Understanding and Treating Attachment Problems in Children: What Went Wrong and How Problems Can Be Fixed

By Dave Ziegler, Ph.D.

This somewhat complex article reviews the basic tenets of traditional attachment theory and describes both its strengths and weaknesses. Revisions to attachment theory are suggested and detailed explanation is provided of both the causes and treatment of various types of attachment problems. It is both a technical road map and a practical guide to the journey.  Although complex, It has been written to be understandable to professionals and parents alike. (31 pages)   Link to full article here.

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Neurological Reparative Therapy: The Treatment Model of Jasper Mountain

By Dave Ziegler, Ph.D.

It is the human brain that enables individuals to adapt to the world either in optimal or destructive ways.  The choice of a positive or negative direction of adaptation depends on a variety of factors related to both nature and nurture.  The nature element includes epigenetics or the genetic codes that lay dormant or become operational.  The nurture involves the influence of the environment, which is substantial particularly related to adaptations to maximize safety.  Most mental health therapy must take on the challenge of facilitating modifications of the brain’s negative adaptations that take the form of cognitive patterns getting in the way of a functional life.  Effective therapies make an impact at the operational level of the brain, which includes individual neurons and neuro-templates (families of neurons that perform a function).

Altering the brain’s cognitions at the most basic level involves impacting the cellular neurology of brain development.  Psychotherapies attempt to change cognitions or what could be called cognitive mental maps or inner working models.  Both terms describe how the brain understands the conditions of the environment it operates in.  How the brain perceives a situation says a great deal about how it responds. Another way to change the brain is through pharmacological interventions that change the brain on a chemical level, specifically the neurotransmitters of individual neurons.

When the brain is allowed to develop optimally it strives for positive adaptations to the challenges of daily living.  However, when trauma or deprivation become part of the individual’s experience, the brain makes radical adaptive alterations focused primarily upon surviving rather than thriving.  These negative adaptations become the symptoms of most mental health problems such as: anxiety, depression, fear, hypervigilence, trouble connecting with others due to mistrust, inability to properly read social cues, addictions, aggression, and a large variety of behaviors associated with the autonomic fight or flight response to stress.

The brain’s primary function is to promote the survival of the individual. An important additional function of the brain is to successfully negotiate the world it finds itself in. Successful mental health treatment involves the repair of the brain’s adaptive functions and optimal neurological processes to put more focus on thriving and not just on surviving.  Brain research has found that the malleability of the brain works both in causing problematic symptoms due to negative adaptations as well as creating the conditions of health and self repair through the right external guidance.  Such support and assistance from the outside forms the core of Neurological Reparative Therapy.  This is a research based approach to making positive changes in the thinking, emotional expression and behaviors of young children.  It can be described as the facilitation of nerve functioning to optimize integrated cognitive processes, thus an approach that impacts the refocus of brain systems on positive adaptations to self, others and the world the individual functions in.  This approach is less an intervention than an orientation of holistic, ecological and environmental conditions needed to return the brain to its natural state of optimal adaptive functioning.  Brain research has identified that unless damaged in some way, the brain strives for success and even happiness in life.  Once damaged, the brain often needs external intervention to move beyond becoming stuck in negative patterns or putting exclusive focus on survival and reactivity to stress.

The Ten Fundamental Premises of NRT

The ten premises include both goals of this approach and steps that must be integrated into the treatment process.  The first five premises are goals and the last five are intervention steps. Each goal and step will be explained in brain terminology and then in more practical language:

Five Goals

The Five Goals toward neurorepair are general in nature and are not necessarily sequential as the steps that follow the goals.  One or more of the goals are addressed in each step of the process.  The combination of the goals and steps constitute the ten premises of NRT.

1.   Facilitate perceptual changes of self, others and the child’s inner working model

The individual’s experience in life is directly connected to his or her perceptions based upon the inner working model or how the person views self and others.  Based upon the individual’s perceptions the cognitive mental maps plot a course the individual will take including emotions and behaviors.  The first goal is to impact perceptions through altering cognitions in order to provide a more positive and optimistic orientation rather than a negative and depressive mind set.  Therapeutic work is directed toward developing a sense of self efficacy and helping the individual view others as resources for support and assistance.

