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Concerned About Unconventional Mental Health Interventions?

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

Saturday, September 17, 2011

What is Reactive Attachment Disorder? Further Discussion

I’ve made a number of statements to the effect that violent or aggressive behavior, lying, stealing, and so on, were not diagnostic of Reactive Attachment Disorder. Some readers disagree strongly with this perspective. Reader Valle Oberg, for example, has been arguing against my position for several days at

I’d like to call people’s attention to a paper by Charles H. Zeanah and Anna Smyke from Tulane University, arguably the leading U.S authorities on Reactive Attachment Disorder (Zeanah, C.H., & Smyke, A.T. [2008]. Attachment disorders in family and social context. Infant Mental Health Journal, 29, 219-233). This paper discusses criteria for attachment disorders and compares the DSM and ICD-10 versions, as well as referring to categories suggested by Zeanah in previous work.

In none of this material is there any reference to violent or aggressive behavior, self-injury, lying, cheating , stealing, refusing eye contact, or any of these issues so much stressed by therapists and parent groups outside the mainstream of psychological and psychiatric thought. Zeanah and Smyke come no nearer to these issues than referring briefly to the possibility of risk-taking as one aspect of a RAD-like category.

Zeanah and Smyke discuss measures of inappropriate behavior suggesting a disorder of attachment. They point out three ways in which such measurement has been approached. One method looked at whether children wandered away from caregivers without becoming distressed, whether they approached strangers, whether they were never shy with new adults, whether they were friendly with new adults, and whether they would go off with strangers. A second approach considered whether children failed to differentiate among adults (that is, treated all adults the same way and did not have a preferred caregiver), readily went with a stranger, and failed to check back with a caregiver (i.e., by looking back to them or calling to them as distance between them increased or separation became likely). The third method looked at not having a preferred caregiver, lack of reticence with a stranger, failure to check back, and willingness to go with a stranger. (Once again, none of these methods looks at aggressive behavior, lying, self-injury, etc., etc.)

Zeanah and his colleagues several years ago wanted to develop a technique of assessing preschool children’s attachment to caregivers without depending on parent or teacher reports. They developed what they called the “Stranger at the Door” procedure. One of the researchers knocked at the door of the child’s home, and the caregiver and the child answered the door together. The stranger looked at the child and said, “My name is ____. What is your name? Let’s go for a walk.” Observers coded the child’s behavior in response (if the child was willing to go, they walked a few feet, then came back into the house). Children’s willingness to go with the stranger was greatest in the group who had been institutionalized, but there was also atypical willingness in a comparison group of children who had been in foster care.

The Zeanah and Smyke paper noted that in a group of children adopted from institutions, there were no cases of the inhibited form of RAD, but a “substantial minority” showed the disinhibited type, with less avoidance of strangers and less preference for familiar caregivers than is typical among family-reared children.

In discussing “self-endangering” behavior as an aspect of RAD (the nearest thing mentioned to the claims of aggression and self-injury made by some advocates of an unorthodox view of attachment disorders), Zeanah and Smyke emphasize the possibility that risk-taking is part of a “two person” disorder which is difficult to describe in present language. They raise the issue of possible relational attachment disorders (different from RAD as now defined) that are evident only in the context of the association between the child and a specific caregiver. I would add that this is a very interesting idea with respect to the claims made by members of ATTACh and similar groups that children with RAD behave angelically outside their homes, but are difficult or even dangerous in interaction with their mothers.


  1. Are we to conclude from this that adoption is dangerous for some adoptees?
    Would you say 'The Stanger at the Door' was an ethical way to test adoptees?

  2. I don't see how danger to adoptees comes into it. Compared to institutionalization, adoption is not dangerous. In fact, it's a very successful intervention. Children who are exposed to caregivers who are cruel or have swallowed mistaken ideas will suffer whether those caregivers are institution staff or adoptive parents, or indeed birth parents.

