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Reactive Attachment Disorder: Writings: Professionals: Daniel Hughes

Dyadic Developmental Psychotherapy

Over the past twelve years I have actively worked to develop a model of treatment and parenting for children with problems secondary to abuse, neglect, and multiple placements. This model has evolved over those years, incorporating both my experiences in providing such treatment and in teaching other therapists as well as my ongoing readings from attachment and trauma studies in both academic and clinical literature. The purpose of this paper is to clearly state the nature of this treatment and parenting model and to differentiate it from other models. I did not make these differences clear in my two books. In addition, the books were published in 1997 & 1998 and the model has continued to evolve. I will also present the main features of the changes that have occurred over the past 6-7 years.

I have chosen to call this model of treatment Dyadic Developmental Psychotherapy because it is based on the premise that the development of children and youth is dependent upon and highly influenced by the nature of the parent-child relationship. Such a relationship, especially with regard to the child?s attachment security and emotional development, requires ongoing, dyadic (reciprocal) experiences between parent and child. Such experiences are affectively and cognitively matched to the developmental, age-appropriate needs of the child. The parent is attuned to the child?s subjective experience, makes sense of those experiences, and communicates them back to the child. This is done nonverbally as well as verbally. It is done with playfulness, acceptance, curiosity, and empathy. These interactions are contingent, i.e., when the parent initiates an interaction, the child?s response determines the parent?s subsequent action based on the feedback of the child?s subjective experience of the first action. In that way, the parent constantly fine-tunes his/her interactions to best fit the needs of the child. The primary context in which such dyadic interchanges occur is one of real and felt safety. Without such actual and perceived safety, the child?s neurological, emotional, cognitive, and behavioral functioning is compromised.

When a child?s early attachment history consists of abuse, neglect, and/or placements, s/he has failed to experience the dyadic interactions that are necessary for normal development and s/he often has a reduced readiness and ability to participate in such experiences. Many children, when placed in a foster or adoptive home that provides appropriate parenting, are able to learn, day-by-day, how to engage in and benefit from the dyadic experiences provided by the new parent. Other children, having been much more traumatized and compromised in those aspects of their development that require these dyadic experiences, have much greater difficulty responding to their new parents. For these children, specialized parenting and treatment is often required.

For such treatment and parenting to be effective I strongly believe that they must be based on parenting principles that facilitate security of attachments and which incorporate an attitude based on playfulness, acceptance, curiosity, and empathy. The foundation of these interventions -- both in home and in treatment -- must incorporate the above principles and never involve coercion, threat, intimidation, and the use of power to force submission.

The following represents a list of general principles that are characteristic of my treatment and parenting model and, I believe, congruent with attachment and trauma literature.

  1. Eye contact, voice tone, touch (including nurturing-holding), movement, and gestures are actively employed to communicate safety, acceptance, curiosity, playfulness, and empathy, and never threat or coercion. These interactions are reciprocal, not coerced.
  2. Opportunities for enjoyment and laughter, play and fun, are provided unconditionally, throughout every day with the child.
  3. Decisions are made for the purpose of providing success, not failure.
  4. Successes become the basis for the development of age-appropriate skills.
  5. The child?s symptoms or problems are accepted and contained. The child is shown how these simply reflect his history and how they need not be experienced as shameful.
  6. The child?s resistance to parenting and treatment interventions is also accepted and contained and is not made to be shameful by the adults.
  7. Skills are developed in a patient manner, accepting and celebrating ?baby-steps? as well as developmental plateaus.
  8. The adults? emotional self-regulation abilities must serve as a model for the child.
  9. The child needs to be able to make sense of his/her history and current functioning. The understood reasons are not excuses, but rather they are realities necessary to understand the developing self and current struggles.
  10. The adults must constantly strive to have empathy for the child and to never forget that, given his/her history, s/he is doing the best s/he can.
  11. The child?s avoidance and controlling behaviors are survival skills developed under conditions of overwhelming trauma. They will decrease as a sense of safety increases, and while they may need to be addressed, this is not done with anger, withdrawal of love, or shame.
  12. A child may be held at home or in therapy for the purpose of containment when the child is in a dysregulated, out-of-control state only when less active means of containment are not successful in helping him/her regain control, and only as long as the child remains in that state. The therapist/parent?s primary goal is to insure that the child is safe and feels safe. The goal is never to provoke a negative emotional response or to scold or discipline the child. The model for this type of holding is that of a parent who holds an overtired, overstimulated, or frightened preschool child and helps him/her to regulate his distress through calm, comforting, assurances and through the parent?s own accepting and confident manner.

It is easier to list interventions that I never use in therapy nor recommend that a parent use at home, than to list all of the possible interventions that I might use. I am confident that all interventions I use are consistent with principles of attachment and trauma, theory and research.









