Dyadic Developmental Psychotherapy is an evidence-based and effective form of treatment for children with trauma and disorders of attachment . It is an evidence-based treatment, meaning that there has been empirical exploration published in peer-reviewed journals. Craven & Lee (2006) determined that DDP is a supported and worthy of acceptance or satisfactory treatment (category 3 in a six level system). However, their review only included results from a partial preliminary visual representation of an ongoing follow-up study, which was subsequently finished and published in 2006. This primary study equated the results DDP with other forms of treatment, ‘usual care’, 1 year after treatment ended.

It is essential to note that over 80% of the children in the study had had over three prior sequences of treatment, but without any betterment in their sensations or changes and behavior. Episodes of treatment mean a course of therapy with other mental health suppliers at other clinics, consisting of at least five sessions. A second study extended these results out to 4 years after treatment ended. Based on the Craven & Lee classifications (Saunders et al. 2004), inclusion of those studies would have resulted in DDP being classified as an evidence-based category 2, ‘Supported and probably efficacious’. There have been two affiliated empirical studies comparing treatment outcomes of Dyadic Developmental Psychotherapy with a control group. This is the basis for the rating of category two. The criteria are:

1. The treatment has a sound theoretical basis in in general accepted psychological principles. Dyadic Developmental Psychotherapy is based in Attachment Theory (see texts cited below

2. A significant clinical, anecdotal creative writing of recognized artisti value exists indicating the treatment’s efficacy with at-risk children and foster children. See reference list.

3. The treatment is in general accepted in clinical exercise for at danger children and foster children. As demonstrated by the big number of practitioners of Dyadic Developmental Psychotherapy and it’s activity of formally presenting something as a lot of global and national conferences over the last ten or fifteen years.

4. There is no clinical or empirical proof or theoretical basis indicating – that the treatment constitutes a substantial peril of hurt to those receiving it, equated to it is likely benefits.

5. The treatment has a manual that without doubt or question specifies the constituents and administration characteristics of the treatment that allows for implementation. Creating Capacity for Attachment, Building the Bonds of Attachment, and Attachment Focused Family Therapy constitute such material.

6. At least two studies utilizing a heap of form of control without randomization (e.g., wait list, untreated group, placebo group) have traditionalisti the treatment’s efficacy over the passage of time, efficacy over placebo, or found it to be comparable to or better than an already conventional treatment. See ref. list.

7. If multiple treatment outcome studies have been conducted, the overall weight of proof supported the efficacy of the treatment.

These studies help various of O’Connor & Zeanah’s conclusions and recommendations concerning treatment. They state (p. 241), “treatments for children with attachment disorders ought to be promoted only when they are evidence-based.”

Dyadic Developmental Psychotherapy, as with any specialized treatment, must be provided by a competent, well-trained, licensed professional. Dyadic Developmental Psychotherapy is a family-focused treatment .

Dyadic Developmental Psychotherapy is the name for an approach and a set of principals that have proven to be effective in helping children with trauma and attachment disorders heal; that is, formulate healthy, trusting, and secure relationships with caregivers. Treatment is based on five central principals.

At the core of Reactive Attachment Disorder is trauma caused by significant and substantial experiences of neglect, abuse, or prolonged and unsolved pain in the firstborn few years of life. These experiences disrupt the normal attachment routine so that the child’s capacity to form a healthful and secure attachment with a caregiver is distorted or absent. The child lacks a sense trust, safety, and security. The child formulates a negative working model of the world in which:

- Adults are experienced as inconsistent or hurtful.

- The world is viewed as chaotic.

- The child experiences no effective influence on the world.

- The child attempts to rely only on him/her self.

- The child feels an overpowering sense of shame, the child feels defective, bad, unlovable, and evil.

