The hope connection: a therapeutic summer day camp for adopted and at-risk children with special socio-emotional needs.

Purvis, Karyn B. ; Cross, David R. ; Federici, Ron 等

Introduction

The purpose of this article is to explore a camp structure that was developed to address the enduring effects of early deprivation upon the development of adopted and other at-risk children. Originally, internationally adopted children with histories of severe deprivation and commensurate behavioural difficulties were the target population for this intervention. However, a small number of domestically adopted children were included due to the urgent needs of these families and the background similarities of deprivation (Purvis, Cross and Sunshine, 2007).

Although most adopted children do not present serious problems in these areas, many children from deprived backgrounds do, and there is an undetermined number of families who need support addressing them. As noted in two recent meta-analyses by Juffer and van IJzendoorn (2005) and Meese (2005), there is a scarcity of research on interventions in these areas.

Specifically, three areas of psychological development are likely to be affected when inadequate care is provided: attachment, pro-social behaviour and sensory processing. By integrating these three aspects of development into a camp structure that presupposes a dynamic interaction between them, the authors attempted to address a much broader spectrum of developmental deficits with greater efficacy than was achieved using narrowly focused interventions. Additionally, by addressing these areas simultaneously, a synergistic therapeutic effect was anticipated, as each independent construct has been shown to affect the others.

Children eligible for adoption often present developmental impairment and are especially likely to have experienced a wide variety of risk factors (Meese, 2005; Beckett et al, 2006). By definition, adopted children have lost their biological mother through death, abandonment or separation, thus experiencing maternal deprivation, defined here as resulting from a wide range of possibilities, including maternal privation, being deprived of maternal care from birth or separated from the biological mother after some period of maternal care (Ainsworth, 1962; Gandelman, 1992).

In addition to maternal deprivation, children eligible for adoption, especially those with backgrounds of institutional care, may have experienced environmental deprivation (Gandelman, 1992; Gunnar, 2001), postnatal environments that do not include the normal range of non-maternal stimulation, including social and physical stimulation (eg sensory stimulates such as tactile, proprioceptive and vestibular).

Other risks related to the infant's milieu and often found in combination with maternal deprivation include nutritional deprivation, maltreatment (Johnson, 2000) and experiences that have been characterised as global deprivation (Rutter and the ERA study team, 1998; Gunnar 2001). This occurs when environments fail to meet most, if not all, of the child's basic needs, including those for nutrition, physical and social stimulation and relationships. Based on the presence of these risk factors, either singly or in combination, children adopted from foster care or institutional care have been shown to be at serious risk for a variety of delays and developmental impairments (Beckett et al, 2006; Rutter et al, 2007).

There have been many reviews of the international adoption literature which delineate the impact of early deprivations (Johnson, 2000; Gunnar, 2001). The evidence suggests that the consequences of early and severe deprivation can be divided into two broad categories. The first incorporates deficits that tend to be rectified once children are placed in adoptive homes. These include physical growth, general intellectual performance and language (Rutter and the ERA study team, 1998; Gunnar, 2001; Beckett et al, 2006). The deficits in the second category do not remit so easily after adoption and appear to be specifically related to maternal deprivation (Ainsworth, 1962; Gunnar, 2001; Beckett et al, 2006). Likewise, domestically adopted children have often experienced similar deprivations due to neglect and abuse (Purvis, Cross and Sunshine, 2007).

In the following discussion, we will divide these enduring deficits into three sub-categories: attachment, self-regulation and behaviour. Although these categories are often discussed as independent aspects of a child's functioning, there is growing understanding of the relationship between them, based on common developmental histories and underlying neuropsychological processes (Schore, 1994; Siegel, 1999).

Recent research with post-institutionalised (PI) children has documented that maternally and/or globally deprived children are at risk of enduring attachment disturbances (Rutter et al, 2007) and other developmental impairments (Beckett et al, 2006). Specifically, unlike previous findings that emphasise the effect of time on children's development, the English and Romanian Adoptees study found that infants who endured more than six months of institutional deprivation were at risk regardless of duration of deprivation beyond that point and were showing severe deficiencies well into childhood.

