Dyadic Developmental Psychotherapy – An Evidence-Based Treatment For Disorders of Attachment

Dyadic Developmental Psychotherapy is an evidence-based and effective form of treatment for children with trauma and disorders of attachment . 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 (category 3 in a six level system). However, their review only included results from a partial preliminary presentation of an ongoing follow-up study, which was subsequently completed and published in 2006. This initial study compared the results DDP with other forms of treatment, ‘usual care’, 1 year after treatment ended.

It is important to note that over 80% of the children in the study had had over three prior episodes of treatment, but without any improvement in their symptoms and behavior. Episodes of treatment mean a course of therapy with other mental health providers at other clinics, consisting of at least five sessions. A second study extended these results out to 4 years after treatment ended. Based on the Craven & Lee classifications (Saunders et al. 2004), inclusion of those studies would have resulted in DDP being classified as an evidence-based category 2, ‘Supported and probably efficacious’. There have been two related empirical studies comparing treatment outcomes of Dyadic Developmental Psychotherapy with a control group. This is the basis for the rating of category two. The criteria are:

1. The treatment has a sound theoretical basis in generally accepted psychological principles. Dyadic Developmental Psychotherapy is based in Attachment Theory (see texts cited below
2. A substantial clinical, anecdotal literature exists indicating the treatment’s efficacy with at-risk children and foster children. See reference list.
3. The treatment is generally accepted in clinical practice for at risk children and foster children. As demonstrated by the large number of practitioners of Dyadic Developmental Psychotherapy and it’s presentation as numerous international and national conferences over the last ten or fifteen years.
4. There is no clinical or empirical evidence or theoretical basis indicating – that the treatment constitutes a substantial risk of harm to those receiving it, compared to its likely benefits.
5. The treatment has a manual that clearly specifies the components and administration characteristics of the treatment that allows for implementation. Creating Capacity for Attachment, Building the Bonds of Attachment, and Attachment Focused Family Therapy constitute such material.
6. At least two studies utilizing some form of control without randomization (e.g., wait list, untreated group, placebo group) have established the treatment’s efficacy over the passage of time, efficacy over placebo, or found it to be comparable to or better than an already established treatment. See ref. list.
7. If multiple treatment outcome studies have been conducted, the overall weight of evidence supported the efficacy of the treatment.

These studies support several of O’Connor & Zeanah’s conclusions and recommendations concerning treatment. They state (p. 241), “treatments for children with attachment disorders should be promoted only when they are evidence-based.”

Dyadic Developmental Psychotherapy, as with any specialized treatment, must be provided by a competent, well-trained, licensed professional. Dyadic Developmental Psychotherapy is a family-focused treatment .

Dyadic Developmental Psychotherapy is the name for an approach and a set of principals that have proven to be effective in helping children with trauma and attachment disorders heal; that is, develop healthy, trusting, and secure relationships with caregivers. Treatment is based on five central principals.

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:

- Adults are experienced as inconsistent or hurtful.
- The world is viewed as chaotic.
- The child experiences no effective influence on the world.
- The child attempts to rely only on him/her self.
- 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. Reactive Attachment Disorder is frequently misdiagnosed by mental health professionals who do not have the appropriate training and experience evaluating and treating such children and adults. 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.

Approximately 2% of the population is adopted, and between 50% and 80% of such children have attachment disorder symptoms . Many of these children are violent and aggressive and as adults are at risk of developing a variety of psychological problems and personality disorders, including antisocial personality disorder , narcissistic personality disorder, borderline personality disorder, and psychopathic personality disorder . Neglected children are at risk of social withdrawal, social rejection, and pervasive feelings of incompetence . Children who have histories of abuse and neglect are at significant risk of developing Post Traumatic Stress Disorder as adults . 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) (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 .

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.

For example, one eight year old boy who had Reactive Attachment Disorder, Bipolar Disorder, and a variety of sensory-integration disorders wrote about his past therapy and attachment therapy this way (More details of this story can be found in the book Creating Capacity for Attachment, edited by Arthur Becker-Weidman & Deborah Shell):

My first therapy was with Dr. Steve. The therapy was FUN! We ate lots of snacks. I had a bottle. We played lots of cool games like thumb wrestling, pillow rides, giant walk, Superman rides, guess the goodies, eye blinking contests, hide and go seek goodies. I had to follow the rules and play the games just like Dr. Steve said.

