Evidenced Based Practices for insecurely attached children and trauma

February 20, 2013

I am frequently asked about “attachment therapy” and “attachment parenting” and various treatments. Many books and others claim success with their approach and individuals often write glorious reviews of these approaches. Yet, we know that these approaches are NOT supported in the literature and withstanding the scrutiny of peers. As such, I wanted to just briefly compile a short list of assessments, tools, treatments and theory approved by Advocates for Children in Therapy that is evidenced based (researched and replicated with a control group) and a list of unsupported assessments, tools, treatments and theory. These can also be found on the Advocates for Children in Therapy website as well as literature such as Handbook of Attachment, Disorganized Attachment, Disorganized Attachment and Caregiving, Parenting Representations, Clinical Applications of the Adult Attachment Interview and others. I have also included a list of accepted assessment tools for assessing attachment quality.


Parent-Child Interaction Therapy (PCIT)

Kazdin Method for Parenting the Defiant Child

Attachment and Biobehavioral Catch-up Intervention

Circle of Security

Incredible Years

Adult Attachment Interview

Strange Situation

Attachment Q-Sort 

Attachment Story Telling Completion Task

Attachment Doll Play Assessment

Adult Attachment Projective Picture System

Caregiving Helplessness Questionnaire

Working Model of Child Interview

Parent Development Interview

Circle of Security Interview

Attachment Script Sets

Ainsworth Maternal Sensitivity Scales


Below is a list of treatments and interventions, tools and theories  NOT recommended:

  • Attachment Disorder
  • Attachment Therapy
  • Attachment Therapy Parenting
  • Beyond Consequences
  • Cline/Helding Adopted and Foster Child Assessment
  • Cline/Helding Adoptive Parent Attitude Assessment
  • Complex Trauma
  • Corrective Attachment Therapy
  • Critical Care Parenting
  • Dr Post’s New Family Revolution
  • Dyadic Developmental Psychotherapy
  • Emotional Deficit Syndrome
  • Family Centered Regulatory Therapy
  • Holding Therapy
  • Holding Time
  • Humanistic Attachment Therapy
  • Integrative Dyadic Psychotherapy
  • Nancy Thomas Parenting
  • Family Attachment Narrative
  • Pre and Peri Natal Psychology
  • Rage Therapy
  • Rage Reduction Therapy
  • Randolph Attachment Disorder Questionnaire
  • Reactive Attachment Disorder
  • Stress Model
  • Theraplay
  • Z-Therapy

On the Advocates for Children in Therapy Website, they list the names of proponents of the above treatments.  When entrusting your care and the care of your children to someone following one of these models, caution and care must be taken. While there may certainly be some benefits, there is a possibility of doing more harm than good. Remember, the motto of the creators of the Circle of Security state “Parenting in 25 words or less: ALWAYS be BIGGER, STRONGER, WISER, and KIND. Whenever possible, follow the child’s need. Whenever necessary, take charge.” Ensuring proper  treatment for your child is a take charge moment!!!

Back to School Special! A “Wing and a Prayer!”

September 4, 2012

For the past two decades, much research has been done on the student-teacher relationship. Attachment theory proposes that that a child develops a hierarchy of caregivers and that it is the caregivers role to perform the necessary tasks of becoming a haven of safety from which a child’ explores and a base of security to which a child returns. A close and supportive relationship between teacher and student would assume that a teacher performing this role would allow a student to focus on the tasks at hand – peer interaction, academic performance, and interaction with other adults; however, few studies have been able to examine this directly. One study by Ahnert and colleagues (2012) has provided clear and substantial evidence that a teacher who provides a haven of safety and base of security directly influences a child’s ability to regulate stress in a classroom setting.

The challenge that is currently being faced by researchers is finding interventions that are effective. Reflection based interventions (teacher reflects on their behaviors, feelings, intentions, and thoughts) have been promising, but inconclusive. Interpersonal Skills interventions (skills for communicating and interacting with others) have also been promising, but inconclusive.  Hughes (2012, p. 322) suggest that “teachers’ goals and teaching philosophy, teaching self efficasy, and self awareness of their own emotional states and capacity to use this awareness to regulate one’s behavior likely affect their responsiveness to different interventions.”

As I sent my daughter off to school this morning to begin third grade, she was so excited and a bit anxious about school. She set her alarm, got herself dressed and groomed. She came into the bedroom excitedly pronouncing her feats with a big smile on her face and the enthusiasm of a child on Christmas morning. It was delightful! We had breakfast together and played as has been our school morning rituals since kindergarden. When it was time to go, we took all the pictures we could until she gave the proverbial ,”UGH” and then it was off to school!

This year, she has her first male teacher. There is also a boy in her class that pulled her hair once two years ago that makes her anxious as well. Truthfully, I found myself a bit anxious wondering if this male teacher will provide the haven of safety and base of security that I know her previous teachers were able to provide. Certainly, I am gender stereotyping, but I am a worried protective father sending his daughter into the world. This week, my prayers have been filled with themes of protection and safety for her!!