The individual must experience some successes, however small they may be in the beginning.  The person must experience making a positive impact, having some positive influence on others, and is helped to begin to see the world as a more friendly and supportive place.  An example would be to help a child see school as a fun place to learn rather than a scary place where social and academic problems produce failure.

2.   Enhance neuro-integration

Executive functions of the frontal lobes of the neocortex require integration of functions in all parts of the brain.  Neuro-integration is the brain’s ability to access component parts to be integrated into an understandable whole that promotes good decision making.  Enhancing neuro-integration is also strengthening the hemispheric communication between the left (logical, analytic, verbal) and right (intuitive, artistic, emotive) hemispheres of the brain.

In the beginning the higher order thinking must come from the outside, from supportive people.  The individual must learn to combine the logical and emotive regions of the brain through activities that simultaneously involve both hemispheres of the brain.  For example, having a child listen to music and seeing a mental image (right hemisphere) while describing the image (left hemisphere).

3.   Alter the region of the brain’s processing information system

A primary goal of all psychotherapy is to promote functioning of the higher reasoning centers of the brain.  Many traumatized individuals primarily use the limbic region of the brain in daily life.  This region contains the brain’s fear center, as well as traumatic memories and emotional response system.  Combining these factors produces an individual reacting with fear and emotionality to reminders of previous negative experiences.  The much more functional alternative is for the higher reasoning centers of the neocortex to access information from all aspects of the brain and process the information to inform decisions and choices.

The individual must learn to think first, feel second and act third and not the reverse order.  The reactive limbic region of the brain cannot be the primary part of the brain used.  The person must learn to act rather than react in all areas of living.  For example, teaching a child when frustrated to go through a process such as – stop, take a deep breathe and make a request.

4.   Facilitate Orbitofrontal Cortex activation

The optimal goal of brain processing is to activate the Orbitofrontal Cortex in the frontal lobes of the Neocortex.  It is this complex part of the brain that accesses information from all other parts of the brain and enables deliberative and proactive mental activity.  This is the opposite of the reactivity of the limbic brain region.  This region of the brain can be viewed as the chief executive officer because it is the most complex and potentially productive neurological process that can result in effective consideration, planning, goal setting and accurately perceiving challenges, all of which are higher order executive functions.

Over time the goal is to have the individual process most information in the most advanced area of the neocortex.  It is this region that optimally provides goal setting, delaying gratification, moral and ethical reasoning and empathy for others among many other executive functions.  Every intervention that promotes thoughtful consideration, exercises the Orbitofrontal Cortex.

5.   Neuro-template development through repetitive practice

Networks of communication in the brain are made possible by neuro-templates and their individual component parts—neurons.  Neurons have a use dependent developmental process where neurons that are frequently used become larger and stronger as well as do more work and do this work faster.  In contrast, neurons that are never used may atrophy and die, and if seldom used they gradually deteriorate.  One key goal of exercising the brain is repetition, since it is in repeated use that neurons and neuro-templates, composed of millions of individual neurons, get more frequent use.  The more use, the stronger and more capable the brain functioning.

The expression ‘practice makes perfect’ refers to the importance of repetitive efforts to improve the results.  The brain changes gradually over time through the repetitive use of families of neurons that help us to do daily tasks such as: play the piano, type on the computer, or hear critical feedback without reacting with anger.  The more practice the brain has, the more the brain changes.

Five Steps

The Five Steps toward neurorepair are outlined below and provide a process where each step builds upon another.  It is important that each step occur in the proper order to enable the process to build in an optimal healing fashion.

1.   Assess the extent and causes of neurological impairment

All information available should be used to determine the extent of neurological impairment as well as the primary causes.  Traumatic events are the most common causes of serious impairment.  It is not essential to use complex medical scans to identify impairment.  Most problem areas have identifiable symptoms that point to both the level of intensity and the causal factors.  A good evaluation and history will normally provide sufficient information.  A variety of psychological rather than medical instruments are available to assist in the assessment phase.

Start at the beginning with a good assessment of history and current functioning in all areas.  There are a variety of formats and approaches to a good assessment and this model has room to approach this step in multiple ways.

