Ask the Doctor
I have a 7 1/2 year old son whom I have had since birth, but he has also
experienced a great deal of loss and has mild RAD plus Anxiety Disorder and
Sensory Integration Disorder. He has always had bladder problems, daytime and nighttime wetting and sees a specialist and is on medication for both day and night. Problem is, he often wets himself at school and at home during the
day as if he weren't anywhere near a bathroom. He often has extreme urgency
but the blatant wetting when bathrooms are available is what puzzles me. Can
this be a RAD thing because we have tried everything else. Is there a
special therapy we can use? Like changing him like you would a baby
with a diaper? Thanks
I am glad that you have first sought the advice of a medical doctor in your son's case as many times the problem is biological. But it is difficult for even a medical doctor to discern whether the wetting is biological or psychological. Wetting is a common problem in RAD and in individuals with extreme psychological issues because of the need to control. What goes in or out of the body is about the only thing an individual has complete control over so wetting or soiling, along with eating disorders or addictions, are often symptoms of RAD. I don't advocate the practice of changing him like a baby and have never seen this to work in cases where this was done. In most cases the wetting will stop on its own if there isn't a biological component to the problem often because of peer pressure or simply because the child grows tired of the hassle of cleaning up. Do make sure he takes full responsibility for cleaning his own clothes and bed sheets and if he is motivated by reward systems you can try putting one in place if you haven't already done so. Good luck!
Dr. Catherine Swanson Cain, PhD., LMFT
I have an adult friend who was raised by aunts, then foster homes, and
finally residential treatment. It was in the forties when residential
facilities were not like they are today. The nuns used to lock him in a
crawl space, leave him there for behavioral infractions, and the bigger
boys told him the rats would eat his feet and legs. He was also sexually
abused by the older boys. He hates men still. He insists that his
childhood, while different than most, has not affected him in any way. We
have been semi-dating for a couple of months. He constantly does the "I
love you but go away" attitude. I care deeply for him and he is very
involved with my special needs children. I find myself, however, living as
I did when my children with RAD were at their worst. I'm an Olympian
caregiver and realize part of it is that I want to fix him. I feel terrible
that anyone would undergo such treatment. While he is unfailingly loving
to my children and they adore him, it is beginning to be hurtful to me.
He refuses therapy, insisting he doesn't need it, rants and raves about his
job, politics, just about everything but his own problems. He has never
been able to have a successful relationship with a woman since his 29 year
marriage ended, at his insistence. I guess I know my own answer, but how
can I detach from him and have him stay involved with my children. He is an
OT with DDSO here and will be involved with them long-term, since he is the
only OT who works with children. I realize there is no hope for a long-term
relationship with someone who has so much baggage. When he retires, in two
years, he plans to build a cabin in the woods and become a hermit. This has
been his goal since childhood. Is there any hope you can offer for this
situation? If he agreed to go, after hitting a bottom of sorts, is there
adult treatment that could help? Thanks for reading my letter.
You have a clear cognitive awareness of your situation which is good. I think your appraisal of your situation is right in that there isn’t much hope for an intimate emotional relationship with this man unless he is willing to undergo change. He probably has resolved the emotional connection with the abuse he endured which is why he doesn’t feel he would benefit from therapy. What he doesn’t understand is that for him to connect fully at a deeper level with someone, he would have to undergo attachment therapy that focuses on correcting the inner core belief system that he has, which is basically, “I am not worthy of being loved.” Can this be corrected in someone his age? Yes, definitely, but only if he is willing to work on those issues. You can’t change him. I have successfully worked with several adults who overcame similar backgrounds AND went on to change their inner core belief systems. You always have the choice of accepting him for who he is without him making change but if you need more in a relationship then you will have to leave and there is no easy way to do that. With change comes pain. But without pain we would not understand joy. I have seen people retreat from the world as he hopes to do in retirement and live contently without resolving their issues but it is my belief that we are here on earth to resolve such inner issues so that is a cop-out. Take a careful look at what you need in your life and if he does not fit that picture, then it is time to move on. Your responsibility is to yourself. As stated, you cannot change him. Good luck to you.
Dr. Catherine Swanson Cain, PhD., LMFT
My kids are RAD teens. They were making all kinds of progress, but now it
seems as if their brains have totally shut down. Is there still hope that
they will continue to get better or are we at the end?
All of development, whether emotional, physical, spiritual, or psychological consists of peaks and valleys or periods of growth followed by periods of stagnation. Sometimes while one area of development is progressing, another area of development stops or even regresses. It could be that your teens are in one of these down cycles. Down cycles can last weeks or months depending on the individual. If your teens have not progressed in several months then they may have adapted to the strategies you are using and it may be time to change how you interact with them in order to force them to change as well.
Dr. Catherine Swanson Cain, PhD., LMFT
Let me start by saying that I am at the end of my rope. I have a nine year boy
diagnosed with RAD/ODD/ADHD/BD. My husband and I adopted him when he was five. Presently he is in a residential facility because we could not control
his behaviors and he was threatening to kill his classmates. We have tried
the 1-2-3 program, and we have tried the natural consequence. He sees a therapist and a psychiatrist. They keep telling us to keep doing what we're doing but I can't take it anymore. He has progressively gotten worse in the center he is in right now. He was starting to get aggressive with me but now he physically beats up on his roommates and the staff with no remorse. I am at a point where I don't think I can help him. I went from taking generic allergy medications seasonally, to high blood pressure medication, and now anti-depression medication. Is there an end in sight?
