Adoption & Attachment Treatment Center of Iowa, Inc.

Iowa’s Only "Registered Attachment Organization"

Denise L. Best, M.A., L.M.H.C. , R.A.C - Clinic Director
Farrah Bonde, M.A., L.I.S.W., C.A.I.
Tricia L. Hoffman, Psy.D., LP
Jaime Berger, L.M.S.W.

Intensive Outpatient Attachment Program

Since we are acutely aware of the differing needs of families and devise a specific treatment plan accordingly, the services each family is provided will vary from other families. Below is a list of treatment methodologies and services that are utilized depending on the treatment needs of the family. In addition, it is not uncommon for some issues to arise within the family that no one had counted on. Please keep an open mind, and come poised with hope and flexibility!

The intensive outpatient program consists of 30 hours of therapy with two therapists over a 2-week period. The parents, child, hometown therapist (when applicable) and other caregivers as needed participate in the intensive program. We encourage hometown therapists and respite providers to be involved when ever possible to enhance appropriate follow up care for the child. This short term very concentrated treatment program provides numerous advantages for children with a wide range of attachment difficulties. The consistency and intensity of this daily treatment creates an atmosphere where the child’s defenses are reduced, motivation increased, and a significant amount of changes can then occur.

A multi disciplinary treatment team approach is used consisting of a psychologist, therapist, clinical director, hometown therapist, parents, and child. The outcome of this treatment depends on each member of the team fulfilling his or her particular part of the treatment plan. Their roles are defined more as the team collaborates and the treatment plan is devised.

Reactive Attachment Disorder Defined
The human infant is the most helpless of all newborns; their needs need to be met on a consistent, timely and in an appropriate manner for bonding to occur. When the bonding cycle is complete, a parent (most often a mother) provides relief, release, and gratification - over and over every day. Through this a child learns cause-and-effect (I cry, someone comes to help), connection to others, research is now showing that a child’s conscience is developed in the first year of life and most importantly, learns to trust others. Their Internal Working Model is one of trust and connectedness. When an infant’s needs are not met in a timely, consistent, and appropriate manner, the child does NOT learn Cause-and-effect (do the same thing over and over despite consistent consequences), have a connection to Self, objects, and power, their Conscience is a pseudo-conscience - narcissistic, and most significantly - trust only themselves to get their needs met (why they will "take" what they could’ve been given permission for). Their Internal Working Model is one of fantasy; they truly feel they are smarter and stronger than anyone in authority is.

Symptoms

Acts overly charming to get their way: Often these children are the teacher’s best "helper"...and at home, where there is an expectation of emotional reciprocity/being part of a family, their behavior couldn’t be more opposite. They are excellent actors at "playing dumb" and soliciting help when they don’t need it.

Poor eye contact, unless they’re lying.

Indiscriminate affection towards strangers; Getting their needs met "sideways" - safer than the real thing - true, reciprocal love.

Affectionate to parents only on their own terms (usually to butter them up) and/or
Rejects affection from parents (in infants/small toddlers they are stiff, rigid, squirm to avoid hugs.

Can argue for long periods of time; to engage others, they truly believe they are smarter and stronger.

Tremendous need to control people and situations (especially parents, smaller children, animals).

Acts incredibly innocent, even when caught in the act.

Daredevil, Accident prone risk-taking behaviors.

Poor impulse control - often mistaken for ADHD...is really anxiety over losing sense of control.

Steals: Feel that they can’t trust anyone to meet their needs - no matter how long in the family.

Demands things instead of asking for them; sense of control, and assuring their needs are met.

Doesn’t appear to learn from mistakes; (lack of cause-and-effect) thinking.

Makes false allegations of abuse/maltreatment; usually as a "pay-back" for not getting their way.

High tolerance for pain and/or refuses to let anyone help or comfort them when hurt - would be a sign of vulnerability & helplessness, which is intolerable to a child with RAD.

Sneaks things when would’ve been given permission had they asked (assuring needs met).

Lies - crazy made up stories, to get out of trouble, to get others in trouble, fear of abandonment by caregiver.

Food issues: hoards, sneaks gorges, more commonly in my experience, eats very slowly.

Very poor Social Skills; often plays with younger children (to control), or volatile relationships (love/hate).

Temper Tantrums that can last up to 2 hours. These children are so emotionally developmentally delayed; it takes nothing more than a toddler takes to be completely dysregulated; overly tired, overly stimulated. In these fits, may deliberately break things, and then doesn’t appear to miss them.

Nonstop chattering or asking questions; Power & Control/engaging.

Some have preoccupation with fire and gore; wars, abusive to small animals and children, etc.