What I take comfort in at these times, are God’s promises He has made to us:

Psalms 84:11 states “The Lord God is like a sun and shield; the Lord gives us kindness and honor. He does not hold back anything good from those whose lives are innocent.”

Isaiah 43:2 states “When you pass through the waters, I will be with you. When you cross rivers, you will not drown. When you walk through fire, you will not be burned, nor will the flames hurt you.”

Psalm 61:3 states “You have been my protection, like a strong tower against my enemies.”

What is most comforting, is my daughter knows Jesus at her age. All the promises He has made He has graciously offered to her as well. I take refuge in knowing He is watching over her when I cannot, he is protecting her when I cannot, and through the power of the Holy Spirit, He is supporting her her when I cannot and comforting her when I cannot. I believe in Him and His word. I trust Him. I pray to Him. Praise the Lord, God our Savior, who helps us everyday (Psalm 68:19)

Ahnert, L., Harwardt-Heinecke, E., Kappler, G., Eckstein-Madry, T., & Milatx, A. (2012). Student-teacher relationships and classroom climate in first grade: How do they related to students’ stress regulation? Attachment & Human Development, 14, 249-263

Hughes, J.N. (2012). Teacher-student relationships and school adjustment: progress and remaining challenges. Attachment and Human Development, 14, 319 – 327




Addiction: How to Recognize It and What to Do about It

June 15, 2012



Addiction to alcohol and other drugs is a chronic disease. It is progressive, continuous, and long-term. Alcohol or drug abuse means that a person has control over whether he or she drinks or uses but uses it to excess – experiencing emotion, physical and sometime, legal consequences. Alcohol or drug dependence means that a person has lost all control over his or her drinking or using behavior.


Addictive Behavior

People who suffer from addictive diseases engage in compulsive behavior and gradually lose control of their lives. They continue to drink or use drugs, even when they know it will lead to negative consequences. They tend to have low self-esteem and almost inevitably suffer from anxiety and depression.


If someone in your life suffers from addictive disease, you have experienced his or her extreme behavior, ranging from depression to exhilaration. You probably have also experienced the person’s state of denial (“I can quit anytime” or “I don’t have a problem”), dishonesty, frequent disappointments, and the series of ruined relationships. These are the hallmark behaviors when a person suffers from addiction to alcohol or drugs.


Who Is Affected by Addictive Disease


Alcoholism and drug addiction affect people from all parts of society. Addictive disease affects rock stars, writers, artists, and homeless people. Victims also include stay-at-home moms, teenagers, and corporate executives. There are addicts who are students at top universities and physicians in your local hospital. They may be teachers at your neighborhood school or salespeople at the local hardware store.


Studies have shown that there is a genetic predisposition to alcoholism. About half of all alcoholics had an alcoholic parent. Men seem to be more vulnerable than women to the alcoholic traits of their parents. Women may be more affected by factors in the environment (such as financial and life circumstances) than by inherited factors.



The Physical Side of Addiction


Chronic alcohol abuse produces long-lasting damage in many areas of brain function. It damages the capacity for abstract thinking, problem solving, memory, and physical dexterity. It also impairs verbal, visual, and spatial ability. The extent of damage to brain tissue depends on the extent of heavy alcohol abuse. When the drinking stops, a certain amount of healing is possible.


Prescription Drugs


Prescription and illegal drugs with psychoactive side effects target the brain and can change a person’s mood. This causes these drugs to be potentially addicting. Some people think that if a doctor has prescribed a drug, it is not addictive. This is not true.

It is important to tell your doctor if you:


•            Are an alcoholic (using or in recovery)

•            Have ever been addicted to any drug

•            Have taken more than the prescribed dose of a prescribed drug

•            Have taken a prescribed drug for a long time

•            Take a prescribed drug with alcohol


Addictive disease is often progressive and can be fatal. Thankfully, with proper treatment, recovery is possible.




The first phase of treatment of addictive disease focuses on the physical effects of alcohol or drug use. This phase can include detoxification or treating life-threatening disorders such as liver failure.


Since addictive disease is primarily a brain disease that results in behavioral symptoms, the main treatment is psychosocial therapy. Treatment usually focuses on the irrational feelings and distorted thinking that accompany chronic alcohol or drug abuse.

Alcoholism and drug addiction are chronic diseases that require a lifetime recovery plan. Most successful treatment plans include a focus on the 12 steps of Alcoholics Anonymous and involve ongoing, long-term participation in self-help groups. Patients who have been hospitalized for treatment may continue group and individual psychotherapy after they leave the hospital, in addition to attending 12-Step meetings.


Treatment of the Family


Addiction affects every member of the patient’s family. As the disease progresses and the patient continues to drink or use, it causes a range of emotional, spiritual, and financial problems for almost everyone involved, including family, friends and coworkers. When the family is ready to begin the recovery process, Al-Anon and Alateen are excellent resources. A qualified family therapist who understands the process of addiction and recovery may also be consulted to work with the family.


