Reactive Attachment Disorder: Reactive Attachment Disorder: Yes You CanYes You Can

Or, Or,

How to develop parent-child How to develop parent-child bonds & treat difficult bonds & treat difficult children without fearchildren without fear

Marolyn Morford, Ph.D., Marolyn Morford, Ph.D., Center for Center for

Child & Adult Development,Child & Adult Development, State College, PAState College, PA 814-861-3300; mmorford@gmail.com814-861-3300; mmorford@gmail.com

v. 2010v. 2010

Main PointsMain Points Attachment Attachment researchresearch is a relatively new is a relatively new

field; field; Attachment Attachment treatmenttreatment appears to be appears to be

following a separate path only tangentially following a separate path only tangentially related to research. In the latter’s short related to research. In the latter’s short history, versions of it have been history, versions of it have been responsible for children’s inappropriate responsible for children’s inappropriate treatment, wasted time & resources and, treatment, wasted time & resources and, at worst, emotional & physical at worst, emotional & physical maltreatmentmaltreatment

While there is some research to suggest While there is some research to suggest that neglectful and abusive parenting can that neglectful and abusive parenting can be related to externalizing or more be related to externalizing or more impulsive behaviors, there is impulsive behaviors, there is nono evidence evidence to suggest that this alone impairs young to suggest that this alone impairs young children’s ability to form bonds.children’s ability to form bonds.

More importantly, there is absolutely NO More importantly, there is absolutely NO evidence that interventions focused on evidence that interventions focused on forcing bonds to form will reduce forcing bonds to form will reduce externalizing behaviors. Therefore, externalizing behaviors. Therefore, difficult children may not be made less difficult children may not be made less difficult by improving a bond or creating difficult by improving a bond or creating attachment-like behaviors.attachment-like behaviors.

The difficult children we see The difficult children we see areare treatable. treatable. We have to be aware of We have to be aware of all all diagnostic diagnostic possibilities. possibilities.

There are a number of child- & adult-There are a number of child- & adult-friendly well-proven techniques that can friendly well-proven techniques that can change children’s thoughts and behavior change children’s thoughts and behavior for the better as well as those of their for the better as well as those of their caregiverscaregivers

We can treat these children most We can treat these children most effectively if we have the assistance of the effectively if we have the assistance of the caregiver and other adults spending time caregiver and other adults spending time with the child.with the child.

We must recognize and address the We must recognize and address the emotional and psychoeducational needs of emotional and psychoeducational needs of the care giving adult.the care giving adult.

Introduction to the problemIntroduction to the problem

DiagnosisDiagnosis: Reactive Attachment Disorder, : Reactive Attachment Disorder, or “RAD” is a label that has been applied or “RAD” is a label that has been applied to many children in the past 10 years, esp. to many children in the past 10 years, esp. adopted and foster childrenadopted and foster children

TreatmentTreatment: “Specialized” treatments and : “Specialized” treatments and “centers” have emerged to work “centers” have emerged to work specifically with children with this labelspecifically with children with this label

Important Questions…Important Questions…

What do we know about diagnosis of What do we know about diagnosis of Reactive Attachment Disorder?Reactive Attachment Disorder?

What do we know about the treatment of What do we know about the treatment of Reactive Attachment Disorder?Reactive Attachment Disorder?

Larger ProblemLarger Problem

When our questions exceed our answersWhen our questions exceed our answers

Estimates of mental health Estimates of mental health problems of childrenproblems of children

Community samples: 16-22%Community samples: 16-22% Foster care samples: 40-80%Foster care samples: 40-80% Only 11% of CYS children were receiving Only 11% of CYS children were receiving

services in one studyservices in one study 39% of all children who encounter the child 39% of all children who encounter the child

welfare system are aged 0 to 5 years.welfare system are aged 0 to 5 years. 1/3 of children under age 3 had cognitive delay; 1/3 of children under age 3 had cognitive delay;

1/3 under 5 had language delay1/3 under 5 had language delay(US DHHS, 2005)(US DHHS, 2005)

Problem in the clinical fieldProblem in the clinical field

Qualified clinicians become unnecessarily Qualified clinicians become unnecessarily conservative and shy away from conservative and shy away from challenging child cases, assuming there is challenging child cases, assuming there is a sound basis for the ‘new’ clinical a sound basis for the ‘new’ clinical population and ‘treatments’population and ‘treatments’

Other clinicians, lacking training (clinical or Other clinicians, lacking training (clinical or empirical) try valiantly to meet the needempirical) try valiantly to meet the need

Problem: Diagnosis & Problem: Diagnosis & TreatmentTreatment

Importance of a clear, valid definition of Importance of a clear, valid definition of Reactive Attachment DisorderReactive Attachment Disorder Misapplication of the term occurs oftenMisapplication of the term occurs often Next DSM version may have changesNext DSM version may have changes

Importance of evaluation of validity and Importance of evaluation of validity and effectiveness of proposed treatmentseffectiveness of proposed treatments Inappropriate treatments existInappropriate treatments exist

““RAD” label overextended: RAD” label overextended: Is there anything obnoxious that Is there anything obnoxious that

isn’tisn’t here? here? Child is oppositional, impulsive, destructive, lies & steals, is Child is oppositional, impulsive, destructive, lies & steals, is

aggressive, hyperactive, self-destructive, cruel to animals, sets aggressive, hyperactive, self-destructive, cruel to animals, sets fires fires

Child isChild is intensely angry, depressed, moody, anxious, irritable, intensely angry, depressed, moody, anxious, irritable, has inappropriate emotional reactionshas inappropriate emotional reactions

Child has negative beliefs about self, others, & life, has att’n, Child has negative beliefs about self, others, & life, has att’n, learning problemslearning problems

Child lacks trust, is bossy & manipulative, does not give or Child lacks trust, is bossy & manipulative, does not give or receive love or is affectionate with strangers, blames othersreceive love or is affectionate with strangers, blames others

Child has poor hygiene, avoids touch, has toileting problems, Child has poor hygiene, avoids touch, has toileting problems, is accident prone, high pain toleranceis accident prone, high pain tolerance

Child lacks empathy, faith, compassion, remorse, identifies Child lacks empathy, faith, compassion, remorse, identifies with evil and the dark side of lifewith evil and the dark side of life Levy & Orlans (2000)Levy & Orlans (2000)

DSM-IV Criteria for Reactive DSM-IV Criteria for Reactive Attachment Disorder:Attachment Disorder:

A. Markedly disturbed & developmentally A. Markedly disturbed & developmentally inappropriate inappropriate social relatednesssocial relatedness in in mostmost contexts, beginning contexts, beginning before age 5 yearsbefore age 5 years, , as shown by either (1) or (2):as shown by either (1) or (2):

DSM-IV Criteria (cont.)DSM-IV Criteria (cont.)