    Actually, it occurred to me that the "Stranger at the Door" needed to be followed by some discussion with kids who did go along. On the other hand,even without further discussion, it's certainly advantageous for caregivers to be aware that the child might do this without having to wait for it to happen by accident or in some dangerous situation. This makes life safer for the child. So, yes, I would say that it's an ethical method,as there are advantages to the child and the caregiver that more than compensate for the brief anxiety or confusion that may be experienced.

  3. I would say that it is "attachment therapy" and other similar interventions aimed at adopted children that can be harmful, not adoption, per se. These interventions are dangerous, in my opinion, not only with adopted children but with any children they are aimed at. If birth parents got their children involved in such interventions, which sometimes does happen, they are just as dangerous, but no one would conclude that parenting, per se, is dangerous.

    For people who are opposed to all adoption, I am wondering what the alternative would be recommended for children who lost both parents? While I would agree that family preservation wherever possible is desirable and is not attempted often enough, there are some children who have lost both parents for whom that obviously is not possible. If there were no adoption, what would happen to those children? Would they be placed in orphanages? That doesn't sound to me like a good alternative.

  4. Dr. Mercer,

    I responded on the other blog.

    The Mayo Clinic has the symptoms I, other therapists and other parents with kids that have kids with the same behaviors at:

    As I stated in the other blog, the DSM and ICD codes are not that important to I, as a parent of a child that has been diagnosed with RAD by three independent psychiatrists. My child with RAD shows the same symptoms as the DSM criteria along with the, "complications" that Mayo Clinic describes.

    The psychiatric community is only recognizing the post-institutionalized child behaviors as of the past thirty years or so. The community still needs to catch up. Also of interest, in the documents that you referenced, there was not a reference as to how many children were studied. And as I stated before, often the children present themselves differently to the family than schools and doctors because their home is, "safe" and they can act out without fear of harm or being ostracized.

    I remain with my same opinion that instead of just reading journals, books, and other items on the post-institutionalized child, or even the child with RAD, you Drs. need actual experience with them as they do things that would never be expected as I stated on the other blog. Remember that children from orphanages often have cognitive defects from the malnutrition, parasites, and heavy metal poisoning that make the situation much worse.

  5. Isn't there some contradiction between the statements that the children behave well at school because of fear of harm or ostracism, and the common claim that they can't connect cause and effect?

    Be that as it may, these comments make me think of the old dialogue:

    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.

    Insisting that aggressive behavior is part of Reactive Attachment Disorder doesn't make it so, either. No one denies that children from orphanages may have a lot of problems, but there are certain problems that are by definition the result of some factor or factors other than RAD or any aspect of attachment.

    I've referred to this insistence that everything has to do with attachment as MAD or Misunderstood Attachment Disorder, but I begin to think that what it is, is a FAD.

  6. Okay, that is an odd analogy.In dealing with children that have been post-institutionalized, I would presume they have other cognitive issues in addition to any RAD that they have, until proven otherwise. As I stated before, one of my children is diagnosed with RAD and the other has not been; however, they both present with many of the same behaviors and they both had lead and possibly other heavy metal toxicities, parasites, malnutrition, and the institutional exposure for over two years.

    Regardless of what it is called, common behaviors exist in the child with RAD that at least the Mayo Clinic describes as complications. Again, this is where experience in treating this disorder pays off for the practitioner.

  7. I see you haven't answered my question on the other post. Well, never mind. What seems to be happening here is that you believe that personal experience and interpretations of experience are more valuable sources of information than many experiences statistically combined. I disagree strongly and suggest that you read the work of people like Daniel Kahneman.

    You note a wide variety of possible causes for the undesirable behaviors you report, yet you are convinced that Reactive Attachment Disorder is the cause of those behaviors. Once again, I would say you have some thinking to do about how to link cause to outcome.

