Dyadic Developmental Psychotherapy, an attachment-based therapy is an evidence-based treatment for children with Trauma-Attachment Disorders, Reactive Attachment Disorder, and other disorders of attachment that are complicated by severe trauma or histories of maltreatment. See the Center for Family Development's study in the March 2006
issue of Child and Adolescent Social Work, a professional peer-reviewed journal.
The Center for Family Development
has completed a research study following children after treatment and have found that Dyadic Developmental Psychotherapy is an effective treatment method for children with trauma-attachment disorders.
Treatment for Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy
Dyadic Developmental Psychotherapy
(DDP) is an approach to treating disorders of attachment based on attachment theory and research. Previously it was found that, one year after treatment ended, children who received DDP had clinically and statistically significant improvements while those in the control group did not. This study extends those results out to 4 years. The treatment group’s scores on the Child Behavior Checklist (CBCL) remained in the normal range. The control group’s scores on several scales worsened to a statistically significant degree, despite the fact that they received treatment from other providers during the intervening period, averaging 50 sessions.
Children with histories of maltreatment, such as physical and psychological neglect, physical abuse, and sexual abuse, are at risk of developing severe psychiatric problems (Gauthier et al., 1996; Malinosky-Rummell and Hansen, 1993). In particular, they are likely to develop Reactive Attachment Disorder (RAD) (Lyons- Ruth and Jacobvitz, 1999; Greenberg, 1999). The trauma experienced is the result of abuse or neglect, inflicted by a primary caregiver, which disrupts the normal development of secure attachment. Such children are at risk of developing disorganized attachment (Carlson, et al., 1995; Lyons-Ruth and Jacobvitz 1999; Solomon and George, 1999; Main and Hesse, 1990), which is associated with a number of developmental problems, including dissociative symptoms (Carlson, 1988), as well as depressive, anxiety, and acting-out symptoms (Lyons-Ruth, 1996; Lyons- Ruth, Alpern, and Repacholi, 1993). The term ‘disorganized attachment’ is a research category used to describe a pattern and style of attachment behavior and the attachment system. The term ‘Reactive Attachment Disorder’ is a psychiatric diagnosis defined by criteria in the DSM-IV (APA, 1994).
Many children with histories of maltreatment are violent (Robins, 1978) and aggressive (Prino and Peyrot, 1994) and as adults are at risk of developing a variety of psychological problems (Schreiber and Lyddon, 1998) and personality disorders, including antisocial personality disorder (Finzi et al., 2000), narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder (Dozier, Stovall, and Albus, 1999). Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence (Finzi et al., 2000). Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults (Allan, 2001; Andrews et al., 2000). 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) (MacMillian, 2001). The effective treatment of such children is a public health concern (Walker, Goodwin, and Warren, 1992).
The best predictor of a child’s attachment classification is the state of mind with respect to attachment of the birth mother (Lyons- Ruth and Jacobvitz, 1999). A birth mother’s attachment classification before the birth of her child can predict with 80% accuracy her child’s attachment classification at 6 years of age (Main and Cassidy, 1988). Finally, recent research by Dozier (2001) found that the attachment classification of a foster mother has a profound effect on the attachment classification of the child. She found that the child’s attachment classification becomes similar to that of the foster mother after 8 months in placement. These findings strongly argue for a non-genetic mechanism for the transmission of attachment patterns across generations and for the beneficial impact of a healing and healthy relationship.
These findings also strongly suggest that effective treatment requires an affectively attuned relationship (Becker-Weidman, 2005). Siegel (1999, p. 333) stated, ‘As parents reflect with their securely attached children on the mental states that create their shared subjective experience, they are joining with them in an important co-constructive process of understanding how the mind functions. The inherent feature of secure attachment – contingent, collaborative communication – is also a fundamental component in how interpersonal relationships facilitate internal integration in a child. This has implications for the effective treatment of maltreated children. For example, when in a therapeutic relationship the child is able to reflect upon aspects of traumatic memories and experiences without becoming dysregulated, the child develops an expanded capacity to tolerate increasing amounts of affect. The therapist or parent dyadically regulates the child’s level of arousal and affect, keeping the child regulated. Over time, the child internalizes this and so becomes able to self-regulate. This process is similar to what is seen in the healthy infant-parent relationship, where the parent regulates the infant’s states of arousal to maintain homeostasis. The attuned resonant relationship between child and therapist and child and caregiver enables the child to make sense out of memories, autobiographical representations, and affect.
Dyadic Developmental Psychotherapy (DDP) shares many important elements with optimal, sound clinical practice. For example, attention to the dignity of the client, respect for the client’s experiences, and starting where the client is are all time honored principles of social work practice and all are also central elements of DDP. What distinguishes DDP from other clinical work with children is the strong emphasis on maintaining a positive affectively attuned relationship with the child, a deep acceptance of the child’s affect and experience, and greater emphasis on experience and process rather than on verbalization and content. The practice of DDP requires the clinician to become affectively attuned with the child and caregivers, and to develop and maintain a meaningful emotional connection with the child, often at a non-verbal and experiential level. DDP requires a greater use of self than, for example, cognitive-behavioral psychotherapy, behavioral approaches, or strategic or structural family therapy interventions. However, it shares many basic principles of treatment with these other approaches.