(1) (1) PersistentPersistent failure to failure to initiate or respondinitiate or respond in a in a developmentally appropriate fashion to developmentally appropriate fashion to most social most social interactionsinteractions, shown by excessively inhibited, , shown by excessively inhibited, hypervigilant, or highly ambivalent and contradictory hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond with a mixture of responses (e.g., the child may respond with a mixture of approach, avoidance, & approach, avoidance, & resistance resistance to comfortingto comforting, or may , or may exhibit exhibit frozen watchfulnessfrozen watchfulness..

(2) diffuse attachments as shown by (2) diffuse attachments as shown by indiscriminate indiscriminate sociabilitysociability with marked inability to exhibit with marked inability to exhibit appropriate appropriate selective attachments (e.g., excessive familiarity with selective attachments (e.g., excessive familiarity with relative strangers of lack of selectivity in choice of relative strangers of lack of selectivity in choice of attachment figures. attachment figures.

AND…AND…

DSM-IV Criteria (cont.)DSM-IV Criteria (cont.)

B. The disturbance in Criterion A is B. The disturbance in Criterion A is notnot accounted for solely by developmental accounted for solely by developmental delay (as in Mental Retardation) and does delay (as in Mental Retardation) and does notnot meet criteria for a Pervasive meet criteria for a Pervasive Developmental DisorderDevelopmental Disorder

DSM-IV Criteria (cont.)DSM-IV Criteria (cont.)

C. C. Pathogenic carePathogenic care as shown by at least one of as shown by at least one of the following:the following: (1) (1) persistentpersistent disregard of the child’s basic emotional disregard of the child’s basic emotional

needs for comfort, stimulation, and affectionneeds for comfort, stimulation, and affection (2) (2) persistentpersistent disregard of the child’s basic physical disregard of the child’s basic physical

needsneeds (3) (3) repeatedrepeated changes of primary caregiver that changes of primary caregiver that

prevent formation of stable attachments (e.g., prevent formation of stable attachments (e.g., frequent changes in foster care)frequent changes in foster care)

AND…AND…

DSM-IV Criteria (cont.)DSM-IV Criteria (cont.)

D. There is a presumption that the care in D. There is a presumption that the care in Criterion C is responsible for the disturbed Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care Criterion A began following the pathogenic care in Criterion C). in Criterion C).

(Note: “grossly pathological care does not (Note: “grossly pathological care does not always result in the development of Reactive always result in the development of Reactive Attachment Disorder”, Attachment Disorder”, DSM-IV-TR, p. 128DSM-IV-TR, p. 128))

DSM-IV Criteria (cont.)DSM-IV Criteria (cont.)

Prevalence: Data limited, but true Reactive Prevalence: Data limited, but true Reactive Attachment Disorder appears to be very Attachment Disorder appears to be very uncommonuncommon

Foundation of the Problem:Foundation of the Problem:

Nosology – how we classify pathologyNosology – how we classify pathology

Misattribution of causalityMisattribution of causality

*Criteria for Diagnostic Category*Criteria for Diagnostic Category

An observable, operational definition that An observable, operational definition that anyone can use and agree with others in anyone can use and agree with others in applyingapplying

That is distinct from other categories That is distinct from other categories (mutually exclusive)(mutually exclusive)

And has predictive utility: we know other And has predictive utility: we know other things about the person based on the things about the person based on the application of this categoryapplication of this category

*Misapplication of a diagnosis*Misapplication of a diagnosis

OverextensionOverextension: Applying the label to a : Applying the label to a broader set of criteria and a wider age broader set of criteria and a wider age range than specified by the definition range than specified by the definition UnderextensionUnderextension: Applying the label to a : Applying the label to a smaller set of criteria or smaller age range smaller set of criteria or smaller age range than specified by the definition than specified by the definition

*Thinking Errors*Thinking Errors

Misattribution of causality:Misattribution of causality: When two events are observed either at the When two events are observed either at the

same time or in sequence (one event same time or in sequence (one event preceding another) , we have a tendency to preceding another) , we have a tendency to conclude that the two events are related in conclude that the two events are related in some way. (Correlation=/=Causation)some way. (Correlation=/=Causation)

Post hoc reasoningPost hoc reasoning For events in sequence, we can (erroneously) For events in sequence, we can (erroneously)

conclude that first event caused the second.conclude that first event caused the second. For example, if a child comes from foster For example, if a child comes from foster

care, we cannot predict (care, we cannot predict (a priori) a priori) any any particular behavior might occur. However, if a particular behavior might occur. However, if a therapist hears then that the child is hoarding therapist hears then that the child is hoarding food or lying to cover-up a bedwetting food or lying to cover-up a bedwetting incident, the therapist may make an incident, the therapist may make an assumption that the behavior is due to the assumption that the behavior is due to the earlier experience. earlier experience.

Confirmatory biasConfirmatory bias Paying attention only to the information that Paying attention only to the information that

confirms the hypotheses we already have confirms the hypotheses we already have about the child’s diagnosis – so that even in about the child’s diagnosis – so that even in the face of contradictory evidence (child the face of contradictory evidence (child adopted at birth, child with natural parents) we adopted at birth, child with natural parents) we will stretch the category to make it fit. will stretch the category to make it fit.