    Here's one of the difficulties: when people decide that problems are caused by Reactive Attachment Disorder, they often decide that the treatment must be to "fix" attachment. They then are easily persuaded to choose treatments that imitate the early events that they think cause attachment. Many of those are superficially associated with authority and control, so it's all too easy to believe that in some way controlling the child physically will cause attachment and eliminate Reactive Attachment Disorder, and that that step would get rid of undesirable behavior. Unfortunately, there are many errors of logic here, and the result of these practices is likely to involve iatrogenic problems.

  8. I will look at the other blog for the question at hand.

    Treatment to fix attachment? That is not what I have ever even implied. The treatment for the behavior and underlying cognitive disorders is what is being undertaken.

    I absolutely do NOT agree with any treatment that proposes to imitate the early events that are thought to cause attachment. I think those particular treatments are bizarre and could actually do harm. I believe controlling a child physically is not the answer either because children have free will. I do however, believe that the dangerous and violent child does need at the time of danger to self and others, an external control to their behavior because they are not self regulating and are dangerous to self and others. The question came in on prone versus supine restraint methods.

    And yes, I do agree that the cause of the behaviors or, "complications" as the Mayo Clinic describes is the attachment issue along with any cognitive defects that may be present. This is where experience with the actual children that suffer from these disorders is beneficial to the practitioner. From my experience, there are few practitioners experienced enough on RAD and the post-institutionalized child to truly appreciate the problems that are unique to children that have had that diagnosis or background as these particular children are absolutely NOT normal and cannot benefit from the psychiatric treatment that may benefit the, "normal" child.

    I don't believe that RAD can actually be eradicated; however, I believe that the child can be taught to respect, be kind, care, and share and become a respectable member of society. And that to me is the ultimate outcome, not for the child to actually, "bond", but to become a productive member of society. I am not sure the child can actually, "bond" since that time in their early childhood has passed with very damaging consequences. A certain level of trust can be obtained and learned. Love on the other hand can be learned by some, but not by all.

    My thoughts as an educated parent and not as a practitioner.

  9. Evidence that they cannot benefit from ordinary treatments, please?

    I know that this is a popular statement among ATTACh members and similar people, but as far as I know none of them have investigated the question systematically. I'm not even sure what treatments you're referring to-- would you consider PCIT among them?

    I'd like to hear your comments on the prone v. supine issue.

  10. I'm a foster-adopt parent of 3 young children ages 2,3 and 4 whom we've had for 2 months. We are committed to them but are having lots of behavioral problems with the 3 yr old boy (lots of hitting, biting, scratching) and some as well with the 4 yr old girl. We have a referral for therapy but I am already holding my breath for what they will say.

    I am wanting to be proactive and informed. It seems the entire foster-adoptive community is RAD diagnosis happy and advocating attachment therapy.

    Can you recommend any legitimate therapists in Southern California who are NOT RAD happy? And/or foster-adoptive family support groups that are not attachment therapy happy?

  11. I'd suggest that you look into the Los Angeles Child Guidance Clinic (323-766-2360, 323-373-2400). Its director, Dr. Connie Lillas, is very much aware of the issues you refer to about RAD-happy practitioners..

    If you have time (how likely is that!), I'd like to hear about your experiences with treatment.