Last Modified on: Saturday, August 08, 2009

The following interventions are NOT found within my treatment and parenting model:

  1. Holding a child and confronting him/her with anger.
  2. Holding a child to provoke a negative emotional response.
  3. Holding a child until s/he complies with a demand.
  4. Poking a child on any part of his/her body to get a response.
  5. Pressing against ?pressure points? to get a response.
  6. Covering a child?s mouth/nose with one?s hand to get a response.
  7. Making a child repeatedly kick with his/her legs until s/he responds.
  8. Wrapping a child in a blanket and lying on top of him/her.
  9. Any actions based on power/submission, done repeatedly, until the child complies.
  10. Any actions that utilize shame and fear to elicit compliance.
  11. ?Firing? a child from treatment because s/he is not compliant.
  12. Punishing a child at home for being ?fired? from treatment.
  13. Sarcasm, such as saying, ?sad for you,? when the adult actually feels no empathy.
  14. Laughing at a child over the consequences which are being given for his behavior.
  15. Labeling the child as a ?boarder? rather than as one?s child.
  16. ?German shepherd training,? which bases the relationship on total obedience.
  17. Blaming the child for one?s own rage at the child.
  18. Interpreting a child?s behaviors as meaning that s/he ?does not want to be part of the family,? which then elicits consequences such as:
    • Being sent away to live until s/he complies.
    • Being put in a tent in the yard until s/he complies.
    • Having to live in his/her bedroom until s/he complies.
    • Having to eat in the basement or on the floor until s/he complies.
    • Having ?peanut butter? meals until s/he complies.
    • Having to sit motionless until s/he complies.
  19. Giving the above consequences in a ?loving, friendly tone? does not make them appropriate. That tone may actually cause greater confusion about the meaning of love, parenting, and safety, which we want children to understand.

If an intervention is not on that list, I may or may not use it. A rule of thumb is always that the intervention is something that is congruent with how secure attachments are formed and how traumas are resolved. If one is still uncertain, please contact me rather than assuming that I would recommend that intervention.

This model was primarily developed in working with children and their foster or adoptive parents. If it is used when working with children with parents who previously abused and neglected them, it requires confidence that the parents are no longer engaged in such actions of abuse or neglect, that they have acknowledged and accepted responsibility for their actions, and that they are able to actively work to assist their child in resolving the effects of the abuse in a manner that is in the best interests of the child.

Finally, while the above represents the basic premises of this intervention model that have been constant over the past twelve years, there are three areas where the model has gradually changed.

  1. In the past I did occasionally incorporate some interventions that emphasized obedience in order to facilitate a parent being ?in control? of the child?s behavior in the home. For many years now, however, I have avoided recommending such interventions, unless they are necessary for safety as an immediate response to a given situation. I believe that they are inherently dangerous and leave the adult vulnerable to becoming emotionally abusive. If the child does not obey, the parent is left with only one option, which is to escalate the consequences until the child finally submits. These escalations, such as two weeks of ?solitary confinement,? can only traumatize a child, destroy his/her ability to trust the parent, and confuse him/her as to the true nature of parenting and the parents? motives toward the child. I am certainly not advocating total permissiveness since part of good parenting necessitates that the child obey in many circumstances. However, I am stressing that obedience is not the foundation of a secure attachment nor is it the foundation of effective long-term treatment and parenting.
  2. Over the years I have discovered more ways of preventing children from becoming dysregulated in the therapy setting. Trauma clinicians stress the importance of directing children to address their past traumas, but doing it in a manner that is neither too fast nor too slow. I am now more able to determine and effect the optimum speed at which such work is done to avoid both dysregulation on the one hand and defensive avoidance on the other. I have never held children in a coercive manner for the purpose of confronting them in anger or provoking them into rage. Yet, I was not sufficiently aware of active ways of assisting them in remaining regulated and in control while engaging in a treatment and I held children more then than I do now. Today I proceed in treatment in slower and smaller stages, providing more structure, reassurance, and options so that the child is more likely to actively engage in treatment without dysregulation. Causing dysregulation is never a treatment goal, nor has it ever been. Actively working to prevent the child?s dysregulation is now a primary treatment goal.
  3. I also have steadily increased my focus on the child?s adoptive or foster parents? own attachment histories. I am more aware that a child?s serious attachment and trauma problems may well elicit unresolved issues in the parents? histories which then make it difficult for the parent to assist the child in regulating and integrating areas of his- or herself that are unresolved. I am not suggesting that a parent?s own coherence and resolution with respect to his/her attachment history is a necessary, though often not sufficient, factor in their child?s ability to resolve their own past issues.
  4. I hope this clarifies the nature of my treatment and parenting model, differentiating it from other models and explaining how it has changed over the years. If there are any questions about my model, please contact me.

Dan Hughes
November 30,2002

Long a resident of Maine, Dr. Hughes now resides in Pennsylvania, the state of his birth; and is the author of:

Dr. Hughes can be reached at Dyadic Development Psychotherapy.



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