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121 MARCH 2009
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Kissing the frog:Severe attachment disorder development from early childhood to puberty

N. P. Rygaard

“What's in a name? That which we call a rose, by any other name would smell as sweet–
“Shakespeare, Romeo and Juliet

Kiss the frog “and so what?

A basic question for the social worker is: If you kiss a frog, will it turn into a noble prince(ss)?

In other words: how do you plan a realistic and respectful social intervention? Without sinking into depression in the presence of misery and mistrust, while also recognizing the fine line between hope and egocentric illusions. When you meet a young person for the first time, two life stories meet: yours and that of the client. How can you prepare for this crossroad meeting? Social workers often believe the “healing” effort to be successful only if the client begins to think, feel and act like the social worker. Nothing can be more wrong or insulting to the identity of the client.

The therapeutic meeting is only a tiny dialogue in the total sum of the client’s life experiences, and it is disrespectful to ignore how different the premises for the meeting are. If these issues are not resolved, they often result in burn-out syndrome in the social worker, and it forces clients to imitate the values of the social worker instead of getting support to create an identity of their own. Being close to people who suffer requires that you realize that you can’t take their life or pain away from them, unless you understand what premises they live by. This development process for the social worker usually takes about 5 years, if it does not end up in cynicism, apathy, anger, rejection, disappointment or other defensive mechanisms.

Lifespan coherence versus the tyranny of age division

Another limitation is that social life today is split up into disconnected segments: we tend to live in age ghettos where you only meet people of your own age. This has caused a specialization in methods “you learn to work with “babies”, “children”, “pre-schoolers”, “teenagers”, etc., but apparently never with human beings who started somewhere and are going somewhere else? A lot of research and therapy has a very narrow focus on a single life period, losing sight of the helix of life development. As much as I find it important to have a positive and recognizing attitude, I believe that our past is the frame for our future. In other words that without a life perspective there is no meaning.

Sometimes the client’s premises harbours massive deprivation and maltreatment from the very onset of life, and such clients frequently ignite a number of emotional and professional issues in the professional person and group. The most difficult task in working with borderless and identity lacking clients is that the professionals experience an equal process of losing their wits and professional identity when meeting such clients. So, what is a realistic and wholesome approach to the attachment disordered client?

The roots of attachment disorder

The diagnosis of Attachment Disorder (hence: AD) is used when the client is approximately between six and seventeen years of age. However, this “window” is rather narrow, since the causes and symptoms operate very early in life. This paper gives an overview of common lifespan events based on clinical experience and studies of AD. An imaginary typical lifespan case, “Jean” is used, and for each stage of development a general description illustrates the typical traits behind the case. The second section gives examples of prevention at each developmental level of the child or youth. The focus is on the period from conception to puberty.

The disruption of Jean's society

Jean was born into a culture undergoing rapid change. As a consequence, the rituals and roles of early life caretaking in his family were disrupted by industrialization before he was born: the bonds between his mother and the family were more or less broken up. Where formerly she would have learned the practice of caring for the newborn from her grandmother, her mother and other women, she was more or less on her own during her pregnancy. At school she had been forced to speak English, this also denied her access to the “knowledge of caretaking” which had been accumulated in her native language and lifestyle. She did not let baby Jean sleep in a cradle, but in a bed. She did not breastfeed him, but used formula from a bottle. She did not live in a group of women, carrying Jean in a bag on her back; she had to leave him alone, going to the factory for many hours a day. At the factory she was introduced to alcohol and drugs. Jean did not grow up according to native tradition; in fact he never met his father or his grandfather.

General aspects: Ancient caretaking traditions respond to the baby’s survival challenges in the environment. Whenever the environment changes rapidly the percentage of children having attachment problems tends to rise until new relevant coping traditions for care have been formed. You may study the Inuit, the Danes fifty years ago or any other traditional society transforming rapidly: attachment problems increase whenever the social structure is in the melting pot. For example, at present the Chinese experience massive migration from rural to urban environments and economies, this produces a host of abandoned children, adopted children and a temporary disruption of the cultural norms of local baby-care patterns and upbringing systems. Jean was born in the midst of this turmoil. Approximately 3-5 % in a population have signs of severe attachment problems, however in periods of change in society (war, famine, rapid industrialization, migration etc.), the number increases. Most studies in failure of attachment are conducted in the wake of such changes, including John Bowlby’s (Bowlby 1969, 1973, 1988) famous studies in attachment with post-war children.