TREATMENT PROCESS

All families begin with an interview process. This is where parents get to tell their child’s story, and their story. It is an interactive process where we all work together to assess the child’s needs (interpersonal issues and behaviors), and the parent’s needs (as we know by now the stress of parenting a child with RAD has likely taken it’s toll on the parent’s relationship), areas of parenting challenges, and further evaluate/plan for the treatment process. During this time and through-out the intensive, the child will be meeting with a trained play therapist in the play therapy room (children communicate better through play; the playroom is equipped with miniatures of the world, sand tray, art therapy, therapeutic games, and cognitive-behavioral therapy is utilized). The therapist will assess and evaluate specific issues with the child regarding grief/loss, power/control, anger, ability to adapt, parent-child relationships, attention deficits, neurobiological/sensory integration difficulties, and any other relevant areas of concern. During the child’s therapy sessions, the therapist is directing and structuring tasks specifically tailored towards the child’s treatment goals and teaching the child about their “6 jobs.” Throughout the program, when the child is able to do their “6 jobs”, parents and therapists respond with enthusiasm and excitement. These tools are used to monitor the child’s progress in treatment as well as used to build the child’s self-esteem.

A technique called the MIM (Marshak Interaction Method, from Theraplay) may be utilized (for younger children) to assess the Parent - Child Interaction. One parent and the child will be given a task to do in the Family Therapy room. A therapist will be observing and evaluating the child’s responses to the parent and vice versa through closed circuit T.V.

After we have the results of the comprehensive testing (written, interview, play therapy, and the MIM) we will go over them with the parents in detail. The results will steer the course of treatment for the rest of the Intensive; we will go over this with parents so that they will know what to expect. Our clinicians have extensive training in differential diagnosis of RAD, Juvenile Onset Bipolar Disorder, AD/HD, and Post Traumatic Stress Disorder. The therapists are able to do additional testing, treatment, as well as make appropriate referrals for services when necessary. We will make recommendations and referrals for other specialized treatment needs for the child based on our screening tools for neurological, sensory integration, and speech. We work collaboratively with other clinicians to augment treatment with Sensory Integration (very common in these children), Physical, Occupational, Psychiatry, and Speech Therapy. This collaborative work has made a tremendous difference in the children’s progress in healing, especially in school settings.

After this time we will begin addressing issues within the couples’ relationship and provide parents with treatment and techniques to help parents restore their ability to work with and for each other. Building a cohesive parental unit is essential for parents to be successful with their child. Children with RAD are infamous for triangulating parents!

Next we will move into the Parenting Education Phase. This is a very important part of the work we do with parents. Parents will be armed with new techniques and responses to their child’s behaviors that are very effective. We utilize a combination of Therapeutic Parenting and Love & Logic techniques. Parents will be able to observe us demonstrating these techniques with their child while parents are here, which we have found very helpful for parents learning the new skills. We teach parents about how the RAD developed, the effects of the broken bonding cycle, and how the healing process works for a child with RAD. Our current outcome data indicate that on the average parents are reporting that our parenting training is 80% effective and reduces their own symptoms by at least 70%. The most common response by parents to the Therapeutic Parenting Program is "I’m not angry all the time anymore".

Utilizing information from the MIM, and other evaluation tools, we will begin working with the parents and child together. Depending on where the child needs to start, and their age, we will direct parents to do specific tasks with their child. This may include applying lotion, combing hair, giving a back massage, etc. We will move into the child lying across both of the parents’ laps, but primarily located on the mother. This is where the bonding and attachment work begins. We assist the child in identifying what feelings arise for them to be this close to the parent, maintaining eye contact, etc. We are very direct about helping the child identify the hurt part of them that is too scared to trust anyone and doesn’t feel it needs a family; their job is to become "strong" over this part of them.

During this phase we also utilize Narrative Therapy where the parents tell a story that is therapeutic in nature. Therapists work with parents to identify the child's Internal Working Model, (the child’s belief system that drives the child’s behaviors). Often the Internal Working Model was formed during periods of early life trauma, and is therefore erroneous about the truth of their world, but still driving their behaviors. Post-traumatic shock may also impede development, causing the child to become stuck emotionally and behaviorally. Treatment is focused on assisting the child to develop a healthy Internal Working Model. The narratives that the parents tell process the child’s history, helps the child reframe their life story, and facilitates changes in the child’s inner working model. Parents create four types of narratives: Claiming, Developmental, Trauma, and Successful Child. The claiming narrative is used to communicate that from the beginning the child deserved love, safety, and appropriate care. The claiming narrative also assists the child in understanding family traditions and to feel a stronger sense of belonging in the family. The developmental narrative is used to assist the child with progressing properly through differing stages of development. The trauma narrative addresses the child’s history of abuse and neglect, and helps the child to have a new outlook on their past. The successful child narrative is used to assist the child with developing self-esteem improved behaviors, and a sense of empowerment in the child’s ability to be successful. The therapist assists parents in developing these individualized narratives for their child.

While being told a narrative, the child will be provided Bi-Lateral Stimulation (from EMDR: Eye Movement Desensitization & Reprocessing). This simply involves tapping of the foot or hand (back and forth from left - right), which assists the left and the right brain to work together. Trauma is stored in the right side of the brain, and the left side of the brain is the "Interpreter". Since many of these children’s trauma is preverbal, they have no language for it. This assists them in making more sense of the emotions they are feeling at this time. There is research that shows that Narrative Therapy can actually change the neuropathways of the brain. We may have parents give the child a bottle during this time (the purpose of bringing their favorite juice) and/or have the parent feed the child to do some remedial bonding work.

