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Concerned About Unconventional Mental Health Interventions?

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

Thursday, November 8, 2012

Diagnosing Reactive Attachment Disorder with Scales and Questionnaires

I’ve recently been having a correspondence with a birth mother whose two school-age sons have been placed in treatment with an attachment therapist by their stepmother. One child is now being placed in residential treatment. The attachment therapist, who is also evaluating the children and recommending a custody arrangement (he’s a social worker; a psychologist would not be permitted to wear two hats like this), says he has diagnosed one boy with Reactive Attachment Disorder by means of an unidentified scale.

What scale might this be, I wonder? Can there be a scientifically validated test of this type? Psychological scales and tests are generally developed in one of two ways. The first, the one used with intelligence tests for adults, involves developing a large set of questions, throwing out all the ones that everyone or no one answers correctly, and then determining what proportion of the population gets specific scores on the remaining questions. An IQ score is a shorthand statement of how well the person did in comparison with a lot of other people. (Tests for children are a bit different and need to be done separately for each age group.)

In the second method, there is some known accurate way to detect or diagnose a personality characteristic (for example), but it takes a long time to do it or requires special training. The test developers seek information that is easier to get and that correlates highly with the known accurate diagnosis. When the test is developed, it allows less trained people to diagnose in a short time a condition that otherwise takes a lot of work on the part of an expert. This is a good outcome if there really is a reliably accurate way of diagnosing, and if the new test is strongly correlated with that way of diagnosing. If there is no reliable way to diagnose a condition, or if the proposed test does not correlate very well with the accurate method, it may not be useful to employ the new method.

Both of these methods of test development require meticulous work and data analysis. The second method also demands a good design in which people collecting information from the test do not know that diagnosis someone has previously given the tested individual, for example.

Although there has been a good deal of research on the proportions of young children who show different attachment statuses, there is little on that topic for school-age children, and even less on proportions of children diagnosed with Reactive Attachment Disorder. One of the reasons for this lack of research is that no one has put forward a valid technique of diagnosing Reactive Attachment Disorder. The lack of such a method obviously also makes it impossible to follow the second method and develop a scale or questionnaire that gives an accurate diagnosis.

So what scale could the attachment therapist mentioned above have used in his diagnostic efforts? There have in fact been some attempts to create such a test, but so far all present serious problems.

The Randolph Attachment Disorder Questionnaire (RADQ), published by Elizabeth Randolph in 2000, is one of the most questionable efforts along this line. For those who have heard of this or even used it, let me point out an awfully important point:
The RADQ is not intended by its developer to diagnose Reactive Attachment Disorder. It addresses a different set of problems, posited by some attachment therapists and called simply Attachment Disorder.
Calling the test the RADQ and the disorder RAD does suggest that the test is about Reactive Attachment Disorder as commonly defined, but no---  the R is for Randolph.

Whatever the RADQ is meant to diagnose, it does not really matter very much, because Randolph herself observed and diagnosed the children and supervised the parents who filled out the questionnaire, as well as doing the data analysis on information whose background she knew. To comment on this is not to attack Randoph’s integrity; no researcher should trust himself or herself to avoid biases about known information. That’s why everyone is expected to be “blind” to any information that could skew diagnoses or measurements or mathematical analysis. Randolph did not take care about this, and as a result her complicated calculations amount to “garbage in, garbage out”. In addition, she did not clarify what she was looking for when making her own diagnosis, and since in a 2001 publications she stated that she could diagnose RAD from the fact that a child could not crawl backward on command--  well, need I go on?

IN spite of the shortcomings of the RADQ, Sheperis and his colleagues (“The development of an assessment protocol for Reactive Attachment Disorder”, Journal of Mental Health Counseling, 2003, Vol. 25, pp. 291-310) used the test along with various others and proposed that this battery would assess RAD in school-age children. However, in 2005, Cappelletty, Brown, and Shumate examined correlations between the RADQ and other sources of information (“Correlates of the Randolph Attachment Disorder Questionnaire (RADQ) in a sample of children in foster placement”, Child and Adolescent Social Work, 2005, Vol. 22,pp.71-84) and found that the scores for children in foster care (who would presumably be most likely to be categorized as having RAD) were not significantly different from those of other children. These facts suggest that it would have been a mistake for the attachment therapist to have been using the RADQ to produce the diagnosis.

