Attachment-Focused Treatment Institute

A collaboration between the Academy for Human Development’s Graduate Counseling program (a University in Singapore) and the Center for Family Development. This Institute provides training and certification in Attachment-Focused Therapy, Attachment-Focused Family Therapy, and certification as an Attachment-Focused Professional (for residential treatment center milieu staff, teachers, therapeutic foster parents, occupational therapists, and others who wish to use attachment-facilitating methods in their work.
In addition, the Institute providers certification for organizations (Group Homes, Foster Care agencies, Residential Treatment Centers, Wilderness Program, and Therapeutic Boarding Schools as a Certified Attachment-Focused Organization.

The Dyadic Developmental Psychotherapy Primer

The Dyadic Developmental Psychotherapy Primer is now out in print and Kindle at Amazon.  This book describes the principles of Attachment-Focused Treatment, the components of treatment, and the differential use of those 14 components in the five phases of treatment.  It is essential a treatment manual, with many clinical examples, describing the essential elements of attachment-focused family therapy.  

Attachment-Focused Treatment Institute

The Center for Family Development, in conjunction with a University, the Academy of Human Development in Singapore, has opened the Attachment-Focused Treatment Institute. The Institute offers three levels of certification:
Attachment-Focused Therapist
Attachment-Focused Family Therapist
Attachment-Focused Professional

The Attachment-Focused Treatment Institute was founded to provide training and certification in treatment methods based on attachment theory. Attachment-Focused Treatment includes psychotherapy, family therapy, and work by other professionals using the principles of attachment theory to guide interventions, treatment, and programs.

Certification is offered in conjunction with the Academy of Human Development, a university in Singapore, and The Center for Family Development. CEU’s are awarded through the University and the Board of Psychology, Indiana.

There are three Certifications offered: Certified Attachment-Focused Therapist, Certified Attachment-Focused Family Therapist, and Certified Attachment-Focused Professional. The Therapist Certification is for mental health providers. The Professional Certification is for residential treatment center staff, therapeutic foster carers, educators, and others who wish to use Dyadic Developmental Psychotherapy and Attachment-Focused Treatment methods in their work.

Certification by the Institute means that the professional has completed a comprehensive course of advanced study in the application of attachment theory and the latest advances in interpersonal neurobiology to treatment, parenting, programming, and practice.

Attachment-Focused Treatment is grounded in attachment theory, the neurobiology of interpersonal experience, and uses methods and principles from Dyadic Developmental Psychotherapy.

Dyadic Developmental Psychotherapy is an evidence-based, effective, and empirically validated treatment that is grounded in current thinking and research on the etiology and treatment of Complex Trauma or Developmental Trauma Disorder and disorders of attachment. It is now recognized as a general approach to treatment. Treatment is primarily experiential. Teaching parents about attachment-facilitating parenting methods and the importance of attunement and responsive, sensitive parenting is essential.
STEPS TO BECOME CERTIFIED
There are two components to certification. The first is completion of the required number of approved training hours (48), which can be completed through the SKYPE Master Class. The second is the consultation component in which the applicant’s work is reviewed to assess how the material is being applied in practice.

Attachment-Focused Therapist & Attachment-Focused Family Therapist
1. Complete 48 hours of training
2. Provide evidence that you are authorized to practice in your jurisdiction, evidence of applicable insurance, singed attestation form.
3. Completion of the Consultation-Practicum: review of a minimum of six DVDs.

Attachment-Focused Professional
1. Complete 48 hours of training.
2. Letter from your supervisor approving your participation in the Institute’s certification program.
3. Completion of the Consultation-Practicum: review or observation of a minimum of four DVDs.

Certification is valid for three years. Re-certification requirements include either attending an Advanced Practice Seminar (3 hours) or having one DVD illustrating your work reviewed by a consultant.

Attachment Focused Therapy Video

The Association for the Treatment and Training in the Attachment of Children has a wonderful new video about Attachment Focused Therapy. You can view it here. This video is a must see for parents and professionals. It describes the latest information on evidence-based, effective, and empirically validated treatments for Complex Trauma, Reactive Attachment Disorder, and other disorders of attachment. The speakers and presenters are internationally recognized experts in the evaluation and treatment of these conditions.

See the video here.