Children for whom attachments have been deficient may also have experienced a lack of sensory input and inadequate opportunities for transactional experiences with their social and physical environments (Johnson, 2000; Gunnar, 2001). This lack of opportunity denies the infant occasion to develop skills of self-regulation with regard to behaviour and sensation. These abilities to self-regulate appear to emerge from the matrix of early caregiver-child interactions (Schore, 1994; Sroufe, 1996) and, if undeveloped, may affect the child's future interactions with peers and the environment. Sensory deficits, which may result from these environmental deprivations, are conceptualised as disturbances in the child's ability to process, integrate and modulate sensory input (Kranowitz, 1998). The inability to process even the most basic sensory stimuli places the child at risk for concomitant behavioural problems (Rutter and the ERA study team, 1998; Farina, Leifer and Chasnoff, 2004; Juffer and van IJzendoorn, 2005; Meese, 2005) and poor peer relationships (Gunnar, 2001).

These deficits of behavioural self-regulation may develop along at least three pathways. First, institution- or foster-reared children may have been denied the opportunity to develop the self-regulatory processes associated with sensitive and responsive maternal care (Schore, 1994), processes that are believed to help prevent problematic childhood behaviours (Calkins and Fox, 2002). Second, these children may have been denied the opportunity of developing pro-social behaviours that ordinarily evolve by virtue of normative socialisation in the home environment (Grusec, Davidov and Lundell, 2002). Third, maternally deprived children may have developed behaviours and/or survival strategies that are considered antisocial, and hence maladaptive, by their adoptive families and society, but which were perfectly adaptive in the ecologies where they lived, learned and needed to survive before being adopted (Farina, Leifer and Chasnoff, 2004). Thus, parents who adopt children from institutions abroad or from the foster care system at home are faced with the possibility that their adopted child will have problems in the three different areas of development cited above: attachment, self-regulation and pro-social behaviour.

A scarcity of interventions for the family in crisis has led to the development of a therapeutic day camp for these families and children described below. The crux of the approach is the triad of attachment, sensory processing and prosocial behaviour. These areas are treated simultaneously as they are believed to be inextricably connected.

Attachment, sensory and behavioural activities all take place within an environment of felt safety. This concept of felt safety is critical as research has shown how chronic hypothalamic-pituitaryadrenal (HPA) axis activity prevents learning in animals (Garner, Wood and Pantelis, 2007). This atmosphere of felt safety creates an environment designed to lessen the chronic anxiety that has been associated with fearful and/or deficient interactions with caregiver and environment, often a result of institutionalisation. The freedom from chronic anxiety allows cognitive and emotional processes to begin to develop.

The first pillar of our therapeutic triad, attachment, was addressed with prepared scripts and nurturing activities, such as those found within Theraplay[R] principles developed by Jernberg and Booth (1998). The second pillar, a sensory-rich environment, was centred around activities designed to stimulate repeatedly the three internal senses--tactile, proprioceptive and vestibular (Kranowitz, 1998)--and included manual exploration, play and intimate touch. Pro-social behaviour, the third pillar, employed scripts, scenarios and video recordings as a means of allowing the child opportunity to practise, model and witness appropriate behavioural interactions.

It is the purpose of the research reported here to help fill a void by providing data and analysis from a therapeutic summer camp for special needs children. Its ultimate purpose is to demonstrate that efficacious interventions for some of the most damaged children are possible and to impel researchers and clinicians to pursue these strategies, as well as focusing upon the known deficits and pathology associated with severe deprivation.