What about other scales? Thrall, Hall, Golden, and Sheaffer (“Screening measures for children and adolescents with Reactive Attachment Disorder”, Behavioral Development Bulletin, 2009, Vol. 15, pp. 4-10), who apparently can’t spell Cronbach, used two questionnaires which they said discriminated between individuals who had been diagnosed previously with Reactive Attachment Disorder and those who had not. They noted that for those children with a RAD diagnosis, “the diagnosis of RAD, disinhibited subtype, had been made by a mental health practitioner specializing in attachment disorders” and that the children were now in treatment. This raises a question about the original diagnosis, because although most child mental health  practitioners consider attachment issues to be of importance, very few of them would describe themselves as specialists in attachment disorders unless they were much involved with the whole attachment therapy belief system. Thus, it’s questionable whether the questionnaires used by Thrall and her colleagues would actually have discriminated between children diagnosed with RAD by conventional practitioners and those receiving other diagnoses.

One more approach to be considered here: Helen Minnis, a Scottish psychiatrist, has spent years in trying to develop scales to diagnose RAD. (The Thrall paper used one of her questionnaires.) In 2010, Follan and Minnis (“Forty-four juvenile thieves revisited: From Bowlby to Reactive Attachment Disorder”, Child: Care, Health, and Development, Vol. 36, pp. 639-645) proposed a battery of tests to identify RAD for  research purposes (in other words, with less accuracy required  than we would demand for individual evaluation). Very interestingly, Follan and Minnis argued that concerning behaviors were probably due to early maltreatment and genetic vulnerabilities rather than to separation, and that current secure attachments could exist side by side with the condition called Reactive Attachment Disorder. They also noted that “insecure attachment is likely to be very common in child psychiatric populations and although its measurement is useful to develop   a holistic understanding of the child, is not an indication of disorder in itself.”

To conclude, then, there are some points to be made with respect to the attachment therapist who is using a scale for diagnosis of RAD. The first is that there is no scale of this type that  provides the sort of reliable and valid assessment that should be required for use in legal decisions about custody of children. A second is that there may be no reason whatsoever to seek a specific diagnosis of this kind--  other than the fact that insurance claims demand one. As Follan and Minnis note, whatever the concerning behaviors displayed by a child, they may have little to do with attachment per se, and therefore, I would point out, do not require treatment that focuses on attachment. In addition, evidence-based treatments focus on specific characteristics of children and parents rather than assuming that they indicate attachment problems; treatments that make attachment issues the central concern are not at this time evidence-based, although some practitioners make this claim.  


  1. Interesting that you say "he’s a social worker; a psychologist would not be permitted to wear two hats like this." I don't know enough about the two professions to understand why that's true. Is the reason because of different codes of ethics?

    Is it better, in general, for parents to choose a psychologist over a social worker for therapy, even if the social worker has many years of clinical experience?

  2. The ethics guidelines adopted by the American Psychological Association specifically prohibit psychologists from doing both the therapy and the evaluations that will be used in court for an individual or family-- the intention of the guidelines is to keep the psychologist from inadvertently paying too much attention to issues he or she sees from a personal rather than an objective point of view. As far as I can see, social workers have no specific prohibition of this kind, although their ethical guidelines caution them that they should clarify with every member of the family exactly what their (the social workers') roles are.

    If you're talking about choosing a therapist to work with children or with the whole family, I would say that a psychologist is a good deal more likely to have had training in the facts of child development than a social worker is (although there are obviously psychologists who have concentrated entirely on adult life, and some social workers who have looked closely at child and adolescent development).

    Psychologists are also more likely as a group to be aware of the need for evidence-based treatments, although some social workers are now supporting this idea.

    I don't know whether many years of clinical experience make so much difference in the quality of care if the practitioner has not continued to be trained in methods that are supported by good research. Of course, this would be true for psychologists as well as for SWs.

