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Comparative Effectiveness of Holding Therapy with Aggressive Children

Robin Myeroff, PhD Gary Mertlich, PhD


University of Toledo Jim Gross, MA

ABSTRACT: This study was undertaken to assess the effects of holding therapy on children who have a history of aggressive and delinquent behaviors. The study design was a prospective, pre-post, quasi-experimental controlled study. The subjects were recruited through the Attachment Center at Evergreen, Colorado. Eligible subjects were adopted children between the ages of 5-14 years, living in the present adopted home for at least one year. All children had a history of aggressive and delinquent behaviors, which prompted the contact with Evergreen. Findings resulted in significant decrease in the outcome variable for the treatment group within this study. KEY WORDS: Achenbach; Childhood Aggression; Treatment; Holding Therapy; Adoption; Foster Care.

Young aggressive children can commit such defiant and destructive acts as lying, stealing, vandalism, fire setting, and running away.1 While it is well accepted that aggressive and antisocial behaviors in childhood are related (violent, criminal outcomes),2,3,4 it is only over the last ten years that an increase in adolescent violent acts (142% increase in murder and manslaughter) has been identified.5 Consequently, aggression in children has been posted as a major public health concern.6 Aggressive behaviors are included under a wide variety of psychiatric terms ranging from attention deficit hyperactivity through oppositional defiant, conduct, and attachment disorders.7 Distribution of these disorders is estimated to be between 2 to 16 percent of children within the general population.7 It is not surprising that researchers
Received December 20, 1997; For Revision April 7, 1998; Accepted September 22, 1998. Address correspondence to Robin Myeroff, PhD, 3800 Park East Dr., Suite 150, Beachwood, OH 44122.
Child Psychiatry and Human Development, Vol. 29(4), Summer 1999 1999 Human Sciences Press, Inc.

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have identified such behavioral problems as the major impetus for children's mental health referrals. Numerous interventions have been attempted to treat aggressive behavior8 including individual, group, residential, behavioral, and psychopharmacological measures.9,10,1,11 However to date few interventions have been widely successful. Recently, holding therapy, originally used with autistic children, is now being recognized as useful with aggressive behaviors in children. Based on attachment theory holding therapy in part attempts to repair the postulated disruption that occurred in the formative years between the infant and primary caregiver.12,13 A conceptualization of attachment theory explains how this can occur. After a child experiences a repeated number of parenting inconsistencies he will internalize the negative input from the primary caregiver and act this out through abusive and aggressive behaviors toward others. One way that holding therapy impacts on the original disrupted cycle of attachment is by creating a representation of a healthy attachment cycle for the child.14,15 This occurs in the treatment by modeling the healthy attachment cycle in which the child will receive positive input from the therapist and care giver by way of eye contact, physical holding, and cognitive restructuring. The positive input from the therapist and parent assists the child in attaching to the adoptive parent which, will decrease aggression. The child can now internalize positive input from the environment, curbing the tendency towards destructive behavior. During the points in the session when the child becomes activated with anger or despair the parent and/or therapist continues to contain the child physically and assists him in cognitively understanding and self regulating his emotions. This replicates the healthy attachment cycle beginning with the child becoming aroused and the caregiver offering positive input by way of physical holding, soothing, eye contact, and, adds in helping to articulate the child's internal struggle. As the child begins to internalize this process after many hours and days of intense contact with the parent and therapist, internal reorganization begins to take place. When the child's anger is met with love and understanding from the therapist and caregiver, the aggression can then be libidinized with boundaries and not leaving the child with unbound and destructive anger.16 The containment and self-regulation of aggression is more manageable for the child and destructiveness decreases. Simultaneously, the child internalizes the adopted mother and begins to trust her. The relationship between the child and the mother begins to develop as the attachment becomes increasingly more secure. This allows for the