Methods

Participants

Camp participants comprised 19 children with histories of early deprivation and/or maltreatment, living in the United States. Most were adopted from orphanages in Eastern Europe (n = 16). Two were adopted from the custody of Child Protective Services and one was living with a biological parent but had a history of severe deprivation. Children were enlisted through local parent support groups and by referral from child and family therapists. Participants were divided into two separate groups by age, which ranged from three to 14 years. The mean age of the younger group was 5.7 years (range: 4-9), while mean age of the older group was 10.7 (range: 10-13). Females (n = 10) slightly outnumbered males (n = 9). Of the post-institutionalised (PI) children, nine were adopted from Russian orphanages, four from Romanian orphanages and two from other countries. Among the PI children, most entered the orphanage at birth (n = 8). Mean length of orphanage stay was three years four months, whereas mean age at the time of adoption was four years eleven months.

Of parents who spent time in the foreign orphanage from which their child was adopted, most (n = 9) reported the absence of toys or other forms of environmental stimulation. Some parents (n =8) reported mixed sleeping arrangements, ten parents were aware of profound emotional and physical neglect, four reported physical abuse and four that their adoptive child had been sexually abused in the orphanage. Parents of both children adopted through Child Protective Services cited neglect and/or abuse as the reason for the child's being placed in protective custody. The child participant living with a birth parent had been separated from the other birth parent due to severe abuse.

The adoptive families were primarily two-parent households (n = 15), with high levels of education. Eight mothers and six fathers had completed college; four mothers and five fathers had completed some form of graduate education. Most fathers were in professional careers (n = 7) or owned their own business (n = 5). Mean age of the parents was 46.8 for fathers and 42.1 for mothers. Family income in the upper range (over $100,000 a year) was reported by four of the families, while most (n = 8) cited annual incomes between $50,000 and $100,000.

Camp schedule

The camp was conducted at Texas Christian University (TCU), using campus facilities. The schedule was set up to allow parents to drop off the children in the morning and pick them up in the afternoon. The schedule of events throughout the day was intended to allow for a variety of interventions and activities, while providing for intensive supervision and guidance from camp staff. Staff praised children for pro-social behaviours, modelled behaviours, gave corrective guidance and provided a safe base for the children to explore their new surroundings and experiences. Camp participants were divided into two age groups: three to nine and ten to 14. Camp was held in two consecutive sessions, each lasting three weeks, with younger children in Session 1 and older children in Session 2. There was a one-week interval between sessions during which support staff continued planning, preparation and re-structuring for the older children's camp. Prior to each session, each child was assigned a 'buddy', an undergraduate student who had been trained in the therapeutic techniques employed and who would shadow, model behaviour and bond with the children over the course of the camp.

Session 1 started with the scheduled hours of 8.30 am to 5.30 pm. At the end of the first week, due to parent reports of child fatigue, the afternoon portion was scaled back to 3:30 pm, with child care provided for parents whose work schedules prohibited early pick-up. Beginning in the second week and continuing throughout Sessions 1 and 2, camp was conducted on the new schedule.

Owing to the extensive nature of scheduling and programme interaction, the following is only a brief description of the daily camp programme, which consisted of a series of small group activities with explicit therapeutic goals. Activities were designed to be (a) attachment rich, (b) sensory rich and (c) behaviourally structured, as outlined in The Hope Connection: A manual for kids under construction (Purvis and Cross, 2003).

Attachment-rich experiences

During the initial development of this programme, there was little information available about attachment-based interventions due to the scarcity of literature at the time. In an attempt to address the deficits experienced by the children, work done by clinicians working within an attachment framework (eg Jernberg and Booth, 1998) was reviewed. In doing so, we focused on three core principles. First, we created an environment of felt safety, thereby recreating one of the core functions of secure parent-infant attachments (Bowlby, 1973; Simpson, 1999). Second, we devised scripts that explicitly encoded fundamental aspects of attachment relationships. For example, the 'Attachment Ritual' was observed each morning. Part of this scripted interaction consists of two simple questions asked of the parent by the camp staff: 'May I be the boss of [your child] today?' and 'If [your child] would like a hug, may I give [your child] one?' These scripts are designed to replicate artificially lessons of trust and authority, enabling the child to understand that they are not in control of the camp but that they are valued and can receive affection. Third, we included numerous opportunities for nurturing behaviours and activities, many of which were based on Theraplay[R] principles mentioned earlier.

