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Concerned About Unconventional Mental Health Interventions?

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

Saturday, June 16, 2012

ATTACh Tells Us About Attachment Disorders: An Unrecommended Video

You can see at a video entitled “ Attachment Disorder: Diagnosis and Treatment”. The video does not make it clear who made or sponsored it, but shows the logo of the Association for Treatment and Training of Attachment in Children (ATTACh), a parent-professional hybrid group that claims special expertise in mental health problems of children. Those presenting on the video are leaders in ATTACh, but would not be regarded as prominent in mainstream approaches to infant and child mental health. You may want to watch this production, but please read this post first.
Here are some statements from the video that I want to comment on:

1.      (1:25) Sally Popper comments on the inadequacy of the usual definition of attachment disorders, presumably referring to the DSM-IV-Tr criteria for Reactive Attachment Disorder and the ICD-10 criteria for Disinhibited Attachment Disorder. She states that these definitions are not very useful, and that discussion of attachment disorders should include facets such as attention problems. She also states that attachment disorders involve children’s lack of  trust in the caregiving environment. Finally, she refers to such disorders as being caused by interruptions (or other difficulties) in caregiving, especially for babies, but she does not comment on an age range in which such interruptions are most likely to have ill effects.

Popper’s remarks reflect many years of ATTACh claims about the existence of some form of attachment disorder which is “not yet” included in DSM. Unless, it has suddenly been changed, lists a series of signs and symptoms of attachment disorders that are completely incongruent with the DSM criteria. The Randolph Attachment Disorder Questionnaire, once well-thought-of by ATTACh proponents, was stated by its own developer not to be an evaluation of Reactive Attachment Disorder, but of “something else”. ATTACh members have claimed for many years to be able to recognize a disorder caused by a  poor attachment history and not known to anyone else; Elizabeth Randolph stated that she could diagnose this problem when children were unable to crawl backward on command. These claims have been ways of positioning ATTACh as possessed of an expertise that was not available to mainstream mental health practitioners.

The absence of any statement about an age period in which children are especially sensitive to disrupted caregiving relationships is also typical of years of ATTACh statements. Omitting this critical point allows practitioners to claim that any adopted or foster child, no matter how old the child was at placement, suffers from an attachment disorder. There is a connection here to the claim that emotional attachment occurs prenatally and that babies adopted on the day of birth nevertheless suffer emotionally from the separation from the birth mother.

2.      (2:48) Richard Kagan talks about the discoveries of neuroscience about the impact of the brain of neglect and abuse and states that abused or neglected children show poor self-regulation because some brain structures are “shrunken”. Then, abandoning the showing of the neuroscience flag, he goes on to say that children may have learned frightening behaviors as ways to get help when neglected. As Kagan does not mention any diagnostic or treatment usefulness of information about brain structures--  and as he does not seem to see that frightening behaviors as he discusses them may be a form of self-regulation—it is difficult to see the relevance of any of these statements to the supposed topic of the video.

3.      (5:39) Victoria Kelly introduces the idea of Developmental Trauma Disorder, the diagnosis suggested by Bessell van der Kolk but probably not to be included in DSM-V, and proposes that this diagnosis is what really captures the nature of attachment disorders as proposed by ATTACh. Kelly stresses the difficulty of diagnosis and states that children may be seen as having ADHD or bipolar disorder--  but because the real, underlying problem is not being treated, interventions are not successful.

N.B. Nobody in this video talks about how appropriate therapy would be different from ordinary methods, but van der Kolk’s claims that the real problem cannot be accessed cognitively imply that physical methods associated with emotional reactions might be the way to go, in spite of the fact that such methods have no foundation in systematic evidence.

4. (7:11) Gregory Keck is supposed to be speaking about the history of understanding of attachment disorders, and of course I listened to this with great interest. He even begins by citing Foster Cline--  but rather than talking about holding therapy and why (or whether) they don’t do that any more, he simply says that Cline had seen attachment disorders (as he defined them) as psychosocial in nature, and now the field sees them in terms of trauma and brain development. What difference this would make to diagnosis or treatment, the supposed topics of this video, was left unstated.

5. (8:40) Barbara Rila comments on what will happen to children with attachment disorders (undefined)  if they don’t get  proper treatment (also undefined). She claims that the consequences in adulthood will be borderline personality, anti-social personality disorder (this of course has been the mantra of ATTACh for years, usually with names like Jeffrey Dahmer associated), depression, and suicidality. Proper treatment is supposed to ameliorate all of these.

Rila does not compare these statements with the reports of Michael Rutter and the English-Romanian Adoptees study to the effect that the great majority of the children they studied, who had been adopted from the worst possible conditions and therefore most likely to show attachment disorders, did very well. Some were reported as having quasi-autistic features, and some were unusually friendly with strangers as young children, but all were doing quite well in their teens. None were reported as anti-social in behavior; the most common problem was delayed language development.

Rila, by the way, was the author of a chapter on attachment disordered adoptees in a 1997 book edited by Roszia. In the abstract for that chapter, she says "The process of attachment therapy essentially reenacts the attachment cycle. An attempt is made to elicit the child's emotional pain or experience that is blocking present attachments"--  in other words, Rila at that time, at least, was a supporter of holding therapy.

             6. (10:49) Michael Trout states that practitioners now have most of the tools needed to treat attachment disorders (undefined) and that there is hope for children with problematic early experiences. One of his reasons for this statement, he says, is that “babies remember” and their behavior has meaning that helps us understand what they remember.

Let me just point out that Michael Trout is involved not only with ATTACh (which gave him an award) but with the Association for Pre- and Perinatal Psychology (APPAH), a group dedicated to the idea that babies are conscious of their prenatal and even pre-conception experiences as well as remembering the details of their births, and that telepathic communication before birth traumatizes babies whose mothers consider terminating their pregnancies.

One member of APPAH, William Emerson, has performed and encouraged infant massage techniques that will make babies re-experience the discomforts of birth, cry, and thus experience catharsis. His position is that babies need to cry in order to express themselves and escape the effects of early experience. This APPAH position, and Trout’s statements about how “babies remember”, raise the question of physically-intrusive treatment of the holding therapy type and the extent to which they have actually been rejected by ATTACh.

As is so often the case, a careful examination of this ATTACh production in the light of other information suggests that there is less expertise here than appears to meet the eye.

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