Reactive Attachment Disorder is a severe developmental disorder caused by a chronic history of maltreatment for the duration of the initial couple of years of life. Reactive Attachment Disorder is often times misdiagnosed by mental health pros who do not have the suitable training and experience assessing and treating such children and adults. Often, children in the child welfare scheme have a potpourri of former diagnoses. The behavings and sensations or changes that are the basis for these former diagnoses are better conceptualized as resulting from disordered attachment. Oppositional Defiant Disorder behavings are subsumed beneath Reactive Attachment Disorder. Post Traumatic Stress Disorder sensations or changes are the result of a substantial history of abuse and neglect and are another dimension of attachment disorder. Attention troubles and even Psychotic Disorder sensations or changes are many times seen in children with disorganized attachment.

Approximately 2% of the population is adopted, and amidst 50% and 80% of such children have attachment disorder sensations or changes . Many of these children are violent and aggressive and as adults are at risk of fabricating a assortment of psychological difficultnesses and personality disorders, including antisocial personality disorder , narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder . Neglected children are at risk of social withdrawal, social rejection, and pervasive sensations of incompetence . Children who have histories of abuse and neglect are at substantial risk of formulating Post Traumatic Stress Disorder as adults . Children who have been sexually maltreated are at substantial risk of devising anxiety disorders (2.0 times the average), major depressive disorders (3.4 times average), alcohol abuse (2.5 times average), drug abuse (3.8 times average), and antisocial conduct (4.3 times average) (MacMillian, 2001). The effective treatment of such children is a public health concern (Walker, Goodwin, & Warren, 1992).

Left untreated, children who have been maltreated and neglected and who have an attachment disorder become adults whose capacity to give rise to and maintain healthful relationships is deeply damaged. Without placement in an suitable permanent home and effective treatment, the condition will worsen. Many children with attachment disorders develop borderline personality disorder or anti-social personality disorder as adults .

FIRST PRINCIPAL. Therapy ought to be experiential. Since the roots of disorders of attachment occur pre-verbally, therapy must construct experiences that are healing. Experiences, not words, are one “active ingredient” in the healing process.

For example, one eight year old boy who had Reactive Attachment Disorder, Bipolar Disorder, and a assortment of sensory-integration disorders wrote in regards to his past therapy and attachment therapy this way (More details of this story may be found in the book Creating Capacity for Attachment, edited by Arthur Becker-Weidman & Deborah Shell):

My introductory therapy was with Dr. Steve. The therapy was FUN! We ate lots of snacks. I had a bottle. We played a large total of cool games like thumb wrestling, pillow rides, giant walk, Superman rides, guess the goodies, eye blinking contests, hide and go seek goodies. I had to follow the rules and play the games just like Dr. Steve said.

Dr. Steve taught me how to play and have fun with my Mom. But I still didn’t recognise how to love. I would still get real crazy and undertake to injure Mom and break things. Inside I still thought I was a bad boy. I was still afraid Mom and Dad would get rid of me. I had a large total of tantrums at home. Sometimes I would still get out of control and break things and try to injure Mom. I was getting even worse when I got mad.

Stuff Dr. Art Taught Me – I learned regarding my sentiment well. Sometimes I stuff too numerous sensations like mad, frighted and sad into my sentiment well. Then the well will overflow and I could explode with behaviors. But I may stop that by expressing my feelings. Then the well can’t overflow because I let a lot of of the sensations out.

I likewise made pictures of my heart. I was born with a nice heart but then when I went into the orphanage I got cracks in my heart. My heart cracked because they couldn’t take good care of me. I was a baby and I necessitated somebody to hold me and rock me. But they couldn’t because there were too some babies. Then I put 16 bricks around my heart. I was protecting my heart so it wouldn’t get injure anymore. But the bricks kept the love out too. I wouldn’t let Mom’s love in. I had lots of crazy in my heart.

My hard work in therapy got rid of all the bricks. Then Mom’s love got in. The love made the cracks heal. Now I have a bright red heart with no cracks.

I in truth liked Dr. Art now and am proud that I am strong. I still don’t need therapy. I still let Mom’s love into my heart! Sometimes I send e-mail’s to Dr. Art. I tell him how good I’m doing.

I started missing Dr. Art and told Mom. Mom was confused and thought I wanted more therapy. I told Mom “I don’t need therapy. I just want to have lunch with Dr. Art.” So I sent Dr. Art an email to let him know that I wanted to have lunch with him. Then one day we had lunch together.