Jean's family

His father was sometimes very kind and sometimes violent towards his mother. He left for good when Jean was six months old. His mother had left her own home at an early age. She was in many ways still a child, although being 25 when Jean entered the world: she was unable to create a daily rhythm for herself, and emotionally she was unpredictable “she could have fits of rage at one moment and be gay and happy the next.

General aspects: the family pattern producing the AD child is a father who is a): absent, physically or emotionally, b): violent, c): a “serial father” (the mother having many short and superficial relationships with different men). The mother is not particularly young when giving birth; rather she is emotionally unstable and has a fragile personality.

This latter characteristic can be divided into three subgroups: Mothers with a disorganized/ disorientated attachment pattern (who experienced massive early deprivation in her own childhood) (50%). Mothers suffering from psychosis during the first years of the child's life (schizophrenia, manic-depressive, borderline and birth psychosis (40%). Third, the average normal mother (10%) “who either happens to be in crisis due to other events in the first years of the baby’s life “or whose baby is so fragile or handicapped at birth that he/she is unable to perceive the mother’s attempts to make contact “attachment does not take place in spite of her efforts. Two risk groups in this category are presently growing: adopted children (only if deprived prior to adoption and usually if adopted at age 1 or > age 1), and children with extremely low birth weight (Rygaard 1998).

Jean in mother's womb

Jean had odds against him from the start. During pregnancy his mother was overworked and depressed from the loss of her dear ones. Her drinking was toxic to Jean's brain development and
she was unable to care for herself. Jean's birth weight was low and the birth itself very complicated. After birth he cried a lot and she did not have much time to comfort him at her breast and have little dialogues with him (Mummy smiles, Jean smiles, Mummy looks gloomy and laughs, Jean looks gloomy and grunts). As soon as he could hold the milk bottle himself, she stopped taking him up when feeding him.

General aspects: most (not all) children who develop AD have experienced what you may call a “low quality pregnancy and birth”. Thus, the combination of a very fragile and neurologically immature newborn can be devastating when combined with subsequent insufficient parenting. Some children develop AD merely because the parent is unable to be a good caretaker, but in many cases the baby was also fragile from the start. This results in a lack of establishing mutual feedback in the first year of interaction, and this in turn probably results in insufficient neurological growth and in a lack of forming adequate neural networks for emotional and cognitive function and regulation.

Genetically, Jean had the misfortune of being a boy, and boys are much more vulnerable to almost any kind of disease and stress than girls. Approximately 75 % of all children who develop AD will be boys (Schulsinger 1972, McCord 1982).

Baby Jean

When Baby Jean's mother held him, she often scared him for fun beyond the limits of panic, not being very sensitive to his mood. Sometimes she was loving and kind; sometimes she had sudden fits of rage and yelled at him or shook him, or left him alone if she became engaged in something else. She had a habit of starting to nurse him, and then abruptly put him aside in the midst of all. If he cried or screamed, she would become very excited and scold him for not liking her; as if a baby six months old could have intentions behind his actions. Jean often had stomach problems and colic, he didn’t gain weight and height as well as he should, he didn’t sleep well and he often had fever. When a health nurse examined him at 9 months, his head circumference was small for age; he was unable to lift his head when lying on the back or stomach, and his muscle tone was low. She could not make good eye contact with him. Consequently he was admitted to a hospital for a month, and a lot of different persons nursed him during the day.

General aspects: Jean's mother displays many behaviour traits of the attachment pattern “Disorganized/disoriented”, typical for mothers who were severely deprived in their own childhood. This attachment pattern is linked to the development of personality disorder later in life. Already at age one there’s a 70 % chance that Jean will have an identical pattern in adulthood (Shaver & Cassidy 1999).

Neurologically speaking Jean's brain is already far behind:

His brain stem is unable to produce the level of brain activity required because his mother does not touch him or give him vestibular stimulation (which will normally increase brain stem activity and stabilize it at approximately 9 months). This means that his nervous system activity remains as unstable and low as in a newborn: pulse, breath, temperature regulation, regulation of sleeping, waking and attention rhythms. Appetite and digestion patterns remain unstable, and this severe condition can quickly become chronic. Also, the brain stem is responsible for growth hormone production, and the lack of stimulation may result in a lack of growth (psychosocial dwarfism) and a reduced head circumference.

