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Dyadic Developmental Psychotherapy

Posted Dec 27 2008 11:50am

Dyadic Developmental Psychotherapy (DDP) is an evidence-based and effective form of treatment for children with complex trauma and disorders of attachment [1].   It is an evidence-based treatment, meaning that there has been empirical research published in peer-reviewed journals.   Craven & Lee (2006) determined that DDP is a supported and acceptable treatment.   Dyadic Developmental Psychotherapy is a family-focused treatment [2].


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

Ø      Adults are experienced as inconsistent or hurtful.

Ø      The world is viewed as chaotic.

Ø      The child experiences no effective influence on the world.

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

Ø      The child feels an overwhelming 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 during the first couple of years of life.   Often, children in the child welfare system have a variety of previous diagnoses.   The behaviors and symptoms that are the basis for these previous diagnoses are better conceptualized as resulting from disordered attachment.   Oppositional Defiant Disorder behaviors are subsumed under Reactive Attachment Disorder.   Post Traumatic Stress Disorder symptoms are the result of a significant history of abuse and neglect and are another dimension of attachment disorder.   Attention problems and even Psychotic Disorder symptoms are often seen in children with disorganized attachment [3].  


Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms [4].   Many of these children are violent [5] and aggressive [6] and as adults are at risk of developing a variety of psychological problems [7] and personality disorders, including antisocial personality disorder [8], narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder [9].   Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence [10].   Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults [11].   Children who have been sexually abused are at significant risk of developing 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 behavior (4.3 times average) [12] (MacMillian, 2001).   The effective treatment of such children is a public health concern (Walker, Goodwin, & Warren, 1992).  


Left untreated, children who have been abused and neglected and who have an attachment disorder become adults whose ability to develop and maintain healthy relationships is deeply damaged.   Without placement in an appropriate 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 [13].


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


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


SECOND PRINCIPAL.   Therapy must be family-focused.   Therapy helps the child address the underlying trauma in a supportive, safe, secure environment in “titrated” and manageable doses so that what the parents have to offer can get in and heal the child.   It is the parents’ capacity to create a safe and nurturing home that provides a healing environment.   Being able to have empathy for the child, accept the child, love the child, be curious about the child, and be playful are all part of the “attitude [14] ” 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 can re-experience the painful and shameful emotions that surround the child’s trauma.   Revisiting the trauma is essential 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 can integrate the trauma into a coherent self.


FOURTH PRINCIPAL.   A comprehensive milieu of safety and security must be created.   Traumatized children are often hyper-vigilant, insecure, and deeply distrusting.   A consistent environment that is safe and secure is essential to creating the experiences necessary for the child to heal.   This milieu must be present at home and in therapy.   Good communication and coordination among home, school, and therapy is another important element of effective treatment.  


The primary approach is to create a secure base in treatment (using techniques that fit with maintaining 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 relationship within which contingent collaborative communication occurs helps the child heal.  


The usual 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 difficulties with developing affective attunement with their child may also 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 part 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 important dimension of treatment to help caregivers be more able to maintain an attuned connecting relationship with their child.   Second, the therapist with the caregivers meets with the child in the treatment room. This generally 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, teaching effective parenting methods and helping the caregivers avoid power struggles and, second, maintaining the proper PLACE or attitude.  


Treatment of the child has a significant non-verbal dimension since much of the trauma took place at a pre-verbal stage and is often dissociated from explicit memory.   As a result, childhood maltreatment and resultant trauma create barriers to successful engagement and treatment of these children.   Treatment interventions are designed to create experiences of safety and affective attunement so that the child is affectively engaged and can explore and resolve past trauma.   This affective attunement is the same process used for non-verbal communication between a caregiver and child during attachment facilitating 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 develop secondary mental representations of traumatic events, which allow the child to integrate these events and develop a coherent autobiographical narrative.   Treatment involves multiple repetitions of the fundamental caregiver-child attachment cycle.   The cycle begins with shared affective experiences, is followed by a breach in the relationship (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 essential elements to creating affective attunement.  


Fifth, the child communicates this understanding to the caregiver.

Sixth, finally, a new meaning for the behavior is found and the child’s actions are integrated into a coherent 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, allow the child to integrate the past traumas and to understand the past and present experiences that create the feelings and thoughts associated with the child’s behavioral disturbances.   The child develops secondary representations of these events, feelings and thoughts that result in greater 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 emerging affective states and developing secondary representations of thoughts and feelings, the child’s capacity to affectively engage in a trusting relationship is enhanced.   The caregivers enact these same principals.   If the caregivers have difficulty 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 significant risk for a variety 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 several dimensions of impairment (Cook, et. al., 2005).   Chronic maltreatment and the resulting complex trauma cause impairment in a variety of vital domains including the following:

Ø      Self-regulation

Ø      Interpersonal relating including the capacity to trust and secure comfort

Ø      Attachment

Ø      Biology, resulting in somatization

Ø      Affect regulation

Ø      Increased use of defensive mechanisms, such as dissociation

Ø      Behavioral control

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

Ø      Self-concept.

