Concerned About Unconventional Mental Health Interventions?

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

Thursday, February 14, 2013

Don't Sign the Petition About Reactive Attachment Disorder and Relinquishment


When those change.org petitions come around, it’s so hard not to sign them. They all sound good and deserving. But, of course, there’s nothing to stop petitioners from presenting inaccurate information and asking for help with a matter that is to their own benefit alone. Such seems to be the case with http://www.change.org/petitions/the-president-of-the-united-states-post-adoptive-support-for-children-with-reactive-attachment-disorder. The group posting this petition, Hopefor Healing (spacing sic), has made a series of inaccurate statements and in addition has implied that other wrong information is correct. I hope you will not sign this petition, no matter what its emotional appeal may be.

The basic ideas stated in the “RAD” petition are the following: 1) undesirable behaviors of adoptees may not be displayed until the adoption process is over; 2) these behaviors, referred to as Reactive Attachment Disorder, are highly disturbing and dangerous, and need highly specialized treatment from residential facilities that focus on RAD; 3) parents cannot afford to pay for treatment; 4) parents who relinquish custody of their children voluntarily may be prosecuted, but should be allowed to relinquish quickly;  5) pre-adoptive education should include warnings of the potential of the child for violent behavior; 6) post-adoptive services should include residential treatment for RAD (at least this is my interpretation of the words “escalated to the highest levels of care”).

Before examining these claims under a strong light, I want to refer to a related issue of genuine concern. As was pointed out in the Bazelon Center for Mental Health Law’s 2000 publication Relinquishing Custody, state laws vary on provision of mental health services for children. In some states, parents may be forced to relinquish custody of a mentally ill child to the state before treatment can be provided without charge--  a conclusion that most parents resist as long as they can. This very real problem does not appear to be what “Hopefor Healing” is talking about. They want children’s mental health interventions, as they define and desire them, to be provided at public expense, and they also want to be able to relinquish custody quickly and easily.

But let’s look at “Hopefor’s” points one by one. First, the idea that worrisome behaviors of adoptees are somehow concealed until the adoption is final. According to the long-term research done by Michael Rutter and the English-Romanian Adoptees project, children who had been in the worst of worst conditions as infants and toddlers improved gradually with time in the adoptive family, leading to the conclusion that adoption  is one of the most effective developmental interventions. Among the ERA children, even those who were seen as disinhibited and too ready to go with strangers were by their teens regarded as friendly, outgoing, popular kids. I should point out too that in the ERA study, the most common problem was delayed language development, which was certainly present when the adoption was initiated.

Second, what about the idea that the children are likely to show violent, even homicidal behavior, and that this is evidence of Reactive Attachment Disorder and should be treated as such? There are two separate issues here. Yes, of course, as is the case in any population, some adopted children may be callous and unemotional in behavior and/or may be violently aggressive. However, as Charles Zeanah, the eminent child psychiatrist, has made clear in his discussion of Reactive Attachment Disorder in preparation for the DSM-5 publication (www.dsm5.org/Proposed%20Revision%20Attachments?APA%20DSM-5%20Reactive%20Attachment%20Disorder%20Review.pdf) , in fact these characteristics are not associated with Reactive Attachment Disorder. Thus, even if there were an evidence-based treatment for Reactive Attachment Disorder, it would not be relevant to these cases--  and the fact is that organizations that claim to specialize in treating RAD do not use methods of demonstrated effectiveness. “Hopefor” is asking for children to be publicly funded for treatment that is probably inappropriate for them, as well as lacking in an evidence basis.

Third, it is no doubt true that parents cannot afford to pay for expensive, intensive treatment, and as the Bazelon Center document suggested, we as a society need to correct this problem. However, it will never be appropriate for parents to demand payment for an intervention chosen by them on the basis of their beliefs about the child’s diagnosis, nor will it be appropriate for anyone but an independent evaluator to make such a diagnosis. Caseworkers from an adoption agency and prospective therapists are not the right people to make these decisions. Even if resources were not scarce, we would need to require independent assessments and avoid the apparent confusion of “Hopefor” about the nature and treatment of Reactive Attachment Disorder.

Fourth, although parents who abandon their children may be prosecuted, those who relinquish legally are not (although they may be called upon to repay funds that have been used to care for the child). States have procedures for legal relinquishment that may involve counseling and discussion of possible consequences, as well as providing simplified procedures and “safe havens” for relinquishment of young babies. In practice, also, voluntary relinquishment may be made very simple. In one case in which I testified, a couple adopting from Russia had been persuaded to take a girl as well as the boy they wanted. They did not like the girl much, placed her in attachment therapy, and often sent her to a respite home for periods of time. Finally, they decided they wanted to disrupt her adoption, and the respite family was willing to adopt; this exchange was maneuvered by the caseworkers without the usual formalities. When the girl was apparently mistreated in the new home and the authorities were notified, the family sent her to a boarding school in another state, a school that has been investigated for the use of restraint with children and has argued that this is permissible. There she remains, probably until she ages out at 18, and there has been no prosecution of the original adoptive parents.  

The fifth point, the demand that pre-adoption counseling include the claims about violent and abusive behavior as a part of Reactive Attachment Disorder, may be the real focus of this petition. According to the Hague convention, to which the U.S. is a signatory, candidates for adoptive parenthood must receive a number of hours of pre-adoption education. At this point, the nature and provision of those hours are up to the adoption agency involved. Even the Russia-U.S. adoption agreement of last year (now in abeyance) did not outline the pre-adoption education required.  This means that--  as most agencies do not have the time or resources to write their own curricula--  it would be much to the advantage of any interested person to seize the opportunity to write and market educational material. And if this material informed prospective adoptive parents that their children might be dangerous, that the danger was due to RAD, and that only specialized RAD treatment centers could help--  why, so much the more advantageous for the whole group that pushes misinformation about adoption and attachment.

And, sixth, as above--  the petition essentially presses the claims that there is only one set of problems, one diagnosis, and one treatment that must be part of post-adoption services--  the treatment apparently being the complementary-and-alternative, non-evidence-based approach often called Attachment Therapy, an intrusive, time-consuming intervention that is not reimbursed by third-part payers, and for good reason. But what could be better for its practitioners than being able to do an end run around public and private health insurance and have public funds support them in style?

Enough said, I hope?  


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