What to Do When an Alcoholic or Addict Won’t Stop


Sometimes the alcoholic or addict is in such a strong state of denial that the best alternative is to arrange an intervention. This process involves arranging for a professional interventionist to organize a meeting of the family, friends, and employer of the patient. The interventionist helps the group prepare a confrontation that will be followed by the patient entering a treatment center. The patient’s family and friends usually write a brief statement describing how the drinking or drug use has affected them. The interventionist and the group then meet with the patient and read their statements to the patient with the guidance of the interventionist. These interventions, when managed by professionals from respected treatment organizations, often result in successful treatment of the addiction.


If you or someone you know is struggling with alcohol or substance problem, call us at 608-785-7000 or click here for an appointment request. 

For more information, visit:




Predicting Harsh Parenting In Toddlerhood and Beyond….

April 1, 2012

Observation and research data shows that level of parent sensitivity during the first year of life can predict harsh parenting during toddlerhood.  These early predictors , while not in and of themselves the cause, put children at risk later in toddlerhood and school age for behavioral and emotional problems in both the home and school setting. These caregiving patterns, without intervention, have been shown to remain constant and stable through the child’s development into later childhood years.

Attuned sensitive caregiving involves a three task process for caregivers: 1) perceiving a child’s cue 2) interpreting the child’s cue accurately 3) responding to the child’s cues promptly and appropriately. Many internal (what is going on in the caregivers head and heart; depression; anxiety) and external factors (marriage distress; social support network; if a daycare, number of other children) are involved regarding how well a caregiver accomplishes the tasks of providing sensitive and responsive care-giving.

Harsh caregiving may include subtle and blatant acts, either verbal and/or physical ranging from ill timed tone of voice (caregiver is irritated) through physical aggression (slapping or worse).

Parents at risk for harsh and/or abusive parenting may display a challenge in one or more of the above three areas. Milner (1993, 2003) describes four stages involved in parenting strategies that  put children at risk for physical abuse.

Parents at risk for abusive behavior to children often display the following (Milner; 1993, 2003):

1) Less attentive and attuned to their children’s behavior when compared to average, non-abusive and low risk parents

2) Interpretations of the child’s behavior are often negative, including hostile intent (they are doing this to me) and generalized (they always do this; it is how they are wired)

3) Exclusion of the context of behaviors (bad day at school, sad because their friend was hurtful, it is late and the child is tired, etc).

4) Rigidity to parenting strategies and lack insight into how well their strategies are working and the emotional/physical impact of said strategies

Furthermore, other studies  have shown a lack of respect for the child economy and “physical” interference with the child’s behavior, especially during periods of exploration, are also a characteristic of some parents who demonstrate harsh/abusive parenting as a pattern.

The suggested intrusive as well as harsh/abusive parenting as a pattern seem to share a lack of empathy or understanding for the child behavior and motives in both average, daily interactions and discipline moments (Joosen, Mesman, Bakermans-Kranenburg & van Ijzendoorn, 2012).

Caregivers may be misattuned to their own thoughts and dialogues and may or may not be aware of these strategies, often using justifications for their own behavior. This adaptation may often be as of a result of their own history of being cared for, current environmental or relational conditions, and/or their own mental health issues.

For example; in a custody situation, the caregivers may be already stressed and while their has been no historical evidence of harsh caregiving, the threat of the marriage ending may produce enough stress that a parent becomes less attuned and sensitive to their child. They may read the child’s cues properly, but may attribute this cue to something that the other parent (acussed) has done to the infant/child. While the parent may respond appropriately to the child, the attribution of the child’s cue may inadvertently cause the the parent reading the cue to begin to act subtly hostile towards the other parent. Over time, this may become a full blown need to “protect” the child from the other parent and over the years resulted in intrusive caregiving to the child – questioning everything and acting very anxious – which the child would pick up on and adapt accordingly.

Meanwhile, the “acussed parent” over time experiences the child withdrawing due to the anxiety and rather than address this miscue (has a need but is expressing it indirectly, not at all or the opposite of what they need), acts on it, becoming more harsh and resentful towards the child or withdrawing from the relationship with the child.

While sometimes harsh parenting is intergenerational, sometimes it brought on by the situation and environment, and sometimes it is both.

This is why in a custody or placement decision an important part in an assessment is to evaluate the attachment of the child to each caregiver and gain a deeper understanding into the complexity of these dynamics, how to arrange a placement schedule that is beneficial to the child, and help the parents be the best versions of themselves they are meant to be. Parenting is forever – in the eyes of a child. Contact us for more information at 608-785-7000×221 or email info@effectivebehavior.com

Attachment and Custody: The King Solomon Dilemma

February 7, 2012

Written by our Consulting Psychologist – Kip Zirkel, PhD.

The whole area of infant/toddler placement continues to be one of the most difficult issues facing Guardians ad litem, Family Court Commissioners and custody evaluators, and to date there have been little in the way of social science research to give us any guidance. In fact, the two primary research teams who have focused on this issue have come to opposite conclusions, with Judith Solomon’s group suggesting that overnights for young children should be avoided* (see note below), and Kelly and Lamb on the other side suggesting that young children can do quite well with overnights.  The struggle to balance parent’s right to have an ongoing relationship with a child with the child’s need for developing a secure and predictable attachment is at the heart of the problem, and now we have several new studies which go a long way towards resolving these contradictory findings.


