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Abstract: Data from two instruments confirm the effectiveness of treatment for children with attachment disorders at the Family Attachment Center in Minnesota. Data from the Child Behavior Rating Scale show improvement in 70% of children 30 days after treatment and in 79% of children one year after treatment. Data from the Achenbach Child Behavior Checklist show significant improvement in 92.5% of children one year after treatment.

Most children enter the intensive psychotherapy program for children with attachment disorder with multiple diagnoses. Usually these diagnoses are based on behavioral criteria. The common thread, and the underlying cause of the behavior problems, is attachment difficulties. Due to the trauma (abuse or neglect) suffered very early in life, these children view the world, and the adults in it, very differently. Typically, they are skilled manipulators, capable of charming people and behaving appropriately with professionals and others outside the family system, skills honed to cope with the traumatic environment of their early years. In addition, the trauma frequently causes a freezing of the emotional or developmental level of the child, resulting in behavior and emotions that are not congruent with their chronological age.

In our treatment model, attachment issues are the primary focus of treatment. As the attachment and bond between parents and child improves changes in behavior follow. Additionally, as attachment improves the gap between a child's emotional/development level and chronological age tends to narrow, producing additional improvements in behavior. Therefore, significant and lasting improvements in behavior are a sign of improvements in attachment.

Most of these children have been in previous therapeutic interventions with sub-optimal results. This therapy has included play therapy, talk therapy, individual therapy, group therapy and other types of traditional therapy. These well-intentioned therapeutic interventions were unsuccessful because they did not adequately address the root cause of the children's behavior-their attachment difficulties. Standard therapeutic approaches delivered in a weekly format are unlikely to help them, because these children are capable of fooling the best of therapists if the therapist lacks extensive, specialized training in working with this diagnosis. When parents contact us, they are usually exasperated, after months or years of failed therapeutic interventions. They are frustrated and angry with a child who exhibits bizarre and sometimes dangerous behavior.

Program outcomes reported here are based on two parent-report measures in a pre/post design.

• The Child Behavior Rating Scale (CBRS) is a 52-item instrument designed to measure behaviors associated with four diagnoses: Conduct Disorder (CD), Oppositional Defiant Disorder (ODD), Reactive Attachment Disorder, and Attention Deficit Hyperactivity Disorder (ADHD). The CBRS was developed in house, when staff noticed that these four diagnoses were most prevalent in children entering the program.
• The Achenbach Child Behavior Checklist (CBCL) is a standardized, normed instrument designed to assess behavior problems in children 4 to 16 years of age. The CBCL consists of a total score scale, two broadband scales (internalizing and externalizing) and eight narrowband syndromes.

Positive outcomes are measured by comparing the scores for an individual prior to treatment and after treatment. A positive outcome meets one of the following criteria.

1. A child no longer meets criteria for a diagnosis.
2. A child moves from a clinical range into a subclinical range.
3. Improvement in a child's score is clinically significant.

 
CBRS Results

The results of the CBRS indicate improvement in the behavior of children after treatment. Improvement is evident 30 days after the start of treatment and is still evident one year later. Pre/post data are available for 58 children 30 days after treatment (the short term study group). Of these, parents reported that 44 (75.8%) met criteria for at least one of the diagnoses prior to treatment. Thirty days after treatment, parents reported that 31 (70.4%) of these no longer met criteria in at least one diagnostic category for which the child did meet criteria prior to treatment. Pre/post data were available for 53 children 1 year after treatment (the long term study group). Of these, parents reported that 38 met criteria for at least one of the diagnoses prior to treatment. One year after treatment, parents reported that 30 (78.9%) had improved and no longer met criteria in at least one diagnostic category for which the child did meet criteria prior to treatment.

Conduct Disorder
In the short term study group, parents reported that the behavior of 19 of the 58 children (32.8%) met criteria for conduct disorder prior to treatment. Thirty days after treatment, only seven children (12.1%) met criteria, a reduction of 63%. In the long term study group, parents reported that 15 of 53 children (28.3%) met criteria for conduct disorder prior to treatment. One year after treatment, only 4 children (7.5%) met criteria, a reduction of 73%.