My question to you is whether or not he has had attachment therapy. In most cases, traditional therapy does not work with children with RAD. If no attachment therapy has been provided, find yourself a RAD therapist and make sure the therapist really knows how to treat RAD and not just an attachment disorder which is a common mistake. There is hope, even at the age of 9, but the older the child is, the harder it and the more time it takes. Some experts state that once appropriate RAD therapy is started it can take up to 2 months therapy per age of the child, so in his case, 18 months of intense therapy. This is not a once-a-week visit the therapist for an hour type of treatment. It is daily, sometimes 24 hours a day, so it requires a strong support system and active participants in the correctional process. Another option you have is to use an attachment center such as the one in Evergreen Colorado which offers intensive 10-14 day treatment or a Wilderness program such as the one near me right here in middle Tennessee which is excellent called Three Springs (check out their website). Treatment is expensive but without it the prognosis is not good.
Dr. Catherine Swanson Cain, PhD., LMFT
What is your opinion on 1-2-3 magic and time out's with RAD kids. I know
your book says that typically you do not find time-out's effective. Is
there ever a good time to use time out with kids with RAD?
My foster son tends to respond to time outs in a way that sounds like it is
traumatic to him and I am real sure that it has been misused in his past.
At times it is effective in stopping the behavior and when this happens, we
avoid a restraint which can be a daily or several times a day occurrence,
just to ensure safety. If the time out is not effective, we end up doing a
hold anyways and he is in a much deeper and longer lasting rage.
More often than not, he will push and push (even if he needs to attempt to
jump out a window), until he is held and often (when he is in a positive
state of mind) he will tell me that he wants me to hold him when he is out
of control, but he will not let you comfort him without resisting.
Any direction? He is both a fighter and flighter, but more so a fighter!
Every child is different so strategies that work with one child sometimes do not work with another child. In general, I do not see time-out being effective with children with RAD because many of them can dissociate during time-out and so it doesn’t bother them and thus does not change their behavior. Most children with RAD are working from a core base of shame so time-out shames them just as they want. I use and recommend 1-2-3 Magic in some cases and not in others. For example, it helps a child with extreme hypervigilance that needs time to “mind shift” onto another activity and it is effective in a child that is in the learning phase of complying. But in some children who know how to comply, who can shift their direction easily, but are lazy or defiant and just don’t want to comply, I usually give a direction and one chance to comply. In time, I give a direction once and expect compliance.
Restraint and holding therapy are very different techniques and should not be used interchangeably. In addition, both should always be monitored by an attachment expert. Holding therapy in particular, needs to be monitored to make sure it is being done correctly and to be sure the child is responding correctly to it. A child that is pushing and pushing and pushing to get a restraint is not learning to self-regulate but instead, learning how to get YOU to self-regulate. This also gives him control over you rather than you having the control. There are subtle nuisances in the child and in the parent-child relationship that need monitoring to determine the effectiveness of holding therapy thus it should be carefully monitored. I recommend Nancy Thomas’ website to find an attachment specialist near you if you do not already have one, but be careful, I am hearing more and more about unskilled, untrained people who call themselves attachment specialists who really aren’t. For those of you who are interested, I have provided online monitoring with families via webcam sessions.
Dr. Catherine Swanson Cain, PhD., LMFT
What is the best treatment for a 5 year old who often lies?
Lying is about self-protection. Lies help children avoid being caught at deception or not taking responsibility for their actions. Lies also create separation and distance which is the foundation of many RAD children’s core existence. Lying is a form of manipulation and deceit, combining energies of disregard and dismissal with the instinct for self-preservation and self-promotion. I see lying (and stealing) more than not in children who have experienced abuse. I have very successfully dealt with lying when I can get absolute proof beyond a shadow of doubt that the child has lied. I then confront the child in session. The child typically comes up with many scenarios to cover the lie. I take a very neutral, non-punitive, detective-like stance and say “No, no I don’t that that is what happened. Keep thinking. I think you are close to telling me what really happened and I can wait.” The child will feign ignorance, make up excuses, distract, and use every available tool to trick me, distract me, or get out of the process. But I hold strong. I tell kids, “Take as much time as you need to come up with what really happened because I have all day to wait. I can cancel my next client. I can stay late. But I will wait for the truth.” And I do. I don’t let the child distract him or herself with play or conversation. We just sit. Absolutely silent and me positioned closer than the child probably is comfortable with to up the level. I have canceled half a day of clients to wait out a reluctant child in admitting the truth. It is great because once they admit the truth I simply nod, smile, and congratulate the child for knowing and admitting the truth. There is no punishment, just praise for doing what is right. Sometimes it only takes one time of doing this to change a child from lying constantly to not wanting to lie. It is an amazing technique. The key is to not be punitive, to be patient, to look at this as a teaching experience, and to expect truth.
Dr. Catherine Swanson Cain, PhD., LMFT
My 3 foster sons have been diagnosed with.RAD. They are ages 6, 8, and 10.
The youngest likes to terrorize everyone. He recently started to say weird
things like, "Go ahead and kill me... I know you want to chop me up in
pieces." The school called and didn't say what he said, but they did say
that he needs serious therapy. Foster care does nothing. Help?
I hope when you said "foster care does nothing" you did not mean yourself, as a foster parent, because such a belief is the farthest from the truth. I am going to assume that you mean the system. The things your foster son is saying is very common in RAD. In some cases I see kids doing this for attention, but for the most part I see this as an act to control you. They want to get a reaction from you. They want you to go into a lengthy explanation of why you would never want to see them dead or see them in pieces. To counter this, react in a way they would not expect, such as saying "No, I wouldn't want to see you cut into little pieces because it would make a huge mess on my floor and I don't feel like cleaning your mess up." I know this sounds cold, but you have to remember, the child isn't saying this because he needs pity or reasons to live. He is doing it to shock and awe you for the fun of the reaction. So don't react or react in a way he does not expect.