Dyadic Developmental Psychotherapy: Acknowledged in UK as Effective

IN an exciting development, the Institute for Research and Innovation in Social Services, recognizes Dyadic Developmental Psychotherapy as an evidence-based, effective, and empirically validated treatment. The Institute is a large, internationally regarded institute whose function is to promote positive outcomes in the social service field by identifying evidence informed practice and disseminating research, innovations, and improvements in social services policy, practice, and programming.

The Institutes most recent report, “Insights: Attachment-Informed practice with looked after children and young people, had the following key points:

Attachment behaviour ensures the survival of infants and young children by keeping their caregivers close and available to provide protection and comfort. The attachment relationship provides the context for the main developmental tasks of infancy and early childhood, particularly emotional regulation and the development of the capacity to ‘mentalise’.

The characteristics of caregivers affect the organisation and security of children’s attachment relationships with them. Sensitive, responsive parenting and parental ability to reflect on the infant’s own thoughts and feelings are associated with secure attachments in children.

Children who have experienced maltreatment are significantly more likely to develop disorganised
attachments and these can have lifelong physical, emotional and social consequences.

Recent evidence from neuroscience confirms the importance of the early emotional and social experience of
infants for the healthy development of their brains. Maltreatment can disturb the patterns of cortisol
(stress hormone) secretion which can affect immediate and long term mental and physical health.

Looked after children benefit from developing secure attachments with their caregivers and interventions
should support the development of these, whether children remain at home or are cared for outside their family.

Successful placements are more likely when carers are able to respond to children at their emotional age
rather than their chronological one. Interventions with children should aim to address developmental brain
impairment by providing care that can build fundamental brain capacities. For looked after children this will mean less use of verbal techniques and a greater concentration on physical, sensory and emotional ways of working.

Caregivers should be assessed on their capacity to tolerate difficult behaviour and remain sensitive and
responsive to the needs of children.

Support and training should be provided to caregivers on a frequent and regular basis to ensure that they are able to maintain their capacity to be reflective about children rather than reactive to their behaviour.

Attachment-informed practice may require a policy and culture shift to ensure that children’s needs
are appropriately met when they are cared for away from home.

As you can see their key point that carers should respond to children based on their emotional age rather than their chronological age is supported by our study revealing that children with Complex Trauma and disorders of attachment are substantially younger developmentally than their chronological age:
Becker-Weidman, A., (2009) “Effects of Early Maltreatment on Development: A Descriptive study using the Vineland,” Child Welfare, 88 (2)137-161.

The Institue’s paper goes on to state it’s support for Dyadic Developmental Psychotherapy as an evidence-informed and validated treatment approach:
Dyadic Developmental Psychotherapy is an attachment-focused approach in which a therapist supports the caregiver and child’s relationship and the development of secure attachment by encouraging the reflective function of the caregiver, enabling attunement, regulating emotion and co creating meaning. The therapist
interactions are characterised by PACE (playfulness, acceptance, curiosity and empathy) and similar qualities are supported in the caregiver with the addition of love (PLACE). This approach has been well evaluated with foster carers and adoptive parents and recently elements of this model have been successfully introduced within residential child care (Becker-Weidman and Hughes, 2008).

Becker-Weidman, A., & Hughes, D., (2008) “Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment,” Child & Adolescent Social Work, 13, pp.329-337

Disclosure: What is required?

The lawsuit described in a recent New York Times article by Pam Belluck raised important questions regarding the disclosures that should be made by adoption agencies to their adoptive families.

At the Center for Family Development we frequently find that families have not been fully or adequately informed regarding the mental health, health, and psychological status of the child they are wanting to adopt. In many instances the agency has not informed the family of the potential risks and issues that may be presented. We find that this lack is more common in international adoptions, and particularly in those programs that bring a child to the US for a few weeks for “camp,” with a family, and more often with adoptions from Russian and Eastern Europe. We do find that agencies doing domestic adoptions of children in the child welfare system seem to do a more comprehensive job of fully informing parents of actual and potential issues.

By Pam Belluck
New York Times
Apr 28, 2010

Scores of complaints have been made in recent years against adoption agencies by people claiming they were inadequately informed or ill-prepared for problems their children turned out to have.

Many state laws and the Hague Convention now require agencies to disclose “reasonably available” records. But it can be unclear, especially in international cases, how assertive they are expected to be in getting such information.