Dr. Steve taught me how to play and have fun with my Mom. But I still didn’t know how to love. I would still get real mad and try to hurt Mom and break things. Inside I still thought I was a bad boy. I was still afraid Mom and Dad would get rid of me. I had lots of tantrums at home. Sometimes I would still get out of control and break things and try to hurt Mom. I was getting even worse when I got mad.

Stuff Dr. Art Taught Me – I learned about my feeling well. Sometimes I stuff too many feelings like mad, scared and sad into my feeling well. Then the well will overflow and I could explode with behaviors. But I can stop that by expressing my feelings. Then the well can’t overflow because I let some of the feelings out.

I also made pictures of my heart. I was born with a nice heart but then when I went into the orphanage I got cracks in my heart. My heart cracked because they couldn’t take good care of me. I was a baby and I needed someone to hold me and rock me. But they couldn’t because there were too many babies. Then I put 16 bricks around my heart. I was protecting my heart so it wouldn’t get hurt anymore. But the bricks kept the love out too. I wouldn’t let Mom’s love in. I had lots of mad in my heart.

My hard work in therapy got rid of all the bricks. Then Mom’s love got in. The love made the cracks heal. Now I have a bright red heart with no cracks.

I really liked Dr. Art now and am proud that I am strong. I still don’t need therapy. I still let Mom’s love into my heart! Sometimes I send e-mail’s to Dr. Art. I tell him how good I’m doing.

I started missing Dr. Art and told Mom. Mom was confused and thought I wanted more therapy. I told Mom “I don’t need therapy. I just want to have lunch with Dr. Art.” So I sent Dr. Art an email to let him know that I wanted to have lunch with him. Then one day we had lunch together.

Sometimes it’s still hard. I still get mad and sometimes I don’t express my feelings well. Sometimes when Mom helps me I can express my feelings and say “I don’t want to pick up my toys. It makes me mad that I have to but I will”. When I say that it doesn’t make me feel mad anymore. It helps me to listen to Mom. But sometimes when I get mad I pout and stomp my feet and run to my room if I forget to express my feelings. But now I let Mom help me so that I can talk about my feelings and do what she says

It’s been a really longtime since I tried to hurt Mom or break things when I’m mad. I feel good about love now. I know that my Mom and Dad love me. I know that I love Mom and Dad. I don’t feel like I’m a bad boy anymore.

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 ” 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. “Compression-wraps,” invasive and intrusive stimulation designed to evoke rage, “re-birthing,” and other provocative techniques are not part of Dyadic Developmental Psychotherapy. These intrusive and invasive techniques are not therapy, not therapeutic, and have no place in a reputable treatment program.

Fifth Principal. Therapy is consensual and not coercive. At our center we are very clear that physical restraint is not treatment and is not used in treatment in any manner. Treatment is provided in a manner consisted with the Association for the treatment and Training of Children’s White Paper on Coercion in treatment.

The therapist must be well trained, licensed, and have significant experience in treating trauma-attachment disordered children. A good resource to locate such therapists is the Association for the Treatment and Training in the Attachment of Children, ATTACh. In selecting a therapist you should look for the following:

- Significant training from a recognized training program. Ask where the therapist was trained, how long ago, and for how long.
- Ongoing training. Ask when was the last training event the therapist attended and how long was the event.
- Licensure in the state in a recognized mental health discipline.
- Membership in ATTACh.
- A comprehensive informed consent document and appropriate releases.
- An initial assessment to develop a differential diagnosis and treatment plan.

