• Introduction
• Treatment
• The Studies
• The IACD Extended Care Study
• Results of the IACD Study
• Table 1 Mean CBCL Scores
• Table 2 Number of Children with Clinically Elevated Subscale Scores
• Table 3 Mean Scores according to Sub-Groups Placing Parents Rate Throughout
  IACD Parents Rate 6 & 12 months
• IACD Extended Care Study Discussion
• Dr. Myeroff 's Study
• Dr. Myeroff 's Study Discussion
• Summary and Conclusions
• References

For the past several years, The Attachment Center at Evergreen, now known as The Institute for Attachment & Child Development, aka, IACD, has played a major role in research that investigates the effectiveness of attachment therapy as provided by IACD (to be discussed in detail below). In particular, IACD research has investigated the effect that attachment therapy has on reducing aggressive and delinquent behavior in children with attachment disorder. This section will provide a brief summary of the preliminary findings of two separate studies conducted under the auspices of IACD; a study of children who were admitted to the extended care program at IACD (the results of this study were compiled and prepared by Liz Randolph, PhD), and a study of children who received two weeks of intensive attachment therapy (conducted by Robin Myeroff, PhD for her doctoral dissertation).

IACD believes that this research is very important to the practice of attachment therapy, as only minimal research has been done in the past in the field of attachment disorder. While there exist hundreds of studies about attachment in general, very little has been done in the area of attachment disorder, and virtually nothing on the effectiveness of holding and attachment therapies. Only a recent descriptive study by Loy Goodwin, PhD (1996) has even attempted to assess this area. Using the Attachment Disorder Symptom Checklist (ADSCL) both before and after a child received two weeks of intensive attachment therapy at IACD, Dr. Goodwin found significant reductions in 18 of the 19 ADSCL symptoms (only eating problems showed no significant treatment effects). However, because the ADSCL is a non-standardized instrument, because of the time at which children were tested at post-treatment (anywhere from one month to one year), and because this study lacked a control group, it is difficult to draw any significant conclusions about the effectiveness of attachment therapy based upon the results of Dr. Goodwin 's study. Her research does indicate that further investigation of this issue is important.

Other research on attachment disorder in general is limited. Dr. Randolph has conducted several studies on the psychological functioning of children with attachment disorder using the Rorschach inkblot test. She compared these children to maltreated children who have no symptoms of attachment disorder to children with behavior problems who have no history of early maltreatment or other factors that could cause attachment disorder, and to children who have depression and/or anxiety disorders. She found that children with attachment disorder function psychologically in quite different ways from children with other disorders, indicating that attachment disorder is a distinct and separate diagnosis than Reactive Attachment Disorder or Conduct Disorder. She has hypothesized that, in contrast to Reactive Attachment Disorder (which describes a lesser degree of psychopathology), children with attachment disorder must meet the diagnostic criteria for both Reactive Attachment Disorder and either Oppositional-Defiant Disorder or Conduct Disorder.

Dr. Randolph also developed the Randolph Attachment Disorder Questionnaire (RADQ) to assess for the presence of attachment disorder, and has conducted a number of reliability and validity studies for this instrument (contact IACD to obtain information on RADQ materials). She found that the RADQ is a reliable instrument for assessing attachment disorder, and that it distinguishes quite well between children with attachment disorder, and those who have conduct disorder, or who were severely maltreated but do not have symptoms of attachment disorder. She is currently conducting research that will assist the DSM committee to develop a more accurate diagnostic category for attachment disorder.

Tim Harlan, PhD conducted a study of severely maltreated children to determine why some of them develop attachment disorder, while others do not. He found three primary differences between these two croups of children: 1) maltreated children who had attachment disorder scored significantly higher on an intelligence test than maltreated children with other disorders (mean difference between groups was 15 points on the WISC full-scale IQ score); 2) maltreated children who had attachment disorder had less interest in other people, and believed that others would not care for their needs; and 3) maltreated children who had attachment disorder showed distinctly different personality traits than maltreated children who had other disorders. He concluded that these differences between the two groups of children indicated that some children are "asterisk" for attachment disorder, while children with more durable personality traits were better able to survive their early maltreatment (they primarily showed signs of posttraumatic stress disorder, depression, and atypical psychosis).

