Wednesday, March 30, 2011
Reactive Attachment Disorder on the Internet: Confident, but Wrong
Reactive Attachment Disorder is a genuine diagnosis, code 313.89 in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). Young children who receive this diagnosis are either unusually friendly to strangers for their age, or unusually clingy and concerned about separation from familiar people, and they have histories of poor and inconsistent care early in their lives. Appropriate treatment for this condition involves helping caregivers increase their commitment, or investment in an enduring relationship with the child, and become more sensitive to the child’s signals of interest and affection toward the caregiver (see Bernard, K., & Dozier, M. . This is my baby: Foster parents’ feelings of commitment and displays of delight. Infant Mental Health Journal, 32, 251-262). Interestingly, although parents are often very concerned about “disinhibited attachment”-- the child’s willingness to approach strangers-- by the time they reach adolescence, many “disinhibited” children receive social approval for their good social skills and ease of engagement with other people. You’d never know any of this if you got your information about attachment and mental health from http://www.attachtrauma.org. Although this web site lists the DSM criteria for Reactive Attachment Disorder, it also provides a checklist for something else called “Attachment Disorder”. This problem (not to be found in DSM) is said to include the following, among other things: poor eye contact, firesetting, cruelty to animals, toileting issues, unusual speech patterns, and lack of cause and effect thinking. Attachtrauma.org attributes angry moods and behavior to a failure to experience something they call the “bonding cycle”, a series of events in which a caregiver calms, helps, or gratifies a child. This “bonding cycle”, which is almost never mentioned in modern conventional discussions of attachment, resembles the original Freudian view of attachment as “cupboard love”-- a positive emotional response to being fed. As I mentioned earlier, effective treatment for attachment problems of young children focuses on their caregivers’ emotional skills and behavior. The child’s emotional development is considered to depend to a considerable extent on the quality of social interactions and communications with the parent. The attachtrauma approach is much more concerned with treating the child himself or herself, although it includes strong resistance to the idea that the child might receive any treatment without the parents’ involvement. My concern today is with the parts of attachtrauma.org that reject conventional psychological interventions in favor of unconventional approaches like Attachment Therapy, cranial-sacral therapy, neurofeedback, and EMDR-- all methods with weak or no evidence supporting their effectiveness. But attachtrauma.org does not spend time arguing why these unorthodox practices are desirable, which would be hard to do. Instead, the site presents claims against “traditional psychotherapies” (by which they mean “talk” therapies) and against behavioral therapies. In each case, the rejection of the treatment is argued not in terms of systematic evidence but in terms of what would be the case, if certain assumptions happened to be correct. Here’s what the attachtrauma site says about traditional psychotherapies: “[they] don’t work [by the way, “working” is undefined-- JM] with children with RAD [Reactive Attachment Disorder]. The reason is that traditional therapies all depend on a relationship of trust between the child and therapist and/or child and parent. A child with RAD is by definition a child without trust. Therapies that involve the parents and work toward building the trust between parent and child are the kinds of therapies that work. Therapies that don’t involve the parents are WRONG [caps sic] for and usually damaging to a child with RAD.” Let’s look closely at this statement. As I pointed out, what it means for a treatment to “work” or not remains unstated. I can only assume that the desired outcome is what is stated on another attachtrauma page as indicating attachment-- that the child is obedient but not overly submissive, etc., etc. In other words, the focus is not on the attachment relationship at all, but on the child’s obedient behavior, including affectionate actions when desired by the parent. Conventional therapies would not necessarily share these goals and would consider appropriate goals to be different for different ages and circumstances. To go on: do traditional therapies depend on a relationship of trust? No, of course they do not assume that the child or adult patient comes in prepared to hand over trust to a therapist. Building a therapeutic relationship and establishing trust are part of the process. As for the idea that a child with RAD is by definition a child without trust-- this is the definition attachtrauma.org has created for its own purposes. If anything, children with the RAD diagnosis who show disinhibited attachment could easily be described as too trusting, as they are willing to behave toward every adult as they do toward familiar people. But in the next sentence I believe we get to the crux of this matter, as the anonymous author goes on to refer to “therapies that involve the parents”. Conventional therapies like Parent-Child Interaction Therapy do involve parents, of course, and there is much evidence that PCIT (for instance) “works”. However, it’s not at all clear that those are the kinds of treatments attachtrauma is referring to. Is not their concern that a child may talk to or work with a therapist independently and establish a relationship which, however beneficial to the individual, does not give priority to the parents’ needs and wishes? Surely such a relationship would be most helpful in the cases in which parents have difficulty processing the child’s feelings or past history; this might well apply to Russian-adopted children who before adoption had received weekly visits from parents they knew very well. As a final glance at the claims about “traditional” therapies, it’s important to look at the unsupported statement that such therapies are “usually damaging” to children diagnosed with RAD. This is an exceedingly strong statement and goes far outside the normal boundaries of professional criticism, particularly when no systematic evidence is offered to support the argument. There is no doubt that some psychological interventions are ineffective, and even that some are potentially harmful treatments. But this claim, made without evidence, and with the apparent purpose of attracting clients to an unconventional form of treatment, is a shocking departure from ethical conduct in either the medical or the mental health area. There is no meaningful information presented here; on the contrary, as my mother used to say, it’s all an old saying that they just made up. Similar issues appear in the attachtrauma.org statement about behavioral methods, in which we see that “Children with RAD do not respond to rewards”. This is indeed a remarkable statement and suggests that the children in question (either the clingy ones or the ones who follow strangers) function differently from any other known animal right down to flatworms. Attachtrauma also says “Some children see these rewards as another way to trick their parents and prove how stupid adults are”. Here we have an internally inconsistent argument that claims simultaneously that the children cannot respond to a reward, and that they are rewarded by an opportunity to “trick” others. Once again, the author of this material has presented a set of claims based only on unsupported assumptions and has relied on proof by assertion of most unlikely and even paradoxical statements. If you’ve been reading www.attachtrauma.org, or any other website supporting Attachment Therapy, do use your own critical cognitive ability. And, while you’re at it, take a look at the list of therapists approved by that site. If they’ve been willing to have their names associated with the confident assertion of incorrect statements, maybe you should do a little critical thinking about them too.