  3. It wasn't only backward crawling that Elizabeth Randolph thought was diagnostic of "AD." She wrote:

    "Inability to do the developmental movements, particularly with pressing to all fours, rolling from back to front by reaching, and backward crawling seem to be particularly common among children with AD, and are only very rarely seen in children who don’t have AD."

    I think it was 2001 that I attended a presentation by Randolph. She brought onto the stage a teenage girl with "AD" and had the girl demonstrate all the things she was physically unable to do. Randolph also claimed that people with AD are unable to swing their arms when they walk, and the girl demonstrated that, as well. After a break in the conference, the lawyer sitting next to me said she saw the girl walking outside, walked around...and swinging her arms with no problem.

    What concerns me is the prevalence of belief in the existence of Attachment Disorder (but usually referred to as RAD) and how it tends to paint adopted and foster children, who are allegedly commonly afflicted with the disorder, as potentially dangerous. It almost seems like criminal profiling.

    And another thing. It appears that parents of adopted or foster children will use the RADQ, or similar checklists, to diagnose their children themselves.

    1. Another disturbing factor is that babies who are sleeping on their backs, per instructions to prevent SIDS, are likely to be delayed in the developmental milestones you quoted, relative to the existing norms which were taken from data on prone-sleeping babies. This means that parents who believe in Randolph's claims and are watchful for signs of AD may decide they see this notional disorder in infants in the first year of life.

      In addition, toddlers and preschoolers, whose torsos are inflexible because they have not yet developed some rib movements that occur slightly later, do not swing their arms when they walk. Arm-swinging results from counter-rotation of the shoulders to maintain balance as weight is shifted from one foot to the other. If your torso doesn't bend, you don't counter-rotate your shoulders, and your arms don't swing. Therefore Randolph's "signs" condemn most preschoolers to an AD diagnosis.

      Once again, we see the RAD/AD crowd displaying abysmal ignorance about normal developmental changes, just as they show it about natural changes in attachment behavior.

  4. I discovered, in the middle of an IEP meeting for my (foster/adoptive) daughter this week, that she's been diagnosed with RAD by her psychiatrist; no one let me know. But when the school was asking about her medications and diagnoses, and I offered ADHD and PTSD, her social worker chimed in "And RAD." I must've glared at her, because she then whispered to me, "The psychiatrist provided that diagnosis for the Rogers Order." Long story, but in Massachusetts any foster child who needs to receive an atypical anti-psychotic medication needs to have court approval via something known as a Rogers Order. After many other medications were tried, the only medication that helped my daughter get a handle on her aggression (while we attend therapy 3 times weekly) turned out to be Risperdal, and the psychiatrist prescribed it on an emergency basis. She never spoke to me about adding (or rather, reinstating) a diagnosis of RAD. (My daughter had been previously diagnosed with RAD by a social worker, who was recommending that she be placed, permanently, in a group home, at age 10, because she'd never be able to live in a family. Subsequent therapists dismissed that diagnosis and prognosis, with good reason.) So, added to the "need" for a RAD diagnosis by insurance companies, you might want to add the need from the courts, although I'm not yet sure whether that's why this psychiatrist has diagnosed RAD or whether she actually believes it. Time for a discussion, for sure, though I don't believe the diagnosis is correct.

    [I'm posting anonymously to preserve some privacy for my daughter.]

  5. I am certainly learning a lot here. What a disturbing thought, that the courts have bought into this idea! Please,if you don't mind,let me know if you manage to find out whether this was just a pragmatic move on the psychiatrist's part, or what.

  6. Yep, I will. We see the psychiatrist every 2 months, so it will take a while to get an answer. I'll poke around too and see what social workers know about how the judges in our area tend to rule on Rogers Orders requests, and whether a RAD diagnosis usually helps to get an affirmative ruling. Risperdal is clearly indicated for aggressive behaviors; there's no need to bring RAD into it. But too many people can't seem to comprehend that aggression in children can arise from ADHD and PTSD---and lack of age-appropriate social skills or exposure to domestic/institutional violence (including the overuse of restraints in residential treatment centers), which are very common among older children who have spent years in foster care. But our culture doesn't like to treat or medicate for problems that its own system of "care" helps to create. Diagnosis: Foster Care System Disorder. Treatment: Years of therapy and anti-psychotics. Nope, it's not likely that we'll look at our damage-causing processes head on; let's look for the flaw in the child, instead---or in the birth family, who in most cases cannot respond with any facts that might be relevant or will not be believed.