Dr. Catherine Swanson Cain, PhD., LMFT
Do you have a concise way to explain to someone why behavior management
techniques are ineffective with RAD kids? I think I have even read that it
can be counter productive. My 11 yr old RAD, ADHD, ODD daughter just seems to use the rules and rewards as a whole game to see how many times she can get away with breaking the rules and still get the reward!
There are several reasons why traditional behavior management strategies often do not work with kids with RAD. One reason is that most kids with RAD function from a core belief of shame and doubt. They try to bring themselves back to this core by self-sabotaging their own successes or doing things to get punished. They inwardly do not feel worthy of praise or positive rewards so they try to prevent these from happening. Another reason is that their core desire is control and keeping that control in some children with RAD is more important than doing what is right or any reward you could offer. These are two of the most common reasons why traditional strategies fail.
Dr. Catherine Swanson Cain, PhD., LMFT
I have an 8 year old son with RAD and Bipolar Disorder. We just finished a 20
week intensive attachment therapy program and made some progress! My son is transitioning to a new school in January and when I was discussing Nancy
Thomas's "consequence" article about not giving warnings, and giving him consequences the 1st time a behavior occurs, they did not agree. How do I explain this better, what is the rationale behind it, so I can better help them
understand. It works at home! Thank You
The school staff needs to be aware that disciplinary strategies used for children with RAD are very different than those used with the general population. The school is right in a typical case a child should be allowed a warning or second chance to comply with a directive, but that is if the child is internally motivated to want to do the right thing or if the child is learning to do the right thing and just has not perfected the behavior yet. In many RAD cases, however, the child knows what to do but deliberately chooses not to do it and giving the reminder or second chance is a waste of everyone's time. The child might see not responding on the first time as a manipulative tool he can use against the adult. He may feel by not responding on the first time, he "wins."
If done correctly, the consequences for specific behaviors were already discussed in detail with the child before he chooses which behavior to use -- the right behavior or the wrong behavior - - so an immediate consequence is warranted rather than a second chance.
Dr. Catherine Swanson Cain, PhD., LMFT
Wow, these questions are all interesting. I am in my 40s and seek behavioral
therapy for anger management and social phobia. I see that my behaviors are
in part a response to childhood trauma and later domestic violence as an adult. Now, ten years after the adult violence, I see behavior in myself that is not productive for my family. In some ways I feel related to the RAD kids. What do you suggest for adult recovery? I have often thought I simply had PTSD. In this vein, I wonder for our soldiers who are experiencing great trauma.
Adults are rarely given a label of RAD when I believe they should be. Some experts believe that most adults diagnosed with anxiety, depression, PTSD, ADHD and bipolar disorder really have adult RAD because they experienced pathological care during the early years of life. Looking at their symptoms through the correct diagnostic lens is critical for recovery. I work long distance with several RAD adults who are making wonderful progress through a cognitive-behavioral approach that addresses RAD issues. Don't give up. Visit one of the adult RAD website forums and learn how they are healing. Find yourself a therapist that specializes in RAD. It is never to late to heal.
Dr. Catherine Swanson Cain, PhD., LMFT
My question is about my stepson. He has been seeing a therapist since May and she has recently brought up that he has a lot of the RAD tendencies. My husband is reluctant to seek a RAD specialist in this area and wants to look into further testing for him. The problem I have with that is that my husband also has some of these tendencies and they are both very charming and manipulative. He wants so much to disprove her theory that I think he will try to sabotage the eval by sugar coating the whole situation. I live day to day on this rollercoaster and am trying to put some of the parenting techniques that I'm reading about to use. It's not really helping much because I think he wants that connection with his Dad or Mom and they have both just learned to ignore the behavior and are convinced that it isn't bad enough to do anything about it. I'm trying my best to make him realize that he does have a deep rooted problem and he will never be a responsible happy adult if we continue to ignore. He is in denial and is reluctantly seeking help. I guess my question is if he goes to a eval doc for testing will they be able to see through the facade?
Your problem is one that I see on occasion. It is a difficult one to resolve as you are finding out. I would definitely go to a family therapist if you can't find a RAD specialist. Family therapists are trained to look for the family dynamics and to treat the entire family rather than just one individual in the family. You can find a listing of Licensed Marital & Family Therapists (LMFTs) in your area at http://www.aamft.org. An experienced therapist should be able to pick up the issues if the evaluation stretches over a few sessions rather than just one. I typically take a minimum of three sessions to do an evaluation. It is important that you have your input too during the evaluation to add in "the other side" to what your husband will sugar coat. An experienced therapist is typically capable of seeing through situations like this. Good luck.
Dr. Catherine Swanson Cain, Ph.D., LMFT
I asked the previous questions about holding therapy verses restraints. I have one more question. If you were to contract, as your book says, with a child for doing holding therapy, what would you include in the contract?
Contracts are specific to the individual child. What will work for one child will not work for another. You need to find out what your foster son will work for. Hopefully, there is something externally motivating to him, although I have met children who are not motivated by just about anything you offer or take away. I usually find that children with avoidant attachments will gladly contract to do holding therapy for time away in their own little world. I use this with children with Autism too, or I let them do their self-stimulation as a reward. Involve your foster son in the process of coming up with what he will work for and the consequence if he doesn't follow through on his part of the deal. Set a reasonable time for holding and a positive and negative consequence if he doesn't hold to the contract. In your case where the holding therapy is not working so well, I have found there are many alternative ways to reach the same goal without holding therapy. I like hold ing therapy because it brings results faster but there are ways to connect with a child in playful banter to get the same results. I think I mention in my book an eleven year old boy that I ended up playing a semi-version of peek-a-boo (at a more mature level which is hard to describe in an email) and by simple things like him twirling around in my office chair and me giving him a high five each time around. Since you read my book, he is the one that we started therapy sessions with him barricaded behind a wall of bean bag chairs under my desk and the most severe case of RAD I have ever seen. He is now adopted and doing quite well. It is hard giving you all you need in a short blurb but if you are interested I do offer long distance counseling. Visit one of my new websites at www.drcainassociates.com to see the online services my therapists and I provide.
