A parent's worst nightmare

A parent's worst nightmare

BY LORI LEIBOVICH

According to Renee Polreis, the bruises that blackened her son's body at the time of his death were self-inflicted. Her adopted son David apparently suffered from reactive attachment disorder (RAD), a condition marked by violent fits of rage, inappropriate emotional responses, severe emotional detachment and an inability to feel pain.

Last week, a Greeley, Colo., judge sentenced her to 22 years in prison for abuse resulting in David's death. Investigators found a broken, bloody wooden spoon wrapped in a diaper in the Polreis home; Polreis had called her attorney and her therapist before calling "911" to report her son's death. U.S. News and World Report reported that Polreis' defense characterized David's behavior as violent and out of control -- David banged his head on the floor, became rigid and smashed his face on the ground and tugged his penis until it bled. Despite the defense's focus on David's uncontrollable behavior, at least two witnesses for the prosecution testified to the mother's loss of control. According to the New York Times, one of the Polreis' family's two therapists, Byron Norton, stated that Renee Polreis called him at 4:30 a.m. on the day David died and told him that she'd hurt David. "I just lost it," Polreis told Norton.

While casting the national spotlight on reactive attachment disorder, the Polreis case may have further muddied the waters around a condition that many have never heard of and few understand. Although recognized by the American Psychiatric Association as legitimate, attachment disorder is controversial because of the therapeutic community's disagreement on the most effective course of treatment. Some doctors advocate "holding therapy," during which the patient is physically restrained until he/she can exhibit appropriate emotions, while others advocate more traditional psychotherapy that involves both parents and children.

Salon recently asked Dr. Alicia Lieberman, director of the Child Trauma Research Project at San Francisco General Hospital and an expert on attachment disorders, to discuss the diagnosis, symptoms and treatment of reactive attachment disorder.

What is attachment disorder?

It is a disorder that occurs when children have not had the opportunity to become emotionally connected to a primary caregiver, particularly in the absence of a biological or adopted mother figure. It is most notable in children who have not had a consistent caregiver for the first three years of life. If the child is not given the opportunity to form a deep emotional connection with an adult who takes care of him, then it becomes a lifelong personality disorder that consists of an inability to form intimate connections with others. Often this manifests itself in a very aggressive, exploitative pattern of relationships or in a withdrawn, scared, unconnected pattern.

How do infants with the disorder act?

"Infant" is defined here as babies ages 0 through 5 years. There are two major patterns in infants. In one, the child is overly gregarious, does not seem to see the difference between one person and another, even between their parent and a stranger. This happens when a child lives in an orphanage for years and has many, many different caregivers and then is adopted. The adoptive parents will complain that the child will follow a stranger who smiles at him. You also see this in children who were raised in institutions; whatever stranger comes into the room becomes the novelty, the attractive person, and the child might want to follow that person out of the room only to turn to the next person they see and follow them. There is an indiscriminate search for connection without any emotional preference. It can be very chilling to see.

The second pattern is withdrawal. Children seem to be afraid of the world. These children are lethargic, apathetic and do not explore or reach out to anybody and seem uniformly afraid of people.

In the Polreis case, the little boy was apparently abusive to himself. He apparently banged his head against the wall.

There can also be a component of aggression -- and that includes aggression toward the self -- but that is much rarer.

Why is there so much controversy around the treatment of attachment disorder?

First of all, there is very little controversy over the fact that this is a real disorder. It is very well documented and nobody who knows anything about children doubts that it is real.

There is an established approach to treating disorders of attachment that emphasizes the importance of giving these children precisely what they have lacked. The research on what makes for a secure attachment and what makes for a disordered one emphasizes the mother's ability to be responsive to the child, to be sensitive. The research has shown what really works is maternal empathy, maternal responsiveness, the ability of the mother to put herself in the child's position and to be sensitive to the child's signals.

The form of treating attachment disorders that I do is called infant-parent psychotherapy. It involves understanding the meaning of the signals a child gives off and helping the mother respond appropriately. I have done research showing that children who were treated this way do much better in terms of their social and emotional functioning, and their mothers become much more competent and sensitive and less angry and less aggressive.

What does this therapy entail?

We can start the first day of life, prenatally even. The whole point is to help the mother recognize the meaning of the child's behavior. When a child is signaling distress, joy or need, we help the mother identify the kinds of behavior that would meet the child's needs. So essentially what we do is awaken a sense of nurturance or love for the child. Many of the mothers who have children with these disorders have been abused or neglected during their own childhoods. So they are not familiar with the things that you and I might take for granted -- to go to children when they are crying, to reassure them when they are scared, to feed them when they are hungry.

It often takes being sensitive to the mother to change the situation with the child. It is only when the mother feels protected and supported by us that she in turn can reconnect with her pain, the pain of not having grown up with this security and caring that she longed for terribly.

What is your opinion of holding therapy?

I've had some mothers call me and say they've gone through it and are having a hard time. I've heard hearsay about it, but I haven't seen it. One thing I think is very important to ask is: "What is developmentally appropriate for children?" One thing we do in our therapy is to try not to exacerbate the symptoms, not to retraumatize the child. Many of these children not only have attachment disorder but also post-traumatic stress disorder because of punishment and loss. We are working with terrified children.

From what I understand, part of the holding therapy is to physically hold the children down until they "break through," finally expressing their true emotions.

These children are already having trouble regulating intense emotions. The best way you can best help them regulate their emotions is to provide a self-container, where you are the person they can rely on to soften their emotions, rather than exacerbate them.

The Polreis case highlighted the situation of an adopted child with attachment disorder. But it sounds like you mostly work with kids and their natural mothers.

Eighty percent of the women I see are biological mothers.

Why then do we seem to hear only about the cases of attachment disorder among adopted children, mostly those adopted from the Soviet Union and Romania?

I think it's because the parents that adopt them are very articulate in explaining the difficulties that these children have. But the disorders of attachment are a rampant problem for infants in our foster-care system. The disorder occurs often in children who are born to mothers who are addicted to drugs and therefore cannot provide consistent care, and the children often have a string of caregivers. Those parents are often not aware of the difficulties their children are enduring and they feel too guilty to talk about it, whereas adopted parents don't feel the disorder is their fault so they seek help. They also have more resources to pay for the help privately.

Is the level of frustration Renee Polreis exhibited something that you often see in parents who are dealing with this illness?

Yes, I think that there are parents who find themselves unable to get through to their child, so that their efforts to get the child to obey, to get the child to mind, to get the child to love them, to be loving and affectionate with them, seem to go nowhere. That's where I think it is very important to seek therapy that looks at the meaning of the behavior. I think it is very important to remember that these behaviors are defenses that the child engages in. These are children who have no reason to trust human relations. Every human relation that these children have had have been disappointing, frightening or confusing. So in a way you have to say to these children, I am going to give you a totally different experience from anything you have experienced until now. And I am going to show you that no matter how much you push me away, how much you make me angry, how much you defy me, I will not hurt you.

SALON | Sept. 30, 1997
http://www.salon.com/1997/09/30/renee970930_2/
http://www.salon.com/sept97/mothers/renee970930.html