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development of a sense of remorse in the child, and results in a decrease in aggressive and delinquent behaviors.16 The shift in the child based on the exposure to the healthy attachment cycle, allows for an increase in secure attachment and, therefore, a decrease in aggressive and delinquent behaviors. Methods Subjects
The total sample consisted of 23 subjects. Subjects were recruited from the referral populations at the Attachment Center at Evergreen, Colorado. Criteria for participation included the requirement that the child's adoptive parents had contacted the Attachment Center at Evergreen between 1996 and 1997. To be considered for treatment the child had to show evidence of destructive behaviors and difficulty attaching to their parents. All children were between the ages of 4 and 14 years at the time of contact. Every child had experienced at least one other type of therapeutic intervention prior to attending the Attachment Center under the care of a professional medical doctor or mental health worker. All children were living in the home at the time of contact and returned home after treatment. The sample consisted of 23 children, 17 males and 6 females, ranging from 5 to 14 years of age. Subjects were either in the treatment or comparison group because of the timing and or the ability to pursue therapy during the projected course of the study. Due to the strict inclusion criteria, only 46% of the treatment population of The Attachment Center at Evergreen were involved as subjects. The two groups were similar in terms of distribution of age, gender, and race (Table 1). They were also similar in regard to the number of pre-adoption placements as identified by the intake data. Measure The Child Behavior Checklist" is a widely used parent report measure designed to assess behavior problems in children 4 to 16-years of age. The CBCL depicts the child's behavioral pattern across both broadband (Internalizing and Externalizing) and narrowband syndromes. A higher score of either 1 or 2 indicates more behavioral problems. The 2 problem scales used in this study are aggression and delinquency. Construct validity is supported by correlates of CBCL scales with significant associations with analogous scales on the Quay-Peterson18 Revised Behavior Problem Checklist and the Connors19 Parent Questionnaire. Criterion-related validity is supported by the ability of the CBCL's quantitative scale scores to discriminate between referred and nonreferred children after demographic effects were parceled out. The Cronbach's or reliability alpha range measures were .74 for delinquent behaviors and .92 for aggressive behaviors for boys age 4-11 years, and .83 for delinquent behaviors and .92 for aggressive behavior for boys age 12-18 years. The range for girls ages 4-11 years is .73 for delinquent behaviors and .92 for aggressive

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Table 1 Demographic Variables Descriptive Statistics Categorical Variables: Variable Treatment Group Comparison Group

N
Gender Race Pre-Adopt. Placement Male Female Caucasian Asian Mix 1-3 years 4-6 years 79 years 10 and above Continuous Variables: Variable Group Treatment Comparison Treatment Comparison
N
12 11 12 11 10 2 10 2 0 8
3 0 1

N
7 4 10 0 1 6 4 1 0

83.3 16.7 83.3 16.7


0.0

63.6 36.4 90.9


0.0 9.1

66.7 25.0
0.0 8.3

54.5 36.4
9.1 0.0

Mean
8.36 9.16 3.55
.92

Range

Age
Income

(6 , 12) (6 , 11) (3,5) (2,6)

behaviors. Girls age 12-18 years shows .92 for delinquent behaviors and .92 for aggressive behaviors. The study design was a prospective two group pre-post-design of convenience.

Recruitment Procedures
Subjects were recruited based on a parent-initiated phone call to the Attachment Center at Evergreen. A description of the therapy was offered to the parent and a series of screening questions about the child's early history and present level of functioning were conducted to determine the potential for treatment. Subjects volunteered to be a part of the study based on the knowledge that a study was being conducted to test the effects of this holding treatment and that the decision to participate would not have any affect on their future treatment at the Attachment Center. The comparison group for the study was comprised of families who did not attend the Attachment Center due to time restraints or finances and parents who were information seeking.

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Their lack of attendance was not due to the condition of the child or parent. Prior to treatment parents were mailed the CBCL for the mothers to fill out one week prior to treatment (time 1). After the treatment was completed the parents were mailed the CBCL for the mother to fill out six weeks post treatment (time 2). The comparison groups were mailed the measures at the same intervals as the treatment groups. Independent Variable-Holding Therapy The following description of the holding therapy conducted at Evergreen is condensed from a procedure manual written by Levy & Orlans.14 The treatment at the Attachment Center at Evergreen is a two-week therapy model often referred to as "a two-week intensive." The referred child, parents, and treatment team, consisting of one therapist and the treatment foster mother, are all present for 30 hours of therapy. This breaks down to three consecutive hours of therapy daily. The 30 treatment hours are broken down to three hours per day for 10 consecutive working days. Each family entering treatment at Evergreen are assigned to a therapeutic parent who houses the child for the two weeks of treatment. This means that the interactions the parent and child have together are the three hours during the actual treatment time, weekends, and certain times during the two weeks when the parent and child have interactions for limited amounts of time. All therapists and therapeutic parents are trained systematically at the Attachment Center. The therapy consists of four basic techniques which include cognitive restructuring, psycho-dramatic reenactment, inner child metaphor, and therapeutic holding. The therapeutic holdings are designed to imitate the infantnurturing position on a couch. The child lies across the therapist's lap with her head resting on a pillow. This allows for close proximity, eye contact, and physical restriction. Each session follows as closely as possible the session outline, which will be discussed in an abbreviated fashion in a session-by-session format. All interventions occur in sequence but may be delayed or accelerated depending on the family dynamics and the strengths of the child. Each session begins with a meeting of all participants with the exception of the child. At this time the child is waiting in a separate room. All sessions after the first session are conducted using the holding technique. Session one begins with a history-taking interview and assessment of the parents and child. The parents and the child contract verbally with the treatment team, entering the treatment based on the mutually agreed upon techniques and goals for the ten days. Session two includes rapport building between client and therapist and providing a cognitive framework for the treatment. This encompasses a description of the first year life cycle and how infants develop trust. A review of the child's early history with both birth parents and other foster placements is reviewed in light of the trust cycle explored above. Also included in the second session is a review of treatment rules and specific behaviors and changes expected of the child. Session three focuses on the resistance of the client and the controlling behaviors displayed both in the therapeutic process and in the adoptive home. Validation and support are offered as the assistance of conscious connections

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between past and present are verbalized and understood. The child is encouraged to release anger, sadness, fear, or rage. The child's perceptions of herself and the adult caregivers in her life are identified. Session four begins with the child expressing thoughts and feelings about the therapy including the therapeutic parents. Issues of attachment and emotional traumas are investigated as they relate to the child's experiences in early life. The child is assisted to correctly identify feelings and begin verbalizing these feelings. Session five begins with the treatment team and parents present discussing the previous day's and evening's events. Parenting techniques and skills are reviewed in light of the therapeutic parents' report of the child's behavior. The second half of the session is spent in a therapeutic hold, continuing the discussion of the early history of the child with the child. Sessions six, seven, and eight are the middle phases of treatment allowing for a more in-depth focus on emotional aspects of the early traumatic experiences. Psychodramatic reenactment is utilized at this time. The treatment team role-plays significant people in the child's past allowing for a gradual progression into the events of the past and the ability to confront and express what is needed leading the child to an interpersonal sense of mastery. This also allows for revisions of old self perceptions and fantasies about self and past significant figures. The inner child metaphor is also utilized during these sessions as the child is asked to visualize herself in the past and, while being held, is asked a series of questions about that early time and how those experiences and feelings relate to her present relationships. In addition to these techniques mother-child exercises are repeated many times including holding, covering with blankets, and feeding with a bottle. Session nine includes exploration of any birth father issues that may be present. The adoptive father now holds the child, as psycho-dramatic reenactment is utilized to provoke and resolve these father issues. The process of grief and mourning is explored in relation to the many losses experienced by these children. This process allows for cognitive restructuring through the dialogue with the role-played birth parents. Reunification with the adoptive family occurs at this point and the child leaves to spend the night with the adoptive parents instead of the therapeutic parent. Session ten begins with a review of the prior night and interactions are discussed. A complete review of the entire ten sessions takes place with everyone on the treatment team including the child. Family members talked about their learning experiences during this time, and a specific follow up plan is then developed.

Results Data analysis consisted of two-tailed independent and paired t tests to discern any between and within group significant differences. The t test was employed in this case as opposed to analysis of variance

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(ANOVA), because the groups were so small (n < 50) that use of ANOVA would have been inappropriate.20 A two tailed t test with this group size is a more robust statistic.20 In addition, equivalent nonparametric tests were performed and validated the following findings. In the treatment group, aggression scores before intervention (time one) ranged from 69 to 91, with a mean of 80.75, and post intervention (time two) aggression scores ranged from 51 to 94 with a mean of 66.27 (SD = 13.87). A paired two tailed t test found a significant difference between the pre- and post-intervention scores (t = 4.26; df = 10; p < .002). In the comparison group, aggression scores ranged from 56 to 92 at time one with a mean of 74.27 (SD = 12.78), while time two scores ranged from 58 to 92 with a mean of 74.33 (SD = 14.18). A paired two tailed t test showed no significant difference between scores at time one and time two (t = .58; df = 8; p = .579). Table 2 summarizes the within group differences in aggression scores. Similar results were obtained with the two groups on delinquency scores. The treatment group delinquency scores at time one, (preintervention) ranged from 62 to 84 with a mean of 72.83 (SD = 6.74), and time two, (postintervention) scores ranged from 50 to 86 with a mean of 65.82 (SD = 10.89). Again paired two tailed t test demonstrated significant difference between the pre and post intervention scores for delinquency (t = 2.37; df = 10; p < .04). With the comparison group, time one delinquency scores ranged from 59 to 84, mean of 70.37 (SD = 8.27), and time two scores ranged from 54 to 81 with a mean of 69.89 (SD = 9.64). Correspondingly, paired t test showed no significant difference between delinquency scores between time one and time two (t = .20; df = 8; p = .85). Table 3 presents the within group findings for delinquency scores. Comparison of pretest aggression sum minus post-test aggression sum scores corroborated a significance between the treatment and
Table 2 Statistical Analysis for Aggression Scores Group Comparison pre time1 post time2 Treatment pre timel post time2
N

Mean 74.27 74.33 80.75 66.27

SD

df

p value

11 9 12 11

12.78 14.18 6.77 13.87

-.58 4.26

0.579

10

.001

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Table 3 Statistical Analysis for Delinquency Scores


Group
Comparison pre time 1 post time2 Treatment pre time 1 post time2

N
11 9 12 11

Mean
70.37 69.89 72.83 65.82

SD
8.27 9.64 6.74 10.89

df

p value

.2

.85 .04

2.37

10

comparison groups with an independent two tailed t test (t = 3.57; df = 18; p < .003). In a like manner t test results for pretest delinquency sum minus post-test delinquency sum scores also demonstrated a significant difference between treatment and comparison groups (t = 2.46; df = 18; p < .04). The results indicate a between group difference on both aggression and delinquency for the comparison and treatment groups over the course of the study. Discussion Efforts to address the problem of aggression and behavioral difficulties range from hospital based21,22 and community based programs.23 Because studies show that children with high rates of antisocial behaviors are likely to continue these behaviors into adulthood,24,25 it becomes increasingly important to find treatment that can impact these behaviors.24,25 Heretofore, there have been no quantitative studies which verify the effectiveness of holding therapy. The purpose of the present study was to investigate the relationship between holding therapy and later aggressive behaviors as compared to children with a similar profile who did not receive holding therapy. The significant decreases in the outcome variables for the treatment group in this study may be due to the holding therapy based upon the theory that disruption in the formative years has a critical impact on the attachment between infant and the primary caregiver.12,13 The comparison group by contrast did not receive any intervention and exhibited no significant changes over time for either the aggression (p = .81) or delinquent (p = .99) scores. Children with high aggression are significantly more likely to have high delinquency scores in the treatment and comparison groups, respectively, (treat-

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ment group rho = .84, p = <0.001; comparison group; rho = 0.61, p = 0.05). It may be that as one score decreases due to an effective intervention, so will the other score. Delinquency tended to have even more of a significant decrease for the treatment groups, (both separately and comparing the two groups), may be because the questionnaire alluded to more of a characterological component for the questions about delinquency (fire setting, running away, truancy or lack of guilt) than for the questions referring to aggression (arguing, destructive action to self or property, temper tantrums). According to our conceptual framework the development of the child's attachment towards the parent simultaneously increases the capability to feel remorse and the capacity for self regulation. Suggestions for Further Research Further investigation and replication are warranted in order to extend knowledge and the effects of holding therapy on the special needs adopted population. Replicating these findings in a controlled multimodel experimental study could provide information in order to evaluate the effectiveness of different forms of treatment. Differences in the specific form of early abuse such as physical and sexual abuse and neglect, along with other possible extraneous variables may offer insight into the reasons some children clearly benefit from this treatment while others do not seem to make any progress. Attachment therapy as it is practiced at the Attachment Center and other facilities across the country is a controversial and provocative treatment. Comparative research into the different forms of holding therapy could result in new parameters for the treatment. Summary This study examined the effects of attachment therapy as performed by the Attachment Center at Evergreen on aggressive children between the ages of 5 and 14 years. The hypothesis that holding therapy will reduce aggressive behaviors in the special needs adopted population was supported. Significant differences in the reduction of aggression and delinquency scores in children who underwent a 2 week treatment program at the Attachment Center at Evergreen were found in this

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study. Delinquency scores decreased across time for the treatment group. The comparison group, who were eligible for treatment at the Attachment Center based on specific criteria but, did not receive any intervention exhibited no significant changes over time for either aggression or delinquency scores as reported from the Child Behavior Checklist. Given that childhood aggressive behaviors can become increasingly more violent and destructive, often at the expense of others including family members, animals, and peers, a strong and effective intervention is necessary in order to assist these individuals in decreasing both the intensity and frequency of their aggressive behaviors. Holding therapy addresses the issues of attachment, early wounding and aggression through the breakdown of psychological defenses in the context of the adoptive family. This finding indicates the importance of using holding therapy as one component of an intervention for children with aggressive and delinquent behaviors between the ages of 5 and 14 years. Further investigation and replication are warranted in order to extend knowledge of holding therapy on this and other populations.