Dr. Catherine Swanson Cain, Ph.D., LMFT
My question is in regards to holding therapy verses restraints and when to do what. I really believe in holding therapy, but also know I have to be careful not to retraumatize this child. He has been raging through hours of holding, spitting in my face until his mouth is dried out, scratching my face (which calms him temporarily while he obsesses over the blood), hair pulling,etc. When that does not get him released, he will completely shut down (fall asleep for short periods of time). I have read that this is common, but this is the first I have seen it. He is making eye contact for very short periods of time during holding and that will typically be followed by another burst of intense rage. Any words of wisdom?
Holding therapy requires the supervision of a therapist who specializes in RAD. I hope you are in contact with one. If this boy is falling asleep or shutting down before the rage is resolved the holdings will be ineffective. Holding therapy is not the same as a restraint and should not be substituted for a restraint. They are very different techniques. The purpose of holding therapy is to connect with the child on an emotional level using eye contact, touch, facial expressions, gestures, and intonation of voice while working through the child's resistance. I am currently working with a family in Canada via the Internet that has a child with RAD. The holdings they did with their child were much like the ones you described with your child, no resolve and with the child ending up shutting down and going to sleep. I watched their child for two hours via webcam and came to realize that she also had severe sensory integration issues which were preventing her from tolerating the
holdings. I diagnosed her with MultiSystem Developmental Disorder and changed the course of treatment. It is critical that you have an attachment specialist to consult with to determine whether holding therapy is what this child needs at this time.
Dr. Catherine Swanson Cain, Ph.D., LMFT
Why does bedtime seem to always be so tough for RAD kids? I notice that
things seem to start falling apart really bad as it starts to get dark
outside, and then it all seems to go down hill from there. I've figured it
out now that it definitely has something to do with it getting dark. So I
try to turn on as many lights in the house as possible, but it doesn't
appear to be helping. As soon as the sun starts to go down, he starts
acting strangely and things just continue to escalate until bedtime. Why is
this?
There could be many reasons why your son has difficulty with the end of the day. Without knowing his background it is difficult for me to know which reason it might be. Some children with RAD were left alone to fend for themselves in fear and thus darkness triggers those memories. Others are so hypervigilant that they cannot turn off their thoughts at night so darkness triggers the thought that they are about to be faced with that struggle. But most often I find that children with RAD don't like being alone with themselves. They need the constant stimulus of their environment and those in it to focus on so they don't have to face their own thoughts and feelings which can be very scary.
Dr. Catherine Swanson Cain, Ph.D., LMFT
What do I say to well meaning friends and relatives who tell me that I need to give my daughter some choices so that she can feel that she has some control, having come from an abusive background where she had no control over what
happened to her. She is now 9 years old, and came to our family at 5. We have seen some attachment, but I wouldn't say that she is healed yet. She especially shows defiant behavior, stalling, and tantrums when she doesn't get her way. I know that children with RAD have control issues, and that it is important to have the parent(s) take control in order for them to heal, but I don't know enough of the Why of it, in order to explain it. At what point do you give children with RAD some choices? I struggle with the balance of compassion and showing unmovable boundaries. Any words of wisdom would be greatly appreciated.
I am glad that you understand that control is the cornerstone issue of RAD and that taking away and giving back control is a delicate balance. My guess is that if you are asking yourself if you are too hard or too giving, then you are achieving that delicate balance. Control should be returned to the child as soon as the child is ready to handle it, but in very small chunks so that the child succeeds. If you gave your child back the right to choose clothing (in small pieces, not all at once) and she handles the new ownership with pride and appropriateness, then it is time to give her more control over what she wears. If she fails, you take ownership of everything back for a predetermined time (two weeks?) and try again.
Control is taken away because it is not normal for a child to have control at an early age. Humans are the most helpless of all animals when born and rely totally on their caregivers for survival. When a young child is traumatized and does not have someone to protect her or provide, she must take on that control at too young of an age. Taking away the control allows the child to experience the world with innocence, completely dependent upon the adult, which forms the emotional attachment. In real life the child earns control in little bits and pieces and taking away the control and handing it back in little chunks replicates this necessary stage of development. Of course, it would take me a chapter in a book to explain the entire process but I hope this helps you understand a little better why control is taken away.