Dyadic Developmental Psychotherapy is a treatment developed by Daniel Hughes, Ph.D., (Hughes, 2008, Hughes, 2006, Hughes, 2003,). Its basic principals are described by Hughes and summarized as follows:

1. A focus on both the caregivers and therapists own attachment strategies. Previous research (Dozier, 2001, Tyrell 1999) has shown the importance of the caregivers and therapists state of mind for the success of interventions.
2. Therapist and caregiver are attuned to the child’s subjective experience and reflect this back to the child. In the process of maintaining an intersubjective attuned connection with the child, the therapist and caregiver help the child regulate affect and construct a coherent autobiographical narrative.
3. Sharing of subjective experiences.
4. Use of PACE and PLACE are essential to healing.
5. Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.
6. Caregivers use attachment-facilitating interventions.
7. Use of a variety of interventions, including cognitive-behavioral strategies.

Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines. Attachment theory (Bowlby, 1980, Bowlby, 1988) provides the theoretical foundation for Dyadic Developmental Psychotherapy. Early trauma disrupts the normally developing attachment system by creating distorted internal working models of self, others, and caregivers. This is one rationale for treatment in addition to the necessity for sensitive care-giving. As O’Connor & Zeanah (2003, p. 235) have stated, “A more puzzling case is that of an adoptive/foster caregiver who is ‘adequately’ sensitive but the child exhibits attachment disorder behavior; it would seem unlikely that improving parental sensitive responsiveness (in already sensitive parent) would yield positive changes in the parent-child relationship.” Treatment is necessary to directly address the rigid and dysfunctional internalized working models that traumatized children with attachment disorders have developed.

Current thinking and research on the neurobiology of interpersonal behavior (Siegel, 1999, Siegel, 2000, Siegel, 2002, Schore, 2001) is another part of the foundation on which Dyadic Developmental Psychotherapy rests.

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. Coercive interventions such as rib-stimulation, holding-restraining a child in anger or to provoke an emotional response, shaming a child, using fear to elicit compliance, and interventions based on power/control and submission, etc., are never used and are inconsistent with a treatment rooted in attachment theory and current knowledge about the neurobiology of interpersonal behavior.

Dyadic Developmental Psychotherapy, as conducted at The Center For Family Development, uses two-hour sessions involving one therapist, parent(s), and child. Two offices are used. Unless the caregivers are in the treatment room, the caregivers are viewing treatment from another room by closed circuit T.V. or a one-way mirror. 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.

The treatment provided often adhered to a structure with several dimensions. It is pictured in Figure 1, below. First, behavior is identified and explored. The behavior may have occurred in the immediate interaction or have occurred at some time in the past. Using curiosity and acceptance the behavior is explored. Second, using curiosity and acceptance the behavior is explore and the meaning to the child begins to emerge. Third, empathy is used to reduce the child’s sense of shame and increase the child’s sense of being accepted and understood. Forth, the child’s behavior is then normalized. In other words, once the meaning of the behavior and its basis in past trauma is identified, it becomes understandable that the symptom is present. An example of such an interaction is the following:

Wow, I see how you got so angry when your Mom asked you to pick up your toys. You thought she was being mean and didn’t want you to have fun or love you. You thought she was going to take everything away and leave you like your first Mom did, like when your first Mom took your toys and then left you alone in the apartment that time. Oh, I can really understand now how hard that must be for you when Mom said to clean up. You really felt mad and scared. That must be so hard for you.

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:

- Self-regulation
- Interpersonal relating including the capacity to trust and secure comfort
- Attachment
- Biology, resulting in somatization
- Affect regulation
- Increased use of defensive mechanisms, such as dissociation
- Behavioral control
- Cognitive functions, including the regulation of attention, interests, and other executive functions.
- 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. Only an experienced and trained therapist can provide attachment therapy.

Treatments for Post-Traumatic Stress Disorder

Post-traumatic stress disorder is a serious mental disorder that affects millions of people around the world. There are many myths and misunderstandings about this condition. This article seeks to give you some information about PTSD and the treatments available for it. If you think you are suffering from PTSD however, you should consult your doctor or a psychiatrist immediately. It is not a condition that you can self-diagnose or treat on your own. There is no shame in asking for help, and in the case of this serious illness, it is in your and your family’s best interests to get professional help as soon as you can.

PTSD is not just a disorder that is suffered by soldiers and individuals form the armed forces. This is a myth. Although many ex-armed forces personal do suffer from it, it can be a problem for many other types of people from all sorts of different walks of life.