His “emotional brain” is not being properly programmed. The neurological network that should help him calm down from states of panic and anxiety develops especially from age 10 to 18 months, and the creation of this network depends heavily on the mother’s ability to soothe her child and help it regulate the intensity of emotions. Jean's prefrontal cortex is not learning to control his “panic center”, the Amygdala, when he becomes excited or scared. This predicts perhaps lifelong problems with emotional regulation and impulsivity; he may become “a victim of his feelings” later in life, unable to calm down or level his emotional reactions.

Third, the brain will normally produce an entire internal “broadcasting network” from birth to age two, an abundant number of possible dendrite connections far exceeding what we will ever need in life. From age two to puberty, much used connections will be stronger, and not used connections will deteriorate “the brain specializes. In Jean's case, the lack of early physical stimulation will result in a 20 % brain weight reduction at age two, and the “internal network” base for further development will be of much poorer quality (Struble 1978, Siegle 1999).

And fourth, as Jean leaves babyhood, the low level of brain activity will probably cause a shift into hyperactive, aimless and restless activity because his frontal lobes are not active enough to dominate the rest of the brain. If the lack of stimulation has been very serious, he may have developed “institutional autism”, being very passive and without any wish for contact with others.

At twenty months, it is about the last call for changing Jean's disorganized attachment pattern into a healthier one (Ackerman & Dozier 2005).

Toddler Jean

At age three, Jean's mother gives up, and Jean is placed in a foster care family. His new “family” is doing a great job, but Jean's behaviour is unfamiliar and confusing to them. Jean has no sense of limits, moral or physical. At one moment he can play with the family’s daughter, age two, the next he will try to strangle her. He creates many fight/flight situations when the foster parents set limits or make demands. At the dinner table he sometimes refuses to eat, sometimes eats until he vomits. He does not cry when he falls, he refuses to have physical contact or be cuddled; he takes a long time falling asleep and often gets up in the middle of the night. His dreams and fantasies are inhabited by volcanoes, dismembered animals and omnipotent villains.

If given an instruction, he is able to repeat it by heart, but immediately forgets it as soon as the adult is out of sight. The foster parents have the notion that he either regards them as enemies (he calls his foster mother “the dragon–), or does not need them at all “he is indifferent, even spiteful towards contact and care. In the kindergarten the other children admire him for his “bravery” (he does not mind jumping from a roof to the ground), and at the same time fear him for his violent temper tantrums. He contacts anybody new in a very irresistible manner, and the foster parents feel misunderstood by those in their usual environment who find him to be a nice, intelligent and charming boy. He quickly makes acquaintances, but no close friendships develop from them. After one year of heroic effort, the foster family gives up when Jean pushes their daughter down the stairs and her arm is broken. Confronted with his actions, Jean's only comment is: “She stood where I wanted to walk “why did she do that? Should we play again, I’d like that?”

General aspects: The problem of attachment usually calls for social attention from age two and onwards. It then becomes clear that emotionally and socially the child develops only at a very slow rate, whereas motor and “intelligence” skills may be relatively unaffected (Rygaard 1998). This contradiction in skills often leads to a too optimistic first-meeting view of the child, based on the child's positive appearance and apparent capacities. However, those who know the child in longer and more intimate relationships realize that the child is imitating the behaviour of others without any understanding of the meaning or intention in that behaviour. Also, that the defence mechanisms in the child are activated by intimate situations that would normally make the child feel safe and loved. These are: fight/flight/freeze patterns, such as vagabonding, attempts to control others “including role reversal in the family, splitting and extremely ambivalent relations “trying to approach and avoid the adult at the same time. The child will function poorly in socially complex situations (many people, more than one task at a time, new environments or topics), and try to avoid demands or any change in the environment (such as new kinds of food).

Jean at school

Jean's social caseworker notices that her hair is turning grey as his case grows heavier. At seven he is placed in another foster home with more experienced foster parents who get regular supervision, and things seem to be alright”

Jean starts in the local countryside school in a positive manner, but after a while there are a number of incidents in his disfavour. His teacher is an experienced woman, and her 6-month report is very clear and matter-of-fact:

–Jean is a very bright and charming little boy, somewhat small for his age. He is able to learn very quickly by heart, but easily forgets what we just talked about. In class, we have had some rather severe conflicts but Jean has found out that I am the leader, and he now obeys somewhat reluctantly. He responds positively to clear and short instructions directed towards him only, he is still unable to attend to a general message to class. In fact he often tries to do what I ask him to do, but he is not able to concentrate and is distracted by what goes on around him, and he is often bored, restless and impatient. He is able to learn quite a lot by copying and repetition, but he has a very concrete way of thinking and does not always grasp the deeper meaning of the issue or text in question. In class he is fairly calm as long as he has my undivided attention, but any new event or unstructured situation turns him upside down, so he still is in conflict outside lessons. He has to be prepared many times each day for what is happening and will happen in the next few minutes. His learning depends on that I break down any subject into little bits which can be learned by heart, one by one. Outside class he now has an “attachment person” who helps him socialize in an acceptable manner.”

