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Concerned About Unconventional Mental Health Interventions?

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

Wednesday, November 27, 2013

Attachment Disorder-- or Life Context?

Last weekend, my husband and I visited friends in another state, a family that has one 9-year-old child, a boy adopted from Latin America when he was 11 months old. On Monday morning, I saw an interesting little scene: before young Phineas (which I’ll call him because it’s pretty obvious that it isn’t his name) was about to leave for the school bus, his mother called him to give goodbye kisses to my husband and me, because we were about to go home, and then she wanted a hug and kiss for herself. Phineas came to her and let her put her arms around him, but he turned his face away with a blank, withdrawn expression and did not participate.

I was struck by the resemblance between Phineas’s behavior and the failure to be affectionate “on the parent’s terms” that proponents of Attachment Therapy regard as a symptom of  Reactive Attachment Disorder (or of their notional entity, Attachment Disorder). And of course there were various other cherries that could be picked to build support for this diagnosis: separation from the birth mother very early; care by a foster family, then separation from them for placement with his adoptive parents. He even had to be told not to be quite so rough with the dog on Sunday afternoon.

So,shall we jump to the conclusion that Phineas is a sad case of RAD, or AD? Let me offer some alternative explanatory factors.

First, let me point out that nine is an age when most children begin to look outward from the family and concern themselves less with their parents and more with their peers. The hugs and kisses that they used to like so much now become more formalized, except perhaps at bedtime. Rough-and-tumble play is very much part of their lives, and they may need to be reminded that pets don’t communicate in the same ways their friends do.

In addition, Phineas’s life has had some bumps in it over the last two years. His developmental pathway had been very smooth in every way, until two events occurred a couple of years ago. The first was that his mother, who is a medical professional, developed an allergy to latex that was of life-threatening proportions. If Phineas had touched rubber bands or latex balloons and then touched her or kissed her, she had a reaction that required a visit to the emergency room, often, of course, with Phineas in tow. Even a visit to a store that had a display of latex balloons could do this, and Phineas became a balloon-detecter, looking around him carefully as they entered each new place. On a couple of occasions, balloons at Phineas’s school meant that his mother had to leave quickly, and there was much correspondence as the mother asked school staff to help her by excluding latex balloons . If the balloons were there, she could not go to the school for classroom visits or parties or many of the events other parents attended (and Phineas’s father’s job rarely gave him the chance to do these things).

At that point, Phineas received a head injury in a playground accident and suffered from post-concussion syndrome that continued over more than a year. He could not tolerate loud noises or crowds, cried easily, and was afraid of another blow to his head. His school attendance had to be managed carefully. And of course this was all complicated by the fact that his mother could not go with him to a doctor’s office unless she knew it was latex-safe, so even his medical care had additional complications. (He also had a medical problem involving a mass on a testicle, which fortunately resolved without further treatment.)

Last summer, just as the effects of the concussion finally seemed to be over, two elderly, much-loved members of the family died, and Phineas’s maternal grandmother had two heart attacks. To help deal with this, his mother went away for two weeks at a time to the neighboring state where her mother lives, leaving Phineas with his father--  the best possible situation for him, but also the first real separation he had had from her.

A week ago, Phineas’s school started a new fund-raising project, making and selling necklaces made of stretchy bands--  latex, of course. His mother told him she would be fine if he did that as long as he changed his clothes when he came home and put them in the washer so she did not have to touch them. But on the school bus he had to sit next to a boy who tends to bully, and when the boy pulled out his rubber bands, Phineas told him “don’t touch me with those, I don’t want to get latex on me. It makes my mother sick. She might even die.” The other child, not surprisingly for him, took this as provocation and rubbed the bands all over Phineas’s shirt, saying “I’m killing your mother!”. Phineas got off the bus in a storm of tears and told his mother “I don’t want you to die! Please don’t die!”

A few days later, Phineas turned his head away when his mother wanted to kiss him goodbye before he went to school. Do we have to look to an attachment disorder to explain this? I think not! This child is intensely attached to his mother, and not unrealistically afraid of losing her. What can he possibly do to feel better about this? His only option is to try to avoid the vulnerability he feels--  or at least to try to act as if he isn’t vulnerable. To interpret this behavior as meaning a lack of attachment would be absurd, and to attempt to treat it by placing him in “therapeutic foster care” would simply exacerbate his fear.

Am I saying that there is no such thing as Reactive Attachment Disorder? Not exactly; I think there are behaviors of quite young children that stem from disturbed attachment relationships. But when we see years of typical development, and then “aloofness” in family relationships, I believe we do well to examine these in the context of all the child’s experiences, both early and recent. Most contextual factors may not be as obvious as they are in Phineas’s case, but they need to be searched for before we assume that attachment is the problem. 


  1. It's so true that context matters. And then there are individual differences between children, too. One of my sisters just didn't like kisses, as a small child, even from our mother, and even when she wanted to be hugged/give hugs! She'd tolerate having mom or dad or a sibling put their arms around her shoulders and their head next to hers, but a peck on the cheek would have her protesting strongly. As she was otherwise developing normally and expressing affection very clearly in her own way, my parents were not upset: they just put it down to "well, she already has a strongly defined personality, this one", and be proud of her even though she challenged their assumptions of how children typically behave. All the other kids in the family were OK with being kissed, just not her. Oh, and she wasn't adopted, btw, we were all biological children of our parents. There were various other sorts of problems in the family, but at least our parents were wise enough (or secure enough in their role as parents?) to allow each kid to express his or her own individual personality.

    1. Good points-- temperament makes so much difference, but when parents are convinced that experience is all that shapes personality, they have a lot of trouble considering those individual differences.