Single Cause Single Cause assumption assumption The tendency to try to explain The tendency to try to explain complexcomplex phenomena phenomena

using using oneone explanation: assuming problems with toilet explanation: assuming problems with toilet training create an obsessive personality, or that foster training create an obsessive personality, or that foster placement creates difficulties with forming bonds with placement creates difficulties with forming bonds with people.people.

Similarly, some clinicians conclude that some Similarly, some clinicians conclude that some oneone factor in a child’s history (such as death of a parent, factor in a child’s history (such as death of a parent, time in foster care) is the cause for some presenting time in foster care) is the cause for some presenting problem, when other factors might be more important problem, when other factors might be more important (intelligence, family biological predisposition to certain (intelligence, family biological predisposition to certain behaviors, normal developmental variation, etc.). behaviors, normal developmental variation, etc.).

““RAD” is example of a label overextended RAD” is example of a label overextended to MANY difficult behaviorsto MANY difficult behaviors

Weak distinguishing or predictive powerWeak distinguishing or predictive power

““Stealing”Stealing” ““Very poor impulse control”Very poor impulse control” ““Learning lags”Learning lags” ““Lack of cause and effect thinking”Lack of cause and effect thinking” ““Abnormal eating patterns”Abnormal eating patterns” ““Poor peer relations”Poor peer relations” ““Sometimes preoccupied with fire”Sometimes preoccupied with fire” ““Preoccupation with blood and gore”Preoccupation with blood and gore” ““Persistent nonsense questions and incessant Persistent nonsense questions and incessant

chatter”chatter”

““RAD” label misappliedRAD” label misapplied ““Phony”Phony” ““Great theatrical displays”Great theatrical displays” ““Chemical self-medication”Chemical self-medication” ““Poor self-soothing techniques”Poor self-soothing techniques” ““Sexually act out at a very young age (seductive Sexually act out at a very young age (seductive

clothing, sexual to other children and animals)”clothing, sexual to other children and animals)” Passive-aggressive behavior (“will say ok if they Passive-aggressive behavior (“will say ok if they

have to do something, then take 1 ½ hour, or have to do something, then take 1 ½ hour, or forget, or act confused”)forget, or act confused”)

““RAD” label misappliedRAD” label misapplied ““Superficially engaging and charming”Superficially engaging and charming” ““Lack of eye contact unless they’re lying”Lack of eye contact unless they’re lying” ““Indiscriminately affectionate with strangers”Indiscriminately affectionate with strangers” ““Non-affectionate on parents’ terms (they can Non-affectionate on parents’ terms (they can

give a hug when they want but if the parent give a hug when they want but if the parent wants it that’s not acceptable)”wants it that’s not acceptable)”

““Destructive to self, others, and material things, Destructive to self, others, and material things, accident prone ‘on purpose’”accident prone ‘on purpose’”

““Cruel to animals”Cruel to animals” ““Lying about the obvious” “crazy lying”Lying about the obvious” “crazy lying”

““RAD” label misappliedRAD” label misapplied

““They act addicted to their own adrenaline”They act addicted to their own adrenaline” ““Refuse to accept responsibility, project blame Refuse to accept responsibility, project blame

on others”on others” ““Exhibit no remorse”Exhibit no remorse” Often suggested that they are future serial killersOften suggested that they are future serial killers

(L. Eshleman, 2001) (L. Eshleman, 2001)

RAD label overextended to RAD label overextended to caretakerscaretakers

Some groups include caregiver “symptoms” in Some groups include caregiver “symptoms” in “diagnosis”:“diagnosis”: Feel isolated and depressed. Feel isolated and depressed. Feel frustrated and stressed. Feel frustrated and stressed. Are hypervigilant, agitated, have difficulty Are hypervigilant, agitated, have difficulty

concentrating. concentrating. Are confused, puzzled, obsessed with finding Are confused, puzzled, obsessed with finding

answers. answers. Feel blamed by family, friends, and professionals. Feel blamed by family, friends, and professionals. Feel helpless, hopeless, and angry. Feel helpless, hopeless, and angry. Feel that problems are minimized by the helping Feel that problems are minimized by the helping

profession. (Institute for Attachment, 2003) profession. (Institute for Attachment, 2003)

Problems with overextensionProblems with overextension

Those labels do NOT appear in the criteria Those labels do NOT appear in the criteria for Reactive Attachment Disorder for Reactive Attachment Disorder

SomeSome of the labels DO appear in other of the labels DO appear in other diagnostic categories that are better diagnostic categories that are better applied to such childrenapplied to such children

These labels are These labels are notnot clinicalclinical and are and are dangerousdangerous in how they make adults think in how they make adults think and feel about the children in their careand feel about the children in their care

Such labels can apply to many types of Such labels can apply to many types of individuals with their own histories and individuals with their own histories and problems and do NOT indicate attachment problems and do NOT indicate attachment problemsproblems

Such labels can apply to the parents of Such labels can apply to the parents of many difficult to raise children, including many difficult to raise children, including those with chronic physical health those with chronic physical health problems.problems.

Controversy about RAD Controversy about RAD DiagnosisDiagnosis

Reliability? Not applied consistently by Reliability? Not applied consistently by independent clinicians independent clinicians

Sometimes an overfocus on the Sometimes an overfocus on the preconditions (foster care, adoption) preconditions (foster care, adoption) instead of symptoms (correlation is not instead of symptoms (correlation is not causation) causation)

Cultural relevance? Some cultures value Cultural relevance? Some cultures value inhibition and limited attachments, some inhibition and limited attachments, some value attachments to more than one value attachments to more than one caretaker. What is definition of caretaker. What is definition of “indiscriminate sociability”? “indiscriminate sociability”?