In a previous study (Becker-Weidman, 2006), it was found that DDP was an effective treatment for children with Reactive Attachment Disorder (RAD). Children were assessed at two time points. Selection criteria were all cases during a 12-month period of time in which the child met the DSM IV criteria for a primary diagnosis of RAD. Children in the treatment group received DDP at the Center for Family Development. Children in the control group were only evaluated and did not receive DDP, although 53% of these children received treatment from other providers not affiliated with the Center (usual care). Children in both groups had significant histories of physical abuse, physical or psychological neglect, sexual abuse, or institutional care and were experiencing Complex Post Traumatic Stress Disorder. All children were between the ages of 5 years old and 16 years at the time treatment began. Most had at least one prior episode of treatment, with the average being 3.4 prior treatment episodes for the treatment group and 2.7 prior treatment episodes for the control group. All children resided with caregivers. In the treatment group, 26 lived with adoptive parents and 8 with foster parents. In the control group, 24 resided with adoptive parents and 6 with foster parents. In the treatment group, 24 are male and 10 are female; in the control group, 14 are male and 16 are female.
Post-test measures were administered a little over one year after treatment ended for the treatment group. Thirty-five follow-up questionnaires were mailed to the treatment group and 34 were returned. Thirty out of 34 questionnaires mailed to the control group were returned. One family in the treatment group had moved and there was no forwarding address. Two families in the control group had moved without leaving a forwarding address and two families declined to participate. All participants completed the questionnaires during an evaluation process involving three sessions: two with the primary caregivers and one with the child, the administration of various psychological tests, and a thorough review of all records and previous evaluations.
The children in foster care had all been residing with their foster parents for more than one year. On the demographic variables measured (age at placement, gender, race, number of prior treatment episodes, age when treatment or the evaluation occurred, and length of follow-up time period), the foster children and adopted children were not statistically different. There were no statistically significant differences between the treatment and control groups on either the demographic variables measures or on the pre-treatment scores on the Child Behavior Checklist and the Randolph Attachment Disorder Questionnaire. There were clinically and statistically significant reductions in behaviors as measured by the Child Behavior Checklist (CBCL, Achenbach, 1991) and the Randolph Attachment Disorder Questionnaire (Randolph, 2000) among those receiving DDP. Children in the control group, about 50% of whom received ‘usual care’ such as play therapy, family therapy, individual therapy, and residential treatment in the time between the initial data collection and the follow-up data collection, showed no clinically or statistically significant changes in the measured behaviors. The children in the control group who received ‘usual care’ received treatment from other agencies or private practitioners not associated with the Center for Family Development.
The current study explored the question of whether the positive changes in behavior seen in the treatment group after one year continued. The longer-term effects of DDP were explored by comparing the initial scores on the CBCL and Randolph Attachment Disorder Questionnaire for the treatment and control groups with the scores for these groups after 3–4 years.
Questionnaires were mailed to the children for whom there was follow-up information in the original study. The average follow-up period was approximately 4 years for those in the treatment group. About two-thirds of the families could be located and returned the questionnaires (24 of 34 for the treatment group and 20 out of 30 for the control group). Most of the families from whom we did not receive questionnaires had moved and we were unable to locate their new address. This study is preliminary and exploratory.
One hundred percent of the control group families had sought and continued in treatment with other treatment providers, with an average of 50 sessions. None of these families received DDP. As will be shown, despite receiving extensive treatment, the control group actually exhibited an increase in symptoms over the 3.3 years. Forty-two percent of the treatment group received treatment after completing DDP. Most of this continued treatment was for co-morbid conditions, such as Bipolar Disorder and Attention Deficit/Hyperactivity Disorder. The majority of the children in the treatment group who received continued treatment after competing DDP received medication management treatment.
Details about sample selection can be found in Becker-Weidman (2006). The average age at adoption was 7 years and the average number of episodes of prior treatment was 3.4 (82% of the children in the treatment group and 83% of children in the control group had previously received treatment, but without improvement in symptoms). Families were referred to the Center for Family Development from a variety of sources including departments of social services, physician offices, other mental health providers and clinics, and ‘word of mouth’. All cases selected were from the closed cases files during a one-year period and all children had a primary diagnosis of RAD using the criteria in the DSM IV.
The Child Behavior Checklist (CBCL) (Achenbach, 1991) is composed of several questionnaires and is a parent-report measure designed to assess behavior problems of children 2 to 18 years of age. The instrument has widely accepted reliability and validity that is reported on extensively in the manual.
The Randolph Attachment Disorder Questionnaire (Randolph, 2000) assesses Attachment Disorder. It consists of 30 items completed by the caregiver who rates each item on a 1–5 scale. The manual (Randolph, 2000) describes in detail the development of the test, scoring, reliability, and validity.