                        Dyadic Developmental Psychotherapy addresses these domains of impairment.   Dyadic Developmental Psychotherapy shares many important 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 practice and all are also central elements of Dyadic Developmental Psychotherapy


In summary, therapy for traumatized children who have disordered attachments must be experiential, consensual, and provide an environment of security, acceptance, safety, empathy, and playfulness.  

[1]Becker-Weidman, A., (2006) “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal.  Vol. 23 #2, April 2006, 147-171.  

Becker-Weidman, A., (2006). “Dyadic Developmental Psychotherapy: A multi-year Follow-up,” in, New Developments In Child Abuse Research, Stanley M. Sturt, Ph.D. (Ed.) Nova Science Publishers, NY, pp. 43 -- 61.

Becker-Weidman, A., (2007)“Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,”

Becker-Weidman, A., & Hughes, D., (2008) “Dyadic Developmental Psychotherapy: An evidence-based treatment for children with complex trauma and disorders of attachment,” Child & Adolescent Social Work, 13, pp.329-337.

Craven, P. & Lee, R. (2006) Therapeutic interventions for foster children: a systematic research synthesis.Research on Social Work Practice,16,287–304.

[2] Hughes, D., (2008) Attachment-focused Family Therapy.   NY: Norton.  

[3] Lyons-Ruth, K., & Jacobvitz, D., Attachment disorganization: unresolved loss, relational violence and lapses in behavioral and attentional strategies.   In Cassidy, J. & Shaver, P., (Eds.) Handbook of Attachment. pp 520-554, NY: Guilford Press, 1999.  

Solomon, J. & George, C. (Eds.).   Attachment Disorganization.   NY: Guilford Press, 1999.

Main, M. & Hesse, E. Parents’ Unresolved Traumatic Experiences are related to infant disorganized attachment status.   In Greenberg, M.T., Ciccehetti, D., & Cummings, E.M. (Eds.) Attachment in the Preschool Years: Theory, Research, and Intervention, pp.161-182, Chicago: University of Chicago Press, 1990.

Carlson, E.A. (1988).   A prospective longitudinal study of disorganized/disoriented attachment.   Child Development 69, 1107-1128.

[4] Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1995).   Finding order in disorganization: Lessons from research on maltreated infants’ attachments to their caregivers.   In D. Cicchetti & V. Carlson (Eds), Child Maltreatment: Theory and research on the causes and consequences of child abuse and neglect (pp. 135-157). NY: Cambridge University Press.

Cicchetti, D., Cummings, E.M., Greenberg, M.T., & Marvin, R.S. (1990). An organizational perspective on attachment beyond infancy.   In M. Greenberg, D. Cicchetti, & M. Cummings (Eds), Attachment in the Preschool Years (pp. 3-50). Chicago: University of Chicago Press.

[5] Robins, L.N. (1978) Longitudinal studies: Sturdy childhood predictors of adult antisocial behavior.  Psychological Medicine,. 8, 611-622.

[6] Prino, C.T. & Peyrot, M. (1994) The effect of child physical abuse and neglect on aggressive withdrawn, and prosocial behavior.  Child Abuse and Neglect, 18, 871-884.

[7] Schreiber, R. & Lyddon, W. J. (1998) Parental bonding and Current Psychological Functioning Among Childhood Sexual Abuse Survivors .   Journal of Counseling Psychology, 45, 358-362.


[8] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000).   Attachment Styles in Maltreated Children: A Comparative Study.  Child Development and Human Development, 31, 113-128.

[9] Dozier, M., Stovall, K.C., & Albus, K. (1999)   Attachment and Psychopathology in Adulthood.   In J. Cassidy & P. Shaver (Eds.). Handbook of Attachment (pp. 497-519). NY: Guilford Press.  

[10] Finzi, R., Cohen, O., Sapir, Y., & Weizman, A. (2000).   Attachment Styles in Maltreated Children: A Comparative Study.  Child Development and Human Development, 31, 113-128.


[11] Allan, J. (2001).   Traumatic Relationships and Serious Mental Disorders. NY: John Wiley.

Andrews, B., Varewin, C.R., Rose, S., & Kirk (2000).   Predicting PTSD symptoms in Victims of Violent Crime.  Journal of Abnormal Psychology, 109, 69-73.


[12] MacMillian, H.L. (2001).   Childhood Abuse and Lifetime Psychopathology in a Community Sample. American Journal of Psychiatry, 158, 1878-1883.


[13] Allan, J. Traumatic Relationships and Serious Mental Disorders, NY: Wiley, 2001.  

Andrews, B., Varewin, C.R., Rose, S. & Kirk.   Predicting PTSD symptoms in Victims of Violent Crime.   Journal of Abnormal Psychology, vol. 109, 69-73, 2000.


[14] Hughes, D., (2007) Building the Bonds of Attachment, 2 nd. Edition, NY: Guilford Press.

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