The case of Chip and Julie Harshaw of Virginia Beach is, in some ways, the reverse of the now-familiar story of a Tennessee mother who put her Russian-born child on a plane home: The Harshaws are committed to raising their Russian son, even though they say they would not have adopted him had they known how severely impaired he was. But when they decided to adopt, the Harshaws told their agency they could care only for a child with minimal health problems and “a good prognosis for normal development,” according to notes in the adoption agency’s paperwork.

They rejected one child because he had abuse-inflicted burns. But when a toddler in a Siberian orphanage appeared to fit their criteria, they brought the boy, Roman, home. ” ‘A beautiful, healthy, on-target, blond-haired boy’ was what they had quoted to us,” Julie Harshaw said.

After the adoption in 2004, Roman began showing “uncontrollable hyperactivity” and aggression, Julie Harshaw said. He has threatened their 5-year-old biological daughter with a steak knife and a two-by-four, and held her underwater in a pool. Their 13-year-old biological son has felt so much stress that he has required therapy.

Therapeutic programs have ejected Roman for kicking, biting, hitting and, most recently, on his 8th birthday, pulling out three of his teeth using a pen cap, fork or spoon.

Doctors finally diagnosed fetal alcohol spectrum disorder, brain damage and neuropsychiatric problems in Roman, whose IQ is 53. He was recently placed in an institution and is not expected to ever live independently, one of his doctors said.

The Harshaws are suing the agency, Bethany Christian Services, seeking compensation for the care Roman will need.

After Roman’s problems were diagnosed, the agency offered to end the adoption, to try placing Roman with another family. The Harshaws refused. “He’s not a dog; you don’t take him to a pound,” Julie Harshaw said.

The family claims that Bethany indicated, inaccurately, that a Russian doctor working for the agency had examined Roman, and that Bethany gave them incomplete medical information when more detailed records were available. (Such records were produced by Bethany more than two years later.)

Bethany, which calls itself “the nation’s largest adoption agency,” disputes most of the claims.

“Bethany is a highly respected adoption agency that provided all the appropriate information for consideration by the Harshaws,” said Mark Zausmer, a lawyer for Bethany, based in Michigan. “Bethany provided this family counseling, extensive documentation, opportunities to consult with physicians, medical records and other materials from which they could fully evaluate how to proceed.”

No organization tracks the number of cases against adoption agencies, and academics and industry officials say many are settled out of court and sealed, so the outcomes are unknown.

But these days, “a far greater percentage of these wrongful adoption suits relate to international adoptions,” said Marianne Blair, a University of Tulsa law professor.

Chuck Johnson, acting chief executive of the National Council for Adoption, an advocacy group, said, “There have been a growing number of families that have sued when they adopted a child from another country.”

Some lawsuits, Johnson said, come from families “expecting you to do the impossible when you did all you could,” but he said there had also been “agencies that have purposely concealed information.”

Issues of disclosure have drawn increasing attention in recent years. Lawsuits erupted in the 1980s over domestic adoptions in which histories of abuse and other problems were kept from adoptive parents.

“The philosophy was the blank slate, that adoption is a new start,” Blair said. Now, she said, experts believe that “disclosure of health information is vital.”

As a result, many states enacted disclosure laws, followed by similar requirements in the Hague Convention, which apply to countries that ratify the treaty, as the United States did in 2008. Russia has signed the agreement but has not yet ratified it.

Those regulations were developing as the Harshaws’ adoption was proceeding, and at most agencies, “the atmosphere was definitely an emphasis in getting what could be obtained and making sure that they disclose that,” said Joan H. Hollinger, a law professor at the University of California, Berkeley, who is serving as an expert witness for the Harshaws. Agencies were also focused on “preparation of adoptive families for what they might encounter,” Hollinger said.

Bethany says it clearly advised the family that children from Russia could have problems, including serious ones, and that records might be inaccurate.

While the Harshaws’ pediatrician raised overall risks after reviewing a video of Roman and a two-page medical summary, observing that some of the notations could indicate learning disabilities, she saw no specific indications of severe problems on the pre-adoption records provided. She noted a lack of detailed, up-to-date information and said she could not see Roman’s face clearly. (Facial characteristics may provide clues to health deficiencies.)

“They were warned about generalities,” said their lawyer, Samuel C. Totaro Jr., but the agency caseworker told them a Russian-trained doctor based in New York had “gone over there and seen him, and you have a healthy, on-target child, and the family took great reassurance from that.”