Understanding AttachmentUnderstanding Attachment

AttachmentAttachment Attachment is a Attachment is a special, biologically basedspecial, biologically based

tie, very hard to eliminate, or damage, given tie, very hard to eliminate, or damage, given its necessity for survivalits necessity for survival

Critical Nature of AttachmentCritical Nature of Attachment

Importance to survival of young and of Importance to survival of young and of speciesspecies

Resilience of critical, adaptive functionsResilience of critical, adaptive functions Attachment & attachment Attachment & attachment behaviorsbehaviors are are

such a basic survival skill, only the most such a basic survival skill, only the most extraordinary cases of extreme extraordinary cases of extreme deprivation result in no attachment deprivation result in no attachment behaviors developingbehaviors developing

A child is not “unattached”: Children vary A child is not “unattached”: Children vary in whether they are in whether they are securelysecurely or or insecurelyinsecurely attached and to whom they are attachedattached and to whom they are attached

How is Attachment Studied?: How is Attachment Studied?: Types of Child Behavior ObservedTypes of Child Behavior Observed

Child SubtypesChild Subtypes

SecureSecure

Ambivalent/resistant (40-50% of Ambivalent/resistant (40-50% of children in a low risk sample, children in a low risk sample, Zeanah, 1996)Zeanah, 1996)

Avoidant Avoidant

Disorganized (20% of children in Disorganized (20% of children in a nonclinical sample, Zeanah, a nonclinical sample, Zeanah, 1996)1996)

Description Description

Secure base to explore, greets Secure base to explore, greets M on returnM on return

Distress even with M, Distress even with M, distress/unsettled at distress/unsettled at separation, angry or passive on separation, angry or passive on returnreturn

Active exploration, no checking Active exploration, no checking with M. Little response to with M. Little response to absence or return of Mabsence or return of M

Little goal-oriented behavior, Little goal-oriented behavior, stereotypies, apprehension of stereotypies, apprehension of parentparent

Note: “Disorganized (20% of children in a Note: “Disorganized (20% of children in a nonclinical sample, Zeanah, 1996)”nonclinical sample, Zeanah, 1996)”

If the rate of occurrence of an attribute or If the rate of occurrence of an attribute or behavior is this high in a nonclinical (20%) behavior is this high in a nonclinical (20%) or low risk population (40-50%), can we or low risk population (40-50%), can we confidently say we are talking about a confidently say we are talking about a disorder?disorder?

Could these beCould these be normal variants normal variants in in response?response?

How is Attachment Studied?:How is Attachment Studied?:Types of Maternal Behavior Types of Maternal Behavior

ObservedObserved Child SubtypesChild Subtypes

SecureSecure

AmbivalentAmbivalent

AvoidantAvoidant

Disorganized, Disorganized, disorienteddisoriented

Associated Maternal Associated Maternal StylesStyles

Accepting, cooperative, Accepting, cooperative, accessibleaccessible

Inconsistent or Inconsistent or unresponsive to child unresponsive to child distressdistress

Rejecting, less positive Rejecting, less positive physical proximityphysical proximity

Less clear but may be Less clear but may be associated with highly associated with highly inconsistent, sometimes inconsistent, sometimes frightening parenting frightening parenting

What do different types of What do different types of attachment predict?attachment predict?

Insecure attachment creates Insecure attachment creates riskrisk for for problems but alone does not cause problems but alone does not cause problemsproblems In low risk families, less relationIn low risk families, less relation between between

insecure attachment & later externalizing insecure attachment & later externalizing problemsproblems

In high risk families, more likely relation In high risk families, more likely relation between insecure attachment & peer between insecure attachment & peer problems, moodiness, depression & problems, moodiness, depression & aggression (Greenberg, 1999)aggression (Greenberg, 1999)

Correlation does not prove causationCorrelation does not prove causation

What else might be behind these What else might be behind these symptoms or difficult behaviors?symptoms or difficult behaviors?

So…if it’s not RAD, what is it? So…if it’s not RAD, what is it?

OrOrReframing to reduce fear and encourage Reframing to reduce fear and encourage

competencecompetence

OCDOCD Mood Disorder (Mood dysregulation)Mood Disorder (Mood dysregulation) DepressionDepression Oppositional Defiant DisorderOppositional Defiant Disorder Conduct DisorderConduct Disorder Impulse Control DisorderImpulse Control Disorder Disruptive Behavior DisorderDisruptive Behavior Disorder Generalized Anxiety DisorderGeneralized Anxiety Disorder Separation Anxiety DisorderSeparation Anxiety Disorder Post-traumatic Stress DisorderPost-traumatic Stress Disorder

Pervasive Developmental DisorderPervasive Developmental Disorder Asperger’s DisorderAsperger’s Disorder Attention-Deficit/Hyperactive DisorderAttention-Deficit/Hyperactive Disorder Adjustment Disorder with Mixed Adjustment Disorder with Mixed

Disturbance of Emotions and ConductDisturbance of Emotions and Conduct Developmental Delay (especially cognitive Developmental Delay (especially cognitive

and language)and language) Normal Development, Caretaker-child Normal Development, Caretaker-child

Temperament mismatchTemperament mismatch Normal Development, Adaptive behaviorNormal Development, Adaptive behavior

What are the advantages of considering What are the advantages of considering other diagnostic categories or any other diagnostic categories or any diagnostic category?diagnostic category?

Importance of considering treatments that Importance of considering treatments that are ethical, based on the child’s needs, are ethical, based on the child’s needs, and have been shown to improve difficult and have been shown to improve difficult behaviors.behaviors.