Sensory-rich experiences

The camp environment was permeated with safe, playful sensory experiences. At the start of each day, children participated in a 'Crash-n-Bump' activity designed by occupational therapists to activate the three internal senses--tactile, proprioceptive and vestibular. Crash-n-Bump activity is designed with components such as a small mini-trampoline, a ladder to climb, from which the children jump into a pool of balls or foam squares, and a crawl-through tunnel.

Beginning with Crash-n-Bump, a major physical activity was scheduled every two hours throughout the day. For continuing sensory input, children had free access to sensory items such as bubble gum and 'fidgets', for instance pressure balls to squeeze when feeling anxious, which were always available provided the children asked their buddy in an acceptable fashion. The camp schedule was orchestrated so that children would benefit from a regular and programmed sensory diet designed to help them regulate attention, activity levels and emotional state (Kranowitz, 1998; see also Johnson, 2000).

Cognitive-behavioural structure Other small group activities were developed to provide active reinforcement of behavioural scripts. These (Abelson, 1981) were developed to structure the children's activity and to help promote their self-monitoring and self-regulating skills (see, for example, Goldstein and Cisar, 1992). A script is a clear, brief auditory reminder/instruction as to what is acceptable and pro-social behaviour. Often children from severely deprived and/or abusive backgrounds have difficulty with auditory processing. Therefore, lengthy disciplinary lectures or complex instructions are lost on them. Typical scripts, like 'Obey the first time' and 'Treat others with respect' are designed to convey expectations to the child in a very concise manner. This approach capitalises on developmental insights about the role of scripts in social behaviour (Hudson, Shapiro and Sosa, 1995, 1997) and is closely related to psychosocial interventions, such as cognitive problem-solving skills training (Kazdin, 2002).

Buddy-child dyads would demonstrate their script rehearsal to the rest of the group while being videotaped. Later, during snack time, the children would receive feedback while watching themselves on video. Other scripts addressed the end of the day, remembering fun activities, resolving conflict between campers or campers and buddies and, finally, looking forward to tomorrow's events.

Assessments

Assessments of children's progress included both parent report and child report measures. One parent report measure was completed only as a pre-test measure, the TCU Survey of the International Adoption Experience (Purvis, Cross and Ware, 1999). Parent report instruments that were completed as preand post-test measures included the Child Behaviour Checklist (CBCL), Beech Brook Attachment Disorder Checklist (Beech Brook) and Randolph Attachment Disorder Questionnaire (RADQ).

In addition to the parent report items, children produced self and family drawings (Kaplan and Main, 1986). The family drawings were scored on the principles of art therapy (eg use of colour, detail and elaboration) and on a set of attachment-related criteria identified by Fury, Carlson and Sroufe (1997), for instance the child figure's proximity to that of the parent figure. Validity of the family drawings has been established in studies showing (a) that the family drawings of children with different attachment histories are reliably different (Fury et al, 1997) and (b) that children with different attachment histories differ in their attention to, and memory for, attachment-relevant information in family drawings (Kirsh and Cassidy, 1997).

Results

The design of the study is a one-group pre-test, post-test design, without a control group. Clearly, from a design standpoint, it would have been desirable to have a control group with random assignment of children to each group. Nevertheless, the argument has been made by clinical methodologists that valuable information can emerge from designs that are not randomised trials (Kazdin, 2003). Specifically, Kazdin argues that simple pre-test and post-test designs can yield valid results if there is corroborating evidence for no change prior to the experiment.

Evidence of this kind was obtained from the TCU survey of the adoption experience, in which parents were asked to report both retrospectively on their children's behaviours at the time of adoption and at the time of the survey (given at pre-testing). A sampling of child problem behaviours, with frequencies of at least five, is shown in Table 1.