Dr. Catherine Swanson Cain, Ph.D., LMFT
I adopted my 13 year old son about 3 years ago. He has a severe abuse and neglect history, is brilliant, engaging, loving, empathic and has a history of being severely oppositional and defiant. He has made a strong attachment to me, despite having RAD, however, he has experienced a recent relapse with the severe defiant, oppositional behavior and rage outbursts anytime he has a chore, faces the a.m. or p.m. routine, hears a correction from me or receives a consequence. It has escalated to the point where I have had to call the police and take him to the ER. Although he intellectually understands his situation and wants to stop it, he, once he feels any level of upset, refuses to use any of his emotional stability tools as contracted in therapy. The situation is becoming unlivable. He is loving and fun when everything is going his way; then stalls, ignores or refuses to do any of his daily responsibilities and becomes enraged when I say anything corrective. The suggestion you gave above for the 15 year old would not be helpful in our situation because just mentioning the behavior when he is calm throws him into a rage. He is going to be confronting his birthmother soon with his rage; is doing neuro and biofeedback, EMDR, we have a therapist who understands RAD... I am trying to avoid medication if possible. I'm a single parent with no family support. My son is homeschooled (very involved with the community) and has become defiant with that as well. It seems that my highly intelligent son is trying to take charge of the home and is refusing to accept me as the head of the household. He is so engaging and charming, that helpers I have tried to put in place are swept off their feet by him and aren't hearing me. He acts well behaved with everyone else, even DURING A RAGE OUTBURST if someone drops by the house unexpectedly! He can turn it off and on in an instant... When he is stable, he is a joy and he is very committed to being close to me. Lately, life has been hell. I have not followed Nancy Thomas' advice because some of her tactics sound abusive and others, my son would refuse to follow anyway. It has come to the point when I must lock him out of the house on the porch for 1/2 hour to stop him from becoming verbally and physically aggressive. That won't work in the cold weather, though.
A couple of things came to mind when reading your email. Children with RAD demand control as your son is doing. Taking away that control calls for drastic measures. You stated that you felt Nancy Thomas' strategies sounded abusive. I have heard that many times but if you want to beat RAD, her strategies cure RAD. I use them and promote them all the time. Kids with RAD are not like other behavioral problem kids. They NEED drastic measures to make change. You are his primary caregiver, and really, his only caregiver. You also home school him so the majority of control comes from you. No wonder he is fighting you so drastically. He is rebelling against all the control you have over him, typical of RAD. Of course he rages when you try confronting him with an issue when he is calm - again, the issue is control. That strategy will work if you take control of it. He has taken control in the fact that you think it will not work with him. You need to confront him and deal with the rages. Kids with RAD often avoid social responsibility for their actions simply by controlling others through pity, rage, or some other emotion. Don't let him control you through rages. Apply the hard strategies in my book or Nancy Thomas' book, and you will overcome the control issue. You said it has come to the point where you have to lock him out of the house when he is in a rage but will not do so when the weather turns cold. He knows that and will use it. How many kids have you seen throw a fit at Wal Mart? They do so because they know they have a better chance of getting away with it in public than in private. He will know you won't follow through on locking him out if it is cold and in his mind, he has won the control of the situation. If he can control his emotions, turning them off and on when people witness them, this is a healthy sign that he can do so all the time. He is simply working you over. How you see him react when in public is how you should expect him to react in private. Anything less is unacceptable.
Dr. Catherine Swanson Cain, Ph.D., LMFT
I have a 19 year old daughter who was adopted from Korea when she was 5 1/2 months old. She had spent the first 4 weeks in an incubator and the following few months in foster care. 2 years ago she began to display outward signs of depression followed by cutting. These symptoms continued to escalate to include obsessive self-mutilation, intense suicidal ideation and multiple suicide attempts. A multitude of therapists, psychiatrists and professionals have been unable to diagnosis or help our daughter. A court order (due to suicidal ideation) has resulted in her placement in a residential type facility. They have been the first to mention the possibility of RAD. Could this be possible, since she was adopted when she was only 5 1/2 months old. I had thought RAD occurred in children who were somewhat older. Thanks for any feedback that you might
offer.
RAD often develops in children that have spent time in an incubator and who experienced foster care placement due to the disruption in the attachment process but I doubt this is the case with her daughter because you stated that she developed symptoms two years ago at the age of 17. If she had RAD she would most likely have had symptoms all along. In nearly every case where I see cutting and self-mutilation, the individual experienced extreme abuse, often in the form of sexual abuse. If your daughter had no symptoms and suddenly developed self-mutilation behaviors I would look into what happened two years ago when the symptoms began.
Dr. Catherine Swanson Cain, Ph.D., LMFT
In your opinion, could a residential treatment facility make matters worse
instead of better for a RAD child and his family? Also, how would a parent
go about finding the level 3 therapeutic foster home that you spoke of in
another post, and exactly what does level 3 therapeutic mean? Is that
different from a respite home, or are they one in the same?
Yes, it is my opinion that a residential treatment facility could make matters worse for a child with RAD for the following reasons: First, most residential facilities are staffed with young, inexperienced, well meaning individuals who are not educated about RAD behaviors. Most children with RAD are experts at manipulating the unaware making a dangerous combination. In addition, staff turnover rates at most residential facilities is about 14 months so staff aren't gaining the experience they need to work with RAD. Plus, children with RAD have an uncanny ability to take on the negative behaviors of the other children. That is not to say all residential programs are like this. There are some that do recognize and treat RAD. I prefer level three foster care because these foster parents are typically people that have been in the foster care system long enough to gain the skill needed to provide care for children with RAD plus they have additional training. Children that are put into state custody are often assigned a level regarding the seriousness of their behavior, from one to four. Level four children are put into residential care. Level three requires special expertise and consideration and these foster parents are typically paid at a higher rate for providing care for these children. The good foster parents at this level run a very militant, controlled environment for the child with RAD and they are wise to RAD behaviors.
Dr. Catherine Swanson Cain, Ph.D., LMFT
We have a daughter who is 9 almost 10. She came to our family at age 5 1/2. Lately we have had a big increase with her problem with stealing money, and lying. It seems mostly related to food, as she takes food from home that she isn't supposed to have (snacks, candy etc). Last week she lied to the teacher that she didn't’ have lunch money when she did. The teacher told me that other students are reporting that she is throwing her packed lunch away (the lunch that Mom fixes and packs for her), and then she is begging food from the other kids in the lunchroom. She also is buying snacks at the after school program with the money she steals (lots of snacks like 4-8 bags of chips or packs of cookies) at a time. Having her do chores to earn the money to repay her debt, taking away privileges and toys does not seem to make an impact on the behavior. I am wondering if this is a rejection of food provided by Mom. She seems to be forming an attachment, but now I wonder. Would appreciate any thoughts or suggestions.