Conclusion: Conclusion: What we know about diagnosisWhat we know about diagnosis

The term “Reactive Attachment Disorder” has The term “Reactive Attachment Disorder” has been applied to a wide range of behaviors that been applied to a wide range of behaviors that can be captured more appropriately with other, can be captured more appropriately with other, existing diagnostic categoriesexisting diagnostic categories

The “problem” behaviors may originate from The “problem” behaviors may originate from other causes:other causes: The child’s genetic or temperament tendenciesThe child’s genetic or temperament tendencies The foster/adoptive parent’s expectationsThe foster/adoptive parent’s expectations The child’s early experiences and expectationsThe child’s early experiences and expectations Cultural expectations/mismatch (Rothbaum et al., Cultural expectations/mismatch (Rothbaum et al.,

2000)2000) Other parenting factorsOther parenting factors

Could RAD (as commonly Could RAD (as commonly used) be captured by Parent used) be captured by Parent

Child Relational Disorder (a ‘v Child Relational Disorder (a ‘v Code’)?Code’)?

What we know about treatmentWhat we know about treatment

There is no There is no oneone treatment (no silver treatment (no silver bullet) for the myriad of problems that are bullet) for the myriad of problems that are described in popular discussions of RADdescribed in popular discussions of RAD

Treatment focuses onTreatment focuses on

The problem behavior (one at a time)The problem behavior (one at a time) The bond The bond

What are the caregiver’s What are the caregiver’s thoughtsthoughts about the about the child and expectations about the relationship?child and expectations about the relationship?

The child often has no problems with The child often has no problems with attachment; the problem is s/he is not attachment; the problem is s/he is not attached to the presenting caregiver. attached to the presenting caregiver.

[My children, who were adopted at 7 mos.] did [My children, who were adopted at 7 mos.] did not begin to show separation anxiety when I left not begin to show separation anxiety when I left them until they were perhaps a year old and the them until they were perhaps a year old and the attachment process had progressed to the point attachment process had progressed to the point where I mattered to them more than someone where I mattered to them more than someone else. A friend reaching for my 18 mo. old else. A friend reaching for my 18 mo. old daughter asked]: “Does she go to strangers?” daughter asked]: “Does she go to strangers?”

““Of course,” I answered, “She’s Of course,” I answered, “She’s livingliving with with strangers.” strangers.”

From L. Melina From L. Melina Raising Adopted ChildrenRaising Adopted Children, Harper Collins, 1998., Harper Collins, 1998.

Treatments should be symptom focused. Treatments should be symptom focused. Known effective interventions for the Known effective interventions for the troubling behaviors are required, incl. troubling behaviors are required, incl. behavior therapy, cognitive therapy, behavior therapy, cognitive therapy, family education, and parent training and, family education, and parent training and, as needed, pharmacological approaches. as needed, pharmacological approaches.

Beware of Beware of damaging, even deadly, effects of invalid, damaging, even deadly, effects of invalid,

coercive “therapies”coercive “therapies” Ineffective treatments that waste limited Ineffective treatments that waste limited

resources and precious time in a child’s young resources and precious time in a child’s young lifelife

AmericanAmericanProfessional Society on the Abuse Professional Society on the Abuse

of Children’s (APSAC)of Children’s (APSAC)Traditional attachment theory holds that Traditional attachment theory holds that

caregiver qualitiescaregiver qualities are key, such as are key, such as Environmental stabilityEnvironmental stability Parental sensitivity, Parental sensitivity, Responsiveness to children’s physical and Responsiveness to children’s physical and

emotional needs emotional needs Consistency, and a safe and predictable Consistency, and a safe and predictable

environment support the development of environment support the development of healthy attachment. healthy attachment.

From this perspective, improving these From this perspective, improving these positive caretaker and environmental positive caretaker and environmental qualities is the key to improving qualities is the key to improving attachment. attachment.

CHILD MALTREATMENT, Vol. 11, No. 1, February 2006 CHILD MALTREATMENT, Vol. 11, No. 1, February 2006 76-8976-89

Problems with “Attachment Problems with “Attachment Therapy”Therapy”

Lack of informed consent to treatment -- Lack of informed consent to treatment -- where is the advocate for the child?where is the advocate for the child?

No link between attachment research and No link between attachment research and current popular treatmentscurrent popular treatments

Illogical and invalid concept that children must Illogical and invalid concept that children must release rage before they can be lovingrelease rage before they can be loving

Unethical targeting of adoptive and foster Unethical targeting of adoptive and foster parent audienceparent audience

Often unlicensed practitionersOften unlicensed practitioners Creation of adult fear of child & erosion of Creation of adult fear of child & erosion of

caregiver confidencecaregiver confidence

Problems, cont.Problems, cont.

““Corrective attachment therapy” is coercive and Corrective attachment therapy” is coercive and resembles psychological methods to destabilize an resembles psychological methods to destabilize an individual to force adherence to a particular individual to force adherence to a particular ideology or point of viewideology or point of view

1) damaging of individual’s defenses through an 1) damaging of individual’s defenses through an intensive devaluing interpersonal process; intensive devaluing interpersonal process;

2) offering an opportunity to escape the process by 2) offering an opportunity to escape the process by accepting and stating required beliefs, refuting accepting and stating required beliefs, refuting previously held beliefs, and confessing to prior previously held beliefs, and confessing to prior behaviors. behaviors.

3) providing social group approval of the individual’s 3) providing social group approval of the individual’s compliance and rejection of competing ideas. compliance and rejection of competing ideas. (Borgattoa and Borgatta, 2000)(Borgattoa and Borgatta, 2000)

Problems, cont.Problems, cont.

Lack of understanding of child’s developmental Lack of understanding of child’s developmental needsneeds

Lack of understanding of child’s adaptation Lack of understanding of child’s adaptation processprocess

Expectation of immediate bonding and Expectation of immediate bonding and interpretation of resistance as “attachment interpretation of resistance as “attachment disorder”disorder”

Physically and emotionally intrusive, thereby Physically and emotionally intrusive, thereby retraumatizing an abused or neglected child and retraumatizing an abused or neglected child and delaying development of trust & securitydelaying development of trust & security

What treatment is recommended? What treatment is recommended?

