Sunday, November 20, 2011

If It's Not RAD-- What Is It?

Again and again, parents and semi-professional therapists turn up on the Internet and in print, stating their claims that aggressive and difficult children have Reactive Attachment Disorder. They go on to say that the undesirable behavior can be cured only by correcting problems of attachment and causing the children to become emotionally attached to their parents. The same group used to press these ideas with respect to autistic children, too, until research showed that those children were normally attached to their parents and caregivers.

Also again and again, various authors (including me) have rejoined that the criteria for diagnosis with Reactive Attachment Disorder do not include aggression, firesetting, or any of the other frightening behavioral symptoms so often claimed for that disorder. At the same time, though, no one commenting on this issue has denied that there are children who display a range of disturbing behaviors. What, then, should be the diagnosis for those children, if it is not Reactive Attachment Disorder?

One possible diagnosis for children who display severe behavior problems early in life is early-onset schizophrenia. This has been said to be the difficulty of Malcolm Shabazz, the grandson of Malcolm X, who started the fire that killed his grandmother, Betty Shabazz. Malcolm Shabazz was reported to have fought with his mother (also apparently mentally ill) until they were both bloody, when he was only three years old. Now in his late teens or early twenties, he has continued to display violent, irrational behavior. Although it is certainly true that Malcolm Shabazz has poor relationships with others, there is evidently far more going on here than problems with attachment.

Early-onset schizophrenia is not frequent. A more likely, and far more common (between 2% and 6% of the population), diagnosis for children with extremely difficult and aggressive behavior is Conduct Disorder. An article by the eminent psychologist Alan E. Kazdin has recently discussed Conduct Disorder-related behavior and appropriate treatments (Evidence-based treatment research: Advances, limitations, and next steps. [2011]. American Psychologist, 66, 685-698). I am going to be quoting his comments directly and indirectly in this post, as well as adding my own remarks.

Here are some characteristic behaviors of the children Kazdin discusses: fighting, destroying property, lying, using a weapon, physical cruelty to people or animals, stealing, forcing someone into sexual activity, firesetting, truancy, and running away. According to Kazdin, “a typical outpatient case would be a 10-year-old boy who is constantly fighting at school and having frequent explosive tantrums at home. Siblings may have been harmed or may be in jeopardy of being harmed. He may be playing with matches in his bedroom at night, not coming home from school, occasionally not going to school even though the parents believe he is there, and making threats to harm others (peers, teachers).” (This child, by the way, might well be labeled a “psychopath” by those who use that term rather freely.)

Kazdin notes that Conduct Disorder is frequently followed by adult psychiatric disorders, and that it has harmful consequences for parents, siblings, and teachers, as well as the child himself or herself. Without commenting on the complex possibilities of cause-and-effect relationships, Kazdin goes on to say that “many children with [Conduct Disorder] are subject to moderate-to-heavy corporal punishment or live in very stressful environments”.

How can Conduct Disorder be treated? The interventions suggested by Kazdin are far removed from the various “attachment therapies” preferred by those who attribute difficult and aggressive behavior to Reactive Attachment Disorder. Kazdin focuses on parent management training (PMT), an intervention that examines parent-child interactions in the home and guides parents in altering interactions that make the child’s behavior more deviant. Randomized controlled trials have shown this method to be an effective one. When there is no parent involvement, for example because of substance abuse or simple refusal to participate, Kazdin recommends a cognitive approach, problem-solving skills training (PSST), which again has been shown to be effective and to significantly reduce undesirable behavior. In contrast to the “attachment therapy” approach, Kazdin’s program thus emphasizes altering parent behavior if possible, and follows up by using well-understood principles of learning rather than efforts at changing basic but poorly-understood attitudes and emotions.

A frequent comment of “attachment therapy” advocates is that conventional treatments make children’s disorders worse, that children must be capable of trust in order to benefit from psychotherapy; in addition, they state that parents who have “tried everything” will be happy with interventions approved by ATTACh and its admirers. Kazdin’s treatment program is of demonstrated effectiveness and does not require that children trust--- on the contrary, trust might be expected to result from behavior changes beneficial to both child and parent. I would hazard the guess that those who have “tried everything” have not tried serious interventions like PMT, but instead have spent a few hours with popular local counselors who have little more than their personal experiences to guide their work.

