Reactive Attachment Disorder

Reactive Attachment Disorder Laura A. Riffel, Ph.D.

What is Reactive Attachment Disorder? (RAD) • The MAYO clinic defines RAD as a rare but serious condition where infants or young children do not build bonds with parents or caregivers. • We see this many times with children who have been in the foster care system for neglect or abuse. We also have seen this with children who were adopted from large orphanages. • RAD develops when the young child’s basic needs for affection, comfort and nurturing are not met. The loving and caring attachments with others are not established.

Why is that important? • This affects the way the brain grows and affects how the child builds relationships in the future. • This is a lifelong condition. • Treatment is required to develop healthy and stable relationships at school and home. • Treatments include: • Psychological counseling • Parent training • School training

We are going to focus on: • School training-

First Step: • Change your mindset: • These are not problem behaviors or bad behaviors…. • These are behaviors you would like to “target” for change. • When you say words like “bad behavior and problem behavior”, a perception of the child forms in your mind. BAD KID- PROBLEM KID- Get the kid out of here. • The child is okay; it is just the behavior you would like to go away- so target it.

Design a Multimodal Treatment • One intervention is not going to change the child’s behavior. • You will need: • Antecedent modifications • Things you do before a behavior has a chance to show up • You determine when those need to be employed by looking at behavior patterns: • Time of day • Day of the week • Contexts, settings, subjects being presented, certain peers being around, certain adults being around etc.

Multimodal design continued • You will need to teach replacement behaviors: • This child has learned that certain behaviors have a pay off • The child will have to be taught ways to release anger and frustration in socially appropriate ways. • We cannot just tell them to “be good”, we have to actually give them techniques that will help them do something different.

Multimodal design continued • You will need to make consequence modifications: • Everyone hates this one because it is “What will you do different when the behavior occurs?” • We don’t like to think about changing ourselves. • How will we avoid paying off with attention or escape from work consequences and yet still manage the behavior? • How do we refrain from going to brain stem?

Discipline without a relationship leads to rebellion. Dr. Josh McDowell So how do I build a relationship with a student who has Reactive Attachment Disorder? …..very carefully……

Focus on the Four “P’s” • Public Relations • Proficiency • Power • Philanthropy

Public Relations • All children need to feel that they belong. • Be their public relations person by letting their appropriate behavior earn the class a reward.

Proficiency • Many behavioral issues occur because the student feels inadequate academically. • Pre-teach part of the lesson in a study session, an online learning lab, or resource room.

Power • Give the child the power to control their destiny by giving them independence. • Using options, teaching them to think “How’s this next decision going to affect me?”

Philanthropy • You will be surprised that these students are generally great working with younger students or students with disabilities. • Their behavior is typically more appropriate with younger and less able students.

Functions in Behavior- true no matter diagnosis Positive Reinforcement Negative Reinforcement To escape: Work Adults Peers Sensory Overload Pain Emotional Physical • To get: • Attention • Adults • Peers • Access to: • Materials • Sensory

How to CARE for behavior • Control • How can I make it appear the child has more control over situations? • Attention • Does the child want the adult attention or peer attention? • Revenge • What social skills can we give the child to help them refrain from reactive strategies? • Escape • Why does the child want to get out of work or get away from a situation? (low self-esteem, inadequate skills, etc.)

Functional Behavior Assessment- FBA What behavior do you want to target for change? What is the payoff for the child? What setting or context typically precedes this behavior? What behavior could replace this behavior? What can the adults do different to avoid paying off? What could you do proactively that would change this?

Functional Behavior Assessment- FBA Saying “F..ing B….ch” out loud in class. Gets sent to office; which allows him to escape. Assignment to write paragraphs on a topic. Writing a 3-2-8- paragraph after being taught. Let them earn some free homework passes for appropriate work. Pre-teach a writing technique in private.

The multi-modal plan: • Does not just put one statement in place: • Consider if your doctor said, “Get better.” • No different to tell a child with a medical diagnosis to “Be Good.” (it only works for ET)

Let’s look at some specific examples:

School-wide PBIS • The focus of Sw-PBIS is on teaching appropriate behavior by the TIPP method: • Teach the behavior • Imprint the behavior by modeling it for the students • Practicing the behavior • Praising the behavior when you see it. (Must be specific)

Label appropriate behavior • Instead of telling the child what “NOT” to do- tell them what to do by labeling it when you see it. • I like the way you….(the more you say- the more you’ll see.) • Get rid of the totalitarian rules: • Don’t __________ • No ____________ • Quit ____________ • Stop ____________

Sticks and Stones • Children with Reactive Attachment Disorder need to learn bonding strategies in order to build relationships: • Teach the RAD child to respond to others rather than react to others. • This is not going to happen in one session.

