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Behavior Change As Reported By Caregivers Of Children Receiving Holding Therapy,
by Virginia S. Lester, M.A., L.S.W.

From 1995 through 1997, data was collected for a freelance research project on adopted children and adolescents receiving holding therapy at the Attachment and Bonding Center of Ohio (ABC). The twelve participating families were clients who sought treatment for behavioral problems thought to be related to attachment difficulties. ABC is an internationally recognized treatment facility specializing in attachment and bonding therapies including holding, rage reduction, EMDR, sensory stimulation and integrative techniques, and parent counseling. Interventions are designed to fit the client's individual needs. As a result, clients may receive intensive treatment (daily three-hour therapy for 10 days) or less intensive therapy and may receive any combination of interventions. The objective of this study was to see if there was any change in the client's behavior over time as reported by the primary caregiver. To measure change, the Devereux Scale of Mental Disorders (DSMD: Naglieri, LeBuffe, & Pfeiffer, 1994) and the Beech Brook Attachment Disorder Checklist were used. These instruments were completed at four points in time: 1) before initial assessment; 2) at the time of initial assessment; 3) before therapy commenced; and, 4) at follow-up (at least four weeks following therapy began). Ten subjects received intensive therapy treatment and all 12 subjects received holding and parent counseling.

THE SAMPLE
The sample consisted of twelve adopted children and adolescents, ages ranging from 4 to 15 years. The racial and ethnic breakout was: 58.3% Caucasian, 16.7% bi-racial, 8.3% African American, 8.3% Asian, and 8.3% Hispanic. Of the sample, 66.7% were male, 33.3% were female; 83.3% had received previous treatment related to emotional and behavioral disturbance; and 66.7% of the sample had history of taking some type of prescription medication. Subjects experienced between 0 and 9 out-of-home placements before the age of two.

THE INSTRUMENTS
The Devereux Scale of Mental Disorders (DSMD) is a 110-item (or 111-item for the adolescent version) behavior rating scale designed to evaluate behaviors related to psychopathology. There are two separate instruments, with comparable items and subscales. The instrument has three composite scores (externalizing, internalizing, and critical pathology) and each is made up of two subscales (conduct and attention [or delinquency for adolescents], depression and anxiety, acute problems and autism). An overall total test T-score is also included. The DSMD total and composite scales have excellent internal reliability and test-retest reliability. There is good interrater reliability with a clinical population. The DSMD is well suited for use in evaluating mental health treatment outcome reflecting the full range of psychopathology, including the more severely disturbed behaviors that are often missing from other rating scales. The Beech Brook Attachment Disorder Checklist is a 75-item checklist developed by clinicians at Beech Brook to identify negative and positive attachment behaviors. The instrument is still in the development stage and was recently piloted on children who are clients of Beech Brook. Preliminary factor analysis on 101 subjects yielded two groupings of items - one labeled "positive attachment" with 17 items, and one labeled "negative attachment" with 16 items. The two subscales are correlated with a negative direction and have reliability of .87 and .85. Mean scores are 1.44 for negative attachment and 2.03 for positive attachment.

RESULTS
The mean DSMD total scores decreased across time and between all trials (79.8 to 68.9) from very elevated to elevated levels. The largest decrease is between the assessment and the time that therapy commenced. This change in mean total scores before therapy commenced may reflect the stress relief of connecting with an empathetic support person.

The mean negative Attachment scores also decreased across time and between all trials (1.7 to 1.4) reaching the 1.44 mean established by a previous clinical sample. However, the largest decrease in negative attachment scores occurred after therapy began through follow-up. Since attachment therapy usually focuses on reducing the negative attachment behaviors, this decrease may be attributed to the intense focus of therapy. The mean positive Attachment scores increased across time and between all trials (1.4 to 1.9) and did not reach the 2.03 mean score established by the previous clinical sample. The largest increase occurs before the initial assessment indicating, again, that perhaps parents of attachment disturbed children attain a more positive perspective after having contacted a supportive person.

In conclusion, the reported Attachment scores changed with the DSMD in the expected direction. Specifically, negative attachment scores and DSMD scores were highest before intervention and decreased throughout study and positive scores were lowest before intervention and increased throughout the study. Telephone interviews with subjects revealed that all participants were extremely satisfied with the therapy and reported feeling that the treatment that they received from ABC was superior to previously tried remedies. While the findings present in this study are very general, they show that families coping with children wth attachment disorders find improvement in the child's negative and positive behaviors over time.