Sometimes it’s still hard. I still get crazy and now and again I don’t express my sensations well. Sometimes when Mom helps me I may express my sensations and say “I don’t want to pick up my toys. It makes me crazy that I have to but I will”. When I say that it doesn’t make me feel crazy anymore. It helps me to listen to Mom. But now and again when I get crazy I pout and stomp my feet and run to my room if I forget to express my feelings. But now I let Mom support me so that I may talk when it comes to my sensations and do what she says

It’s been a genuinely longtime since I tried to injure Mom or break things when I’m mad. I feel good in regards to love now. I know that my Mom and Dad love me. I recognise that I love Mom and Dad. I don’t feel like I’m a bad boy anymore.

Effective therapy uses experiences to aid a child experience safety, security, acceptance, empathy, and aroused attunement within the family. A number of proficiencies and methods are used including psychodrama, interventions congruent with Theraplay, and other exercises.

SECOND PRINCIPAL. Therapy ought to be family-focused. Therapy helps the child address the underlying trauma in a supportive, safe, secure surroundings in “titrated” and manageable doses so that what the parents have to offer may get in and heal the child. It is the parents’ capacity to construct a safe and fostering home that provides a healing environment. Being competent to have empathy for the child, receive the child, love the child, be curious when it comes to the child, and be playful are all share of the “attitude ” that heals. Parents are actively involved in treatment.

THIRD PRINCIPAL. The trauma must be directly addressed. Therapy helps healing by providing the safety and security so that the child may re-experience the painful and shameful emotions that surround the child’s trauma. Revisiting the trauma is necessary if the child is to begin to revise the child’s personal narrative and world-view. It is by revisiting the trauma and sharing the anger and shame with an accepting, empathetic person that the child may comprise the trauma into a consistent self.

FOURTH PRINCIPAL. A comprehensive milieu of safety and security ought to be created. Traumatized children are oftentimes hyper-vigilant, insecure, and deeply distrusting. A consistent surroundings that is safe and secure is necessary to creating the experiences necessary for the child to heal. This milieu must be present at home and in therapy. Good communication and coordination amidst home, school, and therapy is another primary factor of effective treatment. “Compression-wraps,” invasive and irruptive stimulation designed to arouse rage, “re-birthing,” and other provocative proficiencies are not part of Dyadic Developmental Psychotherapy. These intervening and invasive proficiencies are not therapy, not therapeutic, and have no place in a reputable treatment program.

Fifth Principal. Therapy is consensual and not coercive. At our center we are very clear that physical restraint is not treatment and is not applied in treatment in any manner. Treatment is provided in a manner consisted with the Association for the treatment and Training of Children’s White Paper on Coercion in treatment.

The therapist will have to be well trained, licensed, and have significant experience in treating trauma-attachment disordered children. A good resource to locate such therapists is the Association for the Treatment and Training in the Attachment of Children, ATTACh. In selecting a therapist you will have to look for the following:

- Significant training from a recognized training program. Ask where the therapist was trained, how long ago, and for how long.

- Ongoing training. Ask when was the last training event the therapist attended and how long was the event.

- Licensure in the state in a recognized mental health discipline.

- Membership in ATTACh.

- A comprehensive informed consent document and suitable releases.

- An original assessment to manufacture a differential diagnosis and treatment plan.

DETAILED DESCRIPTION OF TREATMENT

Dyadic Developmental Psychotherapy is a treatment devised by Daniel Hughes, Ph.D., (Hughes, 2008, Hughes, 2006, Hughes, 2003,). Its basic principals are described by Hughes and summarized as follows:

1. A focus on both the caregivers and therapists own attachment strategies. Previous exploration (Dozier, 2001, Tyrell 1999) has shown the importance of the caregivers and therapists state of mind for the success of interventions.

2. Therapist and caregiver are attuned to the child’s subjective experience and reflect this back to the child. In the procedure of preserving an intersubjective attuned connection with the child, the therapist and caregiver help the child regulate affect and construct a consistent autobiographical narrative.