It is a condition that occurs when an individual is suffering extreme stress, anxiety, depression and fear as a direct result of a trauma. That trauma can happen at any time in a person life and can be caused by any outside event, force or influence. For example, wars, violent abuse or attacks, witnessing a crime, sexual abuse, abusive relationships, and accidents can all cause PTSD in individuals. There is no set of rules as to why people get it and therefore there are also a wide range of treatments to help the people who do have it.

Sufferers will most likely start of their treatment with a full and professional diagnosis which will be done by their Doctor and Psychiatrist. Once the diagnosis is complete your Psychiatrist and Doctor will know exactly what treatments and medications to recommend for you.

These could include counselling sessions to help you talk about your traumatic experience. Some patients benefit from hypnotherapy, especially when the trauma they suffered is extremely painful to recall and talk about. Some patients may require physical treatments like physiotherapy to deal with injuries sustained during the trauma as these can also cause huge psychological problems for a patient. Therapies like exercise therapy, relaxation, medication, swimming, music and art therapy are also used for patients with PTSD and have shown excellent results.

The important thing to remember is that everyone is different. By working with your doctor and excellent psychiatrists, you will be put on the right path and given the right treatments, therapies and medications to help you.

PSTD is serious, life threatening and affects every aspect of a sufferers life. It can also have far reaching effects on family members and work colleagues. It is for this reason that it needs to be treated properly, carefully and effectively as soon as it is diagnosed. Counselling and professional treatment, medication if required, and a range of therapies are the best way to address the symptoms of PTSD.

In many cases the family members also receive counselling so they get the help they need to cope with their loved ones symptoms and understand what they are going through. It can be such a painful and difficult time for everyone and that is why it is so important to get the right help as quickly as possible.

Preventing Original Infant Trauma When Possible For The Prevention Of Schizophrenia (Part Two)

Delayed Posttraumatic Stress Disorders from Infancy The Two Trauma Mechanism.


As with posttraumatic stress disorder from adult life, antecedent trauma sets the stage for a more severe response to subsequent trauma. Anxiety and suspense cause the event to be more frightening. If one is among friends, in daylight, and someone attempts to startle him, consider the response-versus, if he is walking down a lonely path, on a dark night, full of anticipation and fear, and the same person attempts to startle him.

Thus, we must look to antecedent trauma that could cause the early infant trauma to be experienced as more severe. It is possible that all the second trimester assaults may operate in this way, including viral infections, famine, malnutrition, paternal death, toxins, and anything that threatens survival of the infant or upsets the mother. For references see Second Trimester Factors in Chapter One. Another major antecedent trauma is the birth trauma. A number of researchers have found a higher incidence of schizophrenia among those who have experienced birth trauma. Trauma at birth has to be frightening to the newborn. Anoxia, brain injury, prolonged compression through the birth canal, near death experience-all must leave a mark. The average one year old still flashes back to the birth experience, which is why it fusses and screams when a tee-shirt is pulled over its head. An infant who is severely compromised with a near death experience at birth is even more primed for a later trauma to be more frightening.

In one family, the ninth of ten children had severe anoxia and brain damage at birth. All children were closely spaced and this one was 15 months older than the next. None of the others developed emotional difficulties, but when this one experienced a major separation later in life, there was a return to age 15 months reality. Had the person not experienced the brain injury at birth, it is possible that the age 15 month trauma might not have been sufficiently terrifying to allow for the reawakening as schizophrenia, 30 years later.

Birth trauma is not intentional and for the most part it can not be avoided. Child birth education and good prenatal care can eliminate some of the trauma, but when birth trauma occurs, it should serve as a warning to make greater effort to avoid subsequent trauma, particularly over the next 34 months.