REFERENCES
Naglieri, J., LeBuffe, P., & Pfeiffer, S.I. (1994). Devereux Scale of Mental Disorders. San Antonio, TX: The Psychological Corporation.

[CITE FOR THIS INFORMATION]
Lester, V.S. (1997). [Behavior change as reported by caregivers of children receiving holding therapy.] Unpublished raw data.
Lester, V.S. (1997). Behavior change as reported by caregivers of children receiving holding therapy. Paper accepted for presentation at the annual meeting of ATTACh, Omaha, NE.



Music Therapy With Children With Attachment Disorder
by Melissa C. Heng, M.T.-B.C.

Music therapy began to develop as a profession around the time of World War I. Medical professionals noticed that when music was played during surgery less anesthesia was needed. Music was also used in rehabilitation: for example, playing a wind instrument for respiratory rehabilitation. Since that time music therapy has grown as a profession. Music therapy can be utilized in hospitals, schools, nursing homes and a wide variety of other facilities which promote physical, emotional, and mental development. Music therapy can be a powerful tool when working with children with severe emotional disturbances (SED). Music therapy can bridge the gaps in emotional, developmental and relationship skills. This article will explain some techniques that are used with children with SED and give a short vignette about a child diagnosed with an attachment disorder. Complex therapy cases challenge clinicians and compel them to create effective interventions to reach SED children. A music therapist has the option of utilizing any music related activity to design interventions to address treatment goals. The field of music therapy has refined interventions over the last 45 years. Within the field, universities teach a standard repertoire of activities, which are used in practice and in research. For the purposes of this article, these activities have been categorized into 5 general descriptions: live music production, improvisation, lyric analysis, skill building and self-comforting activities. These categories are not all encompassing of the interventions used by music therapists, but provide a general introduction. Live music production includes a broad range of activities which might include singing, making up a drum pattern as the therapist plays the child's favorite song on the piano, or exploring the interesting sounds one can create on a keyboard. It is music for the sake of making music. A desired response from this activity is access to feelings. A therapist might observe a child's pride in his or her skills, or fear when the child hears spooky music. Another outcome is the spontaneous enjoyment of the aesthetics of live music. Improvisation is a specialized type of live music. Some children will show a natural talent for this or the therapist can teach it. The response the therapist is looking for is identification and expression of a selected feeling. The non-verbal aspect of this intervention is valuable for children with limited verbal skills or those who incurred abuse at a preverbal stage. Often when children are defended and do not like to rely on verbal processing this method can accurately represent the intensity of their feelings.

Lyric analysis relies on the text component of music. A therapist may choose to use popular songs or children's songs. Because of his or her musical training, a therapist can also write a song for a specific child to convey a concept or message. A music therapist also has a variety of songwriting techniques to allow the child to successfully write his or her own song. The content of the song may describe relevant issues which the child is working on. It may also be a way to explore what is absent from the child's life. For example, the loss of a parent, or not seeing siblings. Skill building is not music lessons but adapting educational approaches to bridge developmental delays and enhance self-esteem. Part of the training of a music therapist is to make it possible for anyone to create music. This could be something as simple as pushing the piano key with the red sticker followed by the blue sticker, but the child is making music and the therapist makes it sound "like a real song." The child is allowed to explore a preferred instrument and begin to get some skills under his or her belt. Children with SED have missed so many normalizing activities necessary for developing skills that it is crucial to address this in order to impact arrested development. Finally, self-comforting activities are related to relaxation and receiving comfort from music. Everyone uses music for specific purposes and this is one of the benefits of music which requires no prescription and has no side effects. Endorphins, the pleasure producing chemicals released by the brain, can be produced when listening to music. The ability to receive comfort from music can also, hopefully, lay the groundwork for accepting comfort from human caretakers. Beech Brook is a multi-service agency in Cleveland, Ohio, which provides mental health services for children and families, including outpatient therapy, residential and day treatment, foster care and adoption, and family preservation. The agency uses individual music therapy as a primary therapeutic modality. The following vignette will briefly highlight a prototypical case, describing background history, presenting symptoms, salient treatment themes, and responses to their individualized music therapy approaches. Katy's mother had a criminal record of assault and robbery, a history of alcohol and intravenous drug abuse, and multiple suicide attempts resulting in psychiatric hospitalizations. Police charged her mother and stepfather with physical abuse, sexual abuse, educational neglect and abandonment of their children. Katy and her four siblings entered the social service system after their mother abandoned them.