Many other studies of attachment disorder and the effectiveness of attachment therapy are currently under way across the country, as well as in other countries. We await their results with anticipation.

The treatment model used by the IACD has undergone an evolution over the past 25 years. In the early years, most therapists believed that the only way to reach very severely maltreated children who showed frequent destructive, aggressive, and delinquent behavior was with a highly intrusive, confrontational, and intensive approach to treatment that was called rage reduction or holding therapy. Over the past 26 years there have been many modifications in the practice of holding therapy, to the point that most therapists now refer to what they do as attachment therapy. The holding aspect of the therapy now is far less important than the aspect of helping the child to attach to significant adults in his/her life. Most attachment therapists now view attachment therapy as a form of family therapy, while rage reduction and holding therapies focus far more on the child as the problem. This does not mean that attachment therapists view foster/adoptive parents as the cause of the child 's problems, or that some family systems pathology is maintaining the problem. Rather, because of the amount of time spent with parents during the therapy helping them learn effective parenting skills, attachment therapy is a form of family therapy, and parents are virtually always included in every session with a child, although they may often be behind a one-way mirror watching the session (to help stop the child from trying to get them to feel guilty and/or rescue the child). The following description of the way that attachment therapy is conducted at IACD is condensed from the IACD procedure manual written by Terry Levy, PhD and Michael Orlans, MA (1996).

Attachment therapy, as it is practiced at the IACD, is a two-week intensive therapy model often referred to as an "intensive". The referred child, his/her parent(s) or referring agency (if the child has no parents), the treating therapist in the child 's home town, the IACD therapist, and the primary IACD therapeutic foster parent (usually the mother) are all present for 30 hours of therapy over a two-week period. The therapy is broken down into 10 three-hour sessions that take place daily for 10 consecutive working days. Each family entering treatment at IACD is assigned to a therapeutic treatment family trained by IACD, and the child lives with that therapeutic family throughout the two-week intensive period. The placing parents spend time in the therapeutic foster home learning the parenting tactics that are needed to successfully parent a child with attachment disorder, but otherwise have minimal contact with their child during the intensive unless the child is working hard enough in therapy to earn additional time with his/her parent(s). The treatment team also spends at least an hour each day working with the placing parents to help them learn needed parenting skills.

Attachment therapy itself has evolved over the past 25 years to include four basic therapeutic techniques: 1) cognitive restructuring (helping the child to recognize the cognitive errors in his/her thinking and to learn more healthy ways of thinking about him/herself and about others); 2) psychodrama (taking the child through early life events that are acted out by others in the room so that he/she can find better solutions for dealing with the trauma of those events and so have less need to act-out against others); 3) healing the inner child (helping the child to find ways to give voice and support to the severely wounded inner child); and 4) nurturing and re-parenting where the foster/adoptive parents hold the child in their laps and work with him/her to learn that they will not abuse him/her like other parents have done.

Each session closely follows an outline where the parents, home town therapist, therapeutic foster parent(s), and IACD therapist (the treatment team) meet together each day to discuss the child 's history, current behaviors, and progress since attachment therapy began. During the initial session, while the treatment team is meeting with the parent, the child is completing several psychological tests to assist with treatment planning. The meeting with the parents tends to last longer (often 2 to 3 hours) the first day of the intensive, and for shorter periods on subsequent days, depending upon how well the child is responding to the therapy and to living in the therapeutic foster home. After the treatment team has met, the remainder of each session is spent with the child being held in someone 's lap. This is usually by the therapist, but occasionally by both the therapist and therapeutic foster parent, or by the placing parents, depending upon what issue the child is working on. The child sits on someone 's lap with his/her head resting on a pillow, allowing for close proximity between the child and the therapist, for good eye contact to be maintained by the child, and for easy management of assaultive behavior on the part of the child. The therapist contracts with the child to obtain an agreement about what problems the child is having, and what the child is willing to do to work these problems out. After the child has worked through obstacles to attachment, the therapist focuses on helping the child attach to the parents, which forms the basis for future therapeutic endeavors. Psychodrama, cognitive restructuring, healing the inner child, and other nurturing techniques may be used as needed to help the child access and work through unresolved issues from early childhood. The therapist also helps the family to understand the dynamics of how early maltreatment affects perceptual, emotional, and cognitive functioning, and how the child 's worldview needs to change to include the concept that others can be trusted to meet his/her needs.

