Attachment disorder- treatment/ therapy?

In my placement in children's services, almost every young person I see seems to have a diagnosis of attachment disorder, but it seems few get any sort of help for this, other than possibly a few appointments with CAMHS. Many seem to be placed in residential homes, due to it being recognised they cannot cope with family life following frequent foster placement breakdowns. So it follows that, many, or most, of these children are growing into adults with attachment disorders.

What I'm wondering therefore, as I can't find any information or research about this, is if there are any forms of therapy or treatment that are recognised to be successful with these children/ adults?

I've seen research papers that suggest that attachment problems in childhood are often predisposing factors to the development of borderline personality disorder or other mental health problems- but although attachment disorder seems to be a common 'label' for children, I have never really heard it applied to adults before. 

Can anyone help, or point me to any useful articles/ books/ other resources that might provide me some answers? 

Hi Queenb,

Can't really comment on the childrens' diagnosis because it's not my area. However I will say that there are nine criteria for borderline personality disorder in adults (any 5 will result in diagnosis of pd) and all of them are associated with responses to overwhelming childhood trauma. Bear in mind that 'overwhelming' doesn't necessarily mean 'sudden' or even 'obvious'. There's some excellent work around on invalidation and the invalidating environment (Marsha Linehan, Judith Henman' etc) that can explain the process in much more detail than I have time/space for here.

So, from my perspective, it follows that inadequate assistance for kids struggling to cope with trauma (logically that would impact upon attachment a la Bowlby) would result in adults with impaired coping also. Ergo - attachment disorder in children logically becomes labelled as borderline pd in adults.

If the prevailing attitude for kids so labelled is the same as the medical approach to adults with borderline pd then I'm afraid the outcomes with regard to mental health services interventions may not be very helpful. In the adult sector a great many professionals get caught up in false assumptions about attention seeking or 'manipulation' and so the 'help' they offer is based upon derogatory assumptions that pretty well guarantee a poor outcome for the service-user. This is changing - but slowly.

Cheers,

Stuart

Psychodynamically based counselling should hopefully allow children/adults to reflect on their childhood experiences and how these lead to fear of rejection in the present. I believe it is this fear which underlies many emotional problems in adults. Then, with lots of practice, people can hopefully be helped to identify their triggers for when they are feeling unhappy but be able to handle them in a more appropriate way. For example, taking time out rather than smashing things up. Anger is the most common reaction to fear of rejection, especially in men.

I would recommend the book 'They F**k You Up' by psychologist Oliver James. As he says, reflecting on one's childhood experiences (however painful) can really lead to enlightenment in the present.

I'm going through this process myself at the moment.

"Theraplay" is a useful treatment for children with Attachment Disorder. Based on work by Dan Hughes in America, among others. Read anything by Dan Hughes or Kate Cairns, to get a better understanding of attachment disorders and treatment in fostered and adopted children. Theraplay aims to rebuild bonds of attachment by creating attachment experiences through play with carers. Requires a strong commitment from carers to engage with the process, but it is fun & it works. Theraplay is offered by some CAMHS teams on the NHS, or some Childrens Services Post Adoption Teams will fund it privately.

 Thanks- some interesting ideas there to look into further.  I've never heard of theraplay, don't think the LA where I'm placed use it.

 i found this site this morning whilst browsing the web not sure if its useful or noit but its worth a look.

attachment disorder site

I believe from over 40 years experience that most children with attachment disorder do not get the therapy they need. The Cotswold Community was the only one that worked that I knew of, but that is now an independent school. I got one boy in there, who says now that all his friends from in care are in prison now. After the Cotswold Community, he now is a great Dad with successful relationships. The greatest success of Social Services is stopping children being killed and brain damaged, but the greatest failure is in not making good things happen: the treatment of attachment disorder. We need most importantly the provision of therapeutic communities to develop evidence based therapies for attachment disorder. I too believe there is a link with diagnoses of personality disorder; PD is really the long term effects of child abuse and another way of saying untreated, undiagnosed attachment disorder. The prisons and acute psychiatric wards are full of people with undiagnosed and untreated attachment disorder. I have seen holding therapy and the long term evidence is that it did not work. Really what is needed is families who are trained and supported to let the child regress to being very small and then letting them grow up again. But this does not really exist, and the therapeutic communities have died off for lack of funding. Some friends are desperately looking for therapy. Any ideas?

