Concerned About Unconventional Mental Health Interventions?

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

Friday, May 27, 2016

Reactive Attachment Disorder and Attachment Disorder: Compare and Contrast

My colleague Linda Rosa recently sent me a link to an apparently highly commercialized organization called “The Adoption Exchange”. At https://www.adoptex.org/events/understanding-attachment-2016-april-18/, The Adoption Exchange announced a class that purported to explain the difference between Reactive Attachment Disorder and Attachment Disorder, as well as informing students about parenting methods that “heal attachment issues” in adopted children. The instructor was a licensed professional counselor. Nevada social work education units were said to have been requested for this class. A list of learning objectives was provided, but these were puzzling to me because rather than stating some active performance demonstrating mastery (such as being able to define certain terms or differentiate between two conditions), as such objectives ordinarily do, they simply referred to understanding as an objective. (But this is a problem for the Nevada social work association, not for the rest of us.)

I don’t know what the instructor said about differences between Reactive Attachment Disorder and Attachment Disorder, but I think I can guess, because of the very fact that she proposed to discuss a difference between one well-established diagnosis, and another that is essentially the invention of a group who are confused about the nature of attachment and of any problems that may result from a poor attachment history. The title of the course, “Understanding Attachment”, might be better stated as “Completely Misunderstanding Attachment.”

The term Reactive Attachment Disorder has been in the Diagnostic and Statistical Manual of the American Psychiatric Association since about 1980. It’s a term that has gone through various changes over the years, as has indeed been the case for a lot of other diagnoses as well. RAD was initially a term that shared much with nonorganic failure to thrive (NOFTT) as a description of poor weight gain and physical development in the first year or so of life. Because poor development can and does often result from physical disease processes (referred to as failure to thrive, FTT), RAD/NOFTT was a relatively new concept, suggesting as it did that poor growth and development might also result from disturbances of relationships with caregivers, such that a baby did not ingest enough food or was unable to digests and use what was provided. (I remember a lecture on this topic in the ’70s that gave as an example a mother who was so anxious that her baby would not eat enough that she attempted to entertain him after every bite by putting an umbrella up and taking it down again, which amused the baby but distracted him from eating.)  By the 1980s and ‘90s, the failure-to-thrive aspects of RAD had disappeared from DSM, and the term focused entirely on behavioral indications of infant-caregiver relationships. At that point, a spectrum of attachment relationships was envisioned, with normal attachment behavior in the “Goldilocks” position, and aspects of RAD on either side of that--  one side involving children who were did not seem to prefer one adult to another, and the other side including those who were excessively clingy and afraid of separation. The current, DSM-5, position has divided these possibilities into two separate categories, Reactive Attachment Disorder (involving aloofness, unresponsiveness, difficulty in engaging in relationships,  and difficulty in receiving comfort), and Disinihibited Social Engagement Disorder (lack of preference for familiar people, exploring without normal “checking back”, and willingness to go with strangers). Both of these begin before age 5 years (but after 9 months) and are preceded by poor caregiving experiences.

You can see that those two diagnoses, as currently defined, are based on different kinds of behavior . So, how are they different from attachment disorders? Given that the term “attachment disorder” is written all lower-case, they are not entirely different. “Attachment disorder” (all l-c) is a general term that can be applied to either RAD or DSED, and has been applied to disorganized/disoriented attachment behavior in toddlers.  “Attachment disorder” (all l-c) is not meant to indicate a particular kind of problem, any more than “childhood rashes” necessarily means rubella.

However, when people capitalize those words--  Attachment Disorder—they think they mean something specific. Even in the 1990s, proponents of Holding Therapy/Attachment Therapy, who claimed that childhood aggressive or noncompliant behavior resulted from attachment problems, had been told frequently that the things they were talking about were not Reactive Attachment Disorder. As a result, they proposed a new term, Attachment Disorder (with caps) that they claimed was characterized by failure to make eye contact on a parent’s terms, love of blood and gore, aggression toward small children and pets, etc. Elizabeth Randolph, a psychologist whose license had been revoked in California, self-published a test she called the RADQ (not Reactive Attachment Disorder, but Randolph Attachment Disorder Questionnaire [Randolph, 2000]). Randolph, felt that she could validate this questionnaire against her own diagnosis, because she was able, she said, accurately to determine which children had Attachment Disorder—for example, Randolph stated, they were unable to crawl backward on command. Randolph clearly stated that the RADQ did not diagnose RAD, but instead tested for  Attachment Disorder, a diagnosis that was “not yet” in DSM. Sixteen years later, AD is still not in DSM, and the reason is that no one has done any of the substantiating work to show that such a diagnosis differentiates reliably between a specific problem and other problems a child may have.

No one would deny that there are children who are highly (and dangerously) noncompliant, or who seem fascinated by aggressive acts, or who attack both adults and younger or weaker beings. What would be denied is that there is any evidence that such problems are associated with attachment history, or that they can be cured by treatments that focus on attachment. What would also be denied is that there is a need for an additional diagnosis to replace disorders like Obsessive Compulsive Disorder, Oppositional Defiant Disorder, early onset schizophrenia, and so on.

The Attachment Disorder (with caps) concept has been a money-spinner for a shadowy world of practitioners who have little training in either established theory or research facts about attachment. They have sold their views to adoption organizations, who in turn market them to confused and overwhelmed adoptive parents, for whom the idea of fixing previously-damaged attachment is most attractive.

I doubt very much that the instructor of “Understanding Attachment” made any of these points.
       



12 comments:

  1. Thank you. I have read a number of your posts concerning RAD and I could not agree more. I am no professional but I am the adoptive mother of a four year diagnosed with RAD. I have been to a number of professionals and have been shocked by what they have told me. Yes she is aggressive at times and yes she displays little empathy. I have been told everything from I need to let her have a bottle and relive being a baby to I need to hold her against her will to make her bond with me as well as a whole host of other things that do not sit right with me. I have constantly asserted that I believe in consistency, routine and natural discipline (if she makesa mess she cleans it up for example). I was practically laughed at. Then when I pointed out that I'm not sure she even has RAD but simply was praised for bad behavior so repeats it I wad told I did not understand the condition. I also pointed out that at her age (3 at the time) I felt most children lack empathy as they are mostly concerned with themselves I was again told that I simply didn't didn't know what I was talking about. I was also told to try crossinology. I can report that after finding no help that I considered useful I simply followed my instincts to be consistent and follow a routine. It has worked wonders but makes me question how many children receive this label are improperly treated or even harmed because of it. So thank you for pointing out that this is a problem.

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    1. Dear Jaxzmin-- thank so much for these comments, and thanks on behalf of your little girl for having the common sense to see through these things! If you do find at any point that you need some professional help with parenting, try to find a practitioner who will use evidence-based treatments. www.effectivetherapy.com will give you some guidance on what these are.

      Big surprise, an aggressive four-year-old!

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    2. Natural consequences do work, Jazmine.

      It is so good she feels safe to have a self to be concerned about and with. So many three- and four- year olds don't or are discouraged.

      What is crossinology? A behavioural neuroscience marketer's dream? I may have seen it before, though not by that name or with that face!

      Consistency and routine are of course supported with instinct, that is true, Jazmine.

      It will be good to get census results from a American Psychological Association special interest group and have that disseminated into open source work.

      One child harmed by these is of course too many.

      The distinction between "improper treatment" and "harm" is a nuanced one.

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    3. "crossinology" is a version of the ever-present "cross-crawl" or "patterning" technique that ha been hanging around since the '60s, rejected again and again by professional groups.

      Adelaide, do you know something I don't know about an APA special interest group? As the years go by, we are getting more material published on these topics, but I don't know any special interest group.

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    4. Jean:

      I was speaking a wish. And going through the Steps.

      SIGs are most familiar to me through the graphic design and consumer software user groups.

      I would be most likely to find out through a particular active or committed delegate [such as through a political action group] in an interest area like Multicultural Mental Health or Research Methods.

      Or there might be "crossinology" between Australia and the US as through conferences and exchanges.

      It might be well to work through the Boards [at least the non-vanity ones].

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  2. I would bet the farm that Adoption Exchange intends to promote "Attachment Disorder" (AD). Their library, serving branches in several states, recommends numerous books that present AD and Attachment Therapy as legitimate and best practice.

    Adoption Exchange has also promoted (with funding from Colorado DHS) several speakers involved with Attachment Therapy, such as psychologist Steven Gray.

    By the way, Gray's disgusting book ("The Maltreated Child: Finding What Lurks Beneath") describes the signs of the unrecognized AD diagnosis, but calls it "RAD."

    AD has struck me as the classic quack diagnosis, with so many signs that it can ensnare the child of any parent looking for help. The list of signs that have been attributed to AD is truly remarkable:

    http://www.childrenintherapy.org/attachmentdisorder.html

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    1. "Lurks" indeed! The language alone helps identify quackitude.

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    2. I am reading the chapter in the Maltreated Child about education and rights.

      There are also Gray articles.

      He has spoken lots of times at ATTACh.

      Puzzled in Poughkeepsie

      TruValue part 2

      http://www.grayneuro.com/articles/9acronymscomplexityandtruvaluehardware.pdf

      http://www.grayneuro.com/articles/3hopeandoptimism.pdf [Hope and Optimism]
      [I'd like to ask his four friends some questions!]

      http://www.grayneuro.com/articles/2meltdown.pdf
      [Nuclear Meltdown + Attachment Mayhem]

      http://www.grayneuro.com/articles/23mindfulnessandme.pdf
      Mindfulness and Gray

      http://www.grayneuro.com/articles/22whenloveisenough.pdf
      When Love is Enough [!!!!]

      http://www.grayneuro.com/articles/18insearchofmaturity.pdf
      In Search of Maturity

      http://www.grayneuro.com/articles/14almondcrunch.pdf
      Almond Crunch and Almond Joy

      The Nevada connection: a 16-year-old who studies personality psychology and temperament theory in the Christian context. Her sabbatical is finishing. Look for FlutistPride.

      If this is the sort of hoop she would have to jump over and under, then I can and should do my little bit. Yes?

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    3. Thank you for these-- let's all do our little bits!

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  3. Ah ha ha! I see that this Gray praises Arthur Becker-Weidman"s "randomized controlled study"! Gray apparently does not know what a RCT is, nor has he read the numerous critiques of B-W's work by me, Randy Pennington, etc., nor does he realize that even Daniel Hughes no longer cites B-W in defense of DDP. Perhaps he ought to do some catching up with the journals.

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  4. I am the biological dad of a four year old with R.A.D. this is by no means anywhere near what has been misconstrued as attachment disorder. My son was born highly addicted to methadone which was given to his mother as heroin replacement therapy. She cared more about going to the methadone clinic every day than taking care of her kids. She would leave them alone for who knows how long and eventually after several reports to DHHS the kids were removed. My son was bounced around from home to home as the department worked to put these babies back into a drug addicts home and life. To make a long story short I was finally awarded custody of him in july of last year after 6-7 placements and two failed reunifications with his mom the last leading to her arrest for methamphetamine production. My fiancee and i were extremely vigilant and pro active in his care. We welcomed in home providers into our home even though they judged us and misinterpreted everything we were doing as parents to try and help this little boy learn to make a good choice as scapegoating him and unfairly punishing him for behaviors that would just be outright unexeptable in a normal situation. What we had was far from normal and I tried to best explain that to any provider that we came accross on our journey. They were instantly charmed by his blonde hair and blue eyes. We are fighting tirelessly to get him services that he needs. Residential treatment is what I think he needs. He is 4 but has had more trauma to deal with than most adults. And we continue to fight the stigma of being bad parents for protecting everyone in our home.

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    1. Dear Leland-- I am not sure what you mean when you say your son has RAD and I am wondering where this diagnosis came from, as he seems to have several more troubling issues, including drug exposure, many placement changes, and effects of trauma. I am wondering also what methods you were using that were so concerning for home visitors. What it all boils down to is, I'm not sure what's going on here, and I am especially puzzled by your references to scapegoating and punishment.

      However, I would like to comment on your interest in residential treatment. Although I can see that you and your fiancee may have taken on a task you are not prepared to handle, I want to point out that it will not be possible to "fix" the child and then return him to you. Residential treatment for a child this young is potentially traumatic in itself, especially for a person with your son's history.

      Although, as I said, I am not clear on what's happening in your family, I would suggest in a general way that you and your son could benefit from an evidence-based treatment like Child-Parent Psychotherapy or Parent Child Interaction therapy. Either of those programs would work with you and the child together in order to improve your responses to each other and create a more positive relationship, where you might not feel the need for punishment as it seems that you now do.

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