A recent series of ongoing research studies down in Australia (McIntosh and friends), along with a similar report coming out of the University of Oxford, have begun to shed some light on this issue. And we are also fortunate to have the entirety of the most recent issue of the Family Court Review (July 2011) devoted to infant/toddler attachment and the question of custody and access plans. Interestingly, these articles are coming out at right about the same time as the “50/50” initiative (commonly referred to as the “father’s rights” campaign) is gathering steam around the country. It appears that the issues raised in the research studies mentioned above will generate quite a bit of discussion and argument.


Perhaps to oversimplify a bit, on one side of the table are the “shared placement” proponents, who claim that children need the advantage of a shared placement plan with two involved parents (often interpreted as parents sharing an exact “50/50” division of parenting time) and that states should have  statutes supporting this presumption.  Father’s rights groups traditionally have argued for this approach, citing a supporting body of research to support their legislative initiatives.


On the other side of the table are the “primary residence” proponents, who argue (and also cite research) that babies and toddlers need the safety and security of a primary residence, that there should be a primary caretaker (typically the mother in most cases) and that the non-residential parent should have frequent, ongoing contact. However, overnights should be postponed until the baby reaches a certain age (ranging from 2 until about 4). This argument also presupposes that the very earliest months of a baby’s life require the establishment of a secure attachment to one parent, and that if this process is disrupted, there will be serious emotional consequences down the road.


Upon reviewing the three recent research reports noted above, it is clear that those who argue that a baby or toddler should have one primary residence have the force of this research behind them. This should come as no surprise to most of us, since I along with many of you have agreed that one should not disturb the delicate attachment process by splitting the baby between two homes, but that the non-residential parent should be gradually “phased in” as the baby matures and develops the capacity to separate from his or her primary caregiver. I will summarize below the major points raised by these articles. Of course you are encouraged to read the original sources for yourselves, but if you don’t have the time or inclination, perhaps this summary will assist and inform you.

  1. First of all, gender doesn’t matter. Babies can attach to either gender, as long as that individual is present, available emotionally, sensitive to the child’s moods, “in tune” with the child, responsive, and is not absent for long periods of time.
  2. Every baby needs to form the security of at least one parent (or parent-figure) in order to ensure the attachment security grows. This early attachment should not be disrupted or compromised.
  3. The quantity of time the infant spends with a parent is not as important as the quality of that relationship (although of course there has to be a minimum period of contact for the quality of the relationship to flourish.
  4. Shared time works best for parents who cooperatively work it out without the intervention of courts. But then we don’t see these in the course of our legal practice.
  5. Shared time arrangements for children of any age pose particular risks if there is ongoing conflicts, or the mothers express ongoing safety concerns.
  6. Shared care carries special risks for children under the age or 4, even with cooperative parents.
  7. Parents who enter into shared care arrangements tend over time to drift back to “mother primary” care.
  8. There is no research establishing a clear link between shared time and better outcomes for children. Better outcomes for children arise from a host of other factors (i.e., the quality of care, relationship between parents, temperament of the child, absence of conflict, etc.).
  9. Care arrangements in infancy should support the growth and consolidation of the primary relationship, yet allow for the familiarity and growing attachment with the “second” parent.
  10. If the attachment process in the first two years of life is disrupted, it will affect the hard wiring of the child’s brain, with far reaching consequences later including the possibility that the child will not attach securely to other parent-figures.
  11. Overnight care is not essential to the formation of secure attachment in young children. Overnight care arrangements essentially are ordered to address the rights of the parent rather that the best interests of the child.
  12. Equal or near-equal distribution for giving time is not normative, even in intact families. It is not clear why a separation/divorce situation would require something different.
  13. Thorough assessment of the attachment quality between a child and his parents is an essential component, if not the most important component, of a custody evaluation.

These are the major points brought out in these recent research efforts. They may raise more questions than they answer. For one, how does one go about doing an assessment of the attachment between parents and children in a timely and efficient manner? What factors should be given more weight in doing assessments? Should we attempt to “improve” the attachment between a child and a parent rather than simply placing the child with the other, presumably healthier, parent?

I would encourage you to read through the most recent issue of the Family Court Review (July 2011), available through the AFCC organization.


Click here to register now for our two hour CEU inservice at UW La Crosse. Webinars coming soon!

Contact us for further information on having an attachment assessment completed at info@effectivebehavior.com or click here to make a referral. 

* Clarification:  Dr. Carol George (personal communication, February 19, 2013) “Our position is similar to Jenn McIntosh’s position, which is under high conflict and poor parental communication, overnights are not a good idea.  If parents can negotiate these problems between adults, security can be obtained.”


January 5, 2012

Where Do I Start?

(from American Foundation for Suicide Prevention www.afsp.org)

Know that you are not alone.