Independent Variable: Dyadic Developmental Psychotherapy
Dyadic Developmental Psychotherapy (Hughes, 1997, 2004, 2005) basic principles are summarized as follows:
1. A focus on both the caregivers’ and therapists’ own attachment strategies. Previous research (Dozier et al., 2001; Tyrell et al., 1999) has shown the importance of the caregiver’s and therapist’s state of mind for the success of interventions.
2. Therapist and caregiver are attuned to the child’s subjective experience and reflect this back to the child. In the process of maintaining an intersubjective attuned connection with the child, the therapist and caregiver help the child regulate affect and construct a coherent autobiographical narrative.
3. Sharing of subjective experiences.
4. Use of PACE and PLACE are essential to healing. PACE refers to the therapist setting a healing pace to therapy by being playful, accepting, curious, and empathic. The idea is that the therapist maintains an emotional connection with the client (attunement) and dyadically regulates the child’s affect. In this manner, the therapist ensures that there is an emotionally meaningful component to treatment without the client becoming dysregulated. PLACE refers to the parent creating a healing environment by being playful, loving, accepting, curious, and empathic. These ideas are described more fully below.
1. Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.
2. Caregivers use attachment-facilitating interventions.
3. Use of a variety of interventions, including cognitive-behavioral strategies.
Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines (Becker-Weidman and Shell, 2005). Attachment theory (Bowlby, 1980, 1988) provides the theoretical foundation for DDP. Early trauma disrupts the normally developing attachment system by creating distorted internal working models of self, others, and caregivers.
Current thinking and research on the neurobiology of interpersonal behavior (Siegel, 1999, 2001, 2002; Schore, 2001) is another part of the foundation on which DDP rests. The work of Bruce Perry (Perry, 1994) and the Child Trauma Academy describes how trauma affects the developing child in a profound manner and requires special treatment approaches. The works of Siegel, Shore, and others provide a foundation for understanding how early attachment experiences affect brain development and later behavior. The focus of this work on the nature and quality of the attachment relationship support a major focus of DDP of maintaining a positive affectively attuned relationship as central to healing trauma.
The primary approach is to create a secure base in treatment (using techniques that fit with maintaining a healing PACE (Playful, Accepting, Curious, and Empathic) and at home using principles that provide safe structure and a healing PLACE (Playful, Loving, Acceptance, Curious, and Empathic). Developing and sustaining an attuned relationship within which contingent collaborative communication occurs helps the child heal. Healing is facilitated by the co-regulation of affect and the development of greater reflective capacities (Fonagy et al., 2002).
Dyadic Developmental Psychotherapy, as conducted at the Center for Family Development, uses 2-hour sessions involving one therapist, parent(s), and child. Two offices are used. Unless the caregivers are in the treatment room, the caregivers view treatment from another room by closed circuit television or a one-way mirror. The usual structure of a session involves three components. First, the therapist meets with the caregiver in one office while the child is seated in the treatment room. During this part of treatment, the caregiver is instructed in attachment parenting methods (Becker-Weidman and Shell, 2005). The caregiver’s own issues that may create difficulties with developing affective attunement with their child may also be explored and resolved. Effective parenting methods for children with trauma-attachment disorders require a high degree of structure and consistency, along with an affective milieu that demonstrates playfulness, love, acceptance, curiosity, and empathy (PLACE). During this part of the treatment, caregivers receive support and are given the same level of attuned responsiveness that we wish the child to experience. Quite often caregivers feel blamed, devalued, incompetent, depleted, and angry. Parent-support is an important dimension of treatment to help caregivers be more able to maintain an attuned connecting relationship with their child. Second, the therapist, frequently with the caregiver present as well, meets with the child in the treatment room. This generally takes 60–90 minutes. Third, the therapist meets with the caregiver without the child. Broadly speaking, the treatment with the child uses three categories of interventions: affective attunement, cognitive restructuring, and psychodramatic reenactments. Treatment with the caregivers uses two categories of interventions: first, teaching effective parenting methods and helping the caregivers avoid power struggles and, second, maintaining the proper PLACE or attitude. The caregivers provide a high degree of structure to provide safety for the child. Within this structured world, the caregiver maintains a high degree of affective attunement that is nurturing and that repeatedly enacts the attachment-cycle of engagement, disruption, and interactive repair (Siegel, 2001; Schore, 2001).
The treatment provided in this study (DDP) often adhered to a structure with several dimensions (see Figure 1). First, behavior is identified and explored. The behavior may have occurred in the immediate interaction or have occurred at some time in the past. Second, using curiosity and acceptance the behavior is explored and the meaning to the child begins to emerge. Third, empathy is used to reduce the child’s sense of shame and increase the child’s sense of being accepted and understood. Fourth, the child’s behavior is then normalized. In other words, once the meaning of the behavior and its basis in past trauma is identified, it becomes understandable that the symptom is present. An example of such an interaction is the following:
Therapist: ‘Wow, I see how you got so angry when your Mom asked you to pick up your toys. You thought she was being mean and didn’t want you to have fun or love you. You thought she was going to take everything away and leave you like your first Mom did, like when your first Mom took your toys and then left you alone in the apartment that time. Oh, I can really understand now how hard that must be for you when Mom said to clean up. You really felt mad and scared. That must be so hard for you.’