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

Sunday, July 13, 2014

The Randolph Attachment Disorder Questionnaire: When a Psychological Test Is Not a Test

On several occasions over the last couple of years, I’ve referred on this blog to the case of a mother whose children’s fates seem to be under the control of one Forrest Lien, LCSW, of the Institute for Attachment and  Child Development in Colorado (for instance, http://childmyths.blogspot.com/2013/01/kafka-again-more-on-capture-of-child.html).

As recently pointed out by my colleague Linda Rosa, it turns out that Lien was working under a “stipulation” by his licensing board for some years, beginning in 2009, following an unstated problem in his work. This stipulation, as noted at
required him to be supervised  and mentored by another social worker for two years--  a requirement that must have been rather galling for someone who had years of experience and who was accustomed to supervising others. In addition to the supervision, Lien was required to take 30 hours per year of approved continuing education courses dealing with assessment and diagnosis, ethics, dual relationships, clinical supervision, and recordkeeping.
All of these continuing education requirements give us some idea about the problems that got Lien into trouble in the first place, but the one that needs the most discussion is the requirement for study of assessment and diagnosis techniques. This topic is of interest because of Lien’s past advocacy of tests and diagnoses without acceptable evidence bases. His IACD website, www.instituteforattachment.org (under previous guises), had been engaged with inventive but unsubstantiated diagnostic approaches in the past, then had stopped mentioning them.

But the IACD site is once again making claims that are unsupported and selling a test that has never been demonstrated to be valid or reliable: the Randolph Attachment Disorder Questionnaire (RADQ, not to be confused with another test with the same acronym developed some years ago by Helen Minnis). The RADQ was developed and marketed by Elizabeth Randolph, a practitioner who had lost her license in California and moved to Colorado.

What do I mean when I say that a test has not been shown to be either reliable or valid? Some readers will know this, and others may remember it vaguely from Intro to Psych, so I think I’d better clarify.

Psychological tests have two jobs to do. One is to identify problems quickly and easily, without having to wait years to see how development goes, or having to commit months of time to tedious observations. The other is to help decide whether a treatment has had the effect it was intended to have, and thus whether it should be used again.

In order to do these jobs, a test must be reliable and give the same results each time it is given to a person, unless something like a treatment has acted to change the underlying condition. In addition, the test must be valid--  it must test what it is supposed to test.

 To find out whether a test is reliable, several methods can be used. Sometimes there are two or more test administrations to a group of people, and the results are examined mathematically to see whether they are sufficiently similar. Sometimes the test results for a group are “split” so that the results from one half of the test questions are compared with the results from the other half, and the comparison is examined as before. Reliability is very important when a test is used to determine whether a treatment is effective; if the test does not ordinarily give the same results each time, it can hardly be used to detect whether the treatment changed patients’ characteristics.

However, validity is even more basic to the usefulness of a test. If a test does not give information about the issues it purports to examine, it adds confusion instead of clarity to assessment. But how do we know whether the test is valid? We have to find out whether the test results give us information about people that are similar to the information we could get in some other, more difficult, more time-consuming way. For example, we might give a test to a group of children, then wait until they grew up and see whether the test had done a good job of predicting their adult characteristics. Or, we could give the test and compare it with the results from some other well-validated but expensive or cumbersome test we wanted to replace. Or, if there was agreement among clinicians about how to diagnose a problem, we could give the test, and compare its results to the diagnoses given by clinicians who did not know anything about the test or its results and who were not involved in the test administration.

Let’s look at the RADQ in terms of validity. First, Elizabeth Randolph herself says in her test manual that this is not a test of Reactive Attachment Disorder, but of some other “unofficial” disorder she calls Attachment Disorder. Confusingly, although many people shorten Reactive Attachment Disorder to RAD, the R in RADQ is for Randolph, not Reactive. What is Attachment Disorder, then? According to the IACD website, it is a term that covers a number of dissimilar problems, each with different symptoms as described in DSM or ICD: Reactive Attachment Disorder, Oppositional and Defiant Disorder, Post-Traumatic Stress Disorder, childhood trauma effects, and Pervasive Developmental Disorders (now usually called Autistic Spectrum Disorder). Whatever AD is, it can begin before birth when baby and mother do not bond prenatally (whatever this means) or can occur later. Its symptoms, or perhaps I should say the symptoms of all the diagnoses mentioned earlier in this paragraph, are said to include the usual list used by attachment therapists, including cruelty, provocative behavior, lying, and superficial charm, none of which are actual symptoms of most of the diagnoses named as making up AD.

Evidently, there are problems here. The RADQ is presented as a way to diagnose a number of dissimilar difficulties of behavior and mood. Yet it consists of a fairly small number of questions. Are the answers used to detect a pattern of behavior that is characteristic of each of the diagnoses? No, the total number of answers is supposed to measure the notional Attachment Disorder that somehow shares the sometimes-contradictory characteristics of a whole set of different diagnoses. There is no clear definition of the problem to be assessed, so it is impossible to work out whether the RADQ is a valid assessment of … something.