I spent 2 and half years working in a therapeutic community before I began my social work degree last year. Every child I work with was disgonised with an attachment disorder. The children were given many different types of therapy which included Play therapy,  the one I have seen work the best was psychanalytic therapy, this helped the child to regress back to being a very small child and to overcome his attachment disorder, the theapry was very intense for a child of 10 and was given for an hour, five times a week. I believe that theapry for attachment disorder needs to be done as early as possible to stop the long lasting problems for the child and then when they become an adult, but saying this I fully understand that funding and placements are hard to find especially when a hours psychanalytic thearpy was nearly 100 pound and it took us nearly two years to get sorted for him.

 

With regards to your friends I would suggest that their looked into psychanalytic theapry, if their are adults it will be based on talking though the problems. There are quite a few different types of thearpy out there and it is finding the correct one that suits you. I am also aware that there is a therapeutic community for adults but am unsure of where and what they cover but may be an idea if they are looking for intense thearpy.

 

Hope this helps. Stacey.

 

When I was a student I wrote my dissertation on attachment disorders. A book I bought and found to be useful was 'Attachment Trauma and Healing - understanding and treating attchment disorder in children and families' by Terry M. Levy & Michael Orlans.

A rather belated reply here. David Howe (et al) 1999 book Attachment Theory, Child Maltreatment & Family Support, is usefully divided up so that there are descriptions of what each attachment model looks like across the age span, infancy, childhood, teenage through to the adult and in the role of parent.

The seriously hefty Handbook of Attachment edited by Cassidy and Shaver (published by Guilford, 1999) also includes a chapter on the Adult Attachment Interview (AAI) although the only way to really get to grips with the AAI is to take part in the training run by either the originators of this or their specially trained tutors.  Google Mary Main for more info.  I found this which might be helpful.

Just a few thoughts here.  The term 'diagnosis' usually refers to an accepted medically diagnosable condition.  Attachment disorder, as far as I am aware, is not recognised as a medical or mental health condition, unlike personality disorder for example.  Attachment is a social outcome of events (negative or positive) as it affects the ability to form and maintain relationships, rather than having a medical (and therefore medically treatable) root cause.  However where the impact of those 'events' is so great as to cause the development of an exceptionally negative or harmful attachment model this can result in a medical diagnosis of a recognised mental health problem.  Most adults with a non-secure attachment model get by quite well.  It has even been suggested that most social workers tend to have a mildly ambivalent attachment model!!  (Computer nerds being avoidant of course.)

As for treatment - have a look at some of the stuff written by Kate Cairns (social worker and foster carer), published by BAAF.

As far as I am aware attachment disorders appear both in ICD 10 and DSM IV, therefore they can be diagnosed.

Yes - you're quite right. I didn't think it was there either but it is. Look at F94 in the ICD-10 and you'll see it. Therefore it's diagnosable.

Well - you learn something every day. I thought I knew ICD 10 classifications pretty damn well and then I find that I'd missed a biggy like that! Ho hum.

Cheers,

Stuart

The DSM IV distinguishes the types somewhat differently though, I think. Since I am not allowed to question any diagnosis within the child MH field without the relevant qualifications, I am not going to try and explain why its different, as I am bound to get it wrong. Something about uninhibited versus reactive...any lay person explanations welcomed. What I find interesting is the amount of cases I see which also present with ADHD and ODD. Over here, that's a green light to roll out the meds and drug the kids up. Horrible.

A system that can't bear criticism must be pretty weak in my opinion.