From the point of view of ATTACh and its members, PMT has one characteristic they would very much wish to avoid. This is the fact that parents are asked to examine their own behavior in detail and work to change it. “Attachment therapy”, although it may include some version of parent education, is attractive to parents because it does not ask them to change in any difficult way. Parents may be asked to make intense demands on their children, to watch them constantly, and to refuse to let them “get away with” anything, but all these are matters of investing time and energy-- not the more difficult matter of considering whether what one just did was part of the problem and not part of the solution. To admit that you are not an “awesome parent” is frightening, especially for families where the authority and rightness of the parents is a matter of religious belief. But it may be the most important step in helping children whose actual problem is Conduct Disorder.

18 comments:

  1. This is a much better explanation and diagnosis of violent children than "attachment disorder".I was an aide in a class called "neurologically Impaired" that covered a wide variety of learning and behavioral problems. There were always a few kids in the class that we called, off the record, "future criminals of America" They fit the description of conduct disorder very well. And yes, they went on to be regulars on the local police blotter. None of them were adopted, that was not an issue, but I suspect negligent parenting was. This is a wealthy area, they were not children of poverty either.

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  2. Could be negligent parenting, could be just failing to figure out what the parent does that leads to worse rather than better child behavior-- something that parent training programs can help with and people can't always manage by themselves.

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  3. Negligent parenting is inter- generational.Someone has to be strong enough to break away and free the next generation from emotional poverty.It's all about lack of nurturing/mothering.It's going to get worse because society devalues proper mothering.A daycare/pre school is not adequate enough to substitute for mother's love and bonding.

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  4. Why isn't it adequate? Human beings in all times and cultures have had people other than mothers help care for young children-- from "child nurses" to nannies, grandmothers, fathers and brothers, and now daycare providers. Are you suggesting that mothers must be the primary caregivers until age 5 in order for children to have good mental health?

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    1. The reason I would suggest it is not adequate is because a child care worker is not personally invested in the child as a person. He or she does not have "dreams" for the child (however neurotic or unhealthy those may be). A preschool or daycare is essentially an institutional environment, and as we have seen and continue to see, such settings for young children are psychologically harmful. Nannies and involved community members, such as would be available in a traditional village setting, are persons (emphasis on that powerful word) interacting individually and uniquely with another person (the child).

      None of which is to say that preschool or daycare will harm a psyche irreparably - provided that it is balanced with the aforementioned individual attention and personal investment of someone who deeply cares about the child.

      I would also say that a 6-week old infant (the standard maternity leave in this country) does not belong in a daycare. Though it's physical

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    2. I would certainly agree that low-quality non-parental care is a problem, just as low-quality parental care would be. Standards for high-quality group care require one caregiver for three babies, and make a point of dealing properly with "substitutes" when needed or with shift changes. They also require that caregivers be assigned to specific babies rather than "floating" to wherever they're needed.

      One other point about high-quality child care is that babies are kept in small groups-- you don't have a large room with 12 babies and 4 caregivers, where there's always commotion and the adults can't resist the temptation to talk to each other rather than to the babies.

      There are a lot of things that can be done to make group care provide many of the benefits that would come from more individualized care. When those things are done, too, it may be easier for the caregivers to feel a personal investment, which may be difficult in a low-quality arrangement.

      However, you're certainly right in talking about this, given that the vast majority of day care arrangements in the U.S. are of low quality, especially those run for-profit. By the way, day care centers sponsored by religious organizations usually do not have to follow state regulations for child care.

      Young infants are especially vulnerable in these situations, as you say-- I was taking exception to the previous writer's referring to "Preschools" as a problem for attachment, although of course I don't know exactly what was meant by that, as some people refer to any infant and toddler care center as a "preschool".

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  5. Schizophrenia, adult or child onset, usually does not involve violence. Signs of schizophrenia are irrational beliefs, seeing/hearing things that don't exist, social withdrawal and executive function problemsa. Most schizophrenic people are not violent - they are confused and socially withdrawn and are far more likely to be victims than perpetrators of violence. Violence in schizophrenia is often due to a comorbid condition, one of the same conditions that cause non-schizophrenics to be violent.