2.   Identify specific cognitive, emotional and behavioral problematic symptoms

This is an extension of Step 1.  When specific problem areas are identified it is critical to accurately identify the right problem rather than the most obvious problem and consider the likely causes. Frequently with neurological impairment the representation of the problem area on the surface can look like an entirely different issue than it really is.  For example, the symptoms of ADHD are nearly identical to the observable impacts of trauma on young children.  To have the right problematic symptoms is important to be able to link these symptoms with the interventions in the next step.  This is the second part of the initial neurological assessment.

Insure that the initial assessment includes a careful focus on what the real issues are and what has caused them.  Only when we know the right problem do we have a chance at finding the right solution.  For example, most fire setters have problems other than pyromania (fascination with fire) such as needing attention, expressing a cry for help or reflecting unresolved anger.

3.   Implement interventions addressing the identified problematic emotional and behavioral symptoms

Once it is clear what the causes of the neurological impairment are, the next step is to design interventions that address the emotional and behavioral symptoms. Since behavior is an observable sign of the individual’s perceptual beliefs, or inner working model, cognitions are the focus of treatment as well as emotional and behavioral interventions.  There are many possible approaches that can be used for specific interventions including a large number of evidence based practices.

While behaviors are the most observable problem areas, they arise from how the child thinks and feels about everything in the environment.  The best way to make lasting change is to start with perceptions, and then move to emotional responses and the combination of these two result in externalized behaviors.  Interventions can include a wide range of approaches including many evidence based practices.  This model allows for a multiple of approaches to specific interventions.

4.   Decondition the child’s stress response cycle through multiple forms of relaxation and allostatic training

The most common problems associated with neurological impairment are the wide range of negative influences of neurological adaptations to traumatic experiences. A fundamental negative adaptation is hyperarousal and loss of self-regulation due to the stress response leading to a systemic fight/flight activation of the autonomic nervous system.  Research has identified that many forms of relaxation are the most effective tools to decondition the overactivation of the stress response cycle.  Allostatic training involves assisting the individual to return to a state of calm after arousal, which is the allostatic response.  Stress is a constant in life and the ability to self soothe and regain an inner state of calm is critical to handling the ever present stresses of life.

Reactions to stress are the key factors in emotional and behavioral problems.  Turning down the volume and learning how to produce a state of calm is the brain’s best weapon in the life long struggle with stress.  Find one or more of the many methods of relaxation that will fit best with each individual.

5.   Environmental enhancements promoting the building blocks of brain development

The most effective external impacts on neurological functioning are environmental in nature.  Every aspect of the child’s world should support the goals of enhancing neurological repair including: family, school, community, church, and youth activities among others.  Environmental supports should be in place to provide the building blocks of: safety, security, acceptance, belonging, trust, relationship, self understanding and personal worth throughout the environment the child is working within.  These building blocks enable the child to build personal growth on a predictable and solid personal foundation.

The individual either reacts to or asks for support from the world they experience.  The best interventions to produce the all important building blocks of social success are not individual, isolated and brief approaches, but instead are multi-faceted and coordinated approaches that involve all aspects of the individual’s world.  Environmental interventions for a child might include adjustments at school, at home, expanding involvement in community activities like sports/crafts/hobbies, assigning a mentor, or providing individual and family therapy.

Conclusion

Neurological Reparative Therapy has assisted Jasper Mountain to understand and help some of the most damaged and neurologically impaired children in our system of care.  Outcome data from our work has shown that the vast majority of children reduce serious external behavioral problems, modify emotional disorders, and after leaving our treatment the children usually get much better over time.  We believe these atypical results of intensive treatment are the result of significant impact on the brain’s processing system enabling the individual to successfully face the challenges and stresses of life.  Due to a change in the cognitive mental maps of the child, it becomes possible to rely on others rather than push others away.  Said another way, Neurological Reparative Therapy can return the brain to its natural state of health and thriving.

For additional information about Neurological Reparative Therapy, please refer to Dave Ziegler’s newest book Neurological Reparative Therapy: A Roadmap to Healing Resiliency and Well-Being.

A Residential Care Attachment Model

By Dave Ziegler, Ph.D.