It is one of the reasons I have to come home. The system here does not tolerate much in the way of questioning or testing. As a foreigner, I am not allowed to be critical anyway, the xenophobic claws come out and career options are suddenly limited. I questioned the sheer number of medicated children I was seeing once, and got a very snarky email from a clinician, basically saying that unless I was educated locally to at least her level, my opinion wasn't worth jack. Question obviously entrenched, outdated and oppressive practice, you might as well look for another career.

This may be of some use: http://www.humangivens.com/home.php?xid=0e50fa2aced1859adad0b28dacce49b0 

Quite often people (children)  have co-morbid conditions.   In other words they have several diagnosable conditions.  It is possible for one to be diagnosed,   while another condition is overlooked or not picked up.

Smokey:

Quite often people (children)  have co-morbid conditions.   In other words they have several diagnosable conditions.  It is possible for one to be diagnosed,   while another condition is overlooked or not picked up.

 

where did you find that on google smokey?

as an aside attachment disorder seems to be kinda the 'in thing' at the momemnt. this will pass i'm sure.

Nadine:

. Since I am not allowed to question any diagnosis within the child MH field without the relevant qualifications, .

 

what is your medical qualification? i would have imagined most medical qulaifications are tranferable so to speak. 

Oh no, I don't have any medical qualifications whatsover. I deal with very young kids who are heavily medicated over and over again - from the social work end (investigation/differential response). I can (and do) make direct child mental health referrals, when it is blindingly obvious that the child is ill, as opposed to being behaviourally challenged. I have to be careful with the wording, because of course I am not qualified to even suggest what is wrong, and I understand and respect that. One of the clinicians I work with is a man of thirty plus years of experience, and he has the same misgivings as I do around the meds issue. He also acts as a mentor, and listens often patiently to my rants, answering questions I am struggling with, like is Juvenile DID a real diagnosis?. He is the exception. The question I had (of the clinician in question) was around why so many kids are medicated here, for apparently minor and environmental issues. Improve the horrendous home life, if possible, teach the parents how to, er, parent, get the kids out of the houses/flats and get them fresh air and exercise, change their diet (no McDonalds/Burger King are not restaurants and hotdogs really are made of ****)...its amazing how many of the issues with these kids just disappear. I feel so bad for these zombified kids - they are drugged up because the parents cannot or will not function, not because they are mentally ill.

Nadine:

Oh no, I don't have any medical qualifications whatsover. I deal with very young kids who are heavily medicated over and over again - from the social work end (investigation/differential response). I can (and do) make direct child mental health referrals, when it is blindingly obvious that the child is ill, as opposed to being behaviourally challenged. I have to be careful with the wording, because of course I am not qualified to even suggest what is wrong, and I understand and respect that. One of the clinicians I work with is a man of thirty plus years of experience, and he has the same misgivings as I do around the meds issue. He also acts as a mentor, and listens often patiently to my rants, answering questions I am struggling with, like is Juvenile DID a real diagnosis?. He is the exception. The question I had (of the clinician in question) was around why so many kids are medicated here, for apparently minor and environmental issues. Improve the horrendous home life, if possible, teach the parents how to, er, parent, get the kids out of the houses/flats and get them fresh air and exercise, change their diet (no McDonalds/Burger King are not restaurants and hotdogs really are made of ****)...its amazing how many of the issues with these kids just disappear. I feel so bad for these zombified kids - they are drugged up because the parents cannot or will not function, not because they are mentally ill.

 

 

as your knowledge is not that great i suspect that is why they are not really taking heed. it sounds as if you are also questioning the medical model (a common theme here recently) and using tabloid language such as zombiefied and drugged will not really help you get your views across.

in many cases (like this) patients are overmedicated (if your descrpition is accurate) but a common complaint is that many are under medicated.

swings and roundabouts. 

lizzer:

 i found this site this morning whilst browsing the web not sure if its useful or noit but its worth a look.

attachment disorder site

 

 

doesn't really tell us how to work with children with attachment disorders

I do take Titchamagoo's point. The descriptions are, however, accurate. Language is also different here - rating scales and medical descriptors include what you term tabloid language. I would not use it in my own documentation, but things are much less formal in the spoken/written form where I am. As for questioning the medical model, yes, if necessary. I do not like to see children so medicated, when the problem is clearly the parents, and not the kids.