    One of the conditions most strongly associated with violence is psychopathy. Psychopaths have a developmental disorder affecting their ability to empathize with others - they can tell how others are feeling, but this arouses no reaction in them (even infants will often cry when others are crying, so this is quite atypical). Since it's developmental, there are child psychopaths - every adult psychopath was once a child psychopath (except in a few cases of brain injury). Psychopathy is uniquely associated with proactive, planned aggression, although they can also aggress impulsively. In addition, most psychopaths show a wide variety of criminal/antisocial behavior, such as stealing, setting fires, constant lying, etc. But the big thing that distinguishes them from non-psychopaths with Conduct disorder or related conditions is that they show little fear and no empathy. Most conduct disorder kids, they have a chip on their shoulder and get into trouble, but if they saw a younger child who'd hurt himself, they'd want to help. Not a psychopath - they might find it amusing, or just not care either way.

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  6. Very true that schizophrenia usually doesn't involve violence. But it sometimes does (e.g., the paranoid type), and it is more likely to do so than RAD properly defined.

    Your argument about psychopathy suggests that such people would already show a lack of empathy by not crying when other babies cry. Is that what you meant? (Anyway, I'm not sure why one would argue that babies cry from empathy rather than from hating the sound of crying. Many child abusers attack babies because the babies cry and the adult can't stand it.)

    I think you're trying to make the point that children described as RAD, but showing violent traits, might better be classified in other ways. I certainly agree with that, although I'm not at all sure about the psychopathy construct.

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  7. What would be the correct diagnostic term for children who simply learn many of these "conduct disorder" behaviors from the adults around them? Say, growing up with alcohol- and drug-addicted parents---using that word "parents" very loosely---and a revolving cast of alcohol- and drug-addicted adults in and out of their lives in unpredictable and unusual ways, who may abuse the children with no one noticing or caring. "Fighting, destroying property, lying, using a weapon, physical cruelty to people or animals, stealing, forcing someone into sexual activity, firesetting, truancy, and running away"---all of these can be impulsive actions of a normal young child, which are easily and quickly corrected by a loving, attentive adult in a decent home. But left to their own devices---or worse, fed the most deviant kinds of example from "role models" in their midst---children growing up in the most depraved kinds of crack-house environments will not be taught that any of these behaviors are wrong. And, worse, they may quickly learn that some of these behaviors bring them a modicum of power and protection in a warzone-like home where the adults would more readily sell their children to answer their own needs than address the needs of their offspring. Please don't think I'm exaggerating. While these kinds of homes, thankfully, make up the smallest minority of homes in the USA, they are not impossible to find in every corner of the nation.

    So, my question is, really, along with teaching more pro-social skills to children and their parents (or, more likely, their second set of parents, through foster care and/or adoption) through the kinds of programs described above by Kazdin (PMT and PSST) or others such as DBT, how do we treat the trauma (PTSD, complex trauma) that so often underlies the symptoms we are diagnosing?

    Who are some of the good researchers on trauma treatment for children and adolescents? What are some decent compendiums of evidence-based treatment approaches for children and adolescents?

    I am sick to death of reading about attachment, honestly. But I'd like to know who else to read beyond "Too Scared to Cry," by Lenore Terr; "Trauma and Recovery: The Aftermath of Violence--From Domestic Abuse to Political Terror," by Judith Herman; "Children and Trauma," by Cynthia Monahon; and "The Boy Who Was Raised as a Dog," by Bruce Perry and Maia Szalavitz.

    Do you recommend "The Body Remembers: The Psychophysiology of Trauma and Trauma Treatment," by Babette Rothschild?

    Or "Trauma-Focused CBT for Children and Adolescents: Treatment Applications," by Judith A. Cohen?

    Or "Treating Complex Traumatic Stress Disorders: An Evidence-Based Guide," by Christine A. Courtoi?

    Others?

    I could use some help!

    Signed, One of Your Loyal Readers

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  8. I don't think you're exaggerating-- far from it! But I think there are several possibilities about how "conduct disorders" can come about. One is a sort of "Lorna Doone" scenario, in which children are intentionally socialized into behavior that is problematic for the rest of us. That may or may not be combined with addictions of various kinds and the problems they create, with failure of predictable social interaction, physical neglect, impulsive abuse, failure to supervise, and failure to protect against predatory adults. Added to that may or may not be specific trauma like rape or severe injury,observation of domestic or community violence, and abrupt separation from familiar people.