General aspects: Being more or less intelligent, the resources for learning are often not unfolded in the AD child because of social problems and conflicts overshadowing the learning process.

The basic learning problems in AD children all have to do with a failure in the first learning process: perceiving the first caregiver as a stable emotional entity. These learning problems (emotional at first, in the cognitive sense later) stem from a lack of the first meaningful exercises in a secure relation:

In other words, object constancy “learned in interaction with the first object/caregiver “is the prerequisite for a coherent and stable perception of the emotional, physical and social world around us (Blatt 1988).

Jean the perpetual teenager

After some rather good years in the foster family Jean enters puberty. He is suddenly caught shoplifting outside school hours, and the family discovers that this has been going on for a year, as well as some drug abuse. When confronted his strategy is denial and varying fantastic stories about what happened. He is increasingly angry with his foster parents and blames any problem on their having let him down and not trusting him. In any incident he invariably blames others and is unable to see how he himself influences a situation. There are a number of physical conflicts where the foster parents have to hold him physically in order to control his aggression.

His foster mother is beginning to fear him, and while he still seeks comfort like a child he is also looking for weaknesses and feelings of guilt he can awake in them. After one row, he tries to set the house on fire and runs away. He is found some weeks later in a gang of much older youngsters and is brought home by the police. After a calm period the foster parents are called up by a parent from school because Jean has been sexually aggressive towards a girl of eight, and Jean is expelled.

At 15 he runs away for good without notice and sometimes surfaces in different court rooms and juvenile institutions.

General aspects: If treated, the child will often have a calm period from the start of school to the start of puberty. Depending on the intensity of the puberty turmoil and the tolerance in the environment, the course of events can be a criminal career (usually fraud, impulsive and aggressive actions and sexual offences due to a low ability to discriminate between appropriate and inappropriate partners), especially if drugs are involved, or if protected and followed up intensely, a more restricted life with reasonable demands can give a positive outcome. At age 25 the AD child will often demonstrate the emotional maturity level of age 12-14.

Jean grows up

Even though Jean is no longer criminal at 29, he has a number of problematic behaviours. He often changes jobs, last name and partners and moves around the country, being restless and easily bored with routine. He does not have a realistic view of himself and he often applies for leader or expert jobs. He is often hired at first glance because he is able to imitate any role in a superficial manner, but is also fired within a short time. He likes “getting married” and has produced an abundant offspring and disappointed ex-wives in different cities. If he stays too long with a partner and gets emotionally involved, he sometimes becomes violent and vengeful. At 35 he seems to calm down somewhat: he has a relationship for some years and a regular job.

General aspects: When tested in youth and again at age 40-45, the number of psychopathic traits clearly decreases with age. This is probably due to a “late maturation” of emotional and social function (apart from the mere exhaustion from a very turbulent and exposed life). These traits are:

(from Robert D. Hare’s Psychopathy Checklist (Hare 1985))

Depending on how and when interventions are made, they may prevent an AD development or reduce the symptoms considerably. Early intervention will of course be most effective. Unfortunately, the behavioural consequences of deprivation and disorganized attachment only draw attention and concern from age three and onwards, thus producing a lot of practices aimed at treating symptoms that have already become more or less chronic when starting school.

Possible interventions from pregnancy to adulthood

Pre-birth interventions
The first intervention requires a general mapping process in social welfare systems:

Can we point out families whose behaviour makes it likely that the child will develop disorganized/ disoriented attachment?

  1. Families with a tradition of criminal behaviour, maltreatment and neglect of children.

  2. If substance abuse (alcohol, drugs) also runs in the family, this increases the risk.

  3. The mother is not necessarily young, rather she has a destabilized personality
    (due to her own record of early deprivation/maltreatment; or to psychosis when the child is in the most basic phase of attachment: age zero to age two). The father is physically
    or spiritually absent, or violent.