Katy's behavior had been so unmanageable that she had been in ten different placements by the age of six, with diagnoses of post traumatic stress disorder, separation anxiety, and conduct disorder. Presenting behaviors at the time of her admission to residential treatment included extreme aggression, suicide attempts, sexual acting out, and compulsive lying. Katy also displayed other, more subtle behaviors indicative of attachment disorder, including being highly manipulative, having difficulty trusting others, and rejecting nurturing relationships. Team members thought that these symptoms emanated from her abuse history and subsequent out-of-home placements. The music therapist was asked to address relationship skills. Katy initially used live music performance and improvisation. She developed a relationship to the music but not the therapist. She would use only parallel interaction, not reciprocal during music production. Later in music therapy she distanced herself further from the therapist, but continued to relate her inner self through pop lyrics. Her choice of music reflected powerfully sad core themes that she was unable to verbally relate to the therapist. Had she been in traditional talk therapy, she might not have continued -- but through the projective techniques of music therapy, he was still able to communicate. When improvisation is used with children with attachment disorder, it often serves as a metaphor for their internal relationship capacity. The therapist can gauge the level of a child's ability to relate by the quality of the child's musical involvement (rejecting, independent, parallel or reciprocal), and observe its change over time. Most important, the interdependent and communicative nature of the intervention calls for risk-taking by a child who has learned to avoid intimacy with significant adult figures. Through the practice of risk-taking and developing a new, positive perception of relationships, the child's ability to form healthier future relationships can improve. Interestingly, live music allows a child with attachment disorder to be the "star," and then sets the stage to explore their tendency to be charming and superficially engaging in relationships and thereby avoid intimacy. Because of their avoidance of direct questioning, text or lyrics can be a telling projective tool. Self-comforting activities are also important for this subgroup of children with SED due to their lack of essential early childhood nurturing. Developing a capacity to receive comfort through music lays the groundwork for accepting nurturing and affection from a human caretaker.

Other areas that may or may not be present in a child with an attachment disorder can be addressed with music therapy. It is not uncommon for this subgroup of children to have developmental delays or aggressive behaviors. Such a child can learn songs to develop a feeling vocabulary. Next the child is encouraged to pair instruments with feeling states. With support, the child then connects feelings to life events. The final goal is to allow the child to select a medium to express a feeling, then modulate or change the feeling state, and finally move from a negative to a positive feeling state. Live music making delineates clear limits for behavioral expectations. When a child can execute tasks independently, this indicates increased ability to internalize structure. More sophisticated tasks require more control over impulses. Skill building allows the child to reprocess their negative experiences in a way that promotes a healthier identity. The text of songs may contain lyrics that describe situations that mirror or contrast with the child's violent and abusive relationships. These lyrics offer opportunities for the child to compare violence with healthy, nonviolent relationships and responses. Writing lyrics that describe traumatic experiences allows discharge of feelings in a less threatening manner, thereby gaining a sense of mastery over them. Extremely aggressive youngsters who have histories of maladaptive behaviors often come from environments that did not model healthy problem-solving strategies. These are just a few examples of how music therapy can be used to address common issues seen in children with attachment disorder. Further research and knowledge is needed on how to more effectively treat children with attachment disorder through expressive mediums such as music therapy.

Melissa C. Heng, M.T.-B.C. has been a music therapist at Beech Brook since 1994. She will present information from this article this fall at the national Music Therapy conference.


Attachment and Neurofeedback: A Case Study
by Sebern F. Fisher, M.A.