As you probably know stealing and lying are behaviors often associated with RAD, as are food issues. T he rejection of food could be related to a rejection of the mother but most often I see it as an issue of control. Children can really only control what goes in and what goes out of their body, which is why you often see toileting, hygiene, or food related symptoms. You are doing the right thing by requiring her to do chores to earn the money to repay what she has stolen. Make sure the chores are hard ones, preferably ones she does not want to do. Also, I require the child to pay back the debt two-fold to pay for the parent's time and aggravation. Are you having her do strong sitting, as this is also an important element of teaching the child self-control? I would definitely talk with school personnel and request that they do not allow her to buy anything from the after school program, and have the teacher talk with the class to not share their food with her. Then if she throws away her lunch at school, she'll have to suffer the pains of hunger until she gets home.
Dr. Catherine Swanson Cain, Ph.D., LMFT
I have a little girl (my cousin) that I have had since she was 17 months old. She was neglected, and that’s how I happened to get custody of her. Now at the age of 7, she throws tantrums, hurts herself, lies on others, lies about stupid stuff, lies about me, and she and I do not get along for more than 5 minute. Other people do not see this struggle and they think I am just hard on her because she is not my biological child. I love her but I am finding it hard to love her. She has even went to school and made suggestions to teachers that she is being hurt at home. I am at an end, and feeling hopeless. I need help getting her some help. For a while I started questioning my ability as a parent but I have four other children in the house (not all biological) and we get along just fine. Any suggestions.
It is critical to get help for your child as quickly as you can. I would go to Nancy Thomas' website and find an attachment therapist closest to you. The longer you wait, the less chance you will have of correcting her behavior. I would also highly recommend that you read either my book on attachment disorders and/or Nancy Thomas' book… "When Love Is Not Enough" to learn strategies for working with your child. Obviously your situation is much too complicated to address here. Good luck to you.
Dr. Catherine Swanson Cain, Ph.D., LMFT
My best friend and former boyfriend, whom I grew up with, had a very unstable childhood and has shown issues with attachment since he was a child. He's nineteen years old, so he is entering adulthood while still dealing with many adolescent issues. I've found quite a bit of information about how attachment disorder is manifest in children, but not a great deal about the disorder in adults. How do the ways in which attachment issues show themselves change as a person ages? Also, I've discovered quite a bit of information about how to bond with a child with attachment issues, but not a great deal about bonding in adult relationships. Do you have any suggestions on how to better deal with attachment disorder within an adult relationship? Thanks in advance for any suggestions you can give me on how to better relate to him, love him, and be his friend.
Typically adolescents and adults with RAD are labeled with bipolar disorder or borderline personality disorder. How to deal with your boyfriend would depend on the symptoms he is manifesting, as there are many types of attachment disorders that require very difficult treatment. I am currently working with a couple of adults with RAD and it has been my experience that one of the most common symptoms is anger management issues. Your boyfriend could benefit from therapy that deals with connecting his current behaviors to his past history and not simply focusing on anger if that is his issue. I have heard from an adult with RAD that I provide long distance therapy to over the Internet that there are some adult RAD support groups that are quite good that you might want to look into.
Dr. Catherine Swanson Cain, Ph.D., LMFT
My 18 yo daughter has diagnosed RAD, and now Borderline Personality Disorder, has been diagnosed. Is there any treatment for BPD? Is this an adult form of RAD, or different. Her behaviors change from loving to rageful in a matter of minutes, for no apparent reason. The therapist told us that BPD causes black and white thinking. Our daughter recently returned home after completing two weeks of Chemical Dependency Treatment, refuses to attend twelve step meetings, has the entire household in a uproar. Her moods swing into extreme rage after some incident she sees as "being against her". I would be grateful for any suggestions you might make, and hope I'm giving you enough information. Thanks very much.
There is treatment for BPD but it has been my experience that progress is tediously slow and therapy is long term. I have only been successful in cases where the client was very motivated to change, which it doesn't sound like your daughter is. Research has shown that Dalectical Behavioral Therapy (DBT) is the most successful treatment for BPD. DBT involves teaching the client psychosocial skills and combining this with psychotherapy so the client understands the interrelational connectedness of all things in reality. I recommend two therapeutic manuals: 'Cognitive-Behavioral Therapy for Borderline Personality Disorder, and Skills Training
Dr. Catherine Swanson Cain, Ph.D., LMFT
My son is 15 and the biggest problem we face is absolute defiance. Life has gotten to be hell. My husband has left us (of course it is because of me) Go figure, I think we become more and more like the children we are trying to parent over the years. Do you have any new suggestions for severe defiance?
Defiance in a 15 year old is not easy to curb because behavioral patterns have been building for years and have most likely become set. First, you need to define what defiance is. Is it refusing to do his chores? Refusing to follow curfew? Back talking? Make a list of the specific behaviors. Then, pick one of them to work on. Talk with him about this one behavior at a time when you are both calm. Set consequences, both good and bad, for correcting or not correcting that one behavior. The consequences have to be significant enough to motivate him to change or they will not work. Pick a small window of time to work on the particular behavior. It is too difficult to expect 100% change all of the time so just pick a time like from after school to dinner time. Then follow through with your consequences. You have to be consistent or this strategy will not work. Once you have changed one behavior over a few week's time you can choose another behavior to work on.