In a deposition, the caseworker acknowledged she had said that the doctor, Michael Dubrovsky, visited the orphanages to “see the children” and review pictures, videos and medical information. The agency says the Harshaws misinterpreted that to mean Dubrovsky had examined Roman.

In a deposition, Dubrovsky said he had never seen Roman, had not practiced medicine for years and was a facilitator for Bethany, not a medical screener.

The agency also suggests that the fetal alcohol syndrome was unlikely to have been detected before the adoption, noting that the Harshaws did not receive that diagnosis until two years later.

Zausmer said the agency did not conceal information and provided a translated synopsis of the Russian medical records that was standard at the time.

“We don’t believe that there was anything in the Russian records that would have materially affected any adoption decision,” Zausmer said.

But Dr. Ronald S. Federici, a neuropsychologist who diagnosed Roman’s illness, said the full 10-page medical record the agency produced after the adoption, at the parents’ urging, would have shown that “the boy had fetal alcohol syndrome.”

The Harshaws hope the institution can stabilize Roman enough to send him home; either way, he will need extensive lifetime care.

“What we’ve been through and what we’ve lost,” Chip Harshaw said. “Every day is ‘Groundhog Day,’ a repeat of the stress and anger and frustration.”

Bipolar disorder in Children: Over-diagnosed?

Is Bipolar Disorder being over-diagnosed in children?

Many people erroneously argue that it is, so let’s take a look at the evidence. First, I am talking about children aged five years into adolescence who actually meet the full DSM-IV criteria for Bipolar Disorder. I am not discussing children who only have irritability or aggression without any other manic criteria.

FACTS:
In 1994/1995 the frequency of the Bipolar Diagnosis was 25 cases per 100,000. In 2002/03 the frequecny increaed over forty-fold to 1003 cases per 100,000. (See: National Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in Youth, Carmen Moreno, MD; Gonzalo Laje, MD; Carlos Blanco, MD, PhD; Huiping Jiang, PhD; Andrew B. Schmidt, CSW; Mark Olfson, MD, MPH, Arch Gen Psychiatry. 2007;64(9):1032-1039.)

Put another way, the diagnosis of Bipolar Disorder rose from 0.01% in 1994 to 0.44% in 2002. That is certainly a 40X increase, but is it really over-diagnosis?

The standard method to estimate the actual prevalence of psychiatric conditions is to conduct an epidemiological study, where trained researchers study large representative samples of the general population (not preselected clinical samples) with standardized, validated instruments (like the SCID or MINI or CIDI) to assess and diagnose the general population using DSM-IV criteria (not just irritability or aggression in children as bipolar disorder, for instance). Using those methods in over 5000 persons, the most recent analysis (see: Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication
Ronald C. Kessler, PhD; Patricia Berglund, MBA; Olga Demler, MA, MS; Robert Jin, MA; Kathleen R. Merikangas, PhD; Ellen E. Walters, MS, Arch Gen Psychiatry. 2005;62:593-602.) reports a one year adult prevalence of bipolar disorder (types I and II) of 3.9%. In an analysis of age of onset in the same citation above, the study found that bipolar disorder began before adulthood in a substantial minority of persons: in 25% of persons, it began by age 17, in 10% it began by age 13.

Let’s do the math now and see what results. Excluding the adolescents up to age 17, and using the lower range of the NCS data:
If 10% of bipolar disorder begins by age 13, and 3.9% of the total population is diagnosable with the condition using DSM-IV criteria in a community-based epidemiological study of actual prevalence, then how many children should that clinical study have diagnosed with bipolar disorder? 0.10 multiplied by 0.39 is 0.039, or 0.39%. If we round to 0.4%, then we have the actual prevalence of bipolar disorder in children. The vaunted 40-fold increase from near zero led to the diagnosis being made in 0.4% of children based on percentage of office visits.

0.39% is about the same as 0.44%, so the purported evidence for over-diagnosis seems underwhelming, to say the least.

ATTACh

The Association for the Treatment and Training in the Attachment of Children has achieved a number of major accomplishments recently. In addition to preparing and publishing a Therapeutic Parenting Manual, A Clinical Practice Manual, and a wonderful DVD, it wrote an influential letter to the DSM V committee advocating for the inclusion of a diagnosis of Developmental Trauma Disorder. This is exciting work. This international association, with members from across the US, Canada, Europe and Asia is quite influential. Parents and professionals should visit the website of Association for the Treatment and Training in the Attachment of Children.