Treat the behavior and the bond (not the same Treat the behavior and the bond (not the same issue)issue)

If presented with a child with a history of If presented with a child with a history of attachment disruption, do not immediately attachment disruption, do not immediately assume treatment is necessary. Base assume treatment is necessary. Base interventions on symptom presentation: what interventions on symptom presentation: what behaviors are troubling to the child & the behaviors are troubling to the child & the caregiver?caregiver?

But But dodo think about the caregiver-child think about the caregiver-child relationship relationship

Recommended Approaches for Recommended Approaches for Suspected Attachment Suspected Attachment DisordersDisorders

Give the child (a sense of) more control, don’t Give the child (a sense of) more control, don’t take control away from the child. Do give control take control away from the child. Do give control in areas the care giving adult is comfortable with in areas the care giving adult is comfortable with (give child (give child benignbenign choices). Why? choices). Why?

Enhance the sensitivity of the adoptive parent to Enhance the sensitivity of the adoptive parent to the child rather than the child to the parent the child rather than the child to the parent (Dozier et al., 2002)(Dozier et al., 2002)

Help the adult articulate what they want out of Help the adult articulate what they want out of this relationshipthis relationship

Reduce caregiver’s expectation for rapid Reduce caregiver’s expectation for rapid change and increase their acceptance of change and increase their acceptance of the child’s basic temperament and the child’s basic temperament and developmental needs (Dozier et al. 2002)developmental needs (Dozier et al. 2002)

Unlink the contingency between the child’s Unlink the contingency between the child’s behavior and the permanency of the behavior and the permanency of the placementplacement

Emphasize positive reinforcement and Emphasize positive reinforcement and positive exchanges of affection positive exchanges of affection on the on the child’s termschild’s terms, rather than the parents’ , rather than the parents’ (Speltz, 2002, Dozier, et al. 2002).(Speltz, 2002, Dozier, et al. 2002).

How to Treat Difficult ChildrenHow to Treat Difficult Children

Examples of specific valid interventions for Examples of specific valid interventions for these childrenthese children Comprehensive medical diagnosis and Comprehensive medical diagnosis and

care of childcare of child Developmental assessment of child and Developmental assessment of child and

child’s needs at that particular agechild’s needs at that particular age Respond to the caregiver’s distressRespond to the caregiver’s distress, ,

focus on developing an alliance, identify focus on developing an alliance, identify the major concerns the adult has with the major concerns the adult has with the child’s behaviorthe child’s behavior

Respond to the child’s distress, focus Respond to the child’s distress, focus on alliance and on identifying the child’s on alliance and on identifying the child’s concerns and goals, if age appropriateconcerns and goals, if age appropriate

Treat the relationshipTreat the relationship

Teach caregiver how to interact with child, Teach caregiver how to interact with child, to encourage bonding, cooperation, to encourage bonding, cooperation, addressing child’s developmental level & addressing child’s developmental level & emotional needs, using positive verbal emotional needs, using positive verbal comments, planned ignoring, teaching comments, planned ignoring, teaching parent how to implement child directed parent how to implement child directed interactions and parent directed interactions and parent directed interactions interactions (Dozier, et al., 2002; Eyberg & (Dozier, et al., 2002; Eyberg & McNeill, 2003; Webster-Stratton & Hancock, McNeill, 2003; Webster-Stratton & Hancock, 1998)1998)

Treat the relationshipTreat the relationship

Increase the caregiver’s competence Increase the caregiver’s competence and confidence through training: start and confidence through training: start smallsmall Teach caregiver behavior therapy with Teach caregiver behavior therapy with

child, including behavior substitution, child, including behavior substitution, differential reinforcement of incompatible or differential reinforcement of incompatible or other behaviors, anxiety reduction other behaviors, anxiety reduction techniques, such as gradual exposure, techniques, such as gradual exposure, anxiety hierarchy and related treatments anxiety hierarchy and related treatments

Treat the relationship, cont.Treat the relationship, cont.

Cognitive therapy in the family context to Cognitive therapy in the family context to assist with parental reframing, negative assist with parental reframing, negative cognitions, expectations, and problem solving cognitions, expectations, and problem solving (W-S & H): Examine the thoughts the (W-S & H): Examine the thoughts the caregiver is having about the child & doubts caregiver is having about the child & doubts about their own parenting ability: “You about their own parenting ability: “You cancan parent this child.”parent this child.”

Teach parent how to implement positive Teach parent how to implement positive behavior management in home providing behavior management in home providing consistent rewards for appropriate behaviors consistent rewards for appropriate behaviors (W-S&H, E&M, Barkley): for ex., giving (W-S&H, E&M, Barkley): for ex., giving attention for the positive behaviors the child is attention for the positive behaviors the child is able to do, rather than for the failuresable to do, rather than for the failures

Provide skill instruction with child for Provide skill instruction with child for emotional regulation (e.g., anger emotional regulation (e.g., anger thermometer) and social skills deficits, thermometer) and social skills deficits, including teaching child how to give parent including teaching child how to give parent positive feedbackpositive feedback

Clinical examplesClinical examples

Reactive Attachment Disorder: Reactive Attachment Disorder: Fact and FictionFact and Fiction

FictionFiction Children with behavior problems who have a history Children with behavior problems who have a history

of foster care or residential placement can be of foster care or residential placement can be assumed to have Reactive Attachment Disorder T/Fassumed to have Reactive Attachment Disorder T/F

Children who do not show affection to their adoptive Children who do not show affection to their adoptive or foster parents have problems with attachment T/For foster parents have problems with attachment T/F

Special treatment programs for “Reactive Attachment Special treatment programs for “Reactive Attachment Disorder” are effective and valid T/FDisorder” are effective and valid T/F

Children labeled with Reactive Attachment Disorder Children labeled with Reactive Attachment Disorder must, in many cases, be forced to bond with their must, in many cases, be forced to bond with their parents T/Fparents T/F

Forcing bonding and attachment treats a myriad of Forcing bonding and attachment treats a myriad of problem behaviors T/Fproblem behaviors T/F

Reactive Attachment Disorder: Reactive Attachment Disorder: Fact and Fiction, cont.Fact and Fiction, cont.