    If a child experiences just the first scenario, we may not like the way he turns out, but it may be wrong to think that either trauma or attachment problems are present. If the second set of problems are added, there may be no specific trauma at work, but instead a chronic low level of fear and wariness, whose impact I think has not been carefully studied, as well as cognitive and language delays that make further socialization more difficult. With the third set added,there can also be PTSD, with the related difficulties of hostile or fearful reactions from other people.

    So much of the thinking here focuses on fairly limited events, like attachment in early life or like specific traumatic experiences. But I think it's important to realize that development continues in spite of those events, that a child arrives at new experiences, and that the biggest issue may be the ways the early events distort the child's behavior and thinking in the new situations. For example, suppose there's a child who has been brought up to behave badly in a criminal family. He goes to school, where his behavior and attitude turn off the teachers but also make him unwelcome in groups of "good" children. He can make a place for himself only with other "bad" children, and from them he learns additional "badness", fails to learn "good" social skills like sharing or taking turns, and as time goes on develops a proud identity as a member of the outlaw band. These things all make him further rejected by teachers and by most of the children, but may not cause any problems at home. All of that can happen without any specific trauma or attachment problems, and the behavior may be very little different from that of children with more specific traumas.

    I don't blame you for being sick of reading about attachment. It's certainly not the only issue, and for older children may not be an issue at all in any practical sense. But focusing entirely on trauma, as is presently so fashionable, may not be much help either unless the trauma is considered in terms of its meaning in the child's life context. Whether an individual child experiences an event as traumatic is not necessarily predicted by whether we adults think it would be. (I'm reminded of one of my kids freaking out when a nurse spoke to another nurse about putting a "butterfly" on a wound-- she meant a bandage, he thought she meant an insect.)

    I seriously question claims that "the body remembers" and treatments based on that assumption. CBT methods have an excellent evidence basis, as does Child-Parent Interaction Therapy. But nowadays everybody claims that they've got an evidence-based method, so you have to read carefully.

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    1. I don't really know how many words I can get into each of these, so I thought I might do well to move along here--

      I think it might be of great interest to you to read about the work of James Garbarino about emotional abuse. Although emotional abuse is very difficult to pinpoint and record,and so to connect with later problems, his descriptions will give you some additional ideas about experiences that cause "conduct disorders" or whatever we want to call them.

      Would you mind telling me "why you want to know" (to put it bluntly)? Are you just trying to understand-- do you have a role in policy-making-- are you writing about these issues? I just ask because you've obviously thought so much about childhood mental illness and behavior problems, but I think perhaps not from the perspective of a professional.

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  9. Jean, thanks for asking---No, I'm not a professional. I'm not a policy-maker, and I'm not a writer (not on these issues, though I have published poetry and critical reviews of literature, and I studied for a Ph.D. in English at the Univ. of Rochester, stopping ABD).

    I'm a mom of two foster/adopted daughters, and I often feel like I've fallen down the rabbit hole while figuring out how best to parent them and find good professional help for some serious issues of theirs, which I'm not going to detail here to preserve their privacy.

    I've developed friendships with other parents in the foster/adoption community, but I often end up feeling disappointed in the support offered, and find myself, literally or figuratively, alone in the corner at events---I think, in large part, because of my outlook as a scientist (my undergraduate degree at Wesleyan was in Biology-Psychology, I copy edit medical journals for a living, and I've been an atheist since just about the time I was confirmed as a young teen in the Roman Catholic religion, which obviously was an exercise in something other than sincerity). Thinking carefully about my world is what I do. I don't like to take things on faith.

    I've got a complicated childhood history of my own, which I'm sure fuels some of my interest as well, though on the surface my childhood would appear nothing like that of my daughters'.

    So, there it is---combined with what some folks have called a touch of obsessiveness (LOL), my life has led me here, to try to understand this particular corner of childhood.

    Thanks for your thorough and careful responses to my comments---I appreciate your knowledge and replies.

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  10. You have my sympathy about being "in the corner"--- I have trouble with that too! It's disturbing how many people are quite happy just to mouth some conventional wisdom over and over-- especially unconventional conventional wisdom, if you see what I mean.

    My thanks back to you, for your contributions here.

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  11. Unconventional conventional wisdom is the worst---cultish dogma, agh!

    I hope to read several of your books on child development soon (and correct my own mistaken certainties), as well as something by James Garbarino.

    Since I can't seem to stay part of the gang of "awesome" Trauma Mamas long enough to attend any of their meetings or retreats, I might have time to read---LOL.

    And, one day, I'd like to share what I'm learning through raising my daughters and all my reading/thinking with other frazzled, well-meaning, but not too dogmatic foster/adoptive parents of older kids (especially, god help us, teens).

    The chances of waiting teens in foster care finding permanency (either through adoption or legal guardianship) is so low, and the outcomes of aging out are atrocious---including high rates of joblessness, homelessness, incarceration, addiction, and raising a new generation of children for the system.

    Yet, suicidal, self-injurious, sexually active, drug/alcohol-abusing, and aggressive teens are still, just, teens---and need families too. I think we need a vision about how to make that possible---and how to quickly create safety in the home for everyone living there---before we'll ever increase the number of potential families willing to take a chance on older legal orphans.

    The authoritarian/attachment stuff really, totally, completely falls apart in the face of 6-foot 17-year-old youth who wants a mother but who wants, just as much, to be respected as an independent young man. Like most 17-year-old young men, he'll need years of some kind of parenting before he can fly the coop completely. (I love the book "The Myth of Maturity" for making that so plain.)

    But there's no way to coerce or intimidate him into being "responsible, respectful, and fun to be with" as a condition for participating in life outside the mother/child bond.

    I think I knew that when I dallied with Nancy Thomas's approach with my oldest daughter when she first moved in, and I did not engage in any of the punishing or humiliating parts of her program, but I tried some strong sitting and keeping her world very pared down and lots of obligatory eye contact and non-forced holding time with her.

    It's an odd situation---parenting a child who is not your child, yet. I've often said that arranged marriage, at its best, must be something similar, but of course, that's pure speculation: I know nothing about arranged marriage and, honestly, cannot imagine them being quite as real as the ideal marriage that I, personally, have not yet achieved.

    Funny how our ideals get in the way of something that might actually work, huh?

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  12. I am hoping that your story and your thoughts will be a book in the next few years. You may be the best source of the vision you mention.

    "Arranged parenthood"-- maybe that should be the new name for adoption-- and a title for your work!

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  13. There is a little girl who may get more focused treatment soon because of a gentle question raised about the appropriateness of attachment therapy on her mother's blog. I'm soooo pulling for that little girl---and her family. But the lure of attachment therapy is so strong for families that are almost completely out of energy, resources, and ideas. The best I can wish for is that no harm is done to that little girl through attachment therapy, especially the "trauma work" portion of it. But in spending so much time and money (none of it reimbursed by insurance) and faith on AT, what other, better treatments are being ignored? And what happens to the family's sense of that child when attachment therapy fails to address the violence, the rage, the destructiveness, and the general lack of social/emotional skills of the child? Does the family give up, and initiate another disrupted adoption? Does the child become labeled "untreatable" or "evil"---and get handled accordingly? Do the family and attachment therapist convince themselves that more and more of the same (failed) attachment/trauma treatment is required? Does the child internalize all that "failure"? May one gentle question help this family think a bit deeper.

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  14. It's so true that people under stress and pressure have trouble thinking through the choices open to them and are easily swayed by what seems to be a miraculous offer. I'm afraid that what often happens with attachment therapy is that children are moved to residential treatment where they remain until they age out. In Rachel Stryker's book "The Road to Evergreen", she recounts how parents were encouraged to frame this as "loving at a distance" rather than giving up.

    I'm in correspondence right now with a birth mother whose children have been placed in attachment therapy by their stepmother, and as it "wasn't working" they have been sent for residential care rather than being returned to the birth mother who has been asking for custody for years. An adult has also told me of being sent to the same residential treatment center as a school-age child and kept there until he was 18.

    Unfortunately, it's a human tendency to commit further and further to a choice that has been costly, even though it's clearly not a good choice. Proverbially it's called "throwing good money after bad". Let's hope your question helps a family rethink their options.

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