On a raw November morning, Judy and Rob had to make a quick decision. Sam, Judy's three year-old student in daycare, needed emergency foster care. Although they had never planned to be foster parents and were waiting to start their own family until finances improved, they could not resist this boy. Sam first came to the attention of Child Welfare when he fell out of a third floor window at age two. When they investigated they learned that Sam was profoundly neglected, that he had been hospitalized four times, that both parents had been foster kids, both had seizure disorders, both had serious psychiatric histories and both were substance abusers. They placed Sam with his grandmother who had been diagnosed with Multiple Personality Disorder and he stayed with her for nearly a year. Child Welfare became re-involved with him only after the grandmother returned him to his parents. There was now a baby brother. Again, due to profound neglect and Sam's severe behavior problems both boys were removed from the home and placed in foster care. Sam was nearly uncontrollable. He slept only four hours a night. He stole and hoarded food, attempted to hurt if not kill his brother, was cruel to the family pets, displayed almost constant masturbatory behavior, defecated on the floor, refused to obey the foster parents, never stopped moving, tantrumed constantly and showed no sign of regret or remorse. He was, also, unable to make a sentence of longer than three words, responding when he chose to, only with one word and with gestures. This foster family relinquished him because they feared he would kill his baby brother. The next foster family made him eat his stool when he defecated on the floor and when he started a fire by putting a cloth over a lamp, burned him on the lip with the light bulb. It was the fire that precipitated the emergency placement. The 'honeymoon' with Judy and Rob was short. Sam was voraciously hungry, slept only 3-5 hours a night, was severely hyperactive, did not listen or obey, and generally acted 'like a punk.' He made sexual gestures when he was diapered at night and when bedtime came he would begin to scream, a bout that could go on for three to four hours. It was, as Judy humbly put it, "not easy." The demands of this child strained Judy and Rob's relationship. They had lived a quiet and gentle life before Sam, the thirty pound, ceaseless tornado tore it apart. They had heard about neurofeedback and Sam began this treatment in late November. He had three to five, three to twenty minute sessions a week depending on what he could tolerate. (It does require, to some extent, sitting still). At home they instituted regular holding sessions, often many times a day. They also gave him a bottle, which at first he did not know how to use but which he immediately wanted. They let him eat as much as he wanted. He consumed gallons of yogurt in the first few weeks. There is also-and this may be significant in terms of outcome-no TV in the home and he was fed no sugar or wheat. Within six weeks Judy noted the following changes. "Sam is eating normally, not trying to grab our food and not overeating. He is no longer preoccupied with food. He is slowly gaining weight. He's sleeping twelve hours a night. He still needs frequent holding sessions but has also begun to ask for them. He seems surprised at himself when he does. He is more cooperative and less clingy. (For weeks he would not let Judy out of his sight.) He has many fewer episodes of rage and with prompting will make eye contact. He has remorse and he's not so selfish. He seems to be getting cause and effect. And he is able to play calmly and he asks us to read books!" Judy reported the following episode about four weeks after his placement. "We'd had a long and rough day. I asked him why he thought it was so tough. He started to cry, real, wet tears and said 'I want you!'" After three months, Sam has become an emotionally expressive child. He can, at sad moments, still go dark behind the eyes but he does not go blank. He is increasingly, spontaneously, relational. All sexual gesturing has stopped. He still has holding frequently but increasingly on request. His new parents tuck him in at night, he falls asleep on his own and sleeps for twelve hours. His night terrors have disappeared. He listens and does what he's told. His speech is still seriously delayed but that too is improving. He is using simple sentence structure and is working with his parents on his articulation. Judy and Rob are delighted with Sam and they have begun the adoption process. This is a dramatic but not unique case and it is, of course, still a case in progress. The contribution of neurofeedback seems to be that it facilitates and potentiates all the other indispensable aspects of therapy for children with Reactive Attachment Disorder: holding; talk therapy, therapeutic re-parenting, deep parental commitment, and parental support.

Sebern F. Fisher, M.A. can be contacted by writing her at Psychotherapy, Clinical Consultation, EEG Biofeedback, 34 Elizabeth Street, Northampton, MA 01060 or via e-mail at sebern@bigplanet.com.


EMDR: A Power Tool in the Treatment of Attachment Disorders
by Joanne May, Ph.D., L.P., L.M.F.T.

The Attachment Disorder Center of Minnesota, a division of Eden Prairie Psychological Resources (EPPR) was established in January, 1995. From the first, we incorporated EMDR in all phases of treatment. Our methodology includes nurturing holding by parents, narrative therapy, cognitive restructuring, play therapy and sensory integration. EMDR (eye movement desensitization and reprocessing) was "discovered" by Dr. Francine Shapiro in 1987. The initial focus was the treatment of post traumatic stress disorders (PTSD). Adults who had suffered for years seemed to be able to move beyond the traumatic past in one or two EMDR sessions. Dr. Shapiro hypothesized that the experience of trauma results in an over-excitation of a cortical locus with resulting pathological changes in the brain chemistry. These changes cause information processing to stop. Consequently, the conclusions formed during a traumatic event are "frozen." Dr. Shapiro posited that EMDR had the capacity to trigger a physiological mechanism resulting in the activation of the information processing system.