Attachment disorder is much like many other issues in our society wherein we coin a new term for a very old problem and then scare ourselves about how bad it is.  Don’t misunderstand—an attachment disorder is a serious problem, but it is not what it has been presented to be by sensational stories and made-for-TV books.  Children with attachment disorders are just that—children.  They are difficult, yes; they can be hurtful, yes again; but they are not lost causes, much less developing Ted Bundys.  Our program works with these difficult children every day, and we see clear progress in nearly all of them.

There are tens of thousands of children in our systems of “care”, which means we have far too many children who have not been cared for where it counts—in their families.  These children often have defenses and tough shell that few can penetrate.  Without a knowledgeable and understanding care provider, this can lead to problems in reaching out and bonding.

These children have attachment themes rather than an attachment disorder.  Without someone reaching them while they are still more connected to family than to peer group (usually under the age of twelve), these children may well become the delinquents and criminals of tomorrow.  The halls of our prisons today are filled with the youngsters of our systems of care in the past.  For these children it is either pay now—with resources for social workers, therapists, and trained foster parents—or pay later—with free room and board in our institutions.  These children may well be the criminals of tomorrow, but they should not be confused with children with a true attachment disorder.

Children with a severe attachment disorder have never had a successful attachment to anyone.  Children with a mild to moderate disorder have had only partial and never truly rewarding attachments in their short lives.  These children start life in the first twelve to eighteen months with failure in the most basic of instincts in human beings—bonding immediately, first of all to survive and then to find a successful place in the interdependent world of other human beings.  When things go badly to begin with, the instinct to bond (promoting physical survival) is overridden by avoiding the pain and neglect of attaching (emotional survival).  The seeds of attachment are often sown long before the results are observed.  Without a disruption in the cycle of an attachment disorder, it may grow into a lifelong and unsuccessful search for a place in the social network of our society.

I believe we are still in a phase where as a society we are not sure how to help these children.  In our confusion and to some extent desperation, we have developed what appear to be desperate therapies, and some parents, professionals, and programs believe these intrusive approaches are all that can work.  I suggest that we take our desperation and first work to clearly understand the problem and its causes and then commit the necessary resolve and patience to test our solutions.  I would like to share with you one such patient testing ground, which is a small residential treatment program called Jasper Mountain Center.

How Jasper Mountain Started

 The center was founded by three babyboomers who were raised by their own families with varying levels of health as well as dysfunction.  Armed with college degrees, professional experience and seemingly unlimited energy, the three of us set out to make a difference in the world, following the advice of Mother Theresa—one person at a time.  The goal was to create a seamless integration of our home life and our professional work.  This goal was quite effectively reached, and we are not clear to this day whether this has been as good for us as it has been for the program’s children.  The practical steps are easy enough to recount:  endless meetings to determine the criteria to find the healthiest place in the United States to live, moving to the promised land in southern Oregon, and purchasing a rural ranch.  After six months of acclimating and very long days fixing up the old ranch, we informed the state child protection agency that we were ready for their biggest challenges.  The reaction from the state’s workers was one of equal parts elation and suspicion.  Elation that people interested in accepting very disturbed children into their home would also be experienced professionals with counseling backgrounds.  And suspicion as to why people who had a choice would want very disturbed children in their home!  Many years later there are those who still have suspicions.

Jasper Mountain Center was founded in 1982 on an eighty-acre ranch southeast of Eugene, Oregon.  The scenery was beautiful enough, with two major rivers, heavily wooded forest, waterfalls, an artesian spring, miles of hiking trails, and sheer cliffs rising to a thousand-foot mountain, all of which were on the property.  The ranch even had history as part of the second homestead in this region of Oregon and the end of the Oregon Trail for Cornelius and Jasper Hills.  To this beauty and history we worked to bring hope to some very confused and abused children.  From the beginning the children came to Jasper Mountain telling their stories of abuse and pain.  The program quickly turned its focus to healing the scars of sexual abuse, which were present in almost all the children.  We soon saw that some children healed very differently from others and that some didn’t seem to heal at all.  Of all the children, there were those who didn’t look at you, would push away any affection, and were quick to use and abuse you as they had been themselves.  In the early 1980s we began identifying children who had bonding problems, and invariably they were the most difficult of our difficult children.