    1. Go for it-- I have to say I dread to think what you're going to find out.

  7. I am a limited licensed psychologist with a Psychology Specialist degree in Michigan. A couple of points: A Forensic Psychologist (specializes in legal testimony) is kept separate from the treating psychologist. Code of Ethics 7.03 “In most circumstances, psychologists avoid performing multiple and potentially conflicting roles in forensic matters. When psychologists may be called on to serve in more than one role in a legal proceeding - for example, as consultant or expert for one party or for the court and as a fact witness - they clarify role expectations and the extent of confidentiality in advance to the extent feasible, and thereafter as changes occur, in order to avoid compromising their professional judgment and objectivity and in order to avoid misleading others regarding their role.”

    In the Peamble to the Code of Ethics, psychologists “…perform many roles, such as researcher, educator, diagnostician, therapist, supervisor, consultant, administrator, social interventionist, and expert witness.” The treating psychologist is mandated to ONLY treat what (s)he concurs with diagnostically. In order to provide psychological treatment, the psychologist must provide a diagnosis to provide treatment.

    Secondly, there is not a diagnostic test to determine the presence or absence of Reactive Attachment Disorder. The RADQ stands for Randolph Attachment Disorder Questionnaire, not Reactive Attachment Disorder Questionnaire. Her criteria are not the same as the DSM-IV-TR criteria. While it is one of the better known of Attachment Disorder checklists, its use by attachment therapists and others to diagnose RAD is simply and clearly unethical. The checklist includes 93 discrete behaviors, many of which either overlap with other disorders, like conduct disorder, oppositional defiant disorder, ADHD, bipolar disorder, and adjustment disorder, or are simply not related to attachment difficulties. While the checklist may be extremely helpful to identify specific symptoms, it cannot be used to diagnose or even support a diagnosis. It has no official recognition, has had no validity studies, has not shown the ability to produce results that a differential diagnosis wouldn’t better explain, to mention some difficulties off the top of my head.

    Hope this helps – though I realize it is about a year after the original posts.

    Joe Elwart, Psy.S., LLP

    1. Thanks for the agreement, Joe.

      Your comments about the different hats to be worn are certainly correct on paper, but it's very common in rural areas to find that any psychologists present are doing all the jobs to be done, as well as buying grass seed from their patients at the hardware store on weekends. A judge who tries to enforce differences between forensic and treating psychologists will get into trouble for demanding that the county pay for someone to come from a distance and testify, when there's a psychologist right there who always works with the court anyway.

      By the way, the case I mentioned in this post is still hanging fire, the bio mother has not been allowed any contact with the children, and there is talk of freeing one of the children for adoption-- even though his mother is able and willing to care for him!

  8. "identify RAD for research purposes (in other words, with less accuracy required than we would demand for individual evaluation)"

    Less accuracy? I always thought research diagnoses were more accurate. Clinicians sometimes put kids in a diagnosis that they feel meets their needs, even if it's not technically accurate. Meanwhile, researchers are just focused on the technical accuracy of the criteria, not on whether they think this kid needs therapy funding that is earmarked for X diagnosis.

    1. The thing is, researchers are interested in studying differences between groups of people. On the whole, they are not attempting to make predictions about an individual (e.g., if this person gets a weekend pass from the mental hospital, will he murder his mother with an ax?). Predicting which group will do less ax-murdering, on the average, does not require the same accuracy as predicting which individual will do less. The fact that clinicians sometimes fudge diagnoses (especially of RAD) is neither here nor there.

    2. Just because you want to predict whether a specific individual will be an axe murderer doesn't mean you can. It's only possible to predict that for groups - the researchers are being more honest, not less accurate.