Fact - DefinitionFact - Definition Attachment and attachment behaviors are a most Attachment and attachment behaviors are a most

basic activity of human beings & all mammals; basic activity of human beings & all mammals; only in extraordinary circumstances does only in extraordinary circumstances does attachment fail to occur T/F attachment fail to occur T/F

Infants can show attachment to more than one Infants can show attachment to more than one caregiver, in fact, this is common. T/F caregiver, in fact, this is common. T/F

Reactive Attachment Disorder refers to a narrow Reactive Attachment Disorder refers to a narrow range of disturbance T/F range of disturbance T/F

Disruptions of attachment can create stress Disruptions of attachment can create stress responses in the organism T/Fresponses in the organism T/F

Reactive Attachment Disorder: Reactive Attachment Disorder: Fact and Fiction, cont.Fact and Fiction, cont.

Fact – Definition, cont.Fact – Definition, cont. Observations of ‘disorganized attachment’ Observations of ‘disorganized attachment’

have been associated with later have been associated with later externalizing behaviors, not necessarily externalizing behaviors, not necessarily with ability to form affectionate bonds with ability to form affectionate bonds T/FT/F

‘‘Disorganized attachment’ alone has not Disorganized attachment’ alone has not yet been proven to yet been proven to cause cause later problems. later problems. Both are possibly caused by other factors, Both are possibly caused by other factors, such as a family predisposition to such as a family predisposition to impulsivity or mood dysregulation. impulsivity or mood dysregulation. T/FT/F

Reactive Attachment Disorder: Reactive Attachment Disorder: Fact and Fiction, cont.Fact and Fiction, cont.

Fact – Treatment Fact – Treatment There is no direct relationship established There is no direct relationship established

between foster care, adoptive placement, and between foster care, adoptive placement, and maladaptive behaviors or ability to form bonds maladaptive behaviors or ability to form bonds with others. Many of these children with others. Many of these children nevernever require treatment; many children from require treatment; many children from adequateadequate homes do require treatment. homes do require treatment. T/FT/F

There is no There is no oneone proven treatment for the entire proven treatment for the entire broad range of behaviors broad range of behaviors popularlypopularly referred to as referred to as Reactive Attachment Disorder, in fact, this term is Reactive Attachment Disorder, in fact, this term is misused very frequently. misused very frequently. T/FT/F

Fact and FictionFact and Fiction Fact – Treatment, cont.Fact – Treatment, cont.

Attachment therapy can carry a high risk of Attachment therapy can carry a high risk of psychological injury to the child, can be coercive psychological injury to the child, can be coercive and reminiscent to the child of previous miscues and reminiscent to the child of previous miscues and even abuse by an adult and even abuse by an adult T/FT/F

Attachment therapy meets none of the criteria Attachment therapy meets none of the criteria required for validation at any level. Current required for validation at any level. Current support is only in testimonial form. support is only in testimonial form. T/FT/F

Specific behavior problems can be addressed Specific behavior problems can be addressed individually by validated treatments individually by validated treatments T/FT/F

If attachment disorder is suspected, it is the If attachment disorder is suspected, it is the relationship, not the child, that needs treatment relationship, not the child, that needs treatment T/FT/F

ConclusionConclusion

We have an obligation to We have an obligation to Provide treatment that is better than no Provide treatment that is better than no

treatment and so will not waste the limited treatment and so will not waste the limited resources available to childrenresources available to children

Be rigorous and conservative in our Be rigorous and conservative in our evaluation of diagnoses and treatments evaluation of diagnoses and treatments provided to children, provided to children, especiallyespecially those who those who have no other advocateshave no other advocates

Teach caregivers what we knowTeach caregivers what we know

PostscriptPostscript

Consider the resilience of human Consider the resilience of human naturenature

What is ‘resilience’?What is ‘resilience’?

Capacity to resist the potential negative Capacity to resist the potential negative consequences of risk and develop consequences of risk and develop adequatelyadequately

Reduced vulnerability to stressorsReduced vulnerability to stressors ““Ability to thrive, mature, and increase Ability to thrive, mature, and increase

competence in the face of adverse competence in the face of adverse circumstances” circumstances” (Gordon, Kimberly A.  1996 Infant and Toddler Resilience: Knowledge, (Gordon, Kimberly A.  1996 Infant and Toddler Resilience: Knowledge,

Predictions, Policy, and Practice. Head Start Conference) Predictions, Policy, and Practice. Head Start Conference)

ResourcesResources for parents & therapists for parents & therapists

www.help4adhd.orgwww.help4adhd.org (‘Diagnosis & Trtmt’ link) (‘Diagnosis & Trtmt’ link) www.chadd.orgwww.chadd.org www.effectivechildtherapy.comwww.effectivechildtherapy.com

www.bpkids.orgwww.bpkids.org (‘Learning Center’ link) (‘Learning Center’ link) www.promisingpractices.netwww.promisingpractices.net http://www.apa.org/pi/cyf/cyfnews.htmlhttp://www.apa.org/pi/cyf/cyfnews.html

www.cachildwelfareclearinghouse.orgwww.cachildwelfareclearinghouse.org

Parent Training Programs:Parent Training Programs: www.pcit.orgwww.pcit.org www.incredibleyears.comwww.incredibleyears.com www.triplep-america.comwww.triplep-america.com Trauma focused: Trauma focused: www.tfcbt.musc.eduwww.tfcbt.musc.edu

ReferencesReferences Ainsworth, M. et al. (1978). Ainsworth, M. et al. (1978). Patterns of AttachmentPatterns of Attachment. NY: Basic Books.. NY: Basic Books. American Psychological Association (2002). Criteria for evaluating treatment guidelines. American Psychological Association (2002). Criteria for evaluating treatment guidelines. American PsychologistAmerican Psychologist