  4. Anorectic mothers are at risk of harming the foetus due to malnutrition and problems
    with attachment after birth.

  5. Severely mentally retarded parents.

  6. The birth weight of the child is very low/severe birth complications.

These families/mothers-to-be will often already be known in social security and other systems.

Can we direct an intervention program towards these families/ mothers at the onset of pregnancy?

One intervention is to offer mothers-at-risk a special birth preparation program (Lier 1995). In Denmark (5 million population) there are currently 48 local programs aimed at mothers-at-risk after many years of focusing on older children.

The general idea of these programs is to give the mother a few stable contact persons as soon as pregnancy is spotted. Professionals act as parental figures, helping her cope with daily practical problems, containing and moulding her expectations for motherhood, and helping her reduce eventual abuse problems in order to improve the foetal environment. In the study by Lier at Bispebjerg hospital, mothers admitted to such a program produced babies with normal birth weight and a frequency of birth complications not exceeding that of the population in general. Mothers not included demonstrated a reduced birth weight (by 300 grams) and a high frequency of severe complications (50 % of births in sample).

Another program from a small county may be of interest: a health nurse, a psychologist, a social worker, a nursery worker work in a team. When a pregnant at-risk mother’s name is referred to the team, she immediately has an informal visit from a team member, who becomes her contact person. She is encouraged to work at a special day care centre for children at risk, where the team is also situated. Here, she is supported by the team who is responsible for her work situation and social welfare benefits; she will “work” in a special day care unit and learn the basics of baby care, she is offered therapy and after birth she will be nursing her own child in the day care centre under staff supervision.

The general idea of this intervention is that the team acts as a “parental substitute”, partly administrating all public aspects (social security, working market, hospital contact, etc.) of the mother’s situation.

The goal of the team is to support the mother and baby until the child is age two (and a healthy attachment process has been started between them). In severe cases, the team helps the mother place the child in a foster family or helps her after mandatory placement in custody of her child. The baby may also be placed in a private day-care where the day-care person has no more than two children, and receives supervision at the day-care centre.

A simpler model is in a county that has a number of specially educated day-care mothers who only work with one or two children at a time. Their job is to be the main attachment figure for the babies, and the biological mother is encouraged to let her baby stay in the day-care for most of the day.

The main idea of all these programs is to provide the mother with a “parental” figure “or a “safe base” “during pregnancy and birth; and to provide practical knowledge and substitute caretakers in the first period of attachment.

Interventions for mother/caretaker and baby relations
In the intervention programs described, an understanding of healthy neurological development is embedded since a number of studies have demonstrated the close relationship between caretaking behaviour and brain development in the baby.

Stimulation of the skin and the vestibular sense (rocking, turning, rolling, etc.) seem to have a major influence on the smooth regulation of the general activity level in the baby brain, and thus both on brain growth and the gradual stabilization of brain function. Consequently, a common problem in AD children is hypo- or hyperactivity. The regulating activity is mediated by the Reticular Activation system, which “in order to function properly in the baby “can be activated only by frequent touch (skin, mouth and tongue) and vestibular (balance) movement.

A number of caretaker behaviours become important:

  1. Frequently carry the baby on the body.

  2. Feed the baby in the breastfeeding position on the arm, and spend a lot of time on this. With young fragile babies, a wet nurse can be a good idea.

  3. Use baby massage.

  4. Exercise eye contact only when the baby is touched at the same time. Touch helps the
    baby to focus and make eye contact.

  5. Use a cradle or a hammock for sleeping, never a bed.

  6. Let the baby rest on a lambskin or on terry cloth.

Deprived babies quickly adapt to under-stimulation and avoid normal levels of stimulation and stay under-stimulated. Gradually stimulate the baby for short periods (baby massage). Sensory Integration Therapy (Jean Ayres) is designed to teach children how to process rising levels of stimulation.

The Marte Meo program from Holland consists of video feedback sessions for mothers at risk and their babies. Mother and baby are videotaped, and the supervisor gives feedback, supporting relevant maternal caretaking behaviour. The general idea of the program is to give only positive feedback whenever the mother displays relevant caretaking behaviour.

Interventions for the pre-school child
The abovementioned stimulation methods should be put to use even with toddlers and up to age 6, but of course they will be most efficient at an early age.

  1. With AD preschool children, the emotional and social capacities are comparable to those of a much younger child. You should therefore:

  2. When planning social and emotional demands and caretaker behaviour, divide the child's age by two or three (to match the developmental age of the child).

