Smith ScholarWorks Theses, Dissertations, and Projects 2014 The benefits of child-centered play therapy and filial therapy for pre-school-aged children with reactive attachment disorder and their famiies Andrea S. White Smith College Follow this and additional works at: https://scholarworks.smith.edu/theses Part of the Social and Behavioral Sciences Commons Recommended Citation White, Andrea S., "The benefits of child-centered play therapy and filial therapy for pre-school-aged children with reactive attachment disorder and their famiies" (2014). Masters Thesis, Smith College, Northampton, MA. https://scholarworks.smith.edu/theses/846 This Masters Thesis has been accepted for inclusion in Theses, Dissertations, and Projects by an authorized administrator of Smith ScholarWorks. For more information, please contact [email protected]. Andrea White The Benefits of Child-Centered Play Therapy and Filial Therapy for Preschool-Aged Children with Reactive Attachment Disorder and Their Families ABSTRACT The purpose of this study was to investigate, from a theoretical perspective, the best treatment approach for preschool-aged children with Reactive Attachment Disorder. The challenges and needs of these children can be extensive, and the search for effective treatment is ongoing. Two specific questions of focus were: How are the theories behind Non-Directive Play Therapy/Child-Centered Play Therapy and Filial Therapy useful in conceptualizing the experience of therapy for a child with attachment disorder? And, how could these treatments be used to benefit children with attachment disorders and their families? The research for this paper involved a literature review of peer-reviewed articles on Reactive Attachment Disorder (RAD) and treatment, original sources describing Attachment Theory, Non-Directive Play Therapy and Filial Therapy, and the DSM-IV-TR and ICD-10. Both types of therapy were found to be helpful for children with RAD because they create a therapeutic relationship that encourages secure attachment, allow children to process trauma as needed, and provide conditions which help children build affect-regulation, improve self-concept and regain healthy development. Filial Therapy showed an additional benefit in training parents to provide ideal caregiving conditions. A comprehensive assessment and treatment program, utilizing aspects of both treatment types was suggested for children with Reactive Attachment Disorder and their families; it includes the potential for use in clinical settings, child welfare investigations and with foster and adoptive families. THE BENEFITS OF CHILD-CENTERED PLAY THERAPY AND FILIAL THERAPY FOR PRESCHOOL-AGED CHILDREN WITH REACTIVE ATTACHMENT DISORDER AND THEIR FAMILIES A project based upon an independent investigation, submitted in partial fulfillment of the requirements for the degree of Master of Social Work. Andrea White Smith College School for Social Work Northampton, Massachusetts, 01063 2014 Table of Contents TABLE OF CONTENTS .............................................................................................. i CHAPTERS I INTRODUCTION ................................................................................................ 1 II CONCEPTUALIZATION and METHODOLOGY ............................................. 6 III PRESCHOOL-AGED CHILDREN (AGES 3-6) with ATTACHMENT DISORDERS ........................................................................................................ 9 IV NON-DIRECTIVE PLAY THERAPY/CHILD-CENTERED PLAY THERAPY 49 V FILIAL THERAPY .............................................................................................. 93 V DISCUSSION/CONCLUSIONS ......................................................................... 143 REFERENCES ............................................................................................................. 173 i Chapter I Introduction This paper will look at the challenges faced by preschool-aged children with Reactive Attachment Disorder (RAD) and their families, and investigate types of therapy that may be most beneficial to this population. Attachment is crucial to multiple areas of child development. In infancy a positive secure attachment provides security, safety and comfort within the parental bond. For children between the ages of three and six, the importance of this infant attachment becomes increasingly observable in multiple developmental areas. Psychological, social, emotional and intellectual competency can be seen in the behavior of securely attached children entering preschool or daycare during these ages. However, children who develop insecure attachments often have less success in their development, with the most extreme difficulties being related to disordered attachment. Reactive Attachment Disorder is, by definition, the result of abuse, physical or emotional neglect, or lack of a consistent caregiver, such as experienced in under-staffed orphanages or multiple changes in foster placements. Symptom description shows a lack of age-appropriate social interaction with others, most significantly with regard to parents or other primary caregivers. Social inhibition may be observed in contradictory patterns of approach, avoidance, appearing to freeze in fear and resisting comfort even when distressed. Disinhibited sociability may be demonstrated through charming or friendly behavior toward many adults without concern for safety (i.e. leaving with a stranger) and lack of a deep, emotional connection with a parent or primary caregiver. This history of fearful or unavailable caregivers as well as multiple 1 related behavioral symptoms must be present before the age of five to be considered for the diagnosis. Children with attachment disorders have multiple needs and challenges. Direct manifestations related to a lack of positive attachment experiences include: difficulty in regulating affect and behavior, problems with social relationships and developmental losses in self-awareness and self-concept. In addition, children who have experienced abuse and neglect often suffer traumatic symptoms, and grieve the loss of the biological parents from whom they have been removed. Children who have been moved through multiple foster placements typically have histories involving abuse, neglect and loss as well. These children often have co- existing attachment and trauma symptoms and/or disorders. Children raised in large, under- staffed orphanages have additional conditions and syndromes related to the severe deprivation (ie. insufficient food and medical care, complete lack of stimulation and touch) present in such places. While not directly related to attachment issues, co-occurring diagnoses of attentional problems, aggression, stereotypies and language delays are often found among these institutional-care populations. Further, parents who adopt children with RAD often find it hard to cope with their child’s behavior, misunderstand the child’s psychological experiences and needs, and feel rejected by them. The need for effective treatment for this population is clear. Whether working within the foster care system, carrying out home visits, or in a clinical setting, social workers will no doubt have these children among their client populations. The field of social work is dedicated to the care of such disadvantaged populations as children with RAD and their families. The literature describes two general categories of successful intervention for children with attachment disorder. First, removal from the abusive, neglectful and/or attachment- 2 deprived caregiving environment to a place where a reliable, empathic, attentive, primary caregiver is consistently available can result in considerable improvements in attachment security and healthy development (Morrison & Elwood, 2000). This is especially true for children removed to the optimal caregiving environment by the age of two; children may need more professional help if they remain in very poor caregiving situations much beyond that age (Morrison & Elwood, 2000). Second, therapy for this population may have an impact in ameliorating barriers to healthy attachment in early childhood development. However, as noted by Boekamp (2008), our understanding of what constitutes effective treatment at this point is still evolving. For instance, in the 1980’s and 1990’s many therapists circulated a general clinical belief that these children were impossible to treat, based on clinical experiences in which types of child therapy typically used with other populations were largely unsuccessful (Boekamp, 2008; Chaffin et al., 2006; O’Connor & Zeanah, 2003). As a result, more extreme forms of “attachment therapies” were developed and their use rationalized, despite any clear evidence for their success. “Rage reduction,” “holding therapy” and “re-birthing” are three such therapies that became controversial due to their use of physical restraint (ie. being tightly wrapped in a blanket or held down forcefully by the therapist or parent), and provocation to anger or crying (via poking, yelling at and/or demeaning the child). There is now a general consensus that these treatments should be avoided due to deaths of children and risk of psychological traumatization (Boekamp, 2008; Heller et al., 2006; VanFleet, 2006; Zilberstein, 2006). Thus, the search for successful treatments for children with Reactive Attachment Disorder continues. Behavioral therapies appear to show success in temporarily retraining outward behaviors related to RAD, but their use in providing