57(12), 1052-1059.57(12), 1052-1059. Borgatta, E. & Borgatta, A. (2002) Borgatta, E. & Borgatta, A. (2002) Encyclopedia of sociology, 2Encyclopedia of sociology, 2ndnd Ed. Ed. NY: Macmillan. NY: Macmillan. Bowlby, J. (1988). Bowlby, J. (1988). A Secure BaseA Secure Base. NY: Basic Books.. NY: Basic Books. Bowlby, J. ((1969). Bowlby, J. ((1969). Attachment and LossAttachment and Loss. NY: Basic Books.. NY: Basic Books. Breismeister, J. & Schaefer, C., Eds. (1998). Handbook of Parent Training: Parents as cotherapists for children’s Breismeister, J. & Schaefer, C., Eds. (1998). Handbook of Parent Training: Parents as cotherapists for children’s

behvaior problems. NY: Wiley.behvaior problems. NY: Wiley. Cassidy, J. (1999). The nature of the child’s ties. In Cassidy, J & Shavery, P. (Eds.). Cassidy, J. (1999). The nature of the child’s ties. In Cassidy, J & Shavery, P. (Eds.). Handbook of Attachment: Theory, Handbook of Attachment: Theory,

Research, and Clinical ApplicationsResearch, and Clinical Applications. NY: Guilford Press, 3-20.. NY: Guilford Press, 3-20. Cassidy, J. & Shaver, P., Eds. (1999). Cassidy, J. & Shaver, P., Eds. (1999). Handbook of Attachment: Theory, Research, and Clinical ApplicationsHandbook of Attachment: Theory, Research, and Clinical Applications. NY: . NY:

Guilford Press.Guilford Press. Chaffin, R. et al. (2006). Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Chaffin, R. et al. (2006). Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and

Attachment Problems", Attachment Problems", Child MaltreatmentChild Maltreatment, Vol. 11, No. 1, Feb. 2006, 76-89., Vol. 11, No. 1, Feb. 2006, 76-89. Dozier, M., Dozier, D., & Manni, M. (2002). Attachment and biobehavioral catch-up: The ABC’s of helping foster Dozier, M., Dozier, D., & Manni, M. (2002). Attachment and biobehavioral catch-up: The ABC’s of helping foster

infantsinfants cope with cope with early adversity. early adversity. Zero to ThreeZero to Three 22 (5), 7-13. 22 (5), 7-13. Hanson, R. & Spratt, E. (2000). Reactive attachment disorder: What we know about the disorder and implications for Hanson, R. & Spratt, E. (2000). Reactive attachment disorder: What we know about the disorder and implications for

treatment. treatment. Child Maltreatment: J. of the American Professional Society on the Abuse of Children 5(2), Child Maltreatment: J. of the American Professional Society on the Abuse of Children 5(2), 137-137-145.145.

Huebner, L. et al. (2001). Developmental and psychological outcomes among internationally adopted children.Huebner, L. et al. (2001). Developmental and psychological outcomes among internationally adopted children.Presented at the American Psychological Association, San Francisco, CA.Presented at the American Psychological Association, San Francisco, CA.

Kettlewell, P. (2003). The 7Kettlewell, P. (2003). The 7thth principle of CASSP. principle of CASSP. The Pennsylvania Psychologist QuarterlyThe Pennsylvania Psychologist Quarterly, February 2003, 2-25., February 2003, 2-25. Lilienfeld, S. et al., Eds. (2002). Lilienfeld, S. et al., Eds. (2002). Science and Pseudoscience in Clinical Psychology.Science and Pseudoscience in Clinical Psychology. NY: Guilford Press. NY: Guilford Press. Lilienfeld, S. (2007). Psychological treatments that cause harm. Lilienfeld, S. (2007). Psychological treatments that cause harm. Perspectives on Psychological SciencePerspectives on Psychological Science, 2(1), 53-70., 2(1), 53-70. Nathan, P. & Gorman, J. (2002). Nathan, P. & Gorman, J. (2002). A Guide to Treatments that WorkA Guide to Treatments that Work. Oxford University Press.. Oxford University Press. Richters, M. & Volkmar, F. (1994). Reactive attachment disorder of infancy or early childhood. Richters, M. & Volkmar, F. (1994). Reactive attachment disorder of infancy or early childhood. J. of the American J. of the American

Academy of Child & Adolescent Academy of Child & Adolescent Psychiatry, 33(3). Psychiatry, 33(3). Rothbaum, F. et al. (2000). Attachment and culture. Rothbaum, F. et al. (2000). Attachment and culture. American Psychologist 55(10)American Psychologist 55(10), 1093-1104., 1093-1104. Solomon, J. & George, C. (1999). The measurement of attachment security in infancy and childhood. Solomon, J. & George, C. (1999). The measurement of attachment security in infancy and childhood. Handbook of Handbook of

Attachment: Theory, Research, and Clinical ApplicationsAttachment: Theory, Research, and Clinical Applications. NY: Guilford Press, 287-316.. NY: Guilford Press, 287-316. Solomon, J. & George, C. (Eds.). (1999). Solomon, J. & George, C. (Eds.). (1999). Attachment DisorganizationAttachment Disorganization. NY: Guilford Press.. NY: Guilford Press. Zeanah, C. & Boris, N. (2000). Disturbances and disorders of attachment in early childhood. In C. Zeanah (Ed.), Zeanah, C. & Boris, N. (2000). Disturbances and disorders of attachment in early childhood. In C. Zeanah (Ed.),

Handbook of Infant Mental HealthHandbook of Infant Mental Health, 2, 2ndnd Ed. NY: Guilford Press, pp. 353-368. Ed. NY: Guilford Press, pp. 353-368. Zeanah, C. (1996). Beyond insecurity: A reconceptualization of attachment disorders of infancy. Zeanah, C. (1996). Beyond insecurity: A reconceptualization of attachment disorders of infancy. J. of Consulting and J. of Consulting and

Clinical PsychologyClinical Psychology 64(1), 42-52. 64(1), 42-52.