The frequencies in Table 1 reflect a pattern we have seen both in this sample and in the larger sample of adoptive parents who completed the TCU survey. It can be seen that there are decreases in problems that might be described as internalising behaviours (eg, shy, anxious, fearful), although parents report that between a quarter and a third of these adopted children continue to experience these problems. Conversely, there are increases in problems that might be defined as externalising behaviours (eg manipulating, lying, verbal aggression). These and other data collected from the parents prior to the summer camp suggest that many families were distressed by their children's behaviours and that these difficulties were not improving.

In order to evaluate The Hope Connection directly, repeated measures (ANOVAs) were performed, using a twofactor design with one between-subjects factor (SESSION: Younger vs Older) and one within-subjects factor (TIME: Pretest vs Post-test). The results for the Child Behaviour Checklist are summarised in Table 2, which displays pre-test and post-test means, as well as the number of children in the clinical range on both occasions.

Of the internalising subscales (withdrawn, somatic complaints, anxious/ depressed), there was only one significant effect and that was a significant SESSION main effect for the anxious/ depressed subscale (F(1,17) = 9.14, MSe = 46.62, p = .008). As can be seen in Table 2, the means on this subscale are substantially higher for the older children than for the younger ones.

As for the externalising subscales (delinquent behaviour and aggressive behaviour), there was also only one significant effect and that was a significant TIME main effect for the aggressive behaviour subscale (F(1,17) = 5.01, MSe = 24.19, p = .039). As shown in Table 2, there were decreases from pretest to post-test for both sessions. Although the decrease in aggressive behaviour, as reported by the parents, was smaller for the older children than for the younger ones, the interaction was non-significant (F(1,17) = 1.60, MSe = 24.195, p = .223).

With regard to the four CBCL subscales not included in the internalising or externalising composites, there were significant effects on all but the social problems subscale. There was a significant TIME main effect for the thought problems subscale (F(1,17) = 8.97, MSe = 1.26, p = .008), indicating a significant decrease from pre-test to post-test for both age groups.

Similarly, there was a significant TIME main effect for the attention problems subscale (F(1,17) = 7.67, MSe = 5.30, p = .013), indicating a significant decrease for all of the children attending The Hope Connection. Finally, there was a significant TIME main effect for the other problems subscale (F(1,17) = 6.24, MSe = 14.66, p = .024), again indicating a significant decrease for all of the campers. No other main effects or interactions were statistically significant.

Taken together, these results indicate that there were significant decreases in problem behaviour from pre-test to posttest on four subscales of the Child Behaviour Checklist: thought problems, attention problems, aggressive behaviour and other problems.

A similar pattern was found for the parent report measures of attachment. Results for all of the attachment measures are shown in Table 3, displaying pre-test and post-test means and standard deviations for both camp sessions (younger and older). There was a significant TIME main effect for the Beech Brook positive subscale (F(1,12) = 9.35, MSe = 0.22, p = .010), indicating a notable increase in positive attachment behaviours as measured by this instrument. This main effect was complemented by a significant main effect on the Beech Brook negative subscale (F(1,12) = 8.01, MSe = 0.29, p = .015), indicating a notable decrease in negative attachment behaviours. In addition, there was a significant TIME main effect for the RADQ measure (F(1,16) = 13.16, MSe = 164.26, p = .002), which corresponded to a significant decrease in attachment disturbance.

As can also be seen in Table 3, family drawings exhibited a similar trend as the parent-report measures of attachment. Analysis revealed a significant increase in positive family drawing scores (F(1,11) = 5.57, MSe = 10.87, p = .038) and a significant decrease in negative family drawing scores (F(1,11) = 6.52, MSe = 18.37, p = .027). These differences indicate changes in the children's attachment representations that complement the parents' observations about their children's behaviours.

Discussion

As evinced by statistical and anecdotal evidence, the 19 children participating in The Hope Connection made progress in their social and emotional functioning. Although these gains were more pronounced for children in the younger group, differences in change between the two groups were not statistically significant.