  3. Do not focus much on emotions, reasoning and motivating. Demonstrate the behaviour you
    want in simple, short sequences and let the child learn them by imitating you instantly
    (that’s how babies learn from their mothers). Don’t expect the child to understand the
    meaning of actions.

  4. Keep the child in a “mother/child” circle wherever you go. That is, the child is followed and helped as closely as a mother would follow her baby. All other social contacts should be planned and supported by the caretaker. AD children are vulnerable to new contacts and
    large groups.

  5. Take responsibility for all negative outcomes of social interaction (wouldn’t you do that with a one-year-old?)

As the reader will remember, in our case Jean was placed in a foster care family. Since AD child behaviour is disorganized and a very stressing factor in family life, the following criteria for placement have proven valuable:

  1. Foster parents should be experienced, that is, not too young. If they have children, their youngest child should be at least 5 years older than the AD child placed in the family.

  2. Foster parents should have a stable life without too many new activities and new social contacts. They should be chosen for patience, sensitivity, endurance and stability.

  3. The family’s relations with neighbours/school/day-care should be positive before placement, since these relations will be stressed by the child's behaviour.

  4. Authorities responsible for placement should provide regular monthly supervision.

Mary Dozier (Dozier 2005) of Delaware University has made some very interesting field studies in foster family placement. Some of her most important findings:

  1. If the child is placed in foster care before age 20 months, most children will adapt to the attachment pattern of the foster mother. If placed later, it will probably maintain the attachment pattern acquired from previous caretakers/parent.

  2. If the foster mother has a secure/autonomous attachment pattern, the young child placed will adapt to that pattern. If the foster mother has one of the three other attachment patterns
    (avoidant, ambivalent or disorganized), most children will end up having a disorganized

  3. Foster parents can learn the behaviours associated with secure/autonomous attachment.

And other results produced by Femmie Juffer of Leiden University, The Netherlands, studying adopted children (Juffer 2005): if adoptive parents have a number of consultations with an advisor about common attachment problems for one year after adoption, more children will display a secure/autonomous attachment, compared to a control group of non-advised adoptive parents. The same probably goes for foster parents. It is just as important to attachment outcome to “care for the caretakers” as it is to care for the AD child.

Interventions for the school-child
The interventions recommended here focus on school work settings, due to the author’s experience: that the age five to twelve years is often a reasonably calm period, and that the child often has unused intellectual reserves that are overshadowed by social conflicts. However, the thoughts presented refer to learning processes in general. “Learning” in the following not only refers to school activities, but to learning in a very broad sense.

To identify the nature of learning problems in AD children, the most relevant cause is the lack of early organized communication patterns between the baby and the caretaker. This prevents the creation of a clear internal representation of the mother, in some theories referred to as “the internal working model”, in others as “the object relation”. In fact, early disorganized interplay probably prevents a coherent experience, not only of the first caretaker, but also of all later persons or objects, matters and so forth.

These problems appear both in the social relation with the teacher, with peers, and cognitively when working with the understanding of subject matter, such as figures, letters, grammar, ideas and symbols. As one teacher said to me once: “How can I teach her grammar when she has no sense of herself?”

Interventions should be designed to support the early attention functions (concentration, figure/ background, recognition, etc.) as much as possible, and they should also be the underlying target of exercise in all situations. For example, the duration of concentration should be the teacher’s focus in any activity or learning process. Make very short work/rest intervals (duration of one lesson or activity is perhaps only 5 minutes “or shorter).

The teacher should regard his or her person more as the “parental object” than as “the teacher”, and think in terms of a given number of “parent-child relations” rather than addressing the group of children in general. In other words most of the communication should be between teacher and pupil and not between teacher and group. Only when each child has been in this relation for a year or so and perceives the teacher a secure base can the teacher start doing activities and give instructions on group level.

As a “parental object”, the teacher should be aware that he or she only influences the child's behaviour when being present and visible to the child. As soon as the teacher is not present, there will be little or no retention of the teacher’s opinions, instructions, etc. In short: “you exist in the child's mind only when you are in the presence of the child”. For this reason instructions or dialogues about what the child must remember later should be omitted, and only the present tense and the immediate future should be used.

The class room environment should be designed to help the child focus relevantly and not be disturbed, that is, all children face the teacher, and if a child is easily distracted, a sound isolating “wall” can separate the children so that a child can only see the teacher.