The child 's hometown therapist is an active participant in attachment therapy, as he/she will need to help the family continue to work on issues once they return home. If a child receives only a two-week intensive, the hometown therapist is taught how to continue to work on attachment issues (usually without holding the child unless he/she has participated in training in attachment therapy) with the family once they return home. If the child is going to stay for extended care at IACD, the treatment team will contact the hometown therapist prior to the child 's discharge from the extended care program to plan for post-discharge therapy. Then, during the time that the child remains in the therapeutic foster home and receives ongoing attachment therapy from the IACD therapist, he/she is usually seen on a weekly basis to continue to work in the manner described above.

The two outcome studies reported in this section both investigated the effectiveness of the IACD treatment model, as described above. The IACD study investigated the effectiveness of treatment for children who received a two-week intensive, and then remained in long-term treatment and a therapeutic foster home for a minimum of three months. When children stay in extended care treatment, they are seen for weekly sessions of attachment therapy that continue to follow the model discussed above. After discharge, therapy continues with the hometown therapist who attended the intensive. Dr. Meyeroff 's study investigated the effectiveness of treatment for children who received only a two-week intensive, followed by ongoing therapy with the hometown therapist as described above.

Because the two studies were done separately, they will be presented separately below. However, before moving to that, we will first describe some common aspects of the two studies. The subjects of the study were children between ages four and fourteen whose parent(s) contacted IACD to receive treatment for attachment disorder in their child. As part of the assessment process IACD uses prior to accepting a child for treatment, parents were asked to complete the Child Behavior Checklist (CBCL; Achenbach, 1993). This instrument served as the pretreatment, post-treatment measure for both studies. The CBCL is completed by adults about a child, and yields eight sub scales that are divided into three categories; internalizing problems (withdrawn, somatic problems, and anxious/depression), general problems (social problems, thought problems, and attention problems), and externalizing problems (delinquent behavior and aggressive behavior). It is a widely used test for measuring behavior problems in children, and has been used in a variety of studies of child behavior. It has good reliability and validity data, and so was appropriate for use in these studies. The IACD study examined the impact of the IACD treatment model on all eight CBCL sub scales, while Dr. Myeroff 's study examined only the two externalizing scales - - delinquent and aggressive behavior.

The results of this study clearly and strongly indicate that attachment therapy, as it is practiced at IACD (combining intensive attachment therapy with therapeutic foster parenting, as well as providing a family focus that helps placing parents learn new ways to parent), is quite effective in reducing the problem behaviors shown by children with attachment disorder. While a minority of children (24%) in this study showed mixed progress or no progress with attachment therapy, with only one exception, these were children with multiple psychiatric problems and neurological limitations, so it could be expected that treatment with such children would be more complicated and might require a longer time interval to show much change. In addition, while about 40% of children in this study continued to have clinical elevations on the social and delinquent problems scales, this was about half the number of children who had originally had clinical elevations on those scales. Thus, children with attachment disorder continue to have some problems even with intensive attachment therapy, but these problems are at a more manageable level for parents, teachers, and others to deal with. These findings are quite exciting, as they are the first research indications (other than anecdotal therapist and parent reports of the effectiveness of attachment therapy) that attachment therapy is effective with this severely disturbed population of children who do no respond well to traditional approaches to psychotherapy (Randolph, 1997). Unfortunately, because there was no control group used in this study, it cannot be determined from these results that attachment therapy was solely responsible for the changes that were found. It was possible that these same changes could have resulted from the passage of time, or from a difference in the child 's living environment. However, given the fact that children with attachment disorder show an idiosyncratic resistance to improving, even with extensive other forms of therapy (Randolph 1997), it was unlikely that the significant improvements found in the present study were due to something other than the therapy. However, further similar research needs to be done that includes a control group so that this question can be answered absent a control group, inferential conclusions cannot be drawn from the results of the present study.