If you have lost someone to suicide, the first thing you should know is that you are not alone. Each year over 33,000 people in the United States die
by suicide — the devastated family and friends they leave behind are known as “survivors.” In fact, research shows that during the course of our lifetime
85% of us will lose someone we care about to suicide. That means that  there are millions of survivors who, like you, are trying to cope with this
heartbreaking loss.Survivors often experience a wide range of grief reactions, including some or all of the following:

  • Shock is a common immediate reaction. You may feel numb or  disoriented, and may have trouble concentrating.
  • Symptoms of depression, including disturbed sleep, loss of appetite, intense sadness, and lack of energy.
  • Anger towards the deceased, another family member, a therapist, or  yourself.
  • Relief, particularly if the suicide followed a long and difficult mental illness.
  • Guilt, including thinking, “If only I had.…”

These feelings usually diminish over time, as you develop your ability to cope and begin to heal. We care and want to help.

Professional, compassionate help is available. Call us at 608-785-7000 or click here for an appointment request. 

National Violent Death Reporting System findings with respect to suicide in 2008:

 For 2008, a total of 15,755 fatal incidents involving 16,138 deaths were captured by NVDRS in the 16 states included in this report. The majority (58.7%) of deaths were suicides, followed by homicides and deaths involving legal intervention (i.e. deaths caused by police and other persons with legal authority to use deadly force, excluding legal executions) (26.4%), deaths of undetermined intent (14.5%), and unintentional firearm deaths (0.4%). Suicides occurred at higher rates among males, American Indians/Alaska Natives (AI/ANs), non-Hispanic whites, and persons aged 45–54 years. Suicides occurred most often in a house or apartment (70.6%) and involved the use of firearms (51.5%). Suicides were precipitated primarily by mental health (45.4%), intimate partner (30.9%), or physical health problems (22.6%), or by a crisis during the preceding 2 weeks (27.9%).

 Suicide Patterns

Similar to the 2005–2007 NVDRS data years, the suicide rate for the 2008 data year was highest among males and American Indian/Alaskan Natives, although at least 85% of the suicide victims each year were of white non-Hispanic race/ethnicity. Also, the 2008 suicide rate was highest among those of aged 45–54 years, in general, but the highest rate remained among males of aged ?85 years. These findings have also been documented in other reports (10,11 ).

In 2008, mental health issues (i.e., having a current depressed mood and/or a current mental health condition) remained the most common health characteristic among decedents, which was also reported in previous years (79). Intimate partner and relationship problems, alcohol/substance abuse problems, serious physical health problems and crises immediately prior to death also remained common characteristics or circumstances among decedents (7,8,12–16). This report also showed that intimate partner problems were more common among male decedents and diagnosed mental health conditions were more common among female decedents. However, both male and female decedents were almost equally as likely to be noted as having a current depressed mood prior to death. This finding supports previous research that showed females are more likely than males to seek mental health care and receive a diagnosis for their mental distress (17,18). Among those who received a diagnosis, the majority of both male and female decedents were diagnosed with depression. However, this report revealed some differences in diagnoses by sex; attention deficit disorder was more commonly found among male suicide decedents and bipolar disorder and anxiety disorder were more commonly found among female decedents.

Another similarity with previous data years was that nearly 30% of suicide decedents in 2008 disclosed their intent to commit suicide to others and approximately 20% had made previous suicide attempts (79). This finding indicates that there still remains the need for proper follow-up treatment and monitoring for those who attempt suicide as well as the need for public education on how to respond and seek help when faced with someone disclosing suicidal intentions (79,19).

In contrast to previous NVDRS data years, slightly greater proportions of suicidedecedents in 2008 were identified as having job problems and having financial problems prior to death. In 2008, both proportions were estimated to be 13.4% whereas, in previous data years, the proportion of suicide decedents identified as having job problems ranged from 11.1%–11.5%, and the proportion identified as having financial problems ranged from 11.0%–11.7%. Financial hardship was not found among decedents of undetermined deaths, which further indicated this circumstance was more associated with suicide. Financial and job problems were more common among male decedents and decedents aged >50 years. Job loss can trigger a cascade of negative events, such as more financial problems and relationship problems (20), which can increase risk for suicide. These findings suggest that strategies that incorporate financial planning and social support are warranted for those who might be at risk for losing employment, particularly during difficult economic times.

 Description of System: NVDRS collects data regarding violent deaths obtained from death certificates, coroner/medical examiner reports, and law enforcement reports. NVDRS data collection began in 2003 with seven states (Alaska, Maryland, Massachusetts, New Jersey, Oregon, South Carolina, and Virginia) participating; six states (Colorado, Georgia, North Carolina, Oklahoma, Rhode Island, and Wisconsin) joined in 2004, four (California, Kentucky, New Mexico, and Utah) in 2005, and two in 2010 (Ohio and Michigan) for a total of 19 states. This report includes data from 16 states that collected statewide data in 2008; data from California are not included in this report because NVDRS was implemented only in a limited number of California cities and counties rather than statewide. Ohio and Michigan are excluded because they did not begin data collection until 2010.

To view the entire report, visit:  http://www.cdc.gov/mmwr/preview/mmwrhtml/ss6010a1.htm?s_cid=ss6010a1_e&source=govdelivery

Self Injury and Teenagers

December 26, 2011

Awareness of non-suicidal self injury is on the increase, however; it remains one of the most difficult behaviors to encounter for parents, caregivers, and professionals alike.  None suicidal self injury consists of a broad class of behaviors defined by direct, deliberate, socially unacceptable destruction of one’s own body tissue without the intent to die. Often, these behaviors include but are not limited to, cutting, burning, picking at or intruding on wound healing, hitting oneself, inserting objects under the skin, and often excessive tattooing/piercing (more than 5). It is estimated that approximately 7% of preadolescents (Hilt, Cha, & Nolen-Hoeksema, 2008) , 12 to 40% of adolescents (Ross & Health, 2003), and 17% to 35% of college students Gratz, Conrad, & Roemer, 2002) have engaged in this form of self injury at one time or another.

Self injury may occur in the context of other mental health issues such as depression, anxiety, substance abuse, eating disorders, and/or behavioral disorders. It may also occur in the absence of psychiatric and mental health disorders.  Motivation for engaging in such behaviors  often includes to stop bad feelings, to relieve feeling numb or empty, to feel something in  the absence of other feelings,  punishing oneself, and interestingly enough – to relax.  A simple summary is to describe motivations for engaging in these behaviors as tension reduction.

Self injury may be only “experimental” or may become habitual.  The  1st step towards treatment is a thorough assessment of the self injurious behaviors. A comprehensive assessment can aid in early detection of such behaviors and aid treatment providers in better understanding the motives behind the behavior. Should you or someone you love be engaging in these type of behaviors,  please contact us at 608–785–7000 or click here  to begin the process of getting the help and relief without harm.

Reflections on Beyond Consequences Volume 1: Pseudo – Science Intervention!!!

December 9, 2011

Recently, an adoptive parent came to session  with a number of adopted children of different ages. One of the presenting problems was night waking and binging on food. This is a common problem with adopted children who experienced neglect. The client had read “Beyond Consequences”, which is a well established model in our community. I had not read it. I read an article online by the author, Heather Forbes, and it was well written and mostly in line with attachment literature. So, I ordered the kindle edition (for my IPAD – I love Apple!) and opened to the chapter on “Hoarding and Gorging.”

As I was reading, I was stunned when I got to this part:

Begin bottle-feeding your child… yes, begin bottle-feeding your twelve or even fourteen year-old. 

If a child needs it, regardless of his age, he will take the bottle. The simple gauge is this: if he does not need it,

he will not be inclined to take it. Remember that if the child did not receive sufficient developmental nurturing, 

then he has a barrier in his development. Until the barrier is addressed, the other levels are going to continue to stagger. 

The bottle-feeding should only occur while the child is in the parent’s arms. Forbes LCSW, Heather T. (2010-07-01).

Beyond Consequences, Logic and Control: Volume 1 (Kindle Locations 1139-1143).Beyond Consequences Institute, LLC. Kindle Edition.

Stunned. I hope you are having the same reaction.

She refers to children as having “attachment challenges” in her article online. No attachment expert would support the use of regressive means to assist a child in developing a healthy, secure adaptation. In my opinion, she has taken the opposite stance of the more aggressive, coercive “attachment correction” interventions. This type of regressive intervention is developmentally inappropriate to use with any child past bottle feeding age!! This is an intrusive intervention at best and continuing along the path of insensitive interventions for children. Do not do this type of intervention. It is akin to blood letting with leeches. It is pseudo-science, even with the endorsement she received from the son of the late and great John Bowlby. I also reviewed the professional literature and the Advocates for Children in Therapy DO NOT RECOMMEND Beyond Consequences. 

Heather Forbes has the general idea that the interventions are to be relationship based and behavior should be viewed as a reflection of experience. This is true.

According to research,  behaviors are often attempts to communicate needs or get needs met, previous coping strategies, and miscues based on distrust and fear of adults and close relationships. Attending to internal states and needs is also important such as distress, apprehension, and feelings of being out of control.

A child with difficult acting out/acting in behaviors needs help from the caregivers linking behaviors, thoughts and emotions. Caregivers remaining in the “Bigger, Stronger, Wiser, and Kind” position need to remember to take the initiative in approach, interaction, and contact with sentivity to a child’s lack of experience, join with a child when the child is distressed, aggressive, or fearful, assist in interpreting patterns of behavior, name feelings/thoughts/and links to behavior, support learning to seek help and comfort from the caregiver, and assist the child with practicing new behaviors and new interpretations of events. Bottle feeding a child past bottle feeding age violates the “WISER” position of  “Bigger, Stronger, Wiser, and Kind” caregiving.

The social/emotional relationship interventions ought to communicate at the child’s level, use gentle encouragers through natural means of eye contact (play catch, hide and seek), joint/shared attention (looking out the window at the bird on the tree together and enjoying the moment), and social referencing (the child ‘checking’ back in with the caregiver). Caregivers ought to encourage smiling and positive affect, and talk to the child about feelings…types, parts, and dimensions.

BTW: While I do agree that sometimes, the night time waking behavior is a miscue, that is, the child is distressed (scared, anxious), needs comfort, and seeks comfort not in the context of a safe relationship with the caregiver but through some other means, there is also some research has show that children with the night waking, night terrors, and sleep walking have to go to the bathroom.

Interventions for children should always be sensitive to the development needs and age of the child, gentle, and pass the “common sense” test!!

Please email, call, or contact our office for child development expertise!!


Ted Stein, L.P.C, N.B.C.C, B.C.P.C.C, A.F.C is a marriage, parenting and development expert. He has advanced training in infant attachment (A, B, C, & D) from the experts at the University of Minnesota, Alan Sroufe and Elizabeth Carlson; in toddler age attachment from William Whelan (University of Virginia and Mary B. Ainsworth Attachment Clinic), and  in adult attachment from June Sroufe, University of Minnesota. He has practiced therapy for 17 years and currently specializes in marriage therapy, parent capacity/risk evaluations, custody assessments, and attachment assessments. He is Accredited Forensic Counselor.


Reflections on an article by Nancy Thomas: Reactive Attachment Disorder

September 16, 2011

I was reading an article online by Nancy Thomas called “What is Reactive Attachment Disorder” and find her pre – suppositions rather disturbing. Particularly, when she has no formal training in the assessment of attachment that I can discern from the attachment and child development experts in the field. When I reviewed the list of individual she has trained with, none of them that I was able to research had any formal training in the assessment of attachment quality of children. I may have to dig deeper with whom she has trained and with her trainers have trained with…

1) She presumes attachment is an “all or none” construct. This is a false. She claims on her site ” Attachment is defined as the affectional tie between two people. It begins with the bond between the infant and mother. This bond becomes internally representative of how the child will form relationships with the world. Bowlby stated “the initial relationship between self and others serves as blueprints for all future relationships.” (Bowlby, 1975)”

Her citation by Bowlby is now an outmoded concept. Attachment researchers such as Sroufe, Carlson, Waters, Marvin, Siegel, Soloman, Bretherton and others clearly state that that attachment occurs along a developmental path, and should one have an insecure form of attachment early on, this does not preclude them from developing a secure attachment over their early life or later life with a trusted and sensitive caregiver, spouse, or therapist. For example, let’s assume a mother depressed during the first year of an infants life but during the second year, receives and responds positively to treatment and becomes sensitively attuned to her child – the attachment security and quality can be developmentally altered onto a more secure path. “Blueprints” can be changed. Very, very, very rarely does a child lack an attachment relationship to any caregiver.

2) Her statement: Attachment Disorder is defined as the condition in which individuals have difficulty forming lasting relationships. This is false. This is clearly know as a “hasty generalization” in logic and a fallacy. She has taken a very complex topic as attachment and made an over generalization about it.

3) She then launches into a discussion of “non-attached”. This is very, very rare and false and evidence of all or none thinking. Research is clear that children who have experienced maltreatment can and do often have an attachment relationship with there caregiver. It is often a form of insecure attachment with evidence of what is usually an organized pattern having disruptions to it (known as disorganization). A more accurate reference is a “child with distorted attachment that initiate a maladaptive pathway…(Alan Sroufe, personal communication 9/20/11)

4) Children with “non-attachments” are doomed. This is false. The University of Minnesota has done extensive work with children in orphanages in Romania who exhibited “no attachment pattern” who are now exhibiting increasing security in their caregivers. This is very promising. And, again, lack of attachment to any caregiver is extremely, extremely rare.  A more accurate reference is a “child with distorted attachment that initiate a maladaptive pathway…(Alan Sroufe, personal communication 9/20/11)

5) Attachment Disorder is accepted as a disorder by professionals with a clear definition and she describes the symptoms. This is false.   There is and continues to much debate about the diagnoses of RAD and while progress is being made in the upcoming DSM-V; there remains much work to be done.

6) She lists “causes” of attachment  “disorder.”  Again, the pre-supposition of disorder is rather disturbing. Attachment is a description of the quality of the relationship and how well a child has confidence in his/her caregiver to meet his/her needs consistently and sensitivity. The list she provides are certainly correlated with forms of insecure attachment, however; to claim  a cause is false. Also, children who exhibit secure attachment patterns can later develop an insecure pattern for various reasons: death of a parent, severe illness, divorce, etc.   Patterns of attachment security/insecurity occurs over a lifetime.

What does this all mean…be careful what you read on the internet. Do your research. Be critical. Ask questions. My friend is an author and said, “Writing a book has made me an expert.” I appreciated his comment on this – but writing a book makes someone a writer, not an expert. Only proper knowledge and proper training and proper ongoing research and experience make someone an expert. Clearly, Nancy may have some thoughts and skills on parenting techniques that are helpful, but an attachment expert, she appears very misinformed regarding what attachment is and  not. This is no fault of her own. It is a very misused and abused concepts among treatment professionals who lack specific training from experts in the field.