The progress made by these children could be seen not only quantitatively in the assessments reported here but also in numerous anecdotal reports from the parents, and in qualitative observations made by camp staff. For example, one of the younger participants had only spoken a few words, despite being with his adoptive family for over two years. During the course of the intervention, he became an active participant in conversations with camp staff and his family, often speaking in lengthy sentences for a child of his age. Another boy had never looked his parents in the eye and never said 'I love you'. By the end of camp he was hugging his parents, making eye contact and verbally expressing his affection.

An important feature of the results is that improvements in the children's behaviours tended to occur in the aforementioned domains thought to be most resistant to developmental catch-up following adoption: attachment, self-regulation and pro-social behaviour. All three measures of attachment (Beech Brook, RADQ and family drawings) showed significant improvements in attachment-relevant behaviours.

Furthermore, two of the CBCL subscales showing significant improvement --attention problems and thought problems--may be interpreted as the subscales relevant to executive functioning and self-regulation. A third CBCL subscale showing significant improvements--aggressive behaviour--is believed to have bearing upon pro-social behaviour. The final significant CBCL result, decreases on the other problems subscale, is also interesting as this subscale includes items tapping into aberrant behavioural issues (especially eating and sleeping) commonly displayed by internationally adopted children (Johnson, 2000).

Although the evidence points to improvements in the behaviour of the campers, several caveats are in order. The first and most obvious is the lack of a comparison group. The argument we present is that the simple pre-test/post-test design employed here is valid, based on two separate sources of evidence. First, the data from the TCU Survey of the International Adoption Experience indicate that, with regard to externalising behaviours, the campers' problem behaviours were worsening prior to camp. Second, there is the fact that many, if not most, of the families who enrolled their adopted children in The Hope Connection were desperate for help and looked upon this therapeutic summer camp as their last hope for saving their disintegrating families. Many families had attempted other interventions and, for the majority, the situation was deteriorating and the improvements reported here are reversals of that downward trend.

The lack of a control group leaves the possibility that the effects seen are an outcome of camp attendance rather than what took place. The authors do not believe that this is the case as these children typically do not cope well with change, novel sensory stimulation and behavioural demands, or with other radical changes associated with attending a strange camp in an unfamiliar place. It is believed that attendance at a mainstream summer day camp would be impossible for these children, due to the inevitable behavioural and emotional difficulties that would arise. With the stressors that camp attendance placed upon their fragile behavioural inhibition systems, the effects reported here could even be viewed as that much more encouraging.

A second caveat concerns the measurements used in this study, which entails both strengths and weaknesses. A strength of the study is that a variety of target constructs were assessed. Additionally, the changes in the campers' behaviours were consistent across different measures and, in the case of attachment, across both parent and child report measures. However, the methodology would have been stronger if more direct assessments of the children themselves had been employed and if these had included both behavioural (eg observation) and physiological (eg salivary cortisol) measures to balance the parent-report data. This is an area that we have identified as a major priority for future studies. Another area of weakness may be the absence of any direct measures of sensory processing. The lack of a pre-test and post-test measure is a methodological shortcoming but the inclusion of sensory-rich environments is believed to be a necessary part of the intervention. These findings indicate that the lack of acquired sensory processing skills prohibit prosocial engagement with others and an inability to process properly one's environment. This is also an area for future research.

Other issues relating to the measurement plan are the lack of a follow-up assessment and small sample size. An informal phone interview was conducted five months after the summer camp. From this we found that some of the families found it difficult to sustain the gains made at camp. Based on this feedback, we plan follow-up assessments for future studies and are providing continued support services for the families whose children attend. Much greater emphasis will be placed on the family and on follow-up support, as family participation was minimal and follow-up measures would further validate this intervention model. Sample size remains small due to necessity: funding limitations and the intensity of the intervention prohibit large groups of participants.

