Over the last couple
of years, a number of psychologists, both British and American, have called
attention to the excessive current emphasis on attachment and trauma as causes
of mental and behavioral problems. The emphasis has generally been on diagnosis
and treatment of adopted children, for whom any behavioral problems are so
often attributed to their histories of separation and possible abuse and
neglect. Matt Woolgar and Stephen Scott (Woolgar, M. & Scott, S. [2013] The importance
of comprehensive formulations The negative consequences of over-diagnosing attachment disorders in adopted children. Clinical Child Psychology and Psychiatry. : DOI:
10.1177/1359104513478545) gave examples
of British cases where children were evaluated as having problems caused by
attachment disorders when in fact their major difficulties stemmed from
treatable issues like learning disabilities. The American psychologist Brian
Allen, whom I mentioned in a recent post, has argued strongly against the view that
conduct disorders and callous-unemotional traits should be considered to result
from difficult attachment histories or from the posited “developmental trauma”.
There
are certainly childhood disorders that seem to stem from problematic
experiences with early care, and because such problematic experiences are
likely to lead to termination of parental rights and subsequent adoption, it is
true that adopted children are more likely than others to have these
difficulties. However, it is a great mistake to assume that all problems of
adopted children (or of nonadopted children, for that matter) are caused by
experiences of separation, abuse, or neglect. The evidence at this point is
that attachment problems in children involve either Reactive Attachment
Disorder, a matter of sadness, social withdrawal, and difficulty in seeking
comfort from familiar adults, or Disinhibited Social Engagement Disorder, a
matter of unusually easy rapport with strange adults and failure to prefer
familiar adults over strangers (in contrast, with most young children, who seek
familiar people and are wary of strangers). Aggressive behavior,
callous-unemotional traits, precocious sexuality, unusual tantrums, and
learning difficulties—all serious problems-- are not included here.
Adoption
has been called the most effective treatment for attachment disorders, and most
children who have been adopted and stayed with a family for some years will begin
to show more normal social behaviors. Adoptive families may benefit from
therapeutic support, but treatment is likely to focus on the adults and their
parenting behavior rather than directly on the children.
But
like nonadopted children, adopted children may have a range of psychological
issues in addition to or instead of attachment disorders. All human beings are
subject to psychological disorders that are influenced by biological factors
like genetic influences. Although there are many rare and serious problems that
are genetically determined, the most commonly-diagnosed genetically-caused
psychological difficulty is autism, now known to exist in a wide range of severities (the “autistic spectrum”).
The
British psychologist Joshua Carritt-Baker has recently commented on the
frequency of autistic disorders among adopted children and the mistaken
assumption that these children are suffering from attachment disorders. This
assumption has led to the treatment of numbers of adopted children with non-evidence-based
methods that claim to treat attachment problems (for example, Dyadic
Developmental Psychotherapy as practiced by Daniel Hughes and Kim Golding).
Carritt-Baker has created a video explaining the problems that have not been
solved by the activities of the British Adoption Support Fund, which can be
seen at
Carrit-Baker notes, by
the way, the fact that the United Nations has warned France that its approaches
to treatment of autistic children are violating those children’s human rights,
and points out that the same warning is due to British organizations. The
over-diagnosis of attachment disorders in the United States may deserve a
similar caution.
What has brought about
this difficult situation in which autism as well as other problems gets
confused with attachment disorders?
One source may be the historical one, whose
“trailing edge” still influences thinking about children’s mental health. At
the time when autism was first clearly identified as different from speech
pathologies or mental retardation, psychology and psychiatry put an enormous emphasis
on experience and learning as sources of mental illness. That autism was caused
by aloof, overly-intellectual “refrigerator mothers”, and was related to a lack
of attachment, was taken for granted in the 1940s. Genetic factors were unknown (even the chromosomal causes of Down syndrome
were not identified until the 1950s), and it was not until much later that it
was demonstrated that autistic children had ordinary attachment behavior. The
same stress on experience (as opposed to biology) created an emphasis on early
childhood attachment experiences as the most important—even the only—factor in
determining personality and mental health. This view has lingered with us and
is especially obvious in non-evidence-based alternative therapies.
No one would deny that
attachment is important. But other factors are also important. Children’s
development is determined in complicated ways; biological and experiential
factors interact with each other and have different influences at different
ages. We have learned a lot about this in the last 60 years and should be able
to do better than seems to be the case right now. Choosing the right kinds of
treatments requires us to consider more than one possible problem and more than
one possible treatment. Otherwise we waste public and family resources and do
many children a distinct disservice.
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