One more thing, she discusses her upcoming study on her effectiveness by reducing cortisol levels in parents proving her techniques work. The proper research based on her claims would be assessing the cortisol levels of the children and seeing if those are reduced combined with other measures of assessing attachment security in the children to determine their attachment security. After all, she claims on her website to “provide help for each wounded child….” See below for a direct pull from the site:

“We offer information on adoption / attachment and bonding issues, and Reactive Attachment Disorder (RAD) to families and professionals. We are also the official home of Families by Design providing educational materials and seminars.The goal of this site is to provide help for each wounded child with attachment disorderPTSD (Post Traumatic Stress Disorder)ODD (Oppositional Defiant Disorder)….”

After receiving a posting, I reviewed this article. It appears that the pages that were cited from the Nancy Thomas website are no longer available. I am hoping that the site has been updated to reflect what is currently known from research. Research can provide us with sound information. It allows us to take what we know and make it into models that can hopefully help - as my mentor for the past two year, Dr. Bruce Perry states, "Essentially all models are wrong...but some are useful!"

Hot Topic: Mandated 50/50 placement legislature – Is it in the child’s best interest?

August 16, 2011

Legislating and mandating a 50/50 placement is flat out a bad idea, particularly for young children and especially for infants. I think the idea is well intentioned, but a friend once told me that the “road to hell is paved with good intentions.”  Each situation is unique and there are a myriad of factors involved.

First, early on attachments are developed uniquely with each individual  and attachment relationships are lifelong. The word attachment is often used and misused by professionals and non-professionals alike with many misconceptions surrounding it. Mary Main, Hesse, and Hesse in Family Court Review (July 2011) states “an attachment is one of a sub-set of bonds which tie one individual to another specific individual, binding them together in space and enduring over time….for young children, an attachment may be described as a bond which serves to focus attention on the physical whereabouts or accessibility of one or a few selected, non-interchangeable older individual(s),  whose proximity can then be  sought in times of danger or fright. Separations from the selected attachment figures and unfamiliar or otherwise threatening environments is therefore expected to arouse distress, anxiety, or fear (Bowlby, 1969/1982). ”

Therefore, when we measure attachment security,  what we are looking to measure and a non complex form is essentially, “how confident is a child in the caregivers ability to meet his/her needs and the child’s adaptation to the caregiver’s past history of attempting to meet those needs.”

Alan Sroufe,  professor of child development at the University of Minnesota M lead researcher on the Minnesota longitudinal study of childhood, which is a 30 year research program that has set out to explore the development of children by providing an organizational perspective on early attachment and ecological map of the child’s growing ability to cope with chronic environmental and family straight across lifetime (abbreviated from Sroufe and McIntosh, Family Court Review, July 2011).

Sroufe states the following:  “The major thing I think the judge would do well to know is that attached relationships are lifetime thing. The major  thing I want divorcing noncustodial parents now is that they can have the most full relationship with this child that any parent on this planet will ever have, if they had no overnights for the 1st 2 years. Depending on your age, you have the next 50 or 60 years for a relationship at this child. And they’re going to need you all the time. He will not be displaced: attached relationships aren’t interchangeable. The relationship with any parent is as much as they make of it. The step parent comes along, they can also be a really useful figure in a child’s life. But they’ll never replace that other parent. ….. It is true on the one hand that probabilistically, the attachment you have an infant is a predictor of important aspects of later development. But is also the case that is changeable. One reason is predictive is because often times, the circumstances of children  who have no secure attachments do not change, and  their lives go on being full of stress, the lack of social support from the families, and the general chaos does not change. As we have documented, if the family does experience significant changes, the attached relationship of the baby may change. His social and family support increases between 18 months and 5 years, those children who are insecure at 12 or 18 months,  are not so likely to have behavior problems at 5 years….. I do not like arbitrary guidelines about child ages and overnights, for example because you need to consider number factors and child, like language development in representational capacity to understand what they can handle. Okay, say, the child is 3, but his language is delayed. That makes a huge difference. The child can fully understand, “you can be here and moms at home, are going to take you there tomorrow, and then when you wake up in the morning, we’ll go see mom,” then we have something we can work with. Well 1st of all, 12 month old cannot understand that,., And had no concept of time like we adults do.  You might as well be saying, “you’re going to be here forever.” What would they understand about that? If for some reason the child is 5 days with mom and 2 days overnight with dad, which I’ll get used to it, can they survive? Yes, but you’re making their job harder.”

“You cannot form attachment without regular ongoing interaction. Attachment is built on the history of interaction. There is nothing about this work about the need to put a baby to bed and get them up…..”

He states in his opinion, ” informed by long years of research, is the infant better off having one base until that is completely consolidated, organized, and the bank, and they (the infant) know it. What secure attachment means is the child takes forward and abiding belief that things are okay, and will be okay. If something happens that things are okay, they will be okay again. I’m alright, I know I can get what I need from other people. That is what you want them to have, you do not want them to have doubts about that, uncertainty, ambiguity. So once they have that in the bank, which they can usually get in the 1st 2 or 3 years, then it is not the same type of a problem to start going back and forth.”

And, as such, I hope that all parents do not want to put their children at risk.


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