Despite these caveats, the current findings add to the knowledge base of intervention-based research in the area of special needs and international adoption, as recent meta-analyses have duly noted the scarcity of research with internationally adopted children (Juffer and van IJzendoorn, 2005; Meese, 2005). Specifically, the need is for empirically-based interventions that will enable parents, as well as the professionals who support them, to intervene successfully with emotionally damaged children. In this regard, our research complements Dozier and colleagues' work with foster carers of infants in their striving to provide an empirical basis for intervention with adopted children, especially those with backgrounds of emotional trauma (Dozier, Albus et al, 2002; Dozier, Higley et al, 2002).

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Note: Please contact authors for camp manual and detailed descriptions of camp interventions

--L.B.McKenzie@tcu.edu

Karyn B Purvis and David R Cross are Associate Directors of the Institute of Child Development and Professors of Psychology, Texas Christian University

Ron Federici is a Neuropsychologist, Federici & Associates

Dana Johnson is Director of the Division of Neonatology and Director of the International Adoption Clinic, University of Minnesota

L Brooks McKenzie is an MA-Doctoral student, Texas Christian University

Table 1
Number of parents (n = 14) reporting that their internationally
adopted children displayed common problem behaviours at the time
of adoption and at the time of the survey (pre-test)

 Frequency

Behaviour Time of adoption Time of survey

Shy 5 1
Anxious 7 4
Fearful 8 3
Excessive eating 9 5
Bedwetting 8 4
Manipulative 6 8
Lying 2 6
Verbal aggression 1 6
Physical aggression 5 3

Table 2
Descriptive statistics for subscales of the Child Behaviour Checklist,
displayed by group (younger vs older) and time of testing (pre-test vs
post-test).

 Younger group Older group

Subscale Pre-test Post-test Pre-test Post-test

Withdrawn
Mean 3.9 2.3 4.4 4.3
S.D. (4.1) (3.6) (3.7) (3.7)
No. clinical 2 1 4 3

Somatic complaints
Mean 1.4 1.6 2.1 2.3
S.D. (1.6) (2.8) (2.1) (2.1)
No. clinical 1 2 1 1

Anxious/depressed
Mean 5.4 2.3 10.9 10.2
S.D. (5.8) (2.3) (5) (7.4)
No. clinical 2 0 4 4

Social problems
Mean 4.6 3.7 5.7 5.4
S.D. (3.1) (2.7) (3.2) (4.0)
No. clinical 3 1 5 3

Thought problems
Mean 2.5 1.2 3.1 2.2
S.D. (2.7) (1.9) (2.8) (2.9)
No. clinical 3 1 4 2

Attention problems
Mean 8.3 5.6 10.4 9.0
S.D. (4.8) (3.7) (5.9) (6.5)
No. clinical 4 1 5 4

Delinquent behaviour
Mean 3.5 2.1 3.6 3.2
S.D. (3.2) (2.5) (2.3) (2.7)
No. clinical 3 1 5 0

Aggressive behaviour
Mean 16.9 11.3 15.0 13.4
S.D. (10.0) (6.3) (8.9) (8.7)
No. clinical 4 1 2 3

Other problems
Mean 11.1 6.6 9.8 8.1
S.D. (5.7) (3.7) (4.1) (7.5)
No. clinical N/A N/A N/A N/A

Table 3
Descriptive statistics for the attachment measures (Beech Brook, RADQ
and family drawings) displayed by group (younger vs older) and time
of testing (pre-test vs post-test).

 Younger group Older group

Subscale Pre-test Post-test Pre-test Post-test

Beech Brook
Positive scale
Mean 2.3 3.0 2.5 2.9
S.D. (0.8) (0.9) (0.8) (0.6)

Beech Brook
Negative scale
Mean 1.7 1.1 1.5 0.8
S.D. (0.9) (0.6) (1.3) (0.6)

Randolph Attachment
Disorder Questionnaire
Mean 50.0 29.6 47.4 36.9
S.D. (22.2) (22.5) (21.3) (18.9)

Family drawings
Positive score
Mean 6.6 9.3 9.9 13.3
S.D. (3.4) (6.1) (6.2) (3.7)

Family drawings
Negative score
Mean 15.5 12.0 11.5 6.4
S.D. (2.2) (6.0) (6.7) (4.0)