Concerning the arrangement of learning matter, “peeling the onion” is relevant. This means that the teacher initially observes the faculties of the child and only makes demands when he or she is absolutely certain that the child can already perform the task in question. Even then, there will probably be a number of conflicts because the child perceives the teacher as “the hostile parent” from the original experience of the parent, and this evokes also the aggressive, disorganized or avoidant reactions from this early period. Only when these conflicts have been contained and calmly resolved by the teacher will the child be able to work. It is difficult to be a safe authority without being authoritarian, and this usually takes some years of practice. Never feel as the child feels “stay in your own stable and kind mood. Your feelings should be independent of the child's feelings.

What makes teaching with AD children difficult is not only that the internal working model of the child may be anxious or blurred, but also early adverse experiences will load the child's view of the teacher with negative and hostile feelings and many defensive mechanisms will disturb the communication when the child tries to avoid or disrupt communication. Thus, a calm teaching process in itself is the ultimate goal, what is required is that the teacher learns to be a “container for negative projections” (that is to know that the child's perceptions of you stem from early life and are not really statements to be taken personally). You must also learn to be a good “rodeo cowboy” (that is, the child will often try to create a secure base by role reversal or by taking control of the environment “and that’s you!).

It is equally important to understand that the teacher’s efforts to explain or convey the deeper meaning or essence of a subject can be an insurmountable challenge for the child. Instead, the logics of a task should be translated into a set of behaviours and rituals which the child can simply imitate “the “why” should always be replaced with the “how” demonstration (Rygaard 2006).

Interventions in youth
If you work with youth, you should have two parallel angles as base points since an attachment disordered young person is a baby caught up in a youngster’s body. This means that you have to design activities that respect the baby without humiliating the young person, so you really have to translate childhood learning designs into “teenage acceptable” activities, and change from one perspective to another in a split second. That takes a lot of practice, but the effective attitudes can be summed up from attachment research defining secure parenting styles:

  1. Be aware of any signs of attachment behaviour (pay attention to, encourage and appreciate: sadness, longing, depression, searching for safety, help or caretaking)

  2. Be sensitive (have fixed goals and activities “but flexibly adjust your method to the emotional state of the client)

  3. Be available (whenever the client contacts you about a need, pay attention and give comfort. Never give “half” attention, but state clearly when you are available and when not).

  4. Never feel like the client “stay with yourself (ask yourself every five minutes: “Am I staying in my own mood/intention, or am I being caught again by the client’s mood/ intention?” Be invariably kind, optimistic and firm).

  5. Reflect on the feelings and thoughts of others as an ongoing process (–I wonder what you’re thinking now”, “How do you think I feel now?”, etc. “to exercise the client’s ability to understand the motives of actions).

  6. Consider your degree of intimacy (in the ambivalent client, intimacy automatically provokes fear and subsequent anger “help yourself and the client to monitor the most efficient distance).

  7. Use time-outs (never punish but use time outs if the client gets too excited, find something soothing and familiar to do. “you’re getting excited again, so let’s just take a break–).

This paper has focused on early childhood and school years, and youth has been described in many other places. There are so many intervention programs that it is impossible to give a fair description. In general, programs based on cognitive/behavioural therapies are popular in these years. Without any evidence, it is my experience that these programs work well with many “light” youth criminals, but as with all other methods they have only a temporary effect on youngsters with many psychopathic traits. In these cases, an intense permanent follow up and control procedure is necessary. In a Danish facility for psychopathic criminals (Herstedvester), a permanent follow up is combined with re-incarceration without specified time limit if a parole is violated. The next parole then depends solely on the estimate of prison staff. This method seems to have considerable effect in the most difficult cases.


What has amazed me mostly in working with AD children and youth is the fact that the causes seem to operate from pregnancy to age three, while treatment only starts when the social symptoms become increasingly manifest: from age 2-3 and onwards. This calls for the development of intervention programmes early in life, which is why I started the Global Orphanage Project, designed to deliver free web education to orphaned children staffs worldwide ( So far, it’s gathering momentum in the European version, testing methods for later global versions.

Milieu therapy, in my experience, is a useful method in providing the secure base to extremely insecure and aggressive children. The two most important goals in this are to monitor the environment at all times (which can usually be obtained at least until puberty even in severe cases), and to provide supervision for those who work with the children in order to avoid regression under the pressure of the child's behaviour problems.

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