Dyadic Developmental Psychotherapy: (Part II)

An Effective Treatment for Children with Trauma-Attachment Disorders, Part II

PART II THE STUDY

It was hypothesized that Dyadic Developmental Psychotherapy would have a positive effect on children with Reactive Attachment Disorder in several areas including:
1. Reduction in attachment disorder symptoms,
2. Increased capacity to use the parent, as a secure base for comfort and security.
3. Resolution of grief and loss issues associated with abuse, neglect, and foster/adoptive placements.
4. Improved ability to form social relationships.
5. Improved cause-effect thinking.
6. Reduced aggression.
7. Increased adherence to generally acceptable social behavior.

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METHODS
Subjects
The total sample consisted of thirty-four subjects. Subjects were selected from among the case files of The Center For Family Development, Williamsville, New York, using the following criteria:
1. The case was closed in 2000 or 2001.
2. The child received a diagnosis of Reactive Attachment Disorder, 313.89, using the criteria in the Diagnostic and Statistical Manual IV .
3. The child received Dyadic Developmental Psychotherapy.
4. The child had a significant history of physical abuse, physical or psychological neglect, sexual abuse, or institutional care. These children were experiencing complex Post Traumatic Stress Disorder.

DEMOGRAPHIC VARIABLES
CATEGORIACAL VARIABLES
Variable N=34 %

Gender
Male/Female
24 71%
10 29%

Race
Caucasian/African American/Asian
30 88%
2 6%
2 6%

Type of Adoption
U.S./International
18 53%
16 47%

CONTINUOUS VARIABLES
Variable:
Mean // Range // Standard Deviation

Age at Adoption (years):
7 // .2 - 14.5 // 3.8
Number of Prior Treatment episodes (82%):
3.4 // 0-18 // 4.4
Age began treatment (years):
9.4 // 6 - 15.2 // 2.6
# of Attachment Therapy sessions:
23 // 4 - 39 // 11.6
Length of Treatment (months):
10.9 // 1 - 25 // 5.8
Length of time between follow-up and ending treatment (years):
1.1 // .3 - 2.4 // .6

Dyadic Developmental Psychotherapy
Dyadic Developmental Psychotherapy11,39, as conducted at The Center For Family Development, uses two-hour sessions involving one therapist, parent(s), and child. Two offices are used. Unless the parents are in the treatment room, the parents are viewing treatment from another room by closed circuit T.V. or a one-way mirror. The usual structure of a session involves three components. First, the therapist meets with the parents in one office while the child is seated in the treatment room. During this part of treatment, the parent is instructed in attachment parenting methods40. The parents' 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). Second, the therapist, often with the parents, meets with the child in the treatment room. This generally takes one to one and a half hours. Third, the therapist meets with the parents without the child. Broadly speaking, the treatment with the child uses three categories of interventions: affective attunement, cognitive restructuring, and psychodramatic reenactments. Therapeutic holding is one component of affective attunement. Treatment with the parents uses two categories of interventions: first, teaching effective parenting methods and helping the parents avoid power struggles and, second, maintaining the proper PLACE or attitude. The parents provide a high degree of structure to provide safety for the child. Within this structured world, the parent maintains a high degree of affective attunement that is nurturing and that repeatedly enacts the attachment-cycle of engagement, disruption, and interactive-repair.

Treatment of the child has a significant non-verbal dimension since much of the trauma took place at a pre-verbal stage and is often dissociated from explicit memory. As a result, childhood maltreatment and resultant trauma create barriers to successful engagement and treatment of these children. Treatment interventions are designed to create experiences of safety and affective attunement so that the child is affectively engaged and can explore and resolve past trauma. This affective attunement is the same process used for non-verbal communication between a parent and child during attachment facilitating interactions43. The therapist's attunement results in co-regulation of the child's affect so that is it manageable. Cognitive restructuring interventions are designed to help the child develop secondary mental representations of traumatic events, which allow the child to integrate these events and develop a coherent autobiographical narrative. Treatment involves multiple repetitions of the fundamental parent-child attachment cycle. The cycle begins with shared affective experiences, is followed by a breach in the relationship (a separation or discontinuity), and ends with a reattunement of affective states. Non-verbal communication, involving eye contact, tone of voice, touch, and movement, are essential elements to creating affective attunement.

The treatment provided often adhered to a structure with several dimensions. First, behavior is identified and explored. The behavior may have occurred in the immediate interaction or have occurred at some time in the past. Using curiosity and acceptance the behavior is explored. Second, using curiosity and acceptance the behavior is explore 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. Forth, 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:
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. Fifth, the child communicates this understanding to the parent. Sixth, finally, a new meaning for the behavior is found and the child's actions are integrated into a coherent autobiographical narrative by communicating the new experience and meaning to the parent.

Past traumas are revisited by reading documents and through psychodramatic reenactments. These interventions, which occur within a safe attuned relationship, allow the child to integrate the past traumas and to understand the past and present experiences that create the feelings and thoughts associated with the child's behavioral disturbances. The child develops secondary representations of these events, feelings and thoughts that result in greater affect regulation and a more integrated autobiographical narrative.

As described by Hughes, the therapy is an active, affect modulated experience that involves acceptance, curiosity, empathy, and playfulness. By co-regulating the child's emerging affective states and developing secondary representations of thoughts and feelings, the child's capacity to affectively engage in a trusting relationship is enhanced. The parents enact these same principals. If the parents have difficulty engaging with their child in this manner, then treatment of the parent is indicated.

Arthur Becker-Weidman, Ph.D.
Center For Family Development
5820 Main Street, suite 406
Williamsville, NY 14221
http://www.adoptionforums.com/forumdisplay.php?s=&forumid=50

716-810-0790
Aweidman@Concentric.net
http://www.Center4FamilyDevelop.com