Dr. Catherine Swanson Cain, Ph.D., LMFT
What are your thoughts on the double bind technique? I had never tried up
until recently. I have a highly aggressive and rage filled young lady in my
adult foster home. She had not had more than 2 good days in a row for
months. I started using the technique and she had 11 days of PERFECT
behavior in a row, however that ended and the intensity of the aggression
and rage seems to be much more now. I continued with the technique for a
short time, as I thought maybe she is testing to see if I will continue, but
it made her escalate to the point where I knew I needed to stop it. My
question is mainly, should I keep trying this technique with her? Things do
have a tendency to work very temporarily with her and she begs for
boundaries and rules, but then totally defies them. Any advice?
The double bind technique (reverse psychology) is highly effective and I use it all the time. As you are discovering, your client sabotaged her own success when she realized she was doing what you wanted. I am wondering if anyone praised her for the 11 successful days? If so, that might be your error. I have found with extremely oppositional clients that they cannot tolerate someone acknowledging their successes. You might want to try the technique again intermittently. Eleven good days in a row is a success. With RAD it always seems to be two steps forward, one step back, throughout the course of treatment so don't let this setback discourage you.
Dr. Catherine Swanson Cain, Ph.D., LMFT
Do you know of any residential facilities (specializing in RAD) that are in or very close to Tennessee?
I do not know of any residential facility that specializes in RAD in Tennessee. I prefer that children with RAD not be put into residential treatment if it can be avoided as the therapy in most facilities is not the type of therapy they need. I prefer a level 3 therapeutic foster home for treatment.
Dr. Catherine Swanson Cain, Ph.D., LMFT
We are currently experiencing problems with our insurance. They deny our
claims, saying that our therapist (the ONLY Certified Attachment Therapist in Indiana) doesn't have the right letters behind his name. Do you have any suggestions as to how we can get the insurance company to fund our therapy? Or how we may deal with them better? Maybe what approach we should take with them?
Can you tell me what letters behind his name that he has? Insurance companies are not obligated to pay for anyone that does not have an accepted licensure. That is too bad because there are many good therapists out there that do not have what insurance companies accept, but they must then charge for their services from the family instead of the insurance companies. Most insurance companies (but not all) accept Licensed Marriage & Family Therapists, Licensed Certified Social Workers, Licensed Professional Counselors, etc. I am an LMFT but there are some insurance companies that refuse to pay for my services. There is nothing you can do on this, believe me. They will not budge on this because they do not have to. Occasionally I have been able to get an insurance company to cover my costs under what is called a single case agreement. Unfortunately, you have to prove that there is no one in your area that can provide the service you need, but this is rare. Many therapists are moving toward a fee-for-service model anyway, where the client pays up front and the insurance company is billed as courtesy. I worked my entire practice into this model a couple of years ago but then moved to a very rural area. But now I have built up a reputation for what I do and am ready to move back into that model again - not accepting any insurance companies but expecting payment up front and billing the insurance company as a courtesy.
Dr. Catherine Swanson Cain, Ph.D., LMFT
Are there any medications that I can give my child that will help him deal
with Reactive Attachment Disorder (RAD)?
I am not qualified to prescribe medication and even if I were, I could not do so based on the information I have. Children with RAD do not all have the same symptoms. Some are anxious or withdrawn while others are angry and aggressive so the type of medication prescribed would be based on the symptoms. In addition, I have found that physicians, psychologists, or psychiatrists prescribing medications vary depending upon the region of the country they live in. Sorry I can't be of more help on that one.
Dr. Catherine Swanson Cain, Ph.D., LMFT
Is there such a thing as "too late" for an individual who may have attachment disorders, but have never been diagnosed or treated? I am not a person who easily gives up and I strongly believe that there is hope for healing in the young lady who is living in my adult foster home, but since I am neither guardian or parent, I am having a heck of a time getting her to the therapy I strongly believe she needs. I have purchased your book and use it like a bible have borrowed it out to the county case manager for her to look over, as my suggestions of what I feel is the problem, often are thought of as off the wall. I have found, after much research a licensed attachment therapist, not too far away, but the response I have gotten when I suggest more intensive therapy is either to be blown off, or told that this young lady has been through "tons" of therapy and does not respond well to it. I honestly believe that if she does not get the appropriate therapy that all I do will not ever be enough and this 1 hour once or twice per month, where she simply chats about how her weeks have gone or buffalo's the counselor with her superficial behaviors, just will not cut it. Psychiatrist, social workers, and guardians have all recently threatened this young lady that if her very aggressive and manipulative behaviors continue that she will be move to a more suitable place, which in the psychiatrists words was an institution. I am so fearful that if this young lady has to handle another transition, that there really may be no hope. I am just having a hard time living with the statement made by professionals that this gal may learn to live a simple, spiritless and isolated life in which she avoids any affectionate relationships. Should I really just stand by and believe that is the only option for this precious young lady?
It is never too late for someone to overcome RAD. It just takes longer and is harder work the older the individual gets. I am currently working with three adults in their 30s and 40s with RAD that were not diagnosed until adulthood. All three are highly motivated to beat this and are making great progress and our therapy is conducted online! On the other hand, I have worked with some adolescents where my prediction was like the one you received -- this child is destined to live a simple, spiritless, and isolated life. Two key factors are whether or not the child is highly motivated and/or the intensity and type of therapy she receives. You said she received tons of therapy but if the therapy was not specific to attachment issues, it probably didn't do any good. The therapist that was reluctant to provide intense therapy may have felt that way due to time constraints, financial constraints, or some other reason. I have turned down doing attachment therapy simply because I knew the family did not have the social, financial, or emotional resources to effectively carry out what was necessary to be successful. I recently released a 16 year old from therapy because the family had spent thousands of dollars and years in appropriate attachment therapy and had provided the child with every single strategy I could think of. The child would not respond, Ironically, when I discharged him, and told him why, he suddenly turned around and started getting better! So don't give up!
