If It Isn't Attachment Disorder, What Is It? If We Don't Do Attachment Therapy, What Can We Do?

Many posts on this blog have been dedicated to explaining that Reactive Attachment Disorder does not include various disturbing traits described on websites such as www.attachmentdisorder.net. Whereas Reactive Attachment Disorder includes unusual behavior with respect to other people, including both clinging to caregivers and failing to prefer caregivers to strangers, the characteristics often incorrectly attributed to RAD include control battles, defiance, refusal of affection to caregivers, frequent temper tantrums or “rages”, physical attacks on others, cruelty to animals and smaller children, and so on.

Although some anxious caregivers easily interpret any noncompliance as pathological, of course there are a small number of children whose behavior really is disturbing, uncontrollable, and violent. Not only are adults afraid that these children will harm others (including the adults themselves), they also worry that the children’s apparent lack of empathy for others will continue into adulthood, causing them to be a danger to society and eventually to receive serious punishment for their actions.  The adults’ beliefs about the causes and solutions of these behavior problems makes them look for treatments like Attachment Therapy, and like the associated Love & Logic program, that are presented as appropriate therapies for unruly children.

But if violent and disturbing child behavior is not caused by problems of attachment—is not really any form of “attachment disorder”—trying to treat attachment is not likely to have much effect on them. Is there a more constructive way to think about the child who is described at www.attachmentdisorder.net? And can thinking in a different way guide us to more suitable treatments?

One useful approach has been to look at children who have callous-unemotional (CU) traits. Children classified in this way are described as lacking guilt and empathy, being very egocentric, making use of others for the child’s own gain, and lacking normal emotionality, especially normal anxiety (Herpers, Rommelse, Bons, Buitelaar, & Scheepers, Social Psychiatry and Psychiatric Epidemiology,2012, 47, 2045-2064). There is no clear agreement about whether these characteristics should yield a diagnosis in themselves or whether they cross the lines of various other diagnostic categories, but it is potentially very valuable to define these problems by themselves and to move away from the idea that all such troubles stem from attachment difficulties and can be cured by improving attachment. (It’s interesting, by the way, that in 9 or 10 recent professional articles on CU traits, although there was discussion of CU as a part of Oppositional and Defiant Disorder [ODD] and of other diagnoses, no author considered whether CU was part of RAD,and only one referred to an attachment status, disorganized attachment in early life, as a factor in bringing about CU traits.)

In looking at mental health issues, it is often constructive to think about mood and behavior problems transactionally. This means that mood and behavior of an individual are shaped by factors in the individual and also factors in the environment, certainly including the attitudes and actions of other people; it also means that as an individual matures and learns, the effects of transactions with other people can also change. Taking a transactional point of view, we can look at some characteristics that are thought to be typical of children with CU behavior (as discussed in the Herpers et al paper). Such children may have less anxiety than most people do, and may focus more on rewards they get from their behaviors than on possible punishing consequences, as well as having more trouble than most people in recognizing others’ emotional expressions, especially fear. The transactional approach suggests that, given the CU children’s unusual characteristics, they may respond differently to parenting methods than more typical children would. Parent training programs may be the best approach to treatment for children with CU behavior. Significantly, research on use of restraint and seclusion in child psychiatric programs suggests that reducing these methods is followed by a reduction in violent behavior (Stellwagen & Kerig, Journal of Child and Family Studies,2010,19, 588-595), and this may generalize to parenting practices as well.

One such program, Collaborative Problem Solving, developed by R.W. Greene  and described  in his 2008  book Lost at school, emphasizes the importance of taking a proactive approach to child behavior problems and to making the child an active partner in this endeavor. Rather than focusing on consequences for undesirable behavior, Greene’s CPS approach has child and adult working together to set priorities for what needs to happen, to identify and develop needed skills before the next time they are needed, and to consider situational and trigger factors that make it difficult for the child to control impulses. Attachment is not mentioned—but working together toward shared goals is one of the most important ways for human beings to create social bonds, so a developmentally-appropriate form of attachment may come in the back door as this method is put to work.

Greene stresses two important issues: the need for the adult to exercise genuine empathy and understanding of the child’s needs, and the fact that children who do not do as they are told most often cannot do as they are told, at least not at that time and place. Adults who assume that they must force a child to obey because the child is simply oppositional are missing a real empathic understanding of the child’s experience, and thus they create a transactional process with the child that takes both of them in an unwanted direction.

In Lost at school, Greene answers some questions about comparisons to other parent training programs directed at helping with oppositional or CU behavior. One comparison is between CPS and “Love & Logic”, the commercially-successful program sold to hundreds of school systems and other groups. Foster Cline, one of the forces behind “Love & Logic”, was of course an early practitioner of Holding Therapy/Rage Reduction Therapy/Attachment Therapy. In commenting on “Love & Logic”, Greene says “The Love and Logic program does place an emphasis on empathizing with kids, but the empathy utilized in this program is primarily of the emergent and perfunctory variety, isn’t aimed at gathering information or understanding kids’ concerns, and is typically a prelude to Plan A [this is Greene’s term for responding to a problem by imposing the adult’s will]. The problem-solving that takes place between kids and adults in this program isn’t aimed at reaching mutually satisfactory solutions. And the Love and Logic program relies heavily on adult-imposed consequences” (p.200)--  consequences, as I noted earlier, that may not be responded to by children with CU tendencies. Incidentally, although Greene does not mention this, Love & Logic has not been subjected to outcome research, whereas CPS has.