3. Sharing of subjective experiences.

4. Use of PACE and PLACE are necessary to healing.

5. Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.

6. Caregivers use attachment-facilitating interventions.

7. Use of a assortment of interventions, including cognitive-behavioral strategies.

Dyadic Developmental Psychotherapy interventions flow from assorted theoretical and empirical lines. Attachment theory (Bowlby, 1980, Bowlby, 1988) provides the theoretical foundation for Dyadic Developmental Psychotherapy. Early trauma disrupts the normally constructing attachment system by creating distorted internal working models of self, others, and caregivers. This is one rationale for treatment in addition to the requisite for sensible care-giving. As O’Connor & Zeanah (2003, p. 235) have stated, “A more puzzling case is that of an adoptive/foster caregiver who is ‘adequately’ sensible but the child exhibits attachment disorder behavior; it would seem improbable that bettering parental sensible responsiveness (in already sensible parent) would yield positive changes in the parent-child relationship.” Treatment is necessary to directly address the rigid and dysfunctional internalized working models that traumatized children with attachment disorders have developed.

Current thinking and exploration on the neurobiology of interpersonal conduct (Siegel, 1999, Siegel, 2000, Siegel, 2002, Schore, 2001) is another percentage of the foundation on which Dyadic Developmental Psychotherapy rests.

The necessary approach is to invent a secure base in treatment (using proficiencies that fit with sustaining a healing PACE (Playful, Accepting, Curious, and Empathic) and at home using principals that provide safe structure and a healing PLACE (Playful, Loving, Acceptance, Curious, and Empathic). Developing and sustaining an attuned kinship within which contingent collaborative communication occurs helps the child heal. Coercive interventions such as rib-stimulation, holding-restraining a child in anger or to provoke an aroused response, shaming a child, using fear to elicit compliance, and interventions based on power/control and submission, etc., are never applied and are inconsistent with a treatment rooted in attachment theory and current psychological result of perception learning and reasoning in regards to the neurobiology of interpersonal behavior.

Dyadic Developmental Psychotherapy, as conducted at The Center For Family Development, uses two-hour sessions involving one therapist, parent(s), and child. Two offices are used. Unless the caregivers are in the treatment room, the caregivers are watching treatment from another room by closed circuit T.V. or a one-way mirror. The general structure of a session involves three components. First, the therapist meets with the caregivers in one office while the child is seated in the treatment room. During this part of treatment, the caregiver is instructed in attachment parenting methods (Becker-Weidman & Shell (2005) Hughes, 2006). The caregiver’s own issues that may create troubles with fabricating affective attunement with their child may likewise be explored and resolved. Effective parenting methods for children with trauma-attachment disorders require a high degree of structure and consistency, along with an affective milieu that demonstrates playfulness, love, acceptance, curiosity, and empathy (PLACE). During this percentage of the treatment, caregivers receive support and are given the same level of attuned responsiveness that we wish the child to experience. Quite often caregivers feel blamed, devalued, incompetent, depleted, and angry. Parent-support is an essential dimension of treatment to help caregivers be more capable to maintain an attuned connecting kinship with their child. Second, the therapist with the caregivers meets with the child in the treatment room. This in general takes one to one and a half hours. Third, the therapist meets with the caregivers without the child. Broadly speaking, the treatment with the child uses three categories of interventions: affective attunement, cognitive restructuring, and psychodramatic reenactments. Treatment with the caregivers uses two categories of interventions: first, instructing effective parenting methods and helping the caregivers refrain from power struggles and, second, sustaining the proper PLACE or attitude.