How the Program Works

Jasper Mountain is based on principles of health in body, mind and spirit.  The program ensures clear air, clean water, plenty of exercise, and treatment components in a context of family where the parents are professionals.  This family focus has turned out to be the most important ingredient in the therapeutic stew.  Not that being in a family makes much difference to attachment-disordered children, but in the final analysis it is the ability of the family and its staying power that will make the difference in the bonding process.  In the early years the three of us did everything without outside help.  At this point the program has the state’s highest classification for supervision and treatment which requires one staff for every three children.

The program uses four basic categories of intervention:  environmental, behavioral, psychotherapeutic, and self-esteem.

  • Environmental intervention creates a therapeutic Disneyland, but rather than the happiest place on earth, we strive for the healthiest place on earth.  There is close scrutiny to every environmental aspect of the program, from the architecture of the buildings to diet, and from the amount of natural light to the control of violent themes that reach the children from the outside world (e.g., having no commercial TV).
  • Behavioral interventions include the mundane but important behavior management systems wherein the children earn levels that determine privileges.  At Jasper Mountain the children have a behavioral system for the residence and another for the on-site school.  Although the level system is the most traditional part of the program, the children get up each morning and go straight for the chart to find out what level they are on for the day.  Modifying behavior is an important step, but is only a beginning step in treatment.  Behavioral ways to require a give-and-take framework are essential with children with an attachment disorder.
  • Psychotherapeutic interventions include all the individual, group and family therapy interventions, as well as art and play therapy.  They also include occasional chemical interventions and sessions with the program’s psychiatrist.  Each child has an individual therapist in addition to our psychiatrist to promote skills at developing relationships with various adults.
  • Self-esteem intervention is where some of the unique aspects of the program can be found.  These include a variety of routes to the self-worth of the child, including biofeedback, concentration and meditation training, therapeutic recreation, an equestrian program, hiking and rock climbing, jogging, gardening, visual and performing arts, computer competency, positive video feedback to enhance the self-image of the children, and many others.

But even with magical interventions like the above (and there is something that every child will find magical on this list), there is no guarantee that an attachment-disordered child will use any of these to heal his or her disposition toward others.  With this backdrop of our basic residential treatment program comes the specific approaches used for these challenging children.

 What Makes the Difference?

At Jasper Mountain we are often asked why children with attachment disorders who can strike fear into the hearts of parents, caseworkers, and therapists are not feared in our program.  And here is step one in making a difference with these children—they must not be feared or their controlling nature takes over.  Relationships with these children are often initially no less than warfare.  In this struggle for dominance, if the child wins, everyone loses, and if the adult wins, everyone wins.  I see it as just that simple.  Of course, how to win the struggle with these masters of control is not simple at all.  That we do not fear these children in our program may come from the fact that no matter how good they are, so far none has been able to win the control war at Jasper Mountain.  In most cases the children, who are usually very bright, realize within weeks that they may be able to control an individual staff person for a while but not the whole program.

Another factor critical to our success with these children is to work as a team and control all variables in the child’s life producing a unified approach.  In our program there is only a building change from the residence to the school; the approach and staff act in unison.  We take time to work with caseworkers and family so that the methods the child has used to irritate, control and keep others distant do not work on campus or off.

Treatment with these children not only must strip them of their remarkably intricate insulation and defenses but also must provide a real and attractive alternative.  How can getting close ever look attractive to a child with an attachment disorder?  The answer is as simple as the first principle of negotiation—you get some of what you want only when I get some of what I want.  Despite attempting to look otherwise, these children want lots of things.  They are generally extremely motivated by material belongings, although they believe that if you knew this, it would make them vulnerable, and thus they pretend to be apathetic to almost everything.  Don’t believe it.  At the same time, they will take without giving if you let them.  You must teach them reciprocity and hold them accountable.  There must be a constant pressure to connect.  With normal children (has anyone seen one of these lately?) coercion is not a positive or useful approach.  But with these children they get dessert only after a polite request; they go to the movie only after doing a chore for you; they play fifteen minutes of Nintendo only after sharing two important events at school today.  The approach is clear:  You don’t get something for nothing (except love).