Information processing and the formation of conclusions is a part of every day living. As we experience life, we form conclusions about ourselves, about others and about our experiences. We use our senses to group experiences together. The way something or someone looks or sounds or smells may remind us of another time or place. We are also reminded of the way we felt and the way we thought in that other situation. In fact, it may be "as if" we are experiencing the original encounter. We are forever applying past conclusions to present situations. When the past was traumatic, the application of the previous conclusion may be faulty. For instance, the conclusion of a seven year old molestation victim may be "I'm helpless, others have control over my body." The conclusion may be accurate for the child but does not necessarily apply to the adult. EMDR affects the cognition that accompanies the memory of a traumatic event. Instead of being forever locked in the cognition that accompanied the original trauma, a new more adaptive conclusion is spontaneously achieved. The theoretical conceptualization of Attachment Disorder as a type of PTSD and the application of EMDR as a curative mechanism was an addition to the existing theories of attachment and loss and came after many years of working with Attachment Disordered children in foster care, residential treatment and out patient facilities. My initial theorizing went something like this. "Could it be that the "frozen" developmental and cognitive features seen in Attachment Disordered children are similar to the "frozen conclusion" commonly seen in adult PTSD client? If it is a similar phenomenon, would the application of EMDR shift the dysfunctional conclusions shared by many Attachment Disordered children?" This would include the conclusion that parents and other caring adults cannot be trusted. My early theorizing led me to the work of Bessel van der Kolk and Bruce Perry. Dr. van der Kolk was a key note speaker at the ATTACh conference in October. It is my understanding that his recent brain scan research indicates that the application of EMDR results in a dramatic increase in the activity in the anterior cyngulate which filters impulses from the amygdala as they rise toward the cortex. This increased activation results in the brain's ability to screen out inappropriate levels of activation. Basically, it sounds as if the application of EMDR, allows the brain to conclude that the past is different from the present and that the old "frozen conclusion" is no longer valid. After two and one/half years of using EMDR with Attachment Disordered children, it is possible to conclude that EMDR consistently provides a mechanism for shifting frozen conclusions. Typical dysfunctional conclusions are: 1. The abuse I endured must mean I am bad or evil. 2. It is not safe to trust adoptive parents. 3. The only way I can survive is to be in control. 4. I am bad or evil and my behavior is who I am. 5. There is nothing I can do that is right. 6. I deserve to be hated. 7. Others deserve my hate. A common concern is that EMDR will "re-traumatize" the children. This has not been our experience. Attachment Disordered children have often experienced trauma in the first two years of life. The young child that is unable to use a fight or flight response will often "freeze" or disassociate. When parent cannot be relied on to provide protection and comfort, the adaptive survival response is vigilance. In order to remain vigilant, affect is disassociated (secondary or peritraumatic dissociation). This may account for the diminished affect (other than anger/rage) so often observed in Attachment Disordered children. When we use EMDR to revisit the original trauma, the child often gives a non-emotional, detailed observer account of past trauma and then spontaneously arrives at the conclusion that the abuse was not their fault and that the parent was not being responsible. At times, the child will naturally move into a gestalt, empty chair conversation with the biological parent. Frequently, the child concludes that the parent should have come to therapy to learn to be "responsible and respectful." This cognitive shift is usually achieved without input from the therapist. Later, when attachment is accomplished, we see a full range of affect. For instance, the child may exhibit fear of losing this "new" relationship with the adoptive parent(s). EPPR is a training institute providing internships for master and doctoral interns. In our capacity as a teaching institution, we have a research focus. The first quantitative outcome study on our work with Attachment Disordered children has been completed. The results show significant improvement in behavior in all of the diagnostic categories measured (oppositional defiant, conduct disorder, ADHD, and RAD). This study did not attempt to separate the various treatment components, however. Future research will include a study, with the proper controls, to determine the most robust treatment variables. At this point, our clinical judgement is that EMDR significantly adds to our ability to effectively treat the attachment disorderd children we serve.

[fonte: attach.org]