Treatment of the child has a substantial non-verbal dimension since much of the trauma took place at a pre-verbal stage and is often times dissociated from explicit memory. As a result, childhood maltreatment and resultant trauma give rise to barriers to successful engagement and treatment of these children. Treatment interventions are designed to give rise to experiences of safety and affective attunement so that the child is affectively engaged and may explore and resolve past trauma. This affective attunement is the same routine used for non-verbal communicating amidst a caregiver and child for the duration of attachment palliating interactions (Hughes, 2003, Siegel, 2001). The therapist and caregivers’ attunement results in co-regulation of the child’s affect so that is it manageable. Cognitive restructuring interventions are designed to help the child construct secondary mental representations of traumatic events, which grant the child to incorporate these events and give rise to a consistent autobiographical narrative. Treatment involves multiple repetitions of the rudimentary caregiver-child attachment cycle. The cycle begins with shared affective experiences, is followed by a breach in the kinship (a separation or discontinuity), and ends with a reattunement of affective states. Non-verbal communication, involving eye contact, tone of voice, touch, and movement, are necessary constituents to creating affective attunement.

The treatment provided oftentimes adhered to a structure with assorted dimensions. It is pictured in Figure 1, below. First, conduct is identified and explored. The conduct may have occurred in the prompt fundamental interaction or have occurred at galore time in the past. Using curiosity and acceptance the conduct is explored. Second, using curiosity and acceptance the conduct is explore and the meaning to the child begins to emerge. Third, empathy is applied to reduce the child’s sense of shame and increase the child’s sense of being accepted and understood. Forth, the child’s conduct is then normalized. In other words, once the meaning of the conduct and it is basis in past trauma is identified, it becomes understandable that the symptom is present. An example of such an fundamental interaction is the following:

Wow, I see how you got so angry when your Mom asked you to pick up your toys. You thought she was being mean and didn’t want you to have fun or love you. You thought she was going to take everything away and leave you like your basi Mom did, like when your primary Mom took your toys and then left you alone in the apartment that time. Oh, I may actually comprehend now how hard that must be for you when Mom said to clean up. You genuinely felt crazy and scared. That ought to be so hard for you.

Fifth, the child communicates this understanding to the caregiver.

Sixth, finally, a new meaning for the conduct is found and the child’s actions are integrated into a consistent autobiographical narrative by communicating the new experience and meaning to the caregiver.

Past traumas are revisited by reading documents and through psychodramatic reenactments. These interventions, which occur within a safe attuned relationship, concede the child to comprise the past traumas and to comprehend the past and present experiences that invent the sensations and thoughts related with the child’s behavioral disturbances. The child gives rise to secondary representations of these events, sensations and thoughts that result in more outstanding affect regulation and a more integrated autobiographical narrative.

As described by Hughes (2006, 2003), the therapy is an active, affect modulated experience that involves acceptance, curiosity, empathy, and playfulness. By co-regulating the child’s emergent affective states and fabricating secondary representations of thoughts and feelings, the child’s capacity to affectively engage in a trusting kinship is enhanced. The caregivers enact these same principals. If the caregivers have difficultness engaging with their child in this manner, then treatment of the caregiver is indicated.

Children who have experienced chronic maltreatment and resulting complex trauma are at substantial danger for a potpourri of other behavioral, neuropsychological, cognitive, emotional, interpersonal, and psychobiological disorders (Cook, A., et. al., 2005; van der Kolk, B., 2005). Children and adolescents with complex trauma require an approach to treatment that focuses on various dimensions of handicap (Cook, et. al., 2005). Chronic maltreatment and the resulting complex trauma cause handicap in a assortment of critical domains including the following:

- Self-regulation

- Interpersonal relating including the capacity to trust and secure comfort

- Attachment

- Biology, resulting in somatization

- Affect regulation

- Increased use of defensive mechanisms, such as dissociation

- Behavioral control

- Cognitive functions, including the regulation of attention, interests, and other executive functions.

- Self-concept.

Dyadic Developmental Psychotherapy addresses these domains of impairment. Dyadic Developmental Psychotherapy shares a lot of essential elements with optimal, sound social casework and clinical practice. For example, attention to the dignity of the client, respect for the client’s experiences, and starting where the client is, are all time-honored principles of clinical exercise and all are likewise central elements of Dyadic Developmental Psychotherapy

In summary, therapy for traumatized children who have disordered affixations must be experiential, consensual, and provide an surroundings of security, acceptance, safety, empathy, and playfulness. Only an experienced and trained therapist may provide attachment therapy.

Treating Complex Traumatic Stress Disorders An Evidencebased Guide