The immediate clamping of the umbilical cord is one birth trauma/injury that has become common practice and which can be avoided. The immediate clamping of the cord prior to the infant taking its first breath has been shown to result in petechial hemorrhages throughout the brain in higher primates sacrificed at birth-as compared to ones in which the cord was not clamped. After the struggle through the birth canal, the infant needs all the oxygen he can get and the pulsating cord is still an important supplier of this oxygen. Thus, it should be left intact until the lungs have been inflated fully and are working properly. Conceivably this anoxia and brain hemorrhage at birth could set the stage for later trauma to be more frightening. Both the birth trauma and the brain anoxia/hemorrhagic trauma are associated with a separation (birth), and this may contribute to setting the stage for later separations being more frightening. Just as childbirth classes and good prenatal care are important for reducing birth trauma, prior discussion and planning are important for eliminating this unnecessary cause of traumatic brain hemorrhage.


Another trauma, occurring shortly after birth, is circumcision. This generally is done without anesthesia-because the baby is thought to be too young and therefore unable to feel anything. More accurately, it cannot say or do anything. Undoubtedly it is traumatic and likely it has an effect. If this trauma were to increase the incidence of schizophrenia appreciably, then there would be a much higher occurrence of schizophrenia in men than in women-which reportedly there is not. Nonetheless, this could be studied by evaluating male schizophrenics vs. super normal males and comparing the number of non-circumcised persons in each group.

Other disorders that are more common in males should be studied for correlation with circumcision. This is particularly true with infantile autism. Currently great emphasis is placed on the neurological findings in autism, with the assumption that correlation proves causation. This assumption is false. Some of the neurological change may be the result of the disease process, just as it is in schizophrenia.

Autism is associated with conditions that have neurological lesions, such as congenital rubella, phenylketonuria, tuberous sclerosis, fragile X syndrome and Rett’s syndrome and it is associated with infant trauma in the first 18 months of life.

Most autistics are mentally retarded, language is poorly developed, about one-forth develop grand mal seizures and as many show ventricular enlargement. Thus, a great variety of assaults to the brain appear capable of producing the group of symptoms called autism. Severe early emotional trauma-possibly including circumcision-must not be excluded as a major factor. Fixation and continued activation of early trauma sites-to the partial exclusion of later developing sites, such as the language centers-also can account for the symptoms of autism as well as the differences in brain volume and electrical activity.

There is growing evidence offered by the Pre and Perinatal Association of North America that circumcision may represent a serious trauma to many infants. For this reason it should be studied using our methods. While the trauma of circumcision might or might not heighten appreciably the later trauma of separation (depending on how closely it is linked with separation), it could heighten subsequent castration fears during the Oedipal stage of development. Sigmund Freud described castration anxiety as existing in men and not in women because women cannot be castrated. This explanation is plausible and likely is the primary reason why males have castration anxiety and females do not. Another possibility, however, is that women do not experience circumcision, and circumcision could account for added fear of further cutting injury to the same part later in life. A simple research study of circumcised vs. uncircumcised individuals, using an anxiety rating scale, could determine if this early trauma indeed had an effect on the later development of castration anxiety. Until all correlations between circumcision and emotional disorders are studied further, we recommend against circumcision without anesthesia, and against circumcision or any other painful procedure without the mother being present.



Premature babies are left alone in the hospital. While we do not yet have good data on the separation in the first weeks of life, those who were adopted in the first two weeks of life experience an early separation, and they also have a very high incidence of the later development of mental disorders, including borderline syndromes.

If it is possible to stay with the premature baby during its hospitalization, without sacrificing an older infant or toddler, this is the safest alternative based on present findings and projections. The emotional difference may relate primarily to the early separation from the mother. An interesting study would be to determine the number of non-adopted borderline individuals who were incubator babies and compare this with the number of non-adopted super normals who were incubator babies. If the origin of the borderline syndrome is in the first month of life, the study would confirm this. Until the completion of such a study, we recommend the mother stay with the baby until it is ready to come home.

Fetal Alcohol Syndrome:

This carries with it physical attributes related to the in-utero blood alcohol level. While a host of emotional/mental symptoms also are attributed to the in-utero blood alcohol level, more likely these relate predominantly to the lack of mothering or the inconsistency in mothering that occurs in the first months or years of life, as a result of the mother’s alcohol dependence. For prevention, this may be a time for institutionalization of the mother while she is pregnant, and a time for a continued serious treatment of the alcohol dependence after the baby is born. Ideally, the alcohol dependent woman should be informed about the devastating impact of alcoholism on the baby, and she should have her alcohol dependence treated before she becomes pregnant.


