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

Friday, April 12, 2013

Got RAD? DSM-V Rethinks the Diagnosis; Maybe You Should Too

As most readers will know, the American Psychiatric Association periodically publishes a new edition of the Diagnostic and statistical manual of mental disorders. Years of work between editions contribute to removal or addition of diagnostic categories, and revision of criteria for particular diagnoses. The differences between older and newer standards make it very clear that mental illnesses--  while very real--  are understood through construction and re-construction of ideas about mood and behavior. Childhood mental illness is particularly subject to construction, because most of our thoughts about it have to do with what we adults expect of children, not how children expect or want to feel.

There  is now a new edition of the Diagnostic and statistical manual of mental disorders. Known as DSM-V, it differs in a number of ways from the previous edition, DSM-IV-TR, which came out in 2000. It’s especially interesting to see what changes have been made in the diagnosis of Reactive Attachment Disorder, a childhood emotional problem. DSM-IV-TR (and two editions before that) described two variations in which RAD could appear. One of them, the inhibited form, involved clinging to caregivers and being unusually shy with strangers. The other, disinhibited form, was one in which toddlers and preschoolers did not seem to have the usual strong preferences for familiar people that most children their age show. They did not seem especially interested in or dependent on familiar adults, and were quite happy to interact with unfamiliar people. Both forms were associated with neglectful or abusive early parenting and with frequent changes of caregivers. The problem behaviors appeared before the children were five years old.
How severe are the problem behaviors? There has been enough research to show that they are not very severe (although of course any child may have multiple disorders, some associated with severe mood and behavior problems). Basically, no significant association has been shown between the “clingy” type and externalizing problems like aggressive behavior. Neither has there been a significant association between the “too friendly” category and aggression. The “too friendly” category is moderately associated with inattention and hyperactivity (see http://sti.mimhtraining.com).

Thus, as is the case for some other difficulties of early development, these two versions of RAD were not so much problematic in themselves as in the developmental trajectories they shaped. That is, except for the possibility of abduction, there are no immediate dangers associated either with being “too friendly” or “too clingy”. However, the clingy child misses many opportunities to learn and develop through contacts with other people, and may find school too anxiety-producing to benefit from attendance, thus getting farther and farther behind in social and intellectual skills, compared to more typical children. The disinhibited, “too friendly” child may miss out on learning about family values and attitudes because of his or her willingness to pay as much attention to outsiders as to familiar caregivers. Over the years of development, either of these extremes will probably produce less than ideal social and intellectual development--  although it’s possible that new experiences may help an individual child move in the direction of typical development.

As DSM-V was prepared, committee members working on diagnostic categories consulted professional discussions of diagnostic approaches and examined empirical work--  in the case of RAD, research on the characteristics of children diagnosed with RAD. They received comments from interested members of the public as well as considering diagnostic categories used outside the U.S. The comments are interesting to examine, as in some cases they were concerned with issues outside the matters the DSM committees focused on. For example, at http://blog.radzebra.org/?p=12, the author Julie Beem stated her objection to a proposed change in the RAD category, the addition of a diagnosis called Disinihibited Social Engagement Disorder:  “The criterion…’persistent harsh punishment or other types of grossly inept parenting’ is alarming… The danger of using ‘grossly inept parenting’ as a criterion is the blame it places on whoever is currently parenting the child. Grossly inept parenting is difficult to define and the words are emotionally loaded. This criterion could actually make it harder for children to be correctly treated, served, or diagnosed because of the stigma of bad parenting. It could lead to the removal of children from safe, loving homes where they are exhibiting these symptoms with their new, appropriate caregivers.” Ms. Beem, like a number of commenters, seems to have missed the point that DSM categories are supposed to be based on systematic research, rather than on the possible impact on caregivers of na├»ve application of these categories; she may also have been concerned about whether some of the methods encouraged by radzebra.org could themselves be classed as grossly inept parenting. Like some others (see http://center4familydevelopment.blogspot.com), Ms. Beem wanted  the DSM committee to add a new category, Developmental Trauma Disorder, rather than altering the RAD criteria, but although this proposed diagnosis has received much discussion in certain quarters, the research evidence to support its inclusion does not exist.

What did DSM-V actually do in its construction of Reactive Attachment Disorder? The final decision was to split the previously-existing category into two separate diagnoses. Reactive Attachment Disorder is now defined as a lack of or incomplete formation of preferred attachments to familiar people, with a dampening of positive affect that resembles internalizing disorders (for example, anxiety). Disinhibited Social Engagement Disorder is more like ADHD and may occur in children who have clearly formed, even secure, attachments. This fact suggests strongly that treatment for the second disorder need not focus on attachment (although any mental health intervention has a basis in relationship-building).

Has your child been diagnosed with RAD by someone who claims that the untreated disorder will  lead to serial killing? Do you have an inattentive child who has been said to have an attachment disorder?  It’s time for a new diagnosis by someone who understands and uses evidence-based categories.


  1. It's interesting that the people who promote RAD as being different from the DSM definition get so defensive when anyone dares to suggest they might be less than perfect parents.

  2. Even though it's enough to be a Good Enough Parent...

  3. "Disinhibited Social Engagement Disorder is more like ADHD and may occur in children who have clearly formed, even secure, attachments." This makes sense to me based on what I've seen in children with ADHD coming out of abusive and neglectful early childhoods. Not research or evidence, for sure. But it helps explain why the use of stimulants in a child with ADHD can help improve that child's social functioning---and by "improve," I mean move in the direction of normal, including at home. If this disinhibited relating was due strictly to attachment, stimulants shouldn't have a positive effect on relationships, right?

    1. I suppose you could argue that the children didn't form relationships because they were so inattentive, then could do so when they were more attentive-- but surely it would take a long time for this to happen.

      I'm not suggesting that I think it works that way, just doing the "devil's advocate".

  4. Dr. Milton-- Just wanted to thank you and let you know how happy I am to have found your blog. Our daughter was diagnosed by her psychologist -- not an "attachment therapist" -- with RAD, inhibited subtype, per the DSM-IV-TR criteria. She's certainly no future serial killer. Rather, she's a scared child terrified the world will be pulled out from under her at any time. She needs love, patience, and understanding. She doesn't need domination and control. Imagine my horror when I started getting involved in RAD boards and FB groups and saw how people misuse the diagnosis and are out and out abusing their children, all in the name of "healing." It is outrageous, and I'm sickened on a daily basis by what I see. What can be done other than speaking up on the RAD boards, and blogging, things I'm already doing. I'm at a loss at this point, but something has to be done for these children, who are labeled as future serial killers and send off to insitutions, all for the convenience of the parents who shouldn't even be allowed to have a dog, much less a child.

    1. Hi madmomma-- I'm not Dr. Milton, but I'm glad you found my blog anyway!

      You know what I wish someone like you would do to help fight the AT battle? It would be so great if mainstream churches would take a position about these issues. At the moment, the resources of evangelical groups are devoted to encouraging adoption and in many cases promoting the AT approach. I have tried without success to get the Quakers and the UUs into the picture. And where are the Methodists, the Baptists, and the Presbyterians, who could all help by bringing their moral weight to bear here and fostering appropriate parent education?

      In the Czech Republic,the Roman Catholic church seems to support a version of holding therapy. I hope this is not also true for RCs in the US-- but I don't hear them speaking up to the contrary!

      Do you have any ideas about this, or are you in a position where you could do anything? I understand that mainstream churches don't want to get into culture wars (which this is), but if just one or two leaders in each denomination could be interested, we might make some progress.

      best regards,

      P.S. About the discussion of consanguinity on your blog-- actually the evidence is that where consanguineous marriages are the norm, there are more births and more child deaths, but birth defects are more common only when both parents are carrying recessive genes that cause problems.

  5. I'm so sorry! I meant to type Dr. Mercer-- so embarassed that I screwed that up! I saw so many of Marianne's comments I agreed with that I totally messed up the names.

    I happen to live in the city I often deem ground zero for the evangelical adoption movement-- the home of Russell Moore. The attitudes you categorize are pervasive. I do have some contacts within the mainstream Protestantn world, but for some reason it never occurred to me to attack the issue in that manner. I'll try making some contacts. I've also reached out to Kathryn Joyce, who wrote the recent book The Child Catchers. Maybe some of those contacts will pan out.

    Interesting stuff on consanguinity and birth defects. Being from KY (and a lawyer) you can see why that topic got my goat!

  6. Can we talk behind the scenes when you have time? I'm at jean.mercer@stockton.edu. BTW, I've talked a lot to Kathryn Joyce about this (I think I'm quoted in The Child Catchers, which I MUST remember to buy!) and plan to be talking with her later this week. She's had more luck with publishing through the UUs than I have.

    1. You are quoted in that book, which btw is amazing. Buy it.

    2. I hope people will buy it and counter some of the critical reviews on Amazon--

  7. I found this blog by accident and am disturbed by the way you discuss families/parents of children with attachment disorders. Your lack of understanding is exactly why the DSM needs work on this diagnosis to make it clear that it is not a simple issue of clingy or overfriendly (which by the way is an incorrect assessment of what is in the DSM).

    Having spent time with these children and their parents I have a great deal of compassion for these children AND their families. You clearly have no idea of the day to day lives of these families. It is this type of ignorance that keeps these families from seeking help and THAT is shameful.

    1. So, as I understand your comment, your saying that I don't understand attachment disorders, and I don't understand DSM, which also doesn't understand attachment disorders? Is there then some person or group who in your opinion does understand attachment disorders?

      Maybe you could explain what viewpoint you feel people should take, that would help families seek help.

    2. I agree 100% My husband was awarded custody of his daughter. A local dcf therapist thought she had RAD. The next 3 years of our life was a nightmare. At the age of 7 she molested and threatened 3 children. She killed our family cat by snapping his neck (because the cat was annoying her) she threatened to kill our son who was 3 months old numerous times and was caught smothering him. Not to mention the lies about our family and friends. My husbands best friend molesting her, myself starving her, her father beating her, her teacher hitting her. This child laughed when she was caught in the lie because of how "stupid" we are.... and this is just the jist! We have NEVER harmed this child in any way shape or form!!!!! And the more therapy she is getting with all different kinds of specialist they are all believing she was never abused by her bio mother. She even stated she didn't like her real mom because she spanked her once when she stole her money and threw it away to see what would happen and she didn't like her because she didn't let her eat when she wanted too. So tell me Jean, what classification is this child?!? Attachment issues are clear but tell me, what have we done to her for her to violate our whole family so viciously? I guess I should have gave her extra cookies..........right? Oh and one last thing, the first 3 councelors she had diagnosed her with ptsd...well until the last one finally figured out she was being manipulated and caught her in a lie because she was actually paying attention! This child is now 10 and we have no life, no support system, and our home is so hostile because of all the games she plays. In counceling she would make up horrific stories about her bio mom selling her for drugs where she was repeatedly raped...yes at age 9 this started. This girl was never raped and drs proved that. When the councelor explained rape (penetration) she went on about yes it happened and how awful it is. The next session the councelor showed her the papers proving that never happened and the child smile and said well I must of had it mixed up with a movie I seen, but either way my real mom was horrible. hmmmmmmmm oh and her real mom is now dead, she commited suicide after her daughter was taken from her and in the note she left behind was a chilling tale of everything she went threw with the child.....and how she was the blame and stated maybe I just believed her too much, maybe I should have got her help sooner. So jean, clearly you haven't had enough experience because a LOT of families I now work with experience the same issues (not as bad most of the time thank GOD) but these parents are loving and amazing people. Thank you again for placing blame on parents who have children that are out of control and dangerous. I have ptsd from the trauma she put me and my family threw and so does her father....thank you for re interating into the minds of terrified parents that yes, this is your fault......

    3. Ladies, no one is contradicting your stories about what the children. Why is it so important to you that these problems be called Reactive Attachment Disorder, when the symptoms of RAD are quite different? I am suggesting that there are existing diagnoses that describe the kinds of behavior you are talking about. These include conduct disorders, early-onset schizophrenia, PTSD, ODD, etc. Why not use these diagnoses, whose symptoms can include the things you are talking about? Is it because saying "RAD" allows you to seek "attachment therapy" as advocated by persons like Nancy Thomas?

      BTW, none of the possible diagnoses have anything to do with assigning blame or fault to anyone.

    4. This!
      RAD is certainly a very real disorder but I think that many might find it helpful to step back from the RAD diagnosis and consider other diagnoses that may more completely encapsulate the symptomology that the kiddo is presenting.

      I'm not a RAD parent but a cheerleader who wants the best for your families.

  8. Well if my granddaughter doesn't have RAD, please tell me what she has. She has had the diagnosis of RAD since she was adopted at age 2. She has tried to kill each of her siblings, both older and younger ones, sending various ones to the Emergency Room at times. She lies and cheats. She steals so often that when we enter the mall, the security guards start to follow. She's 12 now but has been stealing since she came into her parents' home. She is always in some form of therapy, including cognitive, neurofeedback, and Tomatis. Every single doctor that sees her says she has severe RAD, and yes she craves attention from others but not her adoptive mother. If I understand correctly, it seems that the new DSM isn't acknowledging all of the aggression and anger that seems to come with RAD. By the way, this child was born with Fetal Alcohol Syndrome, was terribly neglected and was abused in her birth home. All therapists working with her say she is dangerous. I guess I don't understand what y'all are saying.

    1. It seems to me that you are insisting on having the DSM category fit the case you have in mind, instead of seeing what category best fits the case. If she has been seen by practitioners who think Tomatis therapy and neurofeedback are effective treatments (which,if I need to spell this out, they are not), it's no wonder to me that they also have an unorthodox view of Reactive Attachment Disorder!

      But the point in this child's case is not
      to find the name of her disorders. It's to identify the problems and the interventions that may help them. Call it RAD, or don't call it RAD, the difficulties remain the same, and the child needs effective help, not these complementary-and-alternative efforts.

      Why does the family have her in the home if they feel she is a danger to other children? Is it not time for residential treatment using conventional methods (not Tomatis etc.)? I would suggest that the family seek assessment at a teaching hospital, followed by placement in an appropriate residential treatment center--- and when I say appropriate, I mean a place that specializes in working with these problems, not a place chosen because of the family's beliefs.

      I hope her parents will rethink what they are doing, stop being persuaded by these "doctors" (of what, I'd like to know) that some new little treatment will fix everything, and seek help from serious sources-- for the child's sake and the whole family's.

    2. This is very upsetting. I am social worker and a mother of a RAD kids. He is wonderful, special and violent. I love him with all my heart. I treat him well. I have also placed him in a locked facility. RAD must be looked at honestly and be called what it is. There is research on this issue however, the knowledge and acceptance of it is very limited. People like you Jean Mercer, would probably the same kind of people who would advocate labotomies to cure intellectual disabilities.

    3. Is a labotomy the surgical removal of a laboratory? As for lobotomies, I don't think anyone has ever thought they would cure intellectual disabilities.

      I am not at all sure what your unfortunate family situation has to do with my statement that aggressive behavior is not a symptom of RAD. A person is not the same as a diagnosis, and there are obviously people who have a range of problem behaviors. The fact that a person diagnosed with RAD is aggressive does not mean that the aggressiveness is a part of the RAD, only that it's a part of that person's behavior.

      If you have a list of little-known research work on RAD, I would appreciate being told what's on it.

  9. How unnecessarily insulting! You had no call to insult my family or the doctors who work with this child.

    Her parents are well aware that no "new little treatment" will fix everything. Good grief -- part of the diagnoses they have heard for the past 10 years is that NO amount of treatment is going to "fix everything". The "doctors" of what you'd like to know happen to be psychiatrists, psychologists and a geneticist! Neurofeedback is given by an internationally known psychologist. GD was adopted from foster care and as I said before was a victim of extreme abuse and neglect. When adopted at 2, the state assigned her a mental health team that meets every month with her parents. Although through the years members of the team have changed, there is always at least one psychiatrist and one psychologist. Her team, as well as other doctors and residential facilities that have been consulted, say that, since GD has not yet killed an animal or a person, it would be inappropriate to put her in a residential treatment. At some point, this advice might change and, of course, her parents will follow suit.

    When I said you showed ignorance, it is because both Tomatis and Neurofeedback Therapy are indeed considered conventional. Our health insurance plan will NOT accept alternative or complementary health treatment, but covers as CONVENTIONAL both Tomatis Therapy and Neurofeedback! You say these therapies are not good therapy for RAD, and I would agree with that, but they are meant to help her with her additional problems of brain damage from Fetal Alcohol Syndrome. Her parents have taken her to various RAD therapists through the years, but no one has offered much hope!

    "...not a place chosen because of the family's beliefs" -- what could you possibly mean by this statement? The family believes in saving this child, if at all possible! They follow the advice given by the state's mental health team who know my granddaughter well. I don't get what more you want.

    Despite your degree in psychology, you must not respect the field, since you are insulting psychologists. At the very least, you don't seem to understand what many parents of RAD children have come to realize -- that MANY of these children are aggressive, oppositional, and emotionally dysregulated.

    1. Of course there are many children who are aggressive, oppositional, and dysregulated. But what I said was that it's inaccurate and deceptive to claim that these are symptoms of Reactive Attachment Disorder, or to try to treat them by methods that focus on attachment.

      "RAD therapists" are generally people who use unconventional treatments. Practitioners who work with conventional treatments to help a variety of childhood emotional problems do not call themselves
      RAD therapists, but child psychotherapists, child psychologists or psychiatrists, or whatever they may be. If your grandchild's therapists call themselves Registered Attachment Therapists, by the way, that means that their training is through ATTACh, a parent-professional organization that is not affiliated with any of the national professional organizations approving training in mental health interventions.

      Neurofeedback and Tomatis therapy may well be paid for now by the insurance company (although no doubt they will catch on to this in the future and stop), but these methods are implausible and lacking in a systematic evidentiary foundation. That's why they should not be considered conventional treatments, for FAS problems, RAD, or anything else.

      Can you really mean that an animal or a human being has to die before the child can receive residential treatment? That alone, if it's really what the practitioners said, is enough to show that the family needs to find more qualified help. Incidentally, being trumpeted as "internationally known" is no good evidence of excellent practice. You'll find that professionals who actually are internationally known don't say so and don't need to say so. Not every member of every profession is equally well-trained or respectable, and that is especially true about the mental health professions.

      But, be all that as it may, let's get back to the original issue. Did I say aggressive and oppositional behavior is not a symptom of RAD? Yes, I did. Did I say your granddaughter is not aggressive and oppositional, as you say? No,of course I didn't. You yourself say she's diagnosed with FAS, and there are plenty of other things that could be problematic. My bet is that RAD only got into the picture because the therapists employed have been "RAD therapists", therefore if they treat it,it's got to be RAD, and if it's RAD, it's got to involve attachment, etc., etc.

      You'd be better advised to be angry with the mental health team, not with me. "Saving" the child may not mean keeping her at home, where ten years' worth of evidence seems to show that her experiences and interventions have not been successful.

  10. Well, your "bet" would be wrong. The mental health team that she has would not allow her to be seen by the so-called RAD therapists who are involved with ATTach. I don't know why you sound so arrogant! You suggest that she be seen by child psychiatrists and child psychologists, yet that is EXACTLY the specialists who have seen and diagnosed her! YES, she has been seen and diagnosed by three pediatric psychiatrists, five child psychologists, pediatricians (although they are not experts) and countless social workers through the Department of Social Services for foster care children. YES, they tell my family that she has to KILL before she can get residential services. Of course, if they were wealthy, there is always some institution that would accept a child, but it doesn't mean it would be an appropriate placement that would be capable of helping her rather than warehousing her. Of course, if they resorted to putting her in such a place that would cost more per year than the family's total annual income, it would mean my family would be homeless and there would be no place for my granddaughter to come home to. Appropriate placements have long waiting lists and do say that a child needs to kill before they can give placed.

    If you weren't so bent on defending your position which stands against many other doctors in the field, you would probably be impressed by the mental health team she has!

    By the way, her child psychologist, who also does Neurofeedback Therapy, never said he was internationally known. I found that out by searching the Internet for him, since he went out of the country occasionally to give speeches at conferences overseas. He never bragged about it. You are jumping to way too many conclusions, and just don't want to accept that MANY kids have this diagnosis of RAD who are very aggressive.

    Basically, I think you are wrong that RAD doesn't encompass oppositional, aggressive children. Either you are wrong or many other child psychiatrists and child psychologists have misdiagnosed her and many other children. However, if you are right and only you hold a candle of hope, then it is important for you to shine your light a lot more broadly and find ways to help all the parents who are desperately seeking help for their children. If RAD is not the appropriate diagnosis, then as I asked in my first comment, please tell me what is wrong and where to get help. Telling me to seek out child psychologists and child psychiatrists is not helpful because we've done that for 10 years!

  11. Q. How many legs does a donkey have,if you call a tail a leg? A. Four. Calling a tail a leg doesn't make it one.

    So, Q.E.D., saying that aggressive behavior is a symptom of RAD doesn't make it so, when it has been defined otherwise. Now, if you are really talking about the notional diagnosis "Attachment Disorder", as described by some unorthodox practitioners, yes, aggressive and oppositional behavior are included in that.

    No, RAD does not include aggressive behavior. If your granddaughter has been diagnosed with RAD (and FAS, if I remember), and is aggressive, this does not mean that RAD is the cause of the aggressiveness, which could come from another set of problems or even from the familial situation.

    But what difference does it make? It's the individual or the family that needs treatment,not the diagnosis. There is no effective treatment particularly for RAD. If the child is impulsive,oppositional,and aggressive, those are the problems that need treatment. In addition, it would seem that her mother needs help with her worries about the child's aloofness, and the brothers and sisters who have been attacked need help with their legitimate fears about what might happen.

    All real "help" follows the same guidelines. You don't get different "help" for a different psychological diagnosis (other than anxiety disorders), as you might get different help for a muscle injury than for rheumatoid arthritis.

    I have no doubt that many kids who have been given the RAD diagnosis are aggressive. That is not the same as saying that kids who are aggressive should be diagnosed with RAD. Once again, although the diagnosis is important to the insurance company, it does not determine treatment by a conventional practitioner.

    So, the "candle of hope" (not that I thought I was offering one) is to seek conventional treatment. This does not mean neurofeedback or Tomatis therapy. You are in the hands of unorthodox practitioners, no matter what you think. Go to your local hospital or mental health clinic for recommendations, not the Internet.

  12. I guess the fact that I don't seem to be able to get across to you is that many, many practitioners of CONVENTIONAL treatment -- 1 psychiatrist, 6 pediatric psychologists, 2 pediatric psychiatrists, countless social workers, 3 pediatric neurologists -- have diagnoses my granddaughter with RAD and have said that it is the reason for her aggressiveness. There is one lone person who hasn't even met her who is claiming that all the rest of her medical doctors are wrong -- and that is you!! She has been seen at Duke University Hospital by several specialists, the Mayo Clinic and local mental health clinics, the Fetal Alcohol Syndrome program in our state, as well as our local psychiatric hospital -- all giving her the diagnosis of REACTIVE attachment disorder. It has been explained to her parents that the reactive part does indeed include AGGRESSION. Good grief -- this is NOT a diagnosis based on the Internet. Perhaps you are right -- perhaps she doesn't have RAD. If so, there are thousands of kids with the diagnosis of RAD who are incorrectly diagnosed -- according to you. And because their waiting lists are long, most residential homes for RAD kids require that they have already killed -- so I can't help but think you are missing an important component of Reactive Attachment Disorder.

  13. What I can't get across to you, it seems:

    I didn't say she didn't have Reactive Attachment Disorder.

    I didn't say she was not aggressive.

    What I did say was that the aggression is not one of the symptoms of RAD. Read DSM and you'll see what I mean.

    Are you under the impression that there are two separate diagnoses, reactive attachment disorder and plain attachment disorder? Not so; RAD is a matter of social and emotional difficulties that have occurred in reaction to mistreatment or inappropriate experiences with caregivers. The "reactive" part is there to help differentiate maltreated children who later show problems of attachment behavior from children who have been cared for well but because of other difficulties (like Down syndrome, Fragile X, FAS) behave in unusual ways toward adults. One group has developed difficulties in reaction to bad experiences; the other may have some similar behaviors, but not in reaction to experiences.

    As for your statement about RTCs: I can well believe that the state will not pay for residential care unless there is a court-ordered placement, which is not likely to happen unless a severe injury or death has occurred. But a 1997 paper by Eric Lotke estimated that only 940 children out of the entire U.S. were convicted of homicide in 1995, and 2560 juveniles were arrested in homicide cases in that year. In the early 2000s, the Bazelon Center for Mental Health Law reported 50,000 children and adolescents in RTCs in the U.S. Using these numbers, it appears that fewer than 1 in 50 of juveniles likely to be sent to RTCs have killed people, and because some states will send juveniles convicted of homicide to adult prisons, the proportion is probably even smaller. This calculation suggests to me that your statement about RTCs is incorrect--- but if you can direct me to evidence that RTC staff tell people that, I'd be most interested.

  14. I have found that people involved in Attachment Therapy get ugly with anyone who questions their approach to therapy, parenting, and their special understanding of "RAD."

    It's my understanding that Tomatis is not science-based; much of the time it's promoted on the weight of the celebrities who swear by it (e.g. Sting).

    Neurofeedback is a type of biofeedback. Biofeedback devices were "grandfathered" in by the FDA only for "relaxation." It's my understanding that no other claims can currently be made, and that practitioners who do make other claims risk disciplinary action by their licensing board.

  15. Look, I don't want to keep battling you. I have interpreted your article and comments as saying that people are WRONG if they think that their aggressive children have RAD. It's obvious that the DSM does not agree with aggression being part of RAD. However, very reputable institutions list aggression as a symptom. For example, this quote from the Natl Institutes of Health would disagree: "Children diagnosed with RAD appear to demonstrate significantly more behavioral problems and psychosocial problems than children without RAD. Although RAD has received little empirical attention, research has demonstrated that children with RAD score significantly higher than children without RAD on the following dimensions: general behavioral problems, social problems, withdrawal, somatic complaints, anxiety/depression, thought problems, attention problems, delinquent behavior, aggressive behavior, lack of empathy, and excessive self-monitoring (Kay Hall & Geher, 2003), and RAD symptoms are associated with higher rates of hyperactivity and other behavioral and emotional problems (Millward, Kennedy, Towlson, & Minnis, 2006). Clinical case studies suggest that RAD is also associated with deficits in social relatedness, delayed language and motor skill development, failure to acquire age-appropriate self-care skills, problematic eating behaviors), emotional lability, problems with attention and concentration, impulsivity, and oppositional behaviors (Hinshaw-Fusilier, Boris, & Zeanah, 1999; Richters & Volkmar, 1994)." The Mayo Clinic also lists aggression toward peers as one nof the symptoms of RAD (http://www.mayoclinic.com/health/reactive-attachment-disorder/DS00988/DSECTION=symptoms). I guess it's a matter of whether or not you take the DSM as the final word on this. I guess you do, but I don't. Perhaps my granddaughter is not a good example since she has multiple issues (PTSD and FASD, for instance), but I personally know of numerous children who do not have any other diagnoses except for RAD. Can the Mayo Clinic, NIH, and many psychologists and psychiatrists be wrong in diagnosing aggressive children who were severely traumatized in early childhood as having RAD? Should we only consider what the DSM has to say on this matter?

  16. First thing-- I am very curious about why this child has been diagnosed by so many different people. What's going on? Is this why she apparently hasn't had consistent treatment, but instead things have wandered off into the Tomatis maze?

    Second, I see a part of the problem. It's people's failure to read and understand that paper by Hall and Geher. Their statements about the aggressiveness and really serious behavior problems of children with RAD come from Keith Reber! I mean, !!!! Do you have any idea who Keith Reber is? He wrote an article in an extremely obscure journal in 1996 and made all sorts of unsubstantiated claims that came out of the belief system of Holding Therapy people like Foster Cline. Later, he had to surrender his license in Oregon because of his methods, then he went back to Utah and became a massage therapist-- I forget what happened with that license, but one can guess.

    Yes, it would appear that NIH can be very wrong, as they allowed this material to be posted without checking its validity. As for the Mayo Clinic, if you will look at their "tests and diagnosis" page, I think you'll see a somewhat different take on characteristics of RAD-- and a warning about paying attention to checklists (like those Reber drew his material from, by the way).

    Incidentally, if you can find the Hall and Geher paper (look for just Hall, not Kay Hall), you might find their RAD scale of interest. It contains items like "My child takes bites that are too big for his or her mouth" and "My child has nervous twitches". Would you also say that these are symptoms of RAD? What plausible connection do you see?

    DSM contains the standard description of mental health diagnoses. If you don't want it to be the final word for you, that's your decision. But you can't insist that other people define RAD as you do, or that they must assume that all the difficulties your granddaughter has are caused by RAD and therefore RAD is defined by all those difficulties.

    For the last time: I didn't say that aggressive children could not have RAD. Aggressiveness does not exclude a diagnosis of RAD. I do wish you would stop reversing the meaning of my sentences.

  17. "I am very curious about why this child has been diagnosed by so many different people. What's going on?"

    When a child has been in the Dept of Social Services as a foster child and then adopted from that system, she is no longer invisible to the system. Then her parents have tried very hard to overcome the trauma she experienced in her birth home, which was a crack house and an illegal abortion clinic where she witnessed fetuses being thrown away. In addition, at the age of one, she was in a car shot up 27 times in a bad drug deal. The reason she has been seen by numerous people is that her adoptive parents are trying to get her help so she can heal.

    1. No doubt the parents are trying to get help, but what you describe seems to work out to almost 3 diagnoses per year for 10 years. I can think of only two explanations for repeatedly seeking new diagnoses and therapies. One is that the family relocates very frequently, and the other is "doctor shopping". Have the parents been repeatedly dissatisfied with diagnosis or treatment? Why have they not continued for some period of time with the same practitioner?

      Anon, do please consider my statements about Tomatis therapy and neurofeedback. You can do further reading about these yourself, no doubt. But if you go outside material produced by practitioners of these methods, you will see that they are neither evidence-based or in any way to be called conventional.

      Are you saying she remembers spontaneously events that occurred before she was two? That would be very unusual, so I have to wonder whether someone has deduced that these things happened. If I were an illegal abortionist, I doubt that I'd want a toddler underfoot while operating-- it's hard enough to work around them while you're cooking.

  18. My gd does not have 30 diagnoses! Why would you exaggerate like that? Instead of casting aspersions at her parents, you might be grateful that there are people out there who are trying to help this child! They have not been "doctor shopping" but have been guided by the mental health team (recently disbanded due to budget cuts) on how to seek help for her.

    From the tone of your comment, I can see that you doubt the veracity of what I'm saying. You see, I live in Appalachia, where the laws are handled differently. While you likely don't believe this, mountain folk KNOW this from experience, and the sheriff told me this directly. (My daughter and I are not from this area.)

    Of course, she can't recall her early months! Again, your tone implies that I am lying. There were many records and reports in her large file that detailed her first 20 months. The Dept of Social Services started following my granddaughter from the time she was born, since she was born with lots of marijuana in her system and, after giving birth, the mother asked the nurses if she could trade baby for a car. Many complaints were called into Protective Services over the months, and all those reports are in her records, made privy to her adoptive parents. Protective Services visited her home several times and wrote their investigative reports. But they did not remove her from the home! She had a half-sister aged 9 living in the home who tried to take care of her, and for some ungodly reason, this made the social workers hope the baby would be okay. When gd was in the car shot up during a drug deal gone bad, it made the news. However, since she wasn't shot and mother not arrested, she was not removed from the home. Every couple years here, there is a young child who dies in a home where DSS is still conducting an investigation. It typically takes several years to remove a child from his/her home.

    When the police finally arrived to remove my gd and her sister, the latest social worker assigned to my gd's case tried to stop the police officer from taking her! When this all came out in court, it was found that that social worker had been getting drugs for herself through the birth mother! Of course, my gd should have been removed much earlier, but kids fall through the cracks every day.

    While illegal abortions were done in the crack home, it was just a side business, not an every day occurrence. We know she saw abortions performed because she acted them out with her dolls once she got into her new home. She also freaked whenever the trash was collected and covered her dolls to protect them! Plus, birth mother later bragged to DSS about her "business". It wasn't until birth mother aborted a little boy at 9 mo and threw him still alive in a dumpster (witnessed by a neighbor) that the police were called to the situation and they took over. BTW, the little boy lived and has been in my daughter's home since he was 2 days old. He has cerebral palsy but is fine as far as mental health. They also have two other children and no one but this particular gd has required mental health services.

    Did birth mother serve time in jail for using a clothes hanger to attempt an abortion on my grandson and then throwing him in a dumpster? Incredibly, NO. Not only that, but DSS required him to have weekly visits with birth mother at their agency in an attempt to get her to parent him. Although birth mother did not show up to many visits, he screamed through every visit he had for his first year. Finally, DSS changed his plan to adoption by his foster family (my daughter and SIL). It's understandable if you think I'm telling you a tall tale. For people who have not tried to take care of children in the foster care system, it's always hard to believe, but I can assure you that I'm telling the truth.

    I'm not sure, but it seems you may have spent a lot of time in an Ivory Tower and don't get to see what really happens to abused children, both in and out of the system.

  19. You listed 12 people who diagnosed her, and added "countless" social workers, so I assumed that meant that the total number of SWs was more than the total number of others, and that makes at least 25 people over ten years. That's how I figured the number I did. But even if the SWs weren't so countless, I still am wondering how all these people came into and out of the picture... you seem to be saying that there were many referrals from the mental health team, is that correct? Why do you think that was? Was it a matter of more people like the SW you describe?

    Believe me, I'm well aware of the horribleness of children's lives in neglectful and abusive homes, foster homes, and even some residential treatment centers, and of the complicity of some caseworkers and others in these terrible events. I don't think you're lying, of course.
    Asking you to elaborate doesn't mean I don't believe you. But I did want to know where you got your information about the child's history, really just out of an interest in these issues.

  20. Jean,

    You said, "...what you describe seems to work out to almost 3 diagnoses per year for 10 years." So I assumed you were speaking about 30 different diagnoses that my gd had been given, not the number of people who have been involved with her. Although there have been many people involved, most were on a team and working together. Generally, they kept giving the same diagnoses -- RAD and PTSD. Up to the age of 10, she was also diagnosed with PDD-NOS several times and then others retracted that, plus dissociative identity disorder by several psychologists and with childhood schizophrenia by a psychiatrist. However, RAD always remained a constant and was always given as the reason for her aggression. Since 10, her symptoms have changed, so now PTSD and oppositional defiant disorder have been added and no one mentions dissociative anymore.

    She and her family (and myself) live in a state where the budget for mental health services has been cut a number of times, especially for pediatric services. Many mental health practitioners have left this southern state over the past decade. My gd has been fortunate to have a mental health team under the auspices of DSS, but that membership has fluctuated throughout the years (and now has been totally disbanded due to lack of funds), likely contributing to a number of diagnoses as new people viewed her case.

    It has been complicated by changes in her behavior over the years. For instance, she used to fall down as if in a trance and speak in an unknown language. Sometimes she rolled back her eyes and howled like a wolf. This made some think she had dissociative, especially since she had been sexually molested in infancy.

    Even though DSS removed her from the birth home, they required her to have weekly visits with her birth mother for an entire year (just as they did her younger brother). These visits were conducted under supervision by a social worker at DSS. Personally, I think this contributed to the RAD behaviors. She has always been rejecting of her adoptive mom, charming and clinging to strangers, depressed and angry. She was incapable of smiling when she came into their home and had frozen watchfulness.

    I've discussed with my daughter what you've said about neurofeedback. However, it is difficult to find psychological counseling for her because she charms practitioners and then accuses her parents of abuse. This becomes a major problem in trying to get her help. At least, the neurofeedback comes from a full-fledged psychologist who sees her weekly and understands that children like my gd falsely accuse parents. So at least she is getting psychological services every week, albeit some of it being neurofeedback. Tomatis services no longer exist in our area.

    At 12, she has the biggest chip on her shoulder of anyone I've ever known. No matter how much love and care she gets, she feels she is not being treated fairly and is jealous of her siblings.

    Sincerely, April

    1. Please don't think me unsympathetic about this. Your position is an agonizing one, I can certainly see that.

      I believe it's a real problem that everyone wants to state a diagnosis, and actually has to do so for insurance purposes, whereas effective treatments focus on changing moods and behaviors which cause great difficulty. Because such moods and behaviors overlap so much from one mental illness to another, diagnoses don't matter so much for treatment planning except when they are able to identify an organic problem that needs treatment.

      I am wondering what has happened when she accused her parents of abuse in the past. Did the practitioners report this, as it is mandatory for them to do? And does the present one not report?

      I am also wondering whether her adoptive mother has any professional support and guidance for her own emotional reactions to this situation.

  21. What a fascinating conversation between two committed and passionate women who care deeply for the well-being of children.
    I've followed your work, Dr. Mercer, for years. I seem to hear some weariness in your "voice" after years of fighting the cottage-industry that's built up around RAD/AD. Our agency has long been concerned about the catch-all diagnosis of the popularized version of RAD. While many, if not most, children in care have significantly compromised attachment histories, making everything an attachment issue reduces people's capacity for complex thought and thus problem-solving. Case in point is this little girl the grandmother is so concerned for...by the clinical community reducing her problems to RAD, it limits a more complex view of what actually may be happening. As discouraging as it may seem...there is much more than just attachment issues going on with this girl...many complex and interacting layers that may take years to discover and work through. I would highly recommend http://www.pbhsolutions.org/pubdocs/upload/documents/radguidelines2009.pdf. It covers much of the RAD controversy and discusses alternative/co-occuring disorders and empirically supported treatment. Best of wishes to all who are seeking to help children heal in peaceful ways.

  22. Thanks so much for commenting and "following". You have said a mouthful when you say that "making everything an attachment issue reduces people's capacity for complex thought and thus problem-solving". My crystal ball tells me that in a few years we'll be making the same statement about developmental trauma, which is shaping as the next big thing.

    And thanks for the very nice RAD guidelines document. I hope people will read it. I do have one beef about it-- the inclusion of Reber's 1996 article in the references. I don't see it in any in-text citation (thank goodness), so it's unnecessary. But in addition I would classify that paper as the Typhoid Mary of child psychopathology -- appearing innocent itself, it spreads incorrect and potentially harmful staements, many of which were made up out of the whole cloth, whether by Reber or other Attachment Therapy proponents I don't know. Reber himself had to surrender his license because of his practices and at least briefly got licensed as a massage therapist, presumably because it allowed him to do the hands-on stuff.

    I've just come across some very interesting work related to ideas about attachment disorders, by the Australian social worker Sara McLean.I'm going to do a post about this in the near future, so I hope you'll "tune in".

    Best wishes to you also--

  23. Thank you both for your advice. I'll read the article proffered.

    Best wishes.

  24. The whole problem is pretending that the DSM refers to something in the real world. Sure it is based on research, but the research is necessarily self-referential, as it presumes the categories that it creates. Reliability and validity are not the same thing. Anyway, there is no reason to believe that the therapists are using fringe methodologies just because they see the world a bit differently that you do. Those of us who work with and diagnose these kids every day know that the DSM-IV does not seem to be very helpful with this population, as evidenced by the alphabet soup of shifting diagnoses that we often see. Re the DSM-V I confess I have not read it yet but it sounds like it will be even less helpful.

  25. I don't think that's the "whole problem" although I certainly agree that it's a problem to have to put square people into round categories in ways that are useful mainly because both public and private insurers demand them. For example, as I understand it, PDDs were invented because various insurers would not pay for autism treatment.

    However, my reasons for saying that therapists are using fringe methods has to do with two things: the plausibility of their methods in terms of well-established evidence about child development (i.e., the assumptions of these methods are not congruent with known characteristics of children's developmental paths), and the absence of well-designed research showing that the treatments are effective.

    That last part is intertwined with peculiarities of diagnosis, because it cannot be very clear whether a treatment has ameliorated a problem when the problem hasn't been stated in a way everyone can understand. For instance, when people conflate attachment with aggressive behavior, and say that if they've reduced aggression they must have increased attachment, this will be meaningless to anyone who follows conventional diagnostic methods in describing outcomes.

    How would you describe "these kids", by the way? Can you say what they have in common, without using any conventional or unconventional diagnostic categories? It's rather mysterious just to call them "these kids", and I would not want to swear that I know what problems you are trying to treat.

  26. Sorry for not being clear-I mean working with many children over the years who have been neglected, abused, passed around, and traumatized since birth, many of whom exhibit constellations of behavioral problems that cannot be captured very well with current DSM categories. In order to capture a reasonably full description using the DSM you often end up diagnosing several conditions. This I think is the reason why the RAD diagnosis has accrued so many characteristics in general use that are not actually contained in the DSM. I was hoping that DSM-V would have a more inclusive definition to fit the profile of a child who is unable to regulate their emotions, full of anxiety, fear, and anger, is often hyperactive and unable to focus, has great difficulty accepting parental authority, has difficulty with transitions, is unable to handle emotional vulnerability, etc. These behaviors tend to cluster together and the DSM does not account for this. What I often see is they end up with multiple diagnosis. Often each provider (therapist, day treatment provider, psychological evaluation, psychiatrist, and residential providers as they are often in and out of residential placements) will make a different primary diagnosis. Some say RAD, some say PTSD, some say bipolar, etc etc (usually all of them will diagnosis ADHD in addition to other diagnoses) The DSM it is still so primitive in my opinion that it often confuses more than it helps.

    1. I think your points about diagnostic categories are very well taken, but I would go farther and say that a child's diagnosis needs to be in context. When you say that a child is fearful, what are his or her daily experiences like? Are caregivers able to detect cues about fearfulness and help before it becomes overwhelming to the child? And-- when you say the child has great difficulty accepting parental authority, how is that authority expressed? Are the parents too frightened by the child or by their own impulses to be able to exert authority effectively? What is the nature of the transitions that are hard to handle?

      Similarly, when it comes to treatment for the child, is there parallel treatment and guidance for parents?

      I agree that DSM leaves much to be desired, and with respect to children it is especially lacking in developmental concepts and makes few efforts to deal with the meaning of a behavior at different ages. In my earlier post, I didn't mean to say "DSM is great"; I am just concerned about the tendency to invent new diagnoses that go through periods of being the latest thing and then lose traction, without ever being supported by serious investigation. People like Elizabeth Randolph have declared the existence of a problem that is not RAD, but just Attachment Disorder; Randolph has stated that she can diagnose AD because the children cannot crawl backward on command! I believe that bad as it is, DSM has the edge over that kind of thing.

      Can you explain to me why you think it would be good to have a single diagnostic category for the children you describe? I don't see why, given that categories are to be used, multiple categories are not satisfactory.

  27. Also I should add that in our program we measure outcomes using a global measure of functioning (the Outcome Rating Scale), which is particularly helpful when you have multiple interconnected issues that you are addressing. My concern is that the DSM affects the way that we treat clients by affecting the way we conceptualize their issues. Treating each behavior problem separately with specific targeted interventions is not always the best strategy.

    1. Are you suggesting that a treatment should focus on the posited "inner problem" behind the various behaviors? My opinion is that if we can safely and effectively address any of the separate behaviors, we're way ahead. For example, I've just been reading a report on an 8-year-old boy who freaks out at bedtime. The evaluator has a lot to say about his inner pillar of confidence or something like that. Why not start by addressing the bedtime situation and seeing if that can't be eased for everybody?

      If you have an effective intervention that has been shown to work on everything at once, that's great. Otherwise, I'd go with a step-by-step approach and hope that each improvement will foster others. Michael Linden has recently written about the emotional burden clients may feel while in treatment, and if a gradual approach helps with that, I see it as all to the good.

      But you're certainly right that either the DSM or some alternative diagnostic concept will influence how clients are approached... as do all assumptions about how a problem was caused.

  28. I don't see it as an either or. At times it is very helpful to be specific and concrete, and to focus on a single behavior. But when children have complex and extreme behaviors resulting from past trauma and loss, it is usually very important for the family (whether adoptive, foster or birth family) to have a concept of the child's problems that makes some sense of the whole picture. This helps them to understand the anxiety driving many of the behaviors, and to empathize with the child, rather than try to control them with anger, shame, escalation, punishment, ultimatums, and threats of abandonment, as the most well-meaning and loving adults tend to do when faced with a child who frightens, disrespects, and often seems to reject them. One problem I see with multiple and changing diagnoses is that families and sometimes even providers start to get very confused and we start to think that if we can just find the "right" diagnosis or set of diagnoses we will get the right kind of treatment and be able to "fix" the child. We can lose sight of the bigger picture of a child in need of unconditonal safety, unconditional love, and enormous patience, as well as what parents do have full control over, which is working on themselves and how they relate to their child. I understand how the idea of "attachment disorder" got started, and I think part of the reason it became so cultish and dangerous is because the research community was not (and is still not) really providing an alternative paradigm. So a lot of people who worked or lived with these children were drawn to the fringe. Anyway, I am not a scientist, these are just my observations as a practitioner. I am guessing that the idea of a developmental trauma disorder is elusive and hard to tease out, thus the failure to find enough evidence to support inclusion in the DSM 5. At our agency we work with people who have all sorts of relationship and mental health issues, but personally my focus has always been the children who have suffered from these very difficult circumstances. Therefore, I am grateful for the work you are doing, as I think you are cautioning people to be skeptical, to rely on science rather than the compelling story or anecdote, and above all to strive to do no harm.

    1. Your comments make a lot of sense! There are some interesting relevant letters to the editor in the NY Times this morning, commenting on an op-ed by Eric Kandel and discussing the problems of describing even so common a symptom as depression. It sometimes seems that we're still at the natural history, descriptive stage of studying mental illness-- but the advantage of a scientific approach is its stress on public communication and sharing of information, rather than having some individual declare that because they have seen ten cases of something, there must be thousands just like that.

      You may be right that people were drawn to the AD idea because there were no legitimate alternatives-- but I think there was also an element of following the guru, especially in the 1970s when the whole mess seems to have begun.

      I certainly agree that there's a problem when people are looking for the "right fix", but how we can help them be comfortable with a more general approach-- that I don't know. It's probably a lot easier to do for parents of infants and toddlers than for parents of older children.

      Anyway, my thanks for your thoughtful contributions to this discussion!

  29. I was hoping that DSM-V would have a more inclusive definition to fit the profile of a child who is unable to regulate their emotions, full of anxiety, fear, and anger, is often hyperactive and unable to focus, has great difficulty accepting parental authority, has difficulty with transitions, is unable to handle emotional vulnerability, etc. These behaviors tend to cluster together and the DSM does not account for this. What I often see is they end up with multiple diagnosis. Often each provider (therapist, day treatment provider, psychological evaluation, psychiatrist, and residential providers as they are often in and out of residential placements) will make a different primary diagnosis. Some say RAD, some say PTSD, some say bipolar, etc etc (usually all of them will diagnosis ADHD in addition to other diagnoses) The DSM it is still so primitive in my opinion that it often confuses more than it helps.

    This is exactly what we are going through with our adopted son. His therapist said RAD. The Department of Children and Families requested a psych eval from a psychologist who said that although he could tell there was something else going on, his ADHD was too intense to figure it out. Said that we needed to medicate the ADHD before we could look deeper. Psychiatrist insisted it was just ADHD and recommended we watch SuperNanny as that was all he needed. His pediatrician thought he had conduct disorder. We were referred to in-home services at which point we got a new therapist, psychologist, and psychiatrist. The psychologist that came out dx'd as ODD and a mood disorder. The therapist that came out felt that the problem was rooted in attachment. The new psychiatrist dx'd ADHD, ODD, and an anxiety disorder. The psychologist and therapist have now decided he does have RAD but that our insurance won't pay for that so they have to tell insurance things like ADHD, mood disorders, etc. I have finally told them all to stop telling me what they think he has. Tell the insurance. Just tell me what to do and how to change myself so that I can better help him. It would be great if there was a diagnosis that encompassed everything in the paragraph I quoted from Kathy Levenston, because my son has every single one of those problems.

    1. Dear Anon--

      If everyone agrees on the problematic symptoms the child shows, I don't understand why a specific name that covers all bases is needed. You have some diagnostic categories that an insurer will reimburse for, and any treatment you seek should focus on the symptoms that worry everyone. The only reason I can think of that you want a RAD, or RAD plus, diagnosis is that you want a therapist who claims to treat attachment disorders, and I would suspect that your insurer does not fail to pay for treatment of RAD, but does refuse to cover "attachment therapy", an implausible, non-evidence-based treatment.

      No diagnostic category describes the reality of a unique human being, and that is not their purpose. But unfortunately we have worked ourselves into a situation where insurance and diagnostic categories are inextricably intertwined, so instead of just listing a child's problems we have to choose the item on the menu that's closest to the set of issues.

      If you are really ready to think how changes in yourself might help your son, I would suggest that you seek Parent-Child Interaction Therapy, a treatment that focuses on modulating ways that parents respond to children, with the goal of making parents more appropriately responsive and children more cooperative. You don't say how old your son is, but PCIT was developed to work with preschoolers and early school-age children.

      I can't for the life of me see how "watching SuperNanny" would be helpful to anyone!

      I am very curious as to which insurance company you have. I'd like to look up their policy about payment for RAD treatment.

  30. Nowhere did I say I wanted a RAD diagnosis. I no longer care what they call it, I just want help. And he IS getting better with our in-home therapists and psychiatrist working together with us to help him. If there was a way to give one name to a disorder in which all of those criteria were under the same umbrella, that would be easier, in my opinion, for my son's case. Not so much of the multiple diagnoses and difficulty in getting the correct diagnosis and treatment due to overlapping symptoms/criteria. Either way, not every treatment works for different people with the same disorder, so we would probably still be where we are now.

    It is interesting to me that you mention PCIT therapy, as 14 months ago when he had just barely turned 5, we participated in a research study done by one of our local universities on the efficacy of PCIT with foster children, which my son was at the time. We had several months of participating in this therapy and it actually made things worse. I believe that is because the "special play time" was akin to forced bonding/attachment and he was not ready for it. But I could totally be wrong. I just know that it was not helpful for him. It was somewhat helpful for us as his parents because we did get reinforcement on how to appropriately respond to physical attacks. The therapy we are currently participating in has been enormously helpful and I am grateful for finally finding something that is helping us and him.

    The SuperNanny comments from the first psychiatrist made my jaw hit the floor. We continued to see him for 2 months while we transitioned to the new program we are with currently, simply so we could continue to monitor and medicate his ADHD. As well as it was not our choice on who to see for provider at that time as he was still a foster child.

    We have Medicaid for him. We have been told they won't authorize payment for our specific in home services if they try to send it through as a RAD dx. He does have anxiety. He does have ADHD. They can get authorization simply using those so that's what they send through. They just tell me that they feel he has RAD because they want me to have a diagnosis that encapsulates more of a "whole picture" I think. I told them not to worry about telling me the dx anymore as I am simply frustrated by any changes, etc. Just look at my boy and then tell the insurance what is honestly wrong with him in a way that will get them to pay for it. If they pay for anxiety treatment, great! Call it anxiety. If they pay for ADHD treatment, great! Call it ADHD. So long as the treatment you give him is the same, I don't care.

    1. Sorry, I see that you didn't just want a RAD diagnosis-- but I was trying to talk about diagnoses in general.

      I am really curious about two things that you say here, and I hope you can take a few minutes to tell me about them. One is, in what way did PCIT seem like "forced bonding" to you? Second, what kinds of things does your in-home therapist do?

      I have never heard anyone say that about PCIT and would just like to understand your experience.

  31. It didn't seem like it so much to me because I loved having the chance to actually play with my son. He normally never wanted to be with me. I think my son thought it seemed like forced bonding because he had never had the intense attention that was so focused on him before that. The reflections, the labeled praise, etc. was something that he seemed to enjoy, but he would have extreme behaviors after the sessions. It was completely overwhelming to him to have such a focus on him. Part of him would eat it up and part of him wanted to run as far as possible away from such closeness and one on one time. I think it felt good inside and he'd never felt that before. I think it scared the heck out of him. We did this therapy for several months until we decided that it was just not helping. The forced part was somewhat because we had never required him to participate if he didn't want to, and he frequently didn't want to. With PCIT, if he wanted to use the special toys that were saved for the playtime, he had to be with us. Way too much closeness and happiness for a miserable child.

    Something our in home therapists are doing is lots of family activities but he is not required to participate if he doesn't want to. They push him sometimes, but if he is really feeling overwhelmed, they stop whatever we're doing and we change activities so as to not push him too hard. One nice thing is that the therapists have helped us identify definite physical movements and voice changes that indicate high stress levels for him. If he is pushed too hard he gets suicidal and self harms. Taking it slowly has been a great method. The difference between what we were doing on our own with trying to bond with him through normal family activitites versus what we are doing now, is that we would interact with him, but if he got aggressive, had a tantrum, withdrew, etc. we didn't know how to re-engage him without making it worse. If we tried to cajole him to participate it would just turn into an epic meltdown. So we frequently just dis-engaged ourselves because we didn't want/know how to handle him in the right way. With the in home family therapy, the therapists have gotten to see him as he really is at home, including him having a major tantrum with self harming behaviors, something his previous therapist of nearly 2 years never saw. He went to her office, they talked/played without either of us parents in there, and after about the first 6 or 7 months our son stopped progressing and his behaviors/mood remained stalled with no emotional growth or improvement in self soothing or anything. With the in home services, we get to see techniques modeled by the therapists, we get private therapy time with the therapists to ask questions and go over "paperwork" type learning. Parenting my son takes techniques that do not come natural to us, but we are learning. It is so very different than parenting our daughter, who is also a foster child but has been with us since birth and had no major traumatic experiences. She is actually developmentally advanced according to all training on child development we have been getting through our son's therapists. It is validating to know that we CAN be adequate parents but our son just needs us to parent differently than our daughter. We felt like completely abysmal parents for so long before finally getting the right help for our family. Sorry if this was rambling, I just am so grateful for our current therapists help that I could go on and on forever about it.

    1. Thanks for this very detailed description of your therapy experiences. I think your comments on disengaging when you don't understand the signals or don't know what to do are right on the money for many adoptive parents and quite a few birth parents too.

      I'm sure you're tired of writing about this, but I do still wonder about the way you think your son felt about PCIT. It sounds as if your theory about this is the same as what Attachment Therapists suggest-- that the child is frightened or made uncomfortable by feeling close even when it also feels pleasant. I wonder whether there are other reasons for any post-therapy problems-- maybe, fatigue for him and for you?

      It does seem very beneficial to have the time to talk things over with your therapist, and as you say this is not often included in conventional treatment, so I think parents come to feel somehow in competition or conflict with the therapist.

  32. Wow...reading through these comments remind me why I don't do support groups. I am in the care of 3 rad children. Took me a year to undo the damage the "attachment therapy" and RADish advice. One child isn't aggressive and so is not considered RAD even though meets all criteria more so than other 2. One meets all criteria of severe narcissist personality disorder but due to aggression is diagnosed RAD. People seem to want to diagnose RAD as "so out of control that my parenting is above question". It is dangerous what message we are sending to our kids and and caregivers. I adjusted my life to work with these kids and we are all healing. I don't take a thief to the mall, engage in a rage, publicly humiliate, play the blame game. I limit their world to what they can handle and slowly work on emotion control. Its hard. i believe this RAD label is encouraging child abuse.

    1. Your point is so well taken-- that the RAD diagnosis can be desirable as a way to place or deflect blame, and to suggest that the life adjustments you mention are not needed-- even though it's obvious that if you give birth, your life will have to change to fit with that baby's needs, and we can surely extrapolate from that to the needs of an adopted child.

      I would be very interested to hear specifics about the advice you received and the damage you felt the related attitudes did.

  33. If your problem is with RAD therapy then bash it all you want but quit attacking parents of children with severe disabilities and making ignorant assumption after insulting assumption about our motivations. Why anyone would answer your intrusive and rude questions is beyond me. Frankly, you are just a nobody looking for your niche and doing it in a way that suggests you yourself have a problem with empathy.

    1. I think there is a considerable difference between the concerns you express and the ones I have. I am worried about the experiences the children have and their long-term effects, while you are worried about how the parents feel. In addition, we seem to have different views of what courteous discourse is.