References
1. Kazdin, A.E., Siegel, T.C., & Bass, D: Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children. J Consult and Clinical Psychol, 60, 733-747, 1992. 2. Robins, L.N: Longitudinal studies: Sturdy childhood predictors of adult antisocial behavior. Psychological Medicine, 8, 611-622, 1978. 3. Garrison, S.T., & Stolberg, A.L: Modification of anger in children by affective imagery training. J Abnorm Child Psychol, 11, 115-130, 1983. 4. Lochman, J.E., White, K.J., & Wayland K.K: Cognitive-behavioral assessment and treatment with aggressive children. In P. C. Kendall (Eds.) Child and Adolescent Therapy: Cognitive-Behavioral Procedures. New York: Guilford Press, 1991. 5. Federal Bureau of Investigation (1993). Uniform Crime Report for the United States 1992. Washington, D.C.: U.S. Department of Justice. 6. Walker, B., Goodwin, N.J., & Warren, R.C: Violence: A challenge to the public health community. Journal National Medical Association, 84, 490-496, 1992. 7. American Psychiatric Association DSM-IV: Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: The Association, 1994. 8. Kazdin, A.E: Treatment of Antisocial Behavior in Children and Adolescents. Homewood, IL: Dorsey Press, 1985. 9. Werry, J.S., & Wollersheim, J.P: Behavior therapy with children and adolescents: A twenty-year overview. J Am Acad Child Adolesc Psychiatry, 28, 1-18, 1989. 10. Sanchez, L.E., Armenteros, J.L., Small, A.M., Campbell, M., & Adams P.B.: Placebo response in aggressive children with conduct disorder. Psychopharmacology Bulletin, 30, 209-213, 1994.

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11. Slee, P.T. Family climate and behavior in families with conduct disordered children. Child Psychiat Hum Developm, 26, 255-266, 1996. 12. Bowlby, J: Attachment and Loss Vol. LII: Sadness and Depression. New York: Basic Books, 1980. 13. Egeland, B, & Sroufe, A: Attachment and Early Maltreatment. Child Developm Vol. 52: 44-52, 1981. 14. Levy, T, & Orlans, M: Intensive Short-Term Therapy with Attachment Disordered Children. Unpublished Manuscript, 1995. 15. Myeroff, R: Comparative Effectiveness With The Special Needs Adoptive Population. Unpublished dissertation, Union Institute, Cincinnati, 1997. 16. Barrett, T. Supporting drive fusion: Mitigating Destructive Aggression In Infants, Toddlers And Preschoolers. J Child Anal, Vol. 6, 128-151, 1995. 17. Achenbach, T, & Edelbrock, C: Manual for the Child Behavior Checklist and Revised Child Behavior Profile. University of Vermont, Burlington, 1983. 18. Quay, H.C., & Peterson, D.R: Interim Manual for the Revised Behavior Problem Checklist. University of Miami, Coral Gables, 1983. 19. Conners, C.K: Rating Scales for use of drug studies with children. Psychopharmacology Bulletin: Pharmacotherapy with children. Washington DC: U.S. Government Printing Office, 1973. 20. Munroe, B., & Page, E.B. Statistical Methods for Health Care Research, 2nd ed. Philadelphia: J.B. Lippincott, 1993. 21. Lock, J & Strauss, G: Psychiatric hospitalization of adolescents for conduct disorder. Hospital and Community Psychiatry, Vol 45 (9) 925-928, 1994. 22. Malone, R., Luebbert, J., Pena, A., Biesecker, K: The Overt Aggression Scale in a study of lithium in aggressive conduct disorder. Psychopharmacology Bull, Vol 30 (2) 215-218, 1994. 23. Offord, D., & Bennett, K: Conduct Disorder: Long-term outcomes and intervention effectiveness. J Am Acad Child Adolesc Psychiatry: Oct. Vol 33 (8) 1069-1078, 1994. 24. Robins, L., & Price, R: Adult disorders predicted by childhood conduct problems: Results from the NMH Epidemiological Attachment Area Project. Psychiatry, Vol 54, 116-132, 1991. 25. Loeber, R: Antisocial behavior: More enduring than Changeable? Special Section. J Am Acad Child Adolesc Psychiatry, Vol 30, 393-397, 1991.

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