Adoption should take place at birth, not two weeks later. Nine months should be sufficient time to make the necessary arrangements.

With adoption there already has been a major separation. Every effort has to be made in the direction of providing security, to avoid reawakening and inflaming the original trauma. Adoption must be reserved for the person who wants to be a full time mother to the baby. She must delight over everything the baby does-each developmental landmark, every new utterance, all “cute” behavior. The adopted baby has already endured one separation and must have the devoted attention of one constant mother figure who will be as close at hand as a mother bear with her cub. The busy professional who is not able to take time for a pregnancy and who plans to utilize a “nanny” or a daycare service to rear the child, should rethink the decision in light of our findings. The idea of having an adorable loving child must begin with one full time mother who provides for the needs of the child during infancy. The needs of the mammalian baby for the mother have been established and are deeply entrenched. The adopted baby has already been traumatized or injured and therefore must feel fully protected by having its needs fully met. The adopted baby needs a devoted, full time mother, preferably beginning at birth.


Histories of approximately 300 schizophrenics, and at least as many depressed individuals and borderline patients, have revealed other early traumas that occurred at ages that were specific to the expected age of trauma-based on the symptoms the patient experienced. For example, one patient whose symptoms matched those of a person traumatized at 24 months, was found to have moved into a new house at age 24 months. By using the clinically based expected age of origin, various other early traumas were identified. On occasion it was confirmed that the expected age of origin matched the time the mother was sick and was hospitalized.

Combination Traumas: Pain Plus Separation From Family Plus Separation from Familiar Surroundings:

If the infant/toddler is sick and hospitalized, this can be a multiple trauma. First, the pain or the sickness intensifies the need for the mother. The fear that accompanies the pain makes the child more vulnerable to separation. Furthermore, the child is not only separated from the mother for part of the hospitalization, but the child is separated from its familiar surroundings as well. If this occurs when the baby has stranger anxiety, the trauma conceivable could be even greater.

One parent described the look on the face of his oldest son shortly after his son had surgery at age 18 months. He knew then that something was terribly wrong. When the man and his wife divorced 16 years later, his son returned to age 18 months and spent the next 12 years in institutions. The surgery was the finest available and the surgeon went on to become one of the most noted in the land. Nonetheless, the emotional trauma eventually destroyed the mind of the baby (the parents were not able to follow the recommendation that would have brought about a total or near total recovery). Thus, as a preventive measure, when the infant/toddler is hospitalized, the mother must go to the hospital and remain there with him. This is especially true when painful procedures are involved.

A Second Child:

If there is another child at home under the age of 35 months, the mother must try to offer as much security, reassurance and support as possible to this child as well. The other child can stay with her or visit in the hospital lobby when the hospitalized one is asleep, and/or have telephone contact upon request. If the older child is very young and at an age of origin of schizophrenia or schizoaffective disorders, it could stay in the same room with the mother and baby. While many hospitals are not aware or tolerant of this need, it is necessary to insist because of the potential harm when the infant/toddler is separated from its mother.

When the mother has to be at the hospital and when it is impossible for the infant/toddler to be there with her, this is not a time for the father to place the infant/toddler in a daycare center or in someone else’s home. This would be a double separation-a separation from the mother and a separation from home (which also represents a degree of security). A family member with whom the infant/toddler is familiar or attached, or preferably the father, should stay with the child in the child’s own home. Ideally, the child should know that the caregiver will not leave until the mother returns.

In summary, physical separations are very traumatic to a child under two years eleven months, and the younger the child the more severe it can be. Thus, physical separations have to be avoided or attenuated as much as possible. This includes separation from mother and separation from home and separation from father. If the child is comfortable with the father, he may go places with the father as long as he does not exhibit signs of distress or withdrawal. One must not equate the vacant stare with not being upset. While this is not likely to occur when the infant is with the father, it certainly is present in the early daycare situation: