Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Sunday, November 6, 2011

Lark Eshleman's "Becoming A Family": Approach With Caution

A Pennsylvania school psychologist, Lark Eshleman, published in 2003 a book called “Becoming a Family: Promoting Healthy Attachments With Your Adopted Child”. Although Ms. Eshleman is eager to be helpful and has written an enthusiastic volume, looking through the book unfortunately reveals misunderstandings that could easily lead to inappropriate treatment of adopted children.

Ms . Eshleman quickly focuses on the idea that adopted children are likely to suffer from Reactive Attachment Disorder and presents two definitions of “what RAD looks like”. She does not appear to notice that these “clinical definitions” (as she puts it) have little to do with each other.

Looking at discussion of Reactive Attachment Disorder in the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, Eshleman quotes the following description:

“Reactive Attachment Disorder (RAD) is a complex psychiatric condition that affects a small number of children. It is characterized by problems with the formation of emotional attachments to others that are present before age five. A parent or physician may first notice problems in attachment with the caregiver that ordinarily forms in the latter part of the first year of the child’s life. The child with RAD may appear detached, unresponsive, inhibited or reluctant to engage in age-appropriate social interactions. Alternatively, some children with RAD may be overly or inappropriately social or familiar, even with strangers. The social and emotional problems associated with RAD may persist, as the child grows older.” [I haven’t checked for the accuracy of this quotation. It seems a bit clumsy, but nobody ever said psychiatrists had to be engaging writers.]

Next, apparently with the intention of reinforcing the comments above, Eshleman proceeds to quote the Association for Treatment and Training of Attachment in Children (ATTACh, a hybrid parent-professional group that has in recent years offered credentialing to those trained in their perspective on attachment issues):

“ Attachment disorder is a treatable condition in which there is a significant dysfunction in an individual’s ability to trust or engage in reciprocal, loving, lasting relationships. An attachment disorder occurs due to traumatic disruption or other interferences with the caregiver-child bond during the first years of life. It can distort future stages of development and impact a person’s cognitive, neurological, social and emotional functioning. It may also increase the risk of other serious emotional and behavioral problems.”

Let’s examine these two statements point by point and see to what extent they are in agreement with each other.
The APA statement refers to a specific diagnosis, Reactive Attachment Disorder, which has been listed in DSM for a couple of decades and which originally referred to a type of feeding problem of infants. The ATTACh statement speaks instead of “attachment disorder”, a general term that could be applied to less-than-ideal attachment styles that are nevertheless well within the normal range.
The APA statement makes no comment about treatability of RAD, while ATTACh introduces the idea of treatment before even describing the problem.
The APA statement describes observable behaviors that are part of the disorder and which presumably could be noted by parents and teachers as well as by psychiatrists, psychologists, or social workers. The ATTACh statement refers to vaguely-described problems such as the “ability to trust” or to “engage in reciprocal, loving, lasting relationships” which are not observable, but can only be inferred from behavior that is not described.
The APA statement refers to problems that can be observed beginning in the latter part of the first year of life. The ATTACh statement points to causation by events that occur in the first years (not otherwise specified), but does not cite behavior that occurs early.
The APA description notes that the social and emotional problems of concern, such as detachment and reluctance for social interaction, may persist rather than be “outgrown” as the child gets older. ATTACh warns that attachment disorder can “distort future stages of development”, a different and more serious matter than persistence of early problematic behavior. In addition, ATTACH speaks of impacts on “cognitive, neurological, social and emotional functioning”. The APA description is entirely focused on the social and emotional eccentricities that are the basis for a diagnosis of Reactive Attachment Disorder and never refers to either cognitive or neurological effects.

Following her quotations from APA and ATTACh, Eshleman goes on to add a description of a girl who is said to have some type of attachment disorder. This girl, in her early teens, is described as aggressive, destructive, jealous, and controlling, and steal from the family as well as shoplifting. At this point in her narrative, Eshleman introduces the idea that the girl shows “many of the typical features of RAD”, and cites these as lying, inability to trust, oppositional, acting-out behavior, engaging in dangerous behavior, apparent desire to keep others at a distance, and hypervigilance. None of these, please note, were mentioned as characteristic of Reactive Attachment Disorder in the APA description.

Eshleman appears to disagree on almost every point with the APA concept of Reactive Attachment Disorder. Between her quotation from ATTACh and the conclusions drawn from her case description, Eshleman has provided a view of Reactive Attachment Disorder that thoroughly contradicts that of the APA description.

Why, then, did she include the APA description to begin with? I can only attribute this to a sort of “showing the flag” by citing a conventional professional organization’s views. Or perhaps we might call it “sweetening the well” as the opposite of the persuasive technique of “poisoning the well”. By quoting the American Psychiatric Association, Eshleman claims for herself a modicum of orthodox authority and thus prepares the reader to accept her later statements. As Eshleman and similar authors well know, naïve or careless readers are not likely to say, “Wait… what? That’s not what you said before”, but are likely to read straight on and conflate the two contradictory statements with each other.

When a book displays so many contradictions in a few pages, readers need to be cautious about accepting the content. Even though some material is correct, it would be silly to assume that all of it can be trusted.

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