Simple Analyses of Variance (ANOVAs) were used to compare changes in mean scores over time, and Bonferroni pairwise comparisons were used for the post-hoc tests. Table 1 depicts the mean score for each subscale of the CBCL at pretreatment, at the six-month follow-up measure, and at the twelve-month follow-up measure, as well as the level of statistical significance for subscales that showed significant improvement over time.


 Table 1 
 Mean CBCL Scores     Top of Page

The most significant improvements in children 's behaviors were seen after the first six months of treatment, with minor improvements seen from six to twelve months after the start of treatment (only the AGG subscale showed a significant change from six to twelve months; t=2.13, p<.038). Only the SOM (somatic problems) scale did not show significant improvement with treatment, but this was primarily because the children in this study did not have problems in that area to begin with (mean pretreatment score was 59). Five of the eight CBCL subscales showed highly significant improvement (p<.0001) from pretreatment to the six-month follow-up, the WDL (withdrawn) scale showed quite significant improvement (p<.02), and the SOC (social problems) scale also showed significant, although lesser, improvement during this same time period.

Nineteen children (76%) in this study showed improvements in their scores on the CBCL throughout the course of the study, four (16%) remained essentially unchanged, two (8%) showed mixed changes (improved on 34 subscales, no change on 23 subscales & worse on 12 subscales), and none were worse at either the six-month or twelve-month follow-up. Four of the children who did not improve were male (67%, compared to 64%males in the study), and eleven of the eighteen who did improve were male (61%). Of the six children who did not show significant improvement, five had a disorganized subtype of attachment disorder (one in which there are neurological problems and/or psychosis that accompany the attachment disorder, and that make it more difficult to treat). The other child who did not improve had spent the first five years of life in a Romanian orphanage, and was severely impaired with post-institutional syndrome. He was so empty that it was not possible to reach him with attachment therapy.

Thus, extended care treatment at IACD led to improvements on the mean scores into the subclinical range of functioning on most of the CBCL subscales after six months of treatment, and further improvements after one year of treatment. However, this finding does not answer the question of how individual children fared as a result of treatment. Table 2 shows the number of children at each measurement interval who had clinical elevations on each of the CBCL subscales (scores at or above 70).

As can be seen, very few children in this study had somatic problems. Less than half had problems with anxiety and/or depression, and the number of children with clinical elevations on this subscale was minimal at the six-month follow-up assessment. Only 64% of children showed clinically significant signs of withdrawal prior to treatment, and only half of these (28% 32%) were still showing signs of clinical withdrawal at the 6-month and twelve-month follow-up assessments. These three subscales are all from the subgroup of "internalizing problems" subgroup of the CBCL. These findings indicate that children with attachment disorder have fewer internalizing problems, and that such problems, when present, are easily lessened by attachment therapy.


Table 2
Number of Children with Clinically Elevated Subscale Scores    Top of Page

The DLQ (delinquent behavior) and AGG (aggressive behavior) subscales make up the "externalizing problems" subgroup of the CBCL. About the same number of children (and the vast majority of children) had clinically significant elevations on both of these scales at pretreatment. However, as can be seen in Table 2, aggressive behavior decreased more dramatically at the six-month and twelve-month follow-ups than did delinquent behavior. Although the number of children with clinical elevations on the DLQ scale was cut in half by the end of a year, over 40% continued to have problems in this area, while the number of children with clinical elevations on the AGG subscale fell from 92% to 28% over the course of a year. Again, these results indicate that attachment therapy is a highly effective treatment for attachment disorder, but that some problems are more easily treated than are others.

Finally, it is important to divide the subject group in half according to whether or not the placing parents completed all three CBCLs on their child (PPR), or whether IACD therapeutic foster parents completed some of the CBCLs on their child (IPR) to ensure that the differences seen in the results presented above were not unduly influenced by the IACD parents. Table 3 presents the mean scores for the PPR and IPR groups on each subscale and at each time interval.


Table 3
Mean Scores According to Sub-Groups
Placing Parents Rate Throughout
IACD Parents Rate 6 & 12 mo    Top of Page

The results of this study clearly and strongly indicate that attachment therapy, as it is practiced at IACD (combining intensive attachment therapy with therapeutic foster parenting, as well as providing a family focus that helps placing parents learn new ways to parent), is quite effective in reducing the problem behaviors shown by children with attachment disorder. While a minority of children (24%) in this study showed mixed progress or no progress with attachment therapy, with only one exception, these were children with multiple psychiatric problems and neurological limitations, so it could be expected that treatment with such children would be more complicated and might require a longer time interval to show much change. In addition, while about 40% of children in this study continued to have clinical elevations on the social and delinquent problems scales, this was about half the number of children who had originally had clinical elevations on those scales. Thus, children with attachment disorder continue to have some problems even with intensive attachment therapy, but these problems are at a more manageable level for parents, teachers, and others to deal with. These findings are quite exciting, as they are the first research indications (other than anecdotal therapist and parent reports of the effectiveness of attachment therapy) that attachment therapy is effective with this severely disturbed population of children who do no respond well to traditional approaches to psychotherapy (Randolph, 1997). Unfortunately, because there was no control group used in this study, it cannot be determined from these results that attachment therapy was solely responsible for the changes that were found. It was possible that these same changes could have resulted from the passage of time, or from a difference in the child 's living environment. However, given the fact that children with attachment disorder show an idiosyncratic resistance to improving, even with extensive other forms of therapy (Randolph 1997), it was unlikely that the significant improvements found in the present study were due to something other than the therapy. However, further similar research needs to be done that includes a control group so that this question can be answered absent a control group, inferential conclusions cannot be drawn from the results of the present study.

This was a quasi-experimental, prospective study of the effectiveness of two-week intensive attachment therapy. Subjects were recruited for this study when they contacted IACD (between 9/95 and 6/97) to receive treatment for their attachment disordered child. Parents volunteered to participate in this study, having been told that it was being conducted to test the effects of the IACD treatment program on the special needs adoptive child population. Parents were assured that their willingness to participate would not affect whether or not they were accepted for treatment at IACD. They were also told they could drop out of the study at any time without penalty. Eligible subjects ranged in age from four to fourteen years, had all been adopted, and had been living in their adoptive home for at least one year. Potential subjects, who had children with attachment disorder but who, for some reason, could not work out a way to receive treatment at IACD made up the control group for this study. In no case was the family 's inability to receive treatment at IACD due to the condition of the child or parent. This procedure resulted in twelve children (10 males and 2 females) participating in the experimental group, and eleven children (7 males and 4 females) in the control group.

In the experimental group, parents completed the CBCL one week prior to starting treatment at IACD, and then again one week after completing the two-week intensive. In the control group, parents completed the two CBCLs at the beginning and end of a four-week interval (parents were also asked to complete the CBCL four weeks and eight weeks after the intensive, but the results of this later follow-up data were not yet available for publication). For the purposes of the present study, only the delinquent behavior and aggressive behavior subscales of the CBCL were considered.

Both groups were found to have similar profiles with respect to gender, race, pre-adoption placements, age, and income of the adoptive parents. For subjects in the treatment group, there was a statistically significant decrease from pre to post-treatment on aggression (p<.02) and delinquent behavior (p<.006) scores. No significant changes were seen in aggression and delinquent behavior scores for the control group. Thus, the two-week intensive (which the treatment group received and the control group did not) resulted in significant decreases in aggressive and delinquent behavior within one week after the completion of the two-week intensive, indicating the effectiveness of the IACD treatment model.

In the 1940 's John Bowlby (1944) hypothesized that the aggressive and delinquent behaviors seen in children who had experienced prolonged separations from their mothers during the first two years of life was the result of disrupted attachment. In the 1970 's Foster Cline (among others) began to diagnose children with a history of severe maltreatment and severe behavior problems as "attachment disordered". Attachment theory (as defined in this study) hypothesizes that, after a number of repeated parent inconsistencies, the child will internalize negative input from the primary caregiver, and act this out through aggressive and abusive behaviors toward self and/or others. Attachment therapy can disrupt this pattern by creating for the child a representation of a healthy attachment cycle. This occurs in treatment when the therapeutic foster parents and therapist model the healthy attachment cycle by focusing on the importance of eye contact, reciprocity, and cognitive restructuring in helping the child to recover from his/her severe early maltreatment. As the child forms an attachment to the adoptive parents, there is less of a need for the child to act-out with aggressive and delinquent behavior. When, in the session, the child 's anger, sadness, fear, terror, and rage are met with love and understanding from the therapist(s) and caregiver(s), aggression can then transform from instinctualized unbound anger to libidinized anger that has boundaries. The containment and self-regulation of anger become more manageable for the child, allowing for a decrease in destructiveness. Simultaneously, the child internalizes the adoptive mother and begins to trust her. The relationship between the child and mother begins to develop as the attachment bond becomes increasingly secure. It is this shift in the child 's beliefs about the importance of having others in his/her life (based on exposure to the healthy attachment cycle) that allows for an increase in secure attachment, and therefore, the decrease in delinquent and aggressive problems that were found in this study.

This research project sets the stage for many of those working in the field of psychology to seriously evaluate the continued use of attachment therapy with the special needs adoptive population. Clinicians should pay particular attention to the history of the child and his/her surrounding circumstances. These children often present with a variety of possible diagnoses, and show a high co-morbidity rate with attention deficit disorder, bipolar disorder, and personality disorders, which can create a confusing and complicated clinical picture.

This study, while clinically useful, is only one aspect of the therapy, and should be viewed as such. Presently, several other facets of this study are being further investigated and analyzed. Thus, the results discussed here should be considered preliminary.

Both Dr. Myeroff 's and the IACD studies provided strong support for the effectiveness of the attachment therapy provided at IACD. Because the subject groups in both studies were small, and the IACD study lacked a control group, these results should be considered as preliminary, and as indicating a definite need for additional similar research. However, it should also be noted that, to find such highly significant differences in children 's behavior, particularly the reduction of aggressive and delinquent behavior in this very difficult population, in such small subject groups provides very strong support for the effectiveness of attachment therapy as a treatment modality. Both Dr. Myeroff and IACD plan to continue to collect additional outcome data over the next five years with the intention of gathering a variety of measures of the effectiveness of attachment therapy. One question that will be explored is that of whether or not attachment therapy does more than just reduce the frequency of aggressive and delinquent behavior; does the child 's internal psychological functioning change as well, or is attachment therapy "just a bandaid" that reduces behavior problems, but has no actual impact on building attachments and leading to more psychologically healthy behavior in adulthood? Are children who receive attachment therapy actually able to form more stable attachments in adolescence and adulthood, or do they continue to experience social problems? Given that the findings of the IACD study showed that, after one year of treatment, no significant improvement was found on the CBCL scales that measure Social Problems and Withdrawal, it may be that attachment therapy, in and of itself, is insufficient to significantly impact on the social problems of these children. On the other hand, it may be that a longer period of treatment is needed to impact on the serious problems that these children experience. It may be that, once there is enough follow-up data for children who have received two years of treatment, changes in social problems may become evident. The answer to this question should be available within the next year. Additional research also needs to be done with children who receive attachment therapy at facilities other than IACD. At the present time, there is little standardization of how to conduct attachment therapy, and it is not known which techniques are more useful than others. Only a wider research project that could be coordinated between the major attachment centers across the country could answer this question, and such a study needs to be undertaken in the near future if we are to be able to answer the critics who claim that attachment therapy does not work, is abusive and/or traumatic for its recipients, and is dangerous for the children receiving it. IACD plans to conduct a study in the near future that will assess how much anxiety and trauma attachment therapy creates for children so that we can, finally, put to rest the question of whether this therapy is too traumatic and distressful for children. Let us all make an effort to work together to conduct and coordinate the research that will further our profession, and to help this severely disturbed population of children and the families who hope to be able to integrate them as permanent members of their family.

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Levy, T. and Orlans, M. (1996). Unpublished procedure manual of The Attachment Center at Evergreen.

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