  12. What are some sound and evidence-based treatment approaches that you'd recommend for RAD? My 13-year-old (foster/adopted) daughter has been diagnosed by several psychotherapists and psychiatrists over the years with RAD, and based on my limited knowledge of the DSM and ISO diagnostic criteria, and my familiarity with her history in her birth family and in her multiple placements in foster homes and in a RTC, and her current behaviors, I have no reason to question the diagnosis. We spend our time in therapy working on emotional regulation and conflict resolution; she exhibits many dysfunctional behaviors (outside of attachment); and she is being medicated for ADHD. But little that we've done in the past year of therapy has changed her propensity to "go looking for a new Mommy," as I call it, though it also can manifest as "looking for a new sister" or "looking for a new best friend," and most disturbingly (to me), fantasizing intimate relationships with either fictional people or with people who do not know she exists. The lack of reality or reciprocity in these relationships does not seem to disturb her; in fact, I'm not sure that she recognizes that her imaginary relationships are any different than actual relationships that others have. She appears almost high as she tells stories of these creations to her friends and to me, and she responds with injured outrage when I suggest that her current "boyfriend" (who may have evolved from a name she heard on the radio) is not real and that if she discusses this relationship with her friends, she will be misleading them. We work, in therapy, on behaviors like her pulling the telephone cord out of the wall and hiding my cell phone to prevent me calling for help to a Crisis Hotline over her kicking a hole in her bedroom wall. But that approach hardly seems up to the task of keeping her safe. I have no doubt that she'd follow a stranger at the door. Well, actually, more likely, she'd invite the stranger in and give him/her everything and anything valuable that she could gather to lure the stranger to stay, at least for a few minutes, perhaps to flesh out her fantasy of having a better Whatever (better sister, better mother, better friend, etc.). I don't know---maybe for someone with RAD, this lack of constancy is not dangerous? Maybe it's my attachment that makes the kindness of strangers seem so frightening? I want her so much to settle down, to have and love family, to be able to hold on, but she doesn't enjoy pain or suffering. And I have no worries that she'll let herself be abused or hurt for long by anyone: she'll just open the door to another stranger. Or, have I gone delerious?

  13. First, let me express my sympathy for both you and your daughter in this very challenging situation.

    As for evidence-based treatments, I would say that cognitive behavior therapy is probably most appropriate here. But the real issue is that you need to find a therapist with serious conventional training in treatment of adolescents-- not someone who "specializes in RAD". Many of the problems you mention are not associated with RAD, but in any case a therapist needs to work on the problems themselves, not just on the diagnosis abstracted from those problems. This means that broad training including a range of adolescent problems will be more helpful than a narrow focus. Be sure that the therapist is licensed, and I would recommend a psychologist who works with a psychiatrist rather than a social worker, licensed counselor, licensed mental health professional,etc.

    I don't know how easy this will be for you to find-- I hope you are living in an urban area, because rural areas have very few such practitioners.

    In addition, you sound as if you are aware that your own feelings and concerns, what you call "my attachment", may affect your daughter's moods and behavior. Do you have someone who can work with you separately on a reflective approach to parenting in this difficult situation, and who can help support you as you respond to the apparent rejection expressed by your daughter?

  14. Thank you very much for your response.

    We are currently working with a child and adolescent psychotherapist, who works as part of a mental health agency that also provides psychiatric care to my daughter (who takes Concerta-ER and Clonidine for ADHD, and Risperdal for aggression and extreme mood lability; the psychiatrist is considering adding an SSRI for depression, which often results in suicidality, but she just recently eliminated Lamictal and Buspirone, in favor of the Risperdal, and I would like to try to get to the correct dosage of Risperdal before we change yet another med).

    I will talk with our current psychotherapist about whether she is experienced in cognitive behavioral therapy. (I doubt it.) The mental health agency runs a 6-month DBT program for adolescents, which includes a parents' psychoeducational group. But my daughter has expressed a great desire to stay with our current psychotherapist. (Well, she refused to attend any other therapy, but that's the same thing, in a different language, I believe---the language that helped her survive years of feeling lost and out of control.)

    My older daughter, now 17 (who I foster/adopted 10 years ago, after 5 years of foster care---multiple and in several cases, quite abusive placements), had a fabulous therapist in the same mental health agency for the past several years. But that therapist just recently relocated several hours away. It's a difficult time in our family because my older daughter could use the support of her own therapist while we sort through the sometimes maddening, sometimes simply annoying behaviors of my youngest.