There is a website called ATTACh that may help you.

I think its fair to say that there are a variety of different therapeutic modalities that can be effective with attachment difficulties / disorders, and rather than one definitive one that will suit all, it's more a case of assessing what will be the most useful one for that child / child and family at that time in their lives. Useful therapies can include theraplay as mentioned, art therapy, family therapy, psychodynamic therapy and others. Many of these are offered by child psychology or CAMHS departments nationally but there is a national shortage of therapists and a national shortage of financial investement in expanding the provision of therapy, although there has been investment in some regions.

It's also recognised that some of the best work that can be done with attachment disordered children is not direct work by 'experts' but excellent quality 'therapeutic' care provided by carers who have a thorough understanding attachment disorders and the needs of the child concerned.

Many children can - with time - re-learn healthy patterns of attachment as a result of recieving good quality stable care. The emphasis here is on the word 'stable'....where a child is suffering the negatively-reinforcing experiences of placement breakdowns and frequent changes in care (and subsequent loss of school, peer friendships etc sometimes) they will not be in a position to recover from damaging attchment patterns.

Acheving stability for an attachment disordered child can at times seem like an impossibility, particularly where there is a shortage of the right kind of placements available, but investment in providing the right placement is paramount in the child having any possibility of recovery, before specific therapy for attachment problems can really be considered.

There are specific services in many areas nationally now which are provided by child psychology or CAMHS (e.g SKAYT in Lancashire and equivalent service in Calderdale, don't know the name) that are designed to provide specialised work - mainly for children in care - for children with attachment disorders, but much of their direct work is with the carers of the children concerned, for the reasons above.

It is a developing area nationally, but I'm sure that there is a greater need for services than there are services that currently exist.

 

Smokey is quite right, the chances of co-morbid difficulties such as depression, conduct disorder etc are high with attachment disorder.....with any mental health disorder the odds of co-morbidity are pretty high.

I read your thoughts with interest - I'm an Art Psychotherapist, working with children and adolescents with Autistic Spectrum Disorders - symptoms for attachment disorder are very similar to those for high functioning and come to think of it many low functioning Autism.   I have come to the conclusion that treatment for any child who is either away from home, unable to form an attachment bond with parents in early years for whatever reason, and those who struggle to communicate verbally/physically with parents can present symptoms of attachment disorder - so I employ an attachment based form of intervention with all of the children I see.  Art Psychotherapy provides a secure base, a caring and maternal like relationship where needs are met and feelings held and contained, amongst many other experiences, and meanwhile creativity in any form allows for communiction of feelings, experiences and thoughts.  A very brief description!

It is a beautiful and moving therapy, which unfortunately takes time consequently funding is difficult and our societies' need for instant remedies makes it unpopular in many areas, but its non invasive and patient approach is perfect for young people and also adults who for whatever reason cannot verbalise deep and troubling feelings and experiences.

As you can see, I am passionate about the work and have seen children find their 'emotional feet', come out of dissociative states and find freedom from shame and guild -  I believe that finding somebody, anybody, who can offer warmth, empathy and the ability to feel what you feel, keep hold of it for you until you are strong enough to hold it yourself and then work with you to manage and understand it  does indeed bring hope.  

Some CAMH's offer Art Psychotherapy  but due to funding cuts the amount of time allowed for an individual child can be limited.

Bowlby's work on Attachment, Robinson's film on Early years in Hospital  all useful in understanding what it is and how it affects people.

 

 

 

 

 

 

MargyM

Also read what Michael Rutter thinks of Monotropy.