kopp, 1982). Many children who experience early and chronic maltreatment and neglect cannot modulate behaviors, emotions, and impulses. Children whose parents or caregivers are not attuned to their emotional and physical needs due to depression, substance abuse, or otherwise neglectful patterns of interaction are left with little or no external form of regulatory support (Lynam, 1996). As a result, these children are unlikely to learn how to modulate their own states of arousal. Also, they cannot self-soothe and often internalize caregivers as uncaring or a threat to their well-being.

Typically, affection is never given on anyone's terms but the child's. These children may invade the space of others inappropriately only to reject efforts of affection at appropriate times. These inappropriate displays of affection frequently take place in front of others, seemingly in an effort to create a reaction from those witnessing the incidents. Children diagnosed with RAD often have an attitude that is pouty, sulky, and sullen. They do not appear to gain pleasure from normal activities, which often results in these children being treated for major depressive episodes (Rosenstein & Horowitz, 1996). Social relationships are frequently marked by exploitation and victimization (Levy & Orlans, 1998). Though superficially engaging and charming, these behaviors are often manipulative in nature. Children with RAD generally blame others for mistakes they have made and have difficulty tolerating external control or limits by authority figures. They may set themselves up to be victimized by insulting or challenging larger, more physically adept children to fight with them. Trust and intimacy are not experiences that these children allow themselves because children with attachment disorder assume that emotional relationships are threatening at very basic levels.

Physically, children with RAD may experience body distortion (Levy & Orlans, 1998). This distortion, which may include disturbances in physical/self (e.g., feeling of depersonalization), body image distortions, poor impulse control resulting in aggression toward themselves and others, and a lack of ability to enter into trusting intimate social relationships (Rosenstein & Horowitz, 1996). In order to limit intimacy in social relationships, these children may use poor physical hygiene as a method of controlling the physical distance of others. They may also be over-reactive to minor physical injury while being completely nonreactive to significant physical trauma.

Children diagnosed with RAD often have a grandiose sense of self-importance in that only their desires, concerns, and feelings matter (Levy & Orlans, 1998). Emotionally, these children tend to display intense anger and rage reactions. Often, seemingly minor transgressions or simple limit setting prompts these reactions. In addition, children with RAD tend to lack both remorse for their own behaviors and compassion toward others (Lynam, 1996). Their consciences are marked by a tit-for-tat philosophy. They enjoy watching others experience physical and or emotional pain and typically do not care about the basic premises of right and wrong.

Therapeutic Concerns

Hanson and Spratt (2000) have suggested that beneficial treatments of RAD should include (a) proper diagnosis at an early age; (b) placement in a secure and nurturing environment; (c) instruction in empirically based parenting skills; (d) emphasis on family functioning, coping skills, and interaction as opposed to focusing on vague pathologies; and (e) working with the child's and family's more naturalistic environments as opposed to more restrictive and intrusive settings. Thus, mental health counselors who work with children and adolescents in the foster care system must possess knowledge of psychosocial history from both family of origin and foster care system perspectives in order to accurately diagnose RAD. Part of the therapeutic task is to help a client set clear, attainable goals. In order to do this successfully, the mental health counselor must accurately assess the client's readiness to change. With adolescents suffering from attachment disorder, it is not an easy task. Typically, these children voice a strong desire for things they cannot affectively or cognitively manage such as strong friendships and intimacy. When love and intimacy enter their lives, it scares them, and they sabotage the relationships.

CASE CONCEPTUALIZATION

Therapeutic Foster Care (TFC) is designed to serve special needs children including those with chronic medical conditions and severe mental health issues. In addition to being designated a special needs individual, a child must have a history of failure in the regular foster care system in order to become involved in TFC. The impetus behind TFC is to provide an alternative to hospital settings; in TFC, children who have serious problems can live with trained, caring parents. However, the fact that parents are trained does not ensure an ability to successfully manage the behavior of a child with RAD; nor does it ensure a long-term, stable living arrangement.