Throughout the intensive we will encourage the child to identify and process feelings, validate the child's feelings, assist the child in understanding how those feelings developed, and empower the child to become strong over the part of them that was hurt. We work through trauma/grief/loss issues with the parents and child. We work with the parents and child to reframe their experiences in a healthy manner and facilitate improved self-image and self-confidence in both parents and child. We spend a great deal of time on changing the child’s behavior patterns to increase behavioral compliance and decrease their desire to control others and their environment. We assist parents with understanding their child’s Internal Working Model and to identify when their child is using miscues.

We also utilize the Dyadic Developmental Psychotherapy model of treatment for RAD, developed by Dr. Daniel Hughes. DDP is a treatment approach to trauma, neglect, loss and/or other dysregulating experiences, that is based on principles derived from Attachment Theory and Research and also incorporates aspects of treatment principles for PTSD. It involves creating a safe setting in which the client can begin to explore, resolve, and integrate a wide range of memories, emotions and current experiences that are frightening, stressful, avoided or denied. Insuring that this exploration occurs with nonverbal attunement, reflective-non-judgmental dialogue, along with empathy and reassurance, creates safety. As the process unfolds, the client is creating a coherent life-story, which is crucial for attachment security and is a strong protective factor against psychopathology. The therapeutic progress occurs by the parents doing attachment activities all the while co-regulating affect and co-constructing meaning.

The model includes the parenting component - creating a healing PLACE (Playful, Loving, Accepting, Curious, Empathic) and our treatment component of maintaining a healing PACE (Playful, Accepting, Curious, Empathic). The parents must provide the proper high and consistent degree of structure and warmth necessary for the child to heal by developing trust and security. This environment allows the child to bond with the parent. As all the parents I work with will attest, this is very demanding work; some parents have described it as the hardest thing they have ever had to do. It requires parents who are able to consistently adhere to a structured and well-regulated program. It requires parents who are able to effectively manage their anger and frustration and not allow those feelings to interfere with being a warm and loving parent. It requires parents who can put the needs of the child first.

After each session, parents are given directives for interactions and techniques to facilitate the healing process with their child. Parents are also provided a list of play activities geared for attachment and bonding, as well as developmental skill attainment. Each subsequent session, when parents arrive we will process how the child responded, what worked, what didn’t, and it provides us with further information for where we need to go next.

On the last day of treatment we will have a follow-up plan prepared for the family and will go over it in detail to answer any questions. This will include a list of prescribed techniques for responding to, and directing the child’s behaviors, therapeutic techniques to continue the healing process at home, and follow-up plan for professional treatment, all designed for the child’s specific needs. In addition, we will attempt to assist parents in finding a trained therapist in their area for continued treatment, if one is available; we will provide up to one hour of consultation with the ongoing therapist. After this there will be an additional charge for consultation.

Safety/Risk Management Plan:

The Adoption & Attachment Treatment Center of Iowa adheres strictly to ATTACh’s (Association for the Treatment & Training in the Attachment of Children) Safety Principles and position on the ineffectiveness of "coercive" therapy and the American Academy of Child and Adolescent Psychiatry’s practice parameters for Attachment Treatment. We do not utilize any form of coercive therapy interventions (Therapist holding, rebirthing, etc.). We believe in providing a safe, nurturing environment in which the child can work through myriad of emotions. All sessions are recorded for the safety of the child, parents and treatment team. At AATC of Iowa, we do not believe that intentionally enticing anger/emotion or coercive treatment techniques are therapeutic to children with Reactive Attachment Disorder.

Since we are acutely aware of the differing needs of families and devise a specific treatment plan accordingly, the services each family is provided will vary from other families. Below is a list of treatment methodologies and services that are utilized depending on the treatment needs of the family. In addition, it is not uncommon for some issues to arise within the family that no one had counted on. Please keep an open mind, and come poised with hope and flexibility!

What to bring to your 2 week Family Intensive

• Completed testing, paperwork
• Life Book of the child’s if there is one, Memory Book, Pictures from early years.
• Family photo albums (biological & adoptive).
• Any items brought from orphanage or biological home.
• Favorite snacks (preferably finger food items).
• Favorite Juice (not juice packs, please bring bottle/jar – for younger children).
• Child’s favorite blanket, pillow, teddybear, etc. Comfort items.
• Toys, games, activities for you and your child to do on off-hours.
• Child’s medication.
• An open mind.
• HOPE

We hope this helps you in feeling comfortable about what to expect when you come for your Family Intensive. Please contact us with any questions (319-338-2722) or concerns you have. We want you to feel assured and confident in your decision to seek this form of treatment with us. We are truly looking forward to working with your family!