Teach the “I” strategy for Independence • Share the emotion (feeling) • Explain the why (the cause) • Make a request (the solution) • I feel frustrated when I don’t know the answer to a question. Please teach me a trick to make it easy.

Cool down technique for YOU • Children with RAD seem to be able to send us from frontal cortex to brain stem in 20 seconds flat. • This happens because we have been trained to think, “I must react immediately to this situation because that’s what we do.” • The truth is…we don’t think best when we are upset. • Train yourself to do the following:

Use the late night host technique • If you don’t have enough information yet ask an open ended question like: • “Tell me more.”

When you do deal with it…. • Handle all problems with compassion first. • “Oh, man I can totally understand why you felt like doing that. • But the rules for that are x,y, and z at this school. • So we’ll see you in detention on what day? • After that, let’s get together and talk. • Be sure to come see me the next day.”

Use a Point System • How many of you collect frequent flyer miles or reward points for hotels? • It makes you want to engage in a particular behavior.

3 23 3 3 2 3 3 3 3 3 2 6 3 3= Great Hour- No or very few behavioral learning opportunities occurred 2= Pretty Good Hour- few behavioral learning opportunities occurred 1= This Hour could have been better- more than a few behavioral learning opportunities occurred Student Signature: _________________________________________________ Teacher Signature: _________________________________________________ Parents' Signature: _________________________________________________ For younger students use smiling faces:

Check In- Check Out Program • The most critical factor influencing the development of prosocial behavior is the attachment to at least one prosocial adult who believes in the child and provides unconditional acceptance and support • (Horner et.al., 2008; Hawkins, 1995; Bernard, 1995; Brooks, 1994; & Katz, 1995)

RAD- First instinct is to not trust adults • TUMS for the RAD Child: • Touch them- High-five or gentle touch on forearm when talking to them (not hug). Message: We touch people we like. Be careful with this one- you know the child and how they allow touch and “IF” they allow. • Use their name • Make eye contact • Smile

Cooking Spray- Be “PAM” • Don’t let words from other students stick to you. Be: • Proactive not reactive • Affirmative • Move Away

Proactive not reactive • Teach the child to have a plan to keep themselves in frontal cortex: • Teach them breathing techniques • Give them an outlet for tensing muscles such as a stress ball they keep in their pocket • Teach them how to go to their “zen” place

Affirmative • Teach the child to tell themselves positive statements: • I can handle this. • I am better than this. • This is not worth losing privileges over.

Move Away • Teach the child to say something like: • “Thanks for sharing your opinion and move away.” • Teach the child to not make eye contact when saying the above statement.

Ice it down…. • Know how you can add ice to a hot cup of cocoa and it cools it down to “just right”? Or ice an inflamed muscle and it calms down. • Learn what to say to bring the child down to “just right.” • For example: • If the child likes to set up the overhead projector and you see they are about to go over the edge, ask them to set up the overhead projector for you.

Music calms the inner “beast” • We all have times when our inner beast comes out. • Share with the student what you do….

60 beats per minute • Our resting heart rate is 60 beats per minute • Heart rates during aggressive behaviors reach as high as 147 beats per minute and they reach that rate a full 45-90 seconds prior to the aggressive behavior

Rules for parents & teachers • Have clear expectations- not rules • Don’t say don’t, stop, quit, or no

Keep the expectations simple and positive • Respect Relationships • Respect Responsibilities

Routines • Changes in routine can be just as upsetting to a child with RAD as to a child with Asperger Syndrome or Autism • Stick to the routine and let them know about changes in advance. • Give them “heads up” reminders • When the music stops you will have two minutes before the bell.

Q-TIP • Get yourself a Q-tip • (Quit Taking It Personally) • You are not the cause of the defiance- you are an outlet for the child

Find out what floats their boat

Focus on Strengths

Be Columbo

KISS • Don’t give a lot of words….blah, blah, blah • Be quick, be quiet, be gone

Love Notes • Children with RAD will do the opposite of what you want if you tell the world they are doing a “good job”. Give them love notes privately telling them what they did well.

You catch more flies with…. • Never yell at a child with RAD- remember Newton’s Law of Inertia? • A body persists in its state of … uniform motion unless acted upon by an external unbalanced force.” In other words, if a child is yelling, then yelling at them is not going to change their behavior.

Parents- take turns • The wiggling pinky….it’s my last nerve so it’s your turn…. • Have a signal- have someone you can talk to.

Communication between home and school • Work out a signal between home and school about how the child went out the door- both ends. • This lets the other end get prepared and have some techniques ready to go • Dimmed lights • 60 beats per minute music • Lavender oil

Reactive Attachment Disorder