The organization is now working on a number of projects that will benefit therapists and parents.

Anticonvulsants: Potential risks

Certain anticonvulsant drugs could be associated with an increased risk of suicide, attempted suicide or violent death. Anticonvulsants are used to help people with epilepsy but can also be prescribed for bipolar disorder, mania, neuralgia, migraine and neuropathic pain. Researchers from Harvard Medical School analyzed data from 14 states about patients fifteen-years old and over who started taking anticonvulsants between July 2001 and December 2006. They found that the risk of suicidal acts was increased for gabapentin (Neurontin), lamotrigine (Lamictal), oxcarbazapine (Trileptal), tiagabine (Gabitril) and valproate (Depakote).

You can find out more about this research at

http://psychcentral.com/news/2010/04/15/broadly-used-seizure-meds-may-increase-suicide-risk/12858.html

How does Attachment develop?

The attachment system evolved over time to ensure the survival of the infant. The attachment system is a biologically based system found in nearly all mammals. The attachment system operates in a manner similar to your home heating and cooling system. If the temperature is just right, nothing happens. Only when the temperature goes outside of preset bounds does your heating and cooling system turn on. The same type “homeostatic” process is at the core of the attachment system.
In its most simple form, the attachment system is a proximity seeking system. When the child feels some threat, the child gravitates toward the preferred caregiver, who is most likely to care for and protect the child. This is how the attachment system evolved as a means of ensuring the survival of the vulnerable infant and child. The attachment system and the exploration system operate like a see-saw. If one is activated, the other is deactivated. When the child feels safe and secure, the exploration system is active. When threatened, fearful, anxious, the attachment system is active.
Attachment behavior, which is proximity seeking behavior, is exhibited throughout the life cycle. The toddler, when threatened, will go to the parent, maybe grab the parent’s leg, hide behind the parent, or in some other way make contact with the parent. Once the child feels safe, the child will then go about exploring the environment (playing). An example of attachment behavior in a young adult can be seen in the actions of a young student away at college on 9/ll 2001. On that day the student called home several times during the day to give her parents “news updates” about the unfolding events. Her first call was to, “turn on the TV Dad, a plane just hit the world trade center.” Her second call was, “Mom, did you see, a second plane hit….” And so it went throughout that awful day. Something terrible was happening that was a threat to the girl, and so she felt the need to make contact with her primary attachment figures. For a young adult, the telephone worked fine; while for a toddler, physical contract may be necessary.
So, then, how does this system develop? Remember Erik Erikson’s stages of development? The first stage, Trust vs. Mistrust? During this stage the foundation of attachment and patterns of attachment emerge. Infants cannot easily regulate themselves and they need a caregiver to regulate them. The normally sensitive parent responds to the child’s cries, figures out what is wrong, and then responds to meet the need. When this happens is a fairly regular and consistent manner the child learns, experientially, several important things. The child learns that the world is largely a benign place. The child learns that discomfort will be remedied before it gets too bad; this forms the basis for impulse control. The child learns that its needs will be met in a timely manner. The infant learns that caregivers are largely reliable, good, and helpful. And the child learns that the child is valued, valuable, loved, and loveable.
During the toddler years, which are about shame, the child is ambulatory, exploring the world, and “getting into trouble,” largely because the child does not recognize dangers. As a result, the caring parent is saying “NO!” a lot; to protect the child. When the parent sets this sort of limit, the child experiences shame. The child may cry, hide, cover the child’s face, or in some other manner evidence shame. Shame is about who you are and when we feel shame, we hide. The normally sensitive parent responds by comforting the child while setting the limit. “It’s ok, sweetie, I don’t want you to grab that cup because it is very hot and you could hurt yourself.” The child looks at the parent, experiences that the parent is not angry at the child, and then the parent repairs the relationship and reconnects with the child. When this happens repeatedly, the child moves from shame to guilt. The child learns, experientially, that while the child is loved and loveable, it is what the child does, not the child, that is upsetting the parent. Guilt is about what you do; shame is about who you are. When you feel shame you hide; when you feel guilt you want to confess and fix it.