    Though that therapist often lamented that she did not have the cognitive behavioral therapy training that she felt would be most helpful to my oldest daughter, her ability to cut through my oldest daughter's dismissal and denial was extraordinary, and they did good work together. She has a Psy.D., and we lucked out finding her at our mental health agency, in part I believe because she's an immigrant whose English is not perfect. However, she has moved on.

    I am not particularly drawn to fads in treatment; I am a scientist at heart, and while I have read much about attachment and trauma in the lives of foster/adoptive children (especially by Daniel Hughes, Deborah Gray, and Gregory Keck), I'm not interested in working with someone who has been trained to be an "attachment therapist" in the Nancy Thomas/ATTACh/Foster Cline/Evergreen cultist approach. They scare me.

    And thanks for the reminder to get support for myself again. I waited too long when my first daughter moved in, and I had a roaring case of something (secondary PTSD?) by the time I sought help for myself, about 2 years into this very difficult route of parenting. While my daughters have excellent medical insurance because of their Federal Title IV-E entitlement as special needs foster/adoptees, I am currently uninsured. But I need the help.

    And too many of the "Trauma Mama" blogs and support groups raise my anxiety and fear with their doomsday, dramatic approaches. [cont'd]

  15. [cont'd]

    However, I must say, there are some parents who have been in the trenches of raising foster/adopted children for many decades who are helpful, primarily by their long-term example: they and their children survived the really hard stuff and came out the other end, all fully adult and intact. No disruptions, no estrangements, no prison. Almost all of the positive stories (following years of multiple placements and sometimes abuse in foster care) involved medications---for the parents as well as the children---as well as therapy and what I can only describe as a humble, determined, and respectful journey toward wholeness, with whatever resources they were able to cobble together. Some faith-related (not my thing), some community and education based (much more thing). And suffused with love and acceptance.

    That's all very vague, I know, but at my best moments, I remember that I can't offer a lost, fearful, somewhat core-less child a toe-the-line, highly conditional relationship and imagine they'll want to reciprocate with anything like love.

    Sigh ... It's all very difficult, and all quite crucial.

    Thank you for your work.

  16. If it's any further help on long-term confidence, the work of Michael Rutter in England shows very good outcomes for the great majority of kids adopted from the awful Romanian orphanages.

    I think you're very wise to leave your daughter with the therapist she likes and wants. Just goes to show, doesn't it-- the problem is not an inability to attach!

    I wish I could offer a magic solution for this long hard grind that has hit you so hard. It does sound as if you're taking as balanced a view as possible, but I know that this balancing has got to be like Atlas holding the world on his shoulders.Still, you'd feel even worse if you did let yourself get into the trauma queen mode.

    Incidentally,I would be a bit cautious about Keck and Hage, who both have strong connections with the Evergreen model. Hughes at one time also did, but he says he doesn't use that approach any more.

    Good luck, and thanks so much for demonstrating to readers that someone "in the trenches" can take a reflective approach.

  17. Thank you, again. I'll look at Rutter's work. My best to you!

    1. You can start with my Jan. 9 2011 post on this blog, about Rutter's work.

  18. By the way, the latest therapy among many "Trauma Mamas"?---tapping (or EFT, emotional freedom therapy). Oy vey! I have to introduce myself at support groups and conferences as a scientist before they start with their recommendations, because I just can't stop myself from snorting derisively at some of this stuff. I warn them: I don't generally try any treatment for myself or for my children unless there's some scientific research to back it up. (I don't usually immediately tell them that anecdotes and testimonials are not scientific data, but it usually comes around to that.) Oh, and hooping cures the moms of their blues---yes, hula hooping. Please forgive me, oh universe, for my arrogance! But sometimes I just can't take it ;-)

    1. Oh no,not EFT! There definitely is one born every minute.

      At least hula hoops are cheap and can't do any harm... I guess... they do put the babies down first, don't they?

  19. Anonymous-- and others who might be interested-- I'm starting a new blog of longer and more formal posts, I'd like to publish some readers' posts there, if you have something you want (and have time) to co0mment on.