Dr. Catherine Swanson Cain, Ph.D., LMFT
I have so many questions for you that I hardly even know where to begin. I am dating a man who really needs to have his child properly diagnosed. A school psychologist once mentioned RAD, and I have to admit that I see many signs and reasons why this psychologist might believe this to be RAD. The child comes from a very unstable past, with his mother being a New Orleans Party Girl. His father has also had a really rough life, with no family structure to draw from. I seem to be the very first person that this child has ever taken to in his life, and he seems to crave my constant attention. It has taken months of work for this bond to occur, and I believe that it is partly due to the fact that I come from a similar background. I have been diagnosed with the adult form of this same illness, and I believe that to be the reason why I relate so well to him. Yet, even though he knows that I adore him, he still seems to need constant reassurance. Sometimes he talks of wanting to die, and when his ‘ghost of a mom’ calls, his behavior changes so drastically. I seem to be the only person that can even mention her name in his presence. I am just so unsure as to what to do to help him. I have this fragile little boy who is finally showing some signs of recovery, and if I could, I would move in and take on that all consuming role as his mother. But, my grandfather is sick and on his deathbed. Since my time with this child has been reduced, he is acting up really badly. So I made him a promise that if he could be really good for the entire week, I would let him spend a night at my house. I really want to help this child. Please tell me anything that will help me help him.
First of all, know that by being this child's friend you are already giving a gift that will last a lifetime to this boy. Decades of research show that the number one factor for children becoming resilient and making it through neglectful or abusive childhoods, is that one adult befriended and believed in them. Do not show this child sympathy. In other words, do not try to compensate for the other parts of his life. Do empathize and show understanding. If you sympathize you portray to the child that he is weak and in need of sympathy. It is better to show empathy and understanding but portray to him that he is strong and capable. Keep pointing out his strengths, as he may not see them. Never talk bad about his mother in front of him. She is a part of him and to put her down, puts him down. Make sure you have structure, consistency, and routine when he is with you. You cannot control what happens in his other life so let it go. Good luck to you.
Dr. Catherine Swanson Cain, Ph.D., LMFT
Do you have any effective parenting techniques to handle stealing and lying about it? Basically, what I am after are parenting techniques that will punish behaviors of stealing and lying. Any help would be appreciated.
Stealing and lying are common behaviors in children with RAD. The most difficult thing about this is that the child is typically very good at hiding the truth or covering it up making it impossible for the parent to know if it really took place or not. To begin with, you need to have an incident of lying or stealing you know of that you can gather cold, hard facts. There can be no doubt in your mind that it happened and sufficient evidence to back it up. I then confront the child on the issue and let them begin their lies. I discredit each lie as they tell it in a neutral, non-judgmental way. I might say something like, "Hmmmm, that is not what I heard. Why don't you think about it a little more while I wait." I then sit silently in front of the child for several minutes or longer if necessary. In fact, I will wait as long as it takes. The child needs to know that you will not give up until the truth is revealed. Every now and then I will ask the child if he is ready to admit what really happened. If I get another false story, I again say, "Hmmmm, that isn't quite right either. Keep thinking about it, I know you will come up with the right answer." The child may say, "I forgot" or "I don't remember" and I say, "Yes, I can see that you don't remember, but I know that you can if you try really, really hard so just keep trying and I will wait." If a child is very stubborn I will coax them on a little by saying something like, "You know, I once waited for a child to answer this question and he couldn't remember either, so you know what? I sat here for 2 ½ hours and waited. In fact, I could cancel everything else I have to do today just so I can wait with you to come up with what really happened." If the child is really stumped, and some truly are as they dissociate from anything bad, I will give them clues such as, "Let me help you out. This is about last Thursday around 12pm. It happened at school and it involved Jessica." Once I get a child to finally admit they lied or stole I praise them lavishly and talk about
the good thing they did. I STILL make them pay restitution but this is all done in a neutral, loving, teaching way, not punitive. There are some children, however, who will proudly tell you exactly what they did with no remorse and this will not work with them - that is a very different tactic that is too detailed to include here.
Dr. Catherine Swanson Cain, Ph.D., LMFT
I just ordered the books off of Nancy Thomas' site. I think I found a therapist that will be kind of close. I only have limited time before our niece comes to our house. I am not sure how to explain why we are taking over. Is it better for her to call us aunt and uncle, or should we tell her she can call us mom and dad if she wants? Can you give a little advice on how to start this new life in our house, and the road to recovery with RAD? I appreciate any help I can get.
It has been my experience that you should give the child the option to call you "Mom" or "Auntie" or whatever feels best to them. Typically if a child is forced to call the parent one or the other, they will rebel. In most cases the child starts out with something like "Auntie" and then over time switches on to "Mom" on his or her own. The most common mistake I see new foster or adoptive parents make is to try to compensate for the child's loss by overlooking problem behavior, showering the child with love, and not disciplining hard enough. Think tough love first. I prescribe an almost militant life style that includes a rigid structure and routine (e.g., breakfast at 7, nap at 2, supper at 6, bed at 8 etc). The second most important strategy to have in place is consistency. In other words, as problem behaviors arise, make a plan about how the behavior will be handled and then follow through with the consequence even if you don't want to or second guess yourself that it is not necessary. My book offers detailed strategies for specific RAD behavior but with any child I see with a behavior problem I begin with getting the family to put the above