The effectiveness of treating these children comes down to every interaction between adults and the child.  This means that every contact between a program staff member and the child is a very small part of the puzzle but critical to the overall picture.  Manipulative children do not change if their tricks work on anyone.  If the therapist and parents work together but the school is out of the loop, and the child will never change, due to intermittent variable reinforcement, the same principle that brings confident gamblers to Las Vegas to lose their money time after time.  The child tells himself that he will prevail in the end.

As stated before, these children are usually quite smart, and when they understand that they must work to get what they want, here is their sequence:  First they start by not doing it, to see if you get flustered; then they do it halfway and grudgingly (punishing you); then, if they must do it right, they will do it with a bad attitude; and eventually they just do it.  These progressive steps occur only when they have to do their part to get what they want.  When this pattern is repeated over and over for years the psychological principle of cognitive dissonance steps in, whereby if your behavior changes, eventually your attitude must change and if your attitude changes, then our behavior must eventually change as well.

You must demand that children with attachment disorders do just what you want of them (which are progressive steps toward relationship).  They need not do it with an open heart or with honesty; they just need to do it.  What you begin to systematically show them is that they will not be abused when they are vulnerable and that the world where you get what you want by being close to others is far superior to using others and being emotionally and personally alone in the world.

The last factor that makes a difference is a four-letter word, time.  Time is a four-letter word in our culture because we don’t want to take the time to do most anything right.  We are irritated by the traffic light that delays us three minutes; we want the flu medicine that gives us fast, fast relief; and incredibly we are impatient when we have to wait two and a half seconds to store our documents on our old model computer.  Is it any wonder that we flinch at the prospect of taking years to treat an attachment disorder?  This may have something to do with the do-it-quick “holding” therapies that promise some bonding after an intensive weekend, or at least after the twelve-week special.  Some may believe that the patterns of withdrawal and distance in a true attachment disorder can be extinguished relatively quickly and a new pattern of interdependency and vulnerability learned soon after, but I do not believe there is any shortcut to the years of concentrated effort described above.  For the Star Trek generation, where any galactic problem is solved within the hour, years of effort are inconceivable, but they are truly necessary.

To be fair to all us parents who have a child with an attachment disorder in our home (I have one by adoption), we would have a better chance at putting in years of effort if only we saw some progress, even tiny successes, or at least the reassurance that we were heading in a direction other than futility and exasperation.  This is precisely what our program tries to give parents—a road map.  We all know that human beings that take at least twelve years to raise before the onset of their teen years.  Our current thinking is that the relearning process may take five to seven years.  I believe parents can learn to persist if they are shown a way that works, as long as they don’t get a false message that there is a quick fix.

The Jasper Mountain method works.  Whether it is the place, the people, approach, the time invested, or all of the above simultaneously.  The important thing is that the program wears the child’s defense down before the child wears the staff down.  We do not describe the children as “cured” when they leave Jasper Mountain.  Attaching is not only an instinct; it is also a skill.  We should not leave children in a rather scary and indifferent world without their defenses unless they are given new tools to succeed in the game of life.  It takes a very long time to learn how to bond even after the children decide they want to.  This is usually a process of unlearning and then relearning.  It is important that we not lead these children down this long road to healing if we are not prepared to go the distance.  In residential care this means that you never completely close a case.  Our program’s graduates keep in touch, come by, borrow money, and bring by their fiancé to meet the family.  We have invited our children into our extended family, and nearly all accept.

In adoptions we must understand that there may be no other chance for these children.  Due to the time it takes to free a child for adoption, to place the child in the right home, and to invest the five to seven years with him or her, there may not be time for a “Plan B” and starting the process over with another family.  This may sound like a great deal of responsibility for the adoptive family, but if real bonding doesn’t happen in the first adoptive family, it may never happen.

Perhaps the ultimate abuse is to take a child who is dependent on others for her very life, thwart her survival instinct by not placing her where she can form an attachment, fail to help her connect with others during her early years, and expect her to live the rest of her life emotionally and spiritually alone and separated from friends, a spouse, her own children, and even God.  It comes very close to a definition of hell, doesn’t it?  I hope you agree with all of us at Jasper Mountain that years of hard work are not too high a price to save the quality of life for a child with an attachment disorder.