Therapeutic Interventions

1. Verbalize an accurate understanding of the dynamics of and constructive approaches to coping with childhood attachment disorder. (1, 2)

1. Refer the parents to organizations, literature or Web sites that describe attachment disorder and offer support for affected families (e.g., Attachment Center at Evergreen, (303) 674-1910, www.attachmentcenter.org; Families by Design, (970) 9842222, www.attachment.org.

2. Assign the parents to read books focusing on parenting children with attachment disorder (e.g., When Love Is Not Enough by Thomas or The Whole Life Adoption Book by Schooler.

2. Describe the unattached child's behavior and its affect on the family. (3, 4)

3. Define goals for addressing the problematic behavior of the unattached child. (5, 6)

4. Attend parenting classes, workshops, and seminars that teach strategies for parenting troubled children.

3. Assign parents to complete a normed behavior scale describing the child with symptoms of unattachment from their perspective (e.g., Child Behavior Checklist by Achenbach, or the Randolph Attachment Disorder Questionnaire [RADQ] by Randolph).

4. Ask the family members to describe in behavioral terms how the unattached child impacts the functioning of individuals and the family as a whole.

5. Help the family members define short-, mid- and long-term goals for successful family functioning; caution them that expectations should be clearly stated and obtainable.

6. Assign the parents to list immediate and midterm goals for their unattached child (or assign them the "Steps to Responsible Behavior" activity from the Parenting Skills Homework Planner by Knapp).

7. Refer the parents to a parenting class (e.g., Systematic Training for Effective Parenting (STEP) by Dinkmeyer and McKay) to acquire basic techniques of positive discipline to use with their children.

8. Help the parents initiate parenting strategies of positive discipline learned in parenting classes, seminars, and from recommended parenting books or tapes (e.g., Your Defiant Child: Eight Steps to Better Behavior by Barkley).

5. Structure the household environment to reduce the opportunity for the unattached child's disruptive and problematic behavior. (9, 10, 11, 12)

6. Formulate a system of discipline that identifies clear boundaries, establishes household rules, and promotes responsible behavior. (13, 14, 15, 16)

9. Assist the parents in planning to structure the home environment to reduce the unattached child's disruptive and destructive behavior (e.g., put locks on bedroom doors, food, and toy cabinets; create a safe and sparse time-out area).

10. Encourage the parents to buy healthy food for the home and model healthy eating habits for the children.

11. Advise the parents to establish areas where food is allowed and not allowed, and to require that eating take place in designated areas only.

12. Instruct the parents to "establish respect through speech patterns" (see When Love Is Not Enough by Thomas) by maintaining eye contact, engaging in listening exercises, using firm directions, and insisting on a polite, correct response.

13. Teach the parents how to implement relevant consequences to help the child learn more appropriate behavior patterns (e.g., chores not done leads to loss of television time, late for curfew or bedtime leads to earlier time next night).

14. Assign the parents to create a list of privileges that the unattached child must earn by demonstrating appropriate behavior (e.g., watching television, playing in yard, having toys in bedroom).

15. Instruct the parents to describe the specific positive behavior

7. Devise strategies for administering love, support and nurturing in the face of resistance and rejection from the unattached child. (17, 18, 19)

Siblings i mplement l imit-setting and structured rules for coping with the unattached child. (20, 21)

they want to see (e.g., "Please hand me the book.") rather than the negative behavior they want to eliminate (e.g., "Don't throw the book at me.") when correcting their child.

16. Advise the parents to use very restricted choices to share control with the unattached child (e.g., popcorn or an apple, red shirt or blue shirt, hold mom's hand or dad's hand); explain that unlimited choices (e.g., "What do you want to eat or wear?") confuse and frustrate the unattached child.

17. Encourage the parents to engage the unattached child in activities which promote attachment (e.g., snuggle time, playing games that require interaction, nightly prayers) for a designated period of time each day.

18. Assign the parents to read Holding Time (Welch) to understand the technique of personal touch in promoting the bonding process.

19. Ask the parents to promote feelings of continuity with the unattached child's past by sharing baby and family pictures, telling early childhood stories, recounting the child's first few years of life and connecting with significant others from the past if appropriate.

20. Teach the siblings to set limits with the unattached child (e.g., share only unbreakable toys, game over when rules are

9. Siblings verbalize their successes in establishing a positive relationship with their unattached sibling. (22, 23)

10. Monitor the frequency of the unattached child engaging in positive, target behaviors. (24, 25)

11. Engage in pleasurable, relaxing activities and interests apart from the problematic family issues. (26, 27)

broken, seek adult assistance when behavior becomes threatening.

21. Discuss problematic sibling interactions with the unattached child and siblings and brainstorm solutions (e.g., time-limit interactions; set up a bathroom schedule; keep possessions in safe, designated areas).

22. Instruct the siblings to log interactions with their unattached brother or sister and record interventions that lead to a successful outcome.

23. Assign the unattached child and siblings to keep an ongoing list of activities that create a feeling of attachment and kinship (e.g., one-to-one chats, high fives, daily greetings).

24. Caution the parents against trying to correct too many behaviors at once and instruct them to identify one or two negative behaviors and prioritize them for change.

25. Help the parents to create a color graph to monitor the progress made by the unattached child in several behavioral areas (or assign the parents to complete "The Behavior Progress Chart" in the Parenting Skills Homework Planner by Knapp).

26. Encourage the parents to give themselves and each other time and permission to pursue personal interests and hobbies apart from work and family obligations as a respite from family stress.

Establish a network of support and respite based on understanding family, friends, and professionals. (28, 29, 30)

Agree to work together to solve all family problems. (31, 32)

27. Assign the parents to engage in, as a couple, at least one social activity apart from their child or children per week.

28. Instruct the parents to list their personal and family resources for respite from the unattached child (e.g., friends, family, church members) and to utilize them on a regular basis.

29. Encourage the parents to educate their support groups on the specific strategies recommended for dealing with an unattached child and the essential need for respite.

30. Help the parents access community resources for respite from the unattached child (e.g., social services, support groups, community mental health agencies, Head Start, preschool programs, special education programs).

31. Advise the parents of the importance of a unified front when dealing with the unattached child; encourage them to discuss all areas of disagreement privately or during counseling sessions and to develop a mutually acceptable plan before addressing the problem.

32. Instruct the parents to identify and address areas where the unattached child uses triangulation to divide and control the environment (e.g., lying, asking permission from other parent after being told no, creating conflict between parents and school, relatives, or siblings).

14. Implement strategies for coping with the stress associated with living with an unattached family member. (33, 34, 35)

15. Celebrate family progress and successes in overcoming the trauma of attachment disorder. (36, 37, 38)

33. Encourage the parents to remain in counseling for personal and family support while coping with the stress and constant trauma of living with an unattached child.

34. Assign the parents to engage in one or more affective strategies for stress reduction (e.g., journaling, assertiveness training, using humor, giving personal or mutual affirmations).

35. Instruct the parents to pursue faith options that offer guidance and support during times of trauma (e.g., attending faith based services, spiritual readings, prayer, healing rituals, quiet meditation).

36. Instruct the parents to remain alert to the signs of progress in their unattached child and to record them in the family journal.

37. Caution the parents that overreaction to the unattached child's positive behavior can cause regression; instruct them to recognize positive behavior with low-key affirmations given to the child and to celebrate the progress wildly in their own hearts.

38. Assign the unattached child and siblings to recognize progress in behavior or relationships by entering a photo, drawing or paragraph in the family journal.

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