It is important to recognize that children in a TFC program may remain in treatment for most of their childhood and adolescence. Thus, services should be provided in as effective a manner as possible. For instance, it is likely that a client will remain involved in the TFC system until age 21, receiving therapeutic services twice a week on issues of impulsivity, hyperactivity, anger management, boundaries, and abuse-related issues. On the surface, these types of services may not seem time-effective. However, considering the potential volatile nature of children with severe attachment problems, twice weekly services provide opportunities to maintain stabilization and to work on prevention of placement problems. In fact, TFC is usually a last alternative to residential treatment programs where the cost can exceed $100,000 annually. Thus, it is important to maintain stability through prevention and basic skills building because, once children become institutionalized, it is difficult to bring them back to the mainstream. They are indoctrinated into that system and come to rely on its sterility. They do not have to form close relationships and are not challenged by intimacy. Sterility complements the nature of RAD, which is to avoid prolonged intimate contact with caregivers. Thus, mental health counselors working with children in a TFC program must carefully evaluate the necessity of inpatient care.

Client Background

This case involves Sam, a 17-year-old, White male client, who was diagnosed with RAD at age 12. Although diagnosed at 12, Sam's reported behavior was consistent with RAD diagnostic criteria prior to age 5. Sam is the youngest of a group of three siblings who were involved in Therapeutic Foster Care throughout their teenage years. Sam entered the TFC system when he was 13-years-old. However, like other special needs children, Sam and his elder brothers had a history of placement in regular foster care homes. When Sam was 3 years old, he and his brothers entered regular foster care as a result of substantiated abuse and neglect from their biological family. Initially, the siblings were placed with, and then adopted by, the Browns, a family that appeared to be willing to help. However, the abuse suffered in the Brown's home was even greater and more damaging than that of the children's biological family. The siblings were removed from the Brown home when Sam was 13. Subsequently, the Browns were charged with abuse and neglect and eventually lost all parental rights. However, Sam's emotional state was so distressed that regular foster care was not an option. Since that time, Sam has had chronic problems and has been involved in TFC.

Over the course of his first year of treatment in TFC, Sam was moved to four different foster homes. Each time, Sam contributed to the loss of his placement by running away, causing conflict in the family, and stealing. Keeping Sam in placement was not an easy task for his foster parents or agency staff. Sam had difficulty bonding with others and seemed to sabotage any chances he had at stability. He was considered by his caretakers to be exceptionally good at playing the victim and at instigating an aggressive reaction from people around him.

Elements of Sam's Treatment

One of the key areas of effective treatment is quality foster parent training. Children and adolescents in TFC display a wide range of symptoms, and foster parents must be ready to address any or all of them. It is the foster parents who see the children every day and who implement the treatment protocols that mental health counselors develop. In this case, foster parents were required to participate in 2-hour behavioral parent training sessions every 2 weeks on topics ranging from sexual deviance to hyperactivity. Outside experts were used to provide training to the foster parents on special topics. For example, many TFC children have special needs and are developmentally delayed. Additionally, foster parents are often unaware of their own and the children's fights and need to be trained in order to be able to represent these children in Individual Education Plan (IEP) meetings. In Sam's case, the school officials wanted to place him into Exceptional Student Education (ESE) because of behavior problems affecting academic functioning (e.g., defiance of classroom rules). These behavioral problems kept Sam under disciplanary action (i.e., suspension or Saturday school attendance). Educational consultants helped the foster parents by suggesting several methods for intervention such as an after-school tutoring program and daily progress reports as steps prior to an ESE placement.

Although many children with RAD also experience educational difficulties and require remedial programs, we believed, based on the results of a formal assessment battery, that Sam could function in mainstream classrooms. However, Sam had a lack of motivation in school. Sam was able to maintain his attachment patterns in the school setting through playing the role of problem student, a role with which he was most comfortable. The thought of improving his grades presented too many normalcies for Sam at that point in his life, and he was unable to bring about the necessary changes. Because Sam did not show remorse about his misconduct and because he continued to violate school policies, school officials discussed the option of placement in an alternative school setting. This option was written into his IEP, although it never came to fruition.

Similar to many children with RAD, Sam had a long history of involuntary commitment due to suicidal ideation and gestures. Sam would relay detailed plans of his suicide plan to intake screeners in the crisis intervention unit. Because his plans always had a high degree of lethality and voiced intentionality, these screeners would subsequently admit him to the unit for a 72-hour observation period. For Sam, this appeared to be escapist behavior. He never actually attempted suicide and seemed to enjoy his time in the crisis stabilization unit (CSU). Children with RAD often seek the isolation of an institutionalized setting and admission to such settings should be carefully scrutinized. Thus, the mental health counselor worked closely with admission screeners in an effort to reduce Sam's admissions to CSU. In addition to working with screeners, Sam's child psychiatrist and the mental health counselor were in constant communication, and Sam was independently prescribed several antidepressants, including Elavil, Tofranil, and Trazodone.