 
Oppositional Defiant Disorder

In the short term study group, parents reported that the behavior of 40 of 58 children (69%) met criteria for oppositional defiant disorder prior to treatment. The number meeting criteria declined to 23 (39.7%) 30 days after treatment, a reduction of 42%. In the long term study group, parents reported that 32 of 53 children (60.4%) met criteria for oppositional defiant disorder prior to treatment. The number declined to 16 (30.2%) 1 year after treatment, a reduction of 50%.

 
Reactive Attachment Disorder

In the short term study group, parents reported that the behavior of 29 of 58 children (50%) met criteria for reactive attachment disorder prior to treatment. The number declined to 8 (13.8%) 30 days after treatment, a reduction of 72.4%. In the long term study group, parents reported that 24 of 53 children (45.3%) met criteria for reactive attachment disorder prior to treatment. The number dropped to 9 (17%) 1 year after treatment, a reduction of 62.5%.

 
Attention Deficit Hyperactivity Disorder

In the short term study group, parents reported that the behavior of 31 of 58 children (53.4%) met criteria for attention deficit hyperactivity disorder prior to treatment. This number declined to 17 (29.3%) 30 days after treatment, a reduction of 45%. In the long term study group, parents reported that 29 of a group of 53 children (54.7%) met criteria for attention deficit hyperactivity disorder prior to treatment. The number dropped to 14 (26.4%) 1 year after treatment, a reduction of 52%.

 
CBCL Results

Pre/Post data are available from the CBCL for 40 children one year after treatment. The data show consistent and regular gains across both narrowband and broadband scales in the population treated at the intensive program for attachment difficulties at the Family Attachment Center.

 
Broadband Scales

In the total scores scale, 37 of the 40 children were in the borderline clinical or clinical range (minimum t score of 67) prior to treatment. One year after treatment, 19 had sufficiently improved to move out of these ranges, an improvement of 51.4%. In the externalizing scale, the improvement was 53.1% and in the internalizing scale 50.0% improved.

 
Narrowband Syndromes

Findings in the narrowband syndromes are similar to those in the broadband scales. The range of percent improvement is between 37% in social problems and 53% in somatic. The improvement for all syndromes except social problems is at least 45%.

 
 
Clinical Significance

Our outcomes program also uses the clinical significance methodology to measure outcomes. This methodology takes into account the statistical properties of reliability coefficient and standard deviation for a psychological instrument. A clinically significant outcome is a change in score that is significantly different than the previous score at a 95% level of confidence. This measure indicates whether the status of an individual has improved, even if the individual is still in the same diagnostic range according to the instrument.

 
The table above shows the number of changes in results that were clinically significant and whether the change was positive or negative. Of the 40 children, 37 (92.5%) improved significantly in at least one of the eight narrowband syndromes and 29 (72.5%) improved significantly in one of the two broadband scales or the total scores scale. As the table above shows, all narrowband syndromes demonstrated some clinically positive change, with the frequency ranging from 29 (72.5%) in anxious/depressed to 20 (50%) in thought. All syndromes except aggressive also had at least one case where the change was clinically negative one year after treatment. Two scales, somatic and attention, had fairly high numbers of clinically negative changes. In the two broadband scales and the total score scale, 29 (72.5%) of the children experienced clinically positive change in at least one measure one year after treatment.

 
Conclusion

The treatment program for children with attachment difficulties produces excellent outcomes with an extremely difficult population. Improved parent-child attachment is the goal of the program. In most cases, improved attachment leads to improved behavior. Behavioral improvement is the outcome measure, since level of attachment is difficult to measure.

Using parent report measures, the incidence of behavior problems in children after treatment is much lower than before treatment. This finding is consistent on two measurement instruments, and in both broad and narrow measures. Behavioral improvement is evident 30 days after the start of treatment and is maintained one year later. Improvement in behavior is a sign of the successful treatment of the underlying attachment difficulties in these children.