Because Sam's cognitive abilities were within normal limits and Sam was able to process information and engage in meaningful discourse, a cognitive behavioral approach to treatment was selected. Cognitive behavioral interventions with children who have experienced early childhood trauma have been shown to effectively decrease psychological symptomology (Cohen, Mannarino, Berliner, & Deblinger, 2000). Thus, Sam's goals for success were defined with clear, attainable, and measurable short-term objectives. For example, Sam had difficulty modulating behaviors as evidenced by a tendency to invade others' personal space. The first step for Sam was recognizing the body language of other people with whom he would interact. The mental health counselor and Sam spent several sessions discussing interpersonal communication skills and the importance of personal boundaries. Sam's initial homework was only to take note of the reactions of individuals he engaged in conversation. Reactions and alternative scenarios that would have produced different reactions were discussed in sessions. Sam was able to articulate the reactions of people and to verbalize a desire to change.

However, the attachment and abuse elements were complex. Not only was Sam in four foster homes in the year prior to our working together, but he also had four different mental health counselors over the last few years. Thus, it was difficult for him to trust the therapeutic process. Sam's ability to trust was also influenced by the significant level of trauma and loss he experienced prior to age five, as well as by his early attachment experiences. Bowlby (1988) posited that attachment is an instinctual drive creating emotional and physical bonds between children and their caregivers. That instinctual drive is triggered by certain physiological responses from their caregivers (e.g., smiling, appropriate touch). However, Main and Solomon (1990) discovered that some children display disorganized/disoriented attachment patterns. These atypical patterns contain a mixture of both avoidance and closeness culminating in a distorted sense of boundaries. Many parents of these children were found to have both experienced and manifested abuse. Thus, the children who displayed the disorganized patterns were denied the requisite physiological responses identified by Bowlby. Sam clearly displayed disorganized/disoriented attachment patterns. Through cognitive-behavioral interventions, the mental health counselor was able to actively address some of the issues related to the attachment patterns. Because disorganized/disoriented attachment patterns are deeply ingrained in children with RAD, behavior modification can be a difficult process. It was no different in Sam's case. Through interventions focused in these areas, Sam gradually became more open to communication, and we were able to more effectively address cognitive distortions and errors.

Disorganized/disoriented attachment patterns were particularly salient in Sam's relation to foster parents. It was clear that Sam was trying to sabotage any attempts at intimacy on the part of foster parents and counselors through continued conflict and run away behavior. Over the course of one year, he sabotaged three different therapeutic homes, and the parents from each felt an overwhelming sense of burnout after his departure. Related to the run away behavior was Sam's connection to the family that abused him, which was consistent with a disorganized/disoriented attachment pattern. Although in this case the parental rights were terminated for both biological and adoptive families, in many cases the interactions with biological families present a whole host of other problems. Through interactions with individuals responsible for early childhood trauma, the disorganized/disoriented attachment patterns are reinforced, thus making treatment a difficult process. Regardless of ongoing family contact, children like Sam have a distorted sense of family, related to their lack of attachment from early childhood abuse. Their early memories of family have a great deal of pain attached to them. In Sam's case, he and his brothers were physically and psychologically tortured by the only family he knew up to the age of 13.

Sam's need to return to the family that abused him was similar to results of research on attachment organization patterns in hospitalized adolescents (Allen et al., 1996). Sam's attachment patterns were characterized by derogation of attachment, idealization of both foster parents, and the inability to remember attachment experiences. It was the Brown family that he continued to contact. Sam vowed to return to the Browns' at the age of 18. It is difficult for mental health counselors and parents to address this overwhelming need to return to the abusers. It is even more difficult when the family continues to attempt contact with the children as well. Sam's pattern of behavior was to run-away every weekend. His adoptive family would take him in and did not phone the authorities when he showed up on their doorstep, even though their parental rights had been terminated. Sam also called the Browns any chance he could and, therefore, had to be monitored on the telephone at all times. Several sessions focused on addressing cognitive errors related to Sam's desire to return to his abusive, adoptive family.

Cognitive behavioral interventions with evidence of success in the treatment of trauma were chosen in consideration of treatment related to Sam's abuse history. Cohen et al. (2000) identified a three phase process in the correction of childhood trauma-related cognitive errors with the first phase being the identification of cognitive errors (e.g., self-blame). The second phase of cognitive intervention requires an assessment of cognitive distortions within the child's reasoning process. The third phase of this process is to replace the cognitive errors with accurate cognition. Because Sam had difficulty directly engaging in discussion of the specific traumatic events, indirect techniques were necessary. In single-subject research conducted by Saigh (1987), imaginal flooding through gradual exposure seemed to reduce negative sequelae in adolescents with Post Traumatic Stress Disorder (PTSD). Gradual exposure models of imaginal flooding include less invasive techniques (e.g., drawings and stories; Cohen et al.). Therefore, Sam's hobby of creative writing was used to implement gradual exposure and imaginal flooding. Sam enjoyed creating stories about being kidnapped by attractive women and being forced to have sex with either the women or their daughters. He would be tied up for most of the story and be used as a sex slave. On the surface, these stories may be evident of normal adolescent sexual development. However, considering Sam's background and his consistent victim stance, they seemed representative of his cognitive distortions related to underlying abuse issues. Sam's story themes and outcomes were repetitious. The themes of these stories and their relationship to Sam's trauma experiences were gradually introduced as a discussion point in our sessions. Sam was then given a homework assignment to create a story that had more positive interactions and that ended with him being more self-caring and soothing. The suggestion of alternative scenarios and alternative endings for Sam's stories was a method of addressing his cognitive errors and their effects on his behavior, without directly attending to his past trauma experiences.

Eventually, Sam was able to appropriately restructure his cognitive processes and no longer had the need to express his reactive abuse patterns through fictional stories. We were able to then focus more on behavioral issues and appropriate developmental functioning (i.e., boundaries and independent living skills).

OUTCOME

Although the therapeutic goal for Sam was not cure, there was a goal of stabilization. If Sam could remain with one foster family for an extended time, he would have more chance of success as an adult. Some children in foster care go through as many as 50 or 60 placements. It is impossible to achieve mental health stability amid so much chaos. The latest foster home that Sam entered had more structure than others he had experienced. This was a big factor in his recent success because structure, in this case, equated with consistent reinforcement of appropriate behaviors, adherence to the treatment plan, and feedback about his behavior to the treatment team. Thus, we were able to use a unified approach. Sam stopped running away and began to raise his grades.

CONCLUSION

Sam is one of thousands of adolescents with RAD placed into foster homes each year. These children often enter foster care without being accurately diagnosed. Often children with attachment disorders are misdiagnosed with ADHD, conduct disorder, depression or oppositional defiant disorder. Misdiagnosis can lead to ineffective treatment because the underlying issues are not being addressed. Inaccurate diagnosis may also lead to continued difficulties in foster families due to the inaccurate education given the foster parents. Misinformation and ineffective counseling may continue the cycle of foster parent burnout and children being bounced from one foster home to another.

When RAD children are diagnosed, their mental health counselors are faced with a lack of empirical studies regarding effective treatments for adolescents with RAD in community settings. At present, effective methods addressing disruptive behaviors in adolescents and children are both behavioral and cognitive-behavioral in nature (Durlak & Fuhrman, 1991; Dykeman, 2000). As was the case with Sam, clear development of a treatment plan with measurable goals and outcomes, continued training of foster parents, utilization of a multidisciplinary treatment team approach, and a consistent therapeutic relationship are essential elements in reducing the disruptive behavior and stabilizing disrupted attachment patterns. In order to help treat adolescents with RAD and train foster parents, more research regarding effective treatments for RAD teenagers in community and foster care settings is needed.

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Rosenstein, D. S., & Horowitz, H. A. (1996). Adolescent attachment and psychopathology. Journal of Consulting and Clinical Psychology, 64, 244-253.

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Zeanah, C. H., Larrieu, J. A., Heller, S. S., Valliere, J., Hinshaw-Fuselier, S., Aoki, Y., et al. (2001). Evaluation of a preventative intervention for maltreated infants and toddlers in foster care. Journal of the American Academy of Child and Adolescent Psychiatry, 40, 214-221.

Carl J. Sheperis Ph.D., NCC, LPC, is an assistant professor, Community Counseling Program. Edina L. Renfro-Michel, NCC, is a doctoral student, Community Counselig Program. R. Anthony Doggett, Ph.D., is an assistant professor, School Psychology Program. All are with the Department of Counseling, Educational Psychology and Special Education, Mississippi State University, Mississippi State.
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Author:Doggett, R. Anthony
Publication:Journal of Mental Health Counseling
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Date:Jan 1, 2003
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