There’s more to deal with here. Randolph says she can diagnose AD; one of her methods is to see whether the child is able to crawl backward on command. [I’m just reporting the news, you understand.] So, she can identify AD, and she will validate her test by seeing whether she and the test come to the same decision about each child. In order to do this, of course, what she needed to do was to have someone else administer the test, and to look at the mathematical relationship between the test results and her assessments of a group of children. But, no. That was not what happened. Not only did Randolph administer the test herself, she did so by discussion with each child’s familiar female caregiver. The RADQ is not a test of what children think or do, it is a test of what their mothers or guardians say they think or do. Randolph, who had already worked with and knew the children, administered the test by talking over each question with the caregivers until she and the caregiver came to a conclusion about the correct answer to the question. In other words, Randolph, who had already come to a conclusion about the child, guided the caregiver to a set of answers on the RADQ--  perhaps unwittingly, but it is impossible to think that there was no influence brought to bear.

 Not astonishingly, there was a high correlation between Randolph’s diagnosis and what the RADQ responses said, so Randolph reported that the test was a valid one. But, of course, it was not, and would not have been even if AD existed as a disorder in any meaningful sense. To validate a psychological test, the test administration and the validating criterion (in this case, Randolph’s diagnosis, whatever it meant) must be independent of each other to begin with. If they influence each other, one will predict the other without actually being a valid way to assess a problem.

What does all this mean about Forrest Lien and the IACD? If they are selling the RADQ, as they advertise on the website, they are committing what appears to be a fraudulent act. If they have paid the slightest attention to the professional literature over the last ten years, they must be aware of the criticisms that have been leveled against the RADQ, and are selling it anyway. If they have not paid any such attention, they have failed to keep up with professional development and are not meeting the  practice standards required for continuing licensure.

The stipulation under which Lien practiced for some years did not clearly state the reasons for the disciplinary action, but it did require him to do further study about assessment and diagnosis. Could it have been the use of the RADQ that was the original problem, and that was why the test disappeared from the website for a while? If so, what will happen now that the RADQ is back? What ought to happen is pretty clear to me.  


  1. This comment has been removed by a blog administrator.

  2. Trouble is, real therapists want to talk about what's going on in the home and to deal with parents' feelings and attitudes as well as children's-- this does not jibe with the wish to just get the child repaired as cruises do.

  3. The blogger linked above blogs under a pseudonym. She doesn't use her daughter's real name on the blog and she doesn't allow any faces to appear on the blog. I'm disappointed that this blog would condone and publish a comment doxing that blogger, and more importantly, that blogger's minor daughter. Whatever issues Anonymous has with the blogger's parenting strategies, those could have been expressed without providing the first and last names of the girl and her mother. That girl is old enough to Google herself. Her friends are old enough to Google her and her mother. Even if her mother was wrong in putting it all out there (albeit under a pseudonym), there is something equally if not more disturbing about Anonymous's spreading comments (apparently on more than one site) intending to link the blogger with the family's (and the minor child's) real names. Dr. Mercer, please exercise some discretion.

    1. Your point is well taken. I apologize and have deleted that post. If Anonymous would like to re-submit her comment without the real names, I will post it again.

    2. That blogger happily posts both her full name and the name of her blog all over the internet:


      It's not doxxing if the blogger in question happily outs herself.

      In any case, without names -- a blogger who adopted an older foster kid out of a psych hospital placement didn't bother to find her a therapist for years and years while the kid refused to go to school, threatened to kill herself, trashed the house, etc bc it was too expensive.

      The kid had a breakdown that warranted a two-week in-patient stay on a psych unit a few months back, amommy still can't afford / be bothered to get her kid a therapist but finds plenty of cash to take her daughter on an expensive Caribbean cruise!

  4. 40% of U.S. children lack "secure attachment"?


    1. Yes, and 50% of people are below average in height. Neither insecurity of attachment or shortness of stature is necessarily a problem.

      Here's how this attachment situation came about: Mary Ainsworth's dissertation adviser had a personality theory involving three levels of security. When Ainsworth developed the Strange Situation for assessing attachment, she saw three patterns of behavior with respect to toddlers' responses to a reunion after a brief separation from their mothers. She gave these patterns names related to the apparent quality of security in the relationship. All three patterns were considered to be within a normal range-- it was only much later that disorganized attachment was described as a concerning behavior.

      Although secure attachment is associated statistically with somewhat better outcomes, there is nothing abnormal about insecure (but organized) attachment patterns. In addition, because security of attachment is characteristic of a relationship, a child might have an insecure attachment with the person present during the observation, but a secure attachment with someone else. Also, many people re-work attachment attitudes as they grow up and have more experiences, so people who were insecure as toddlers may test (on a different sort of test) as secure in adulthood.

      The problem is not in the proportion of people with secure or insecure organized attachments, but with the inappropriate conclusions that are drawn about those proportions.

    2. As a psychologist in training, that link made me chuckle.
      Firstly, they're acting like it's a new discovery, when we've been finding the same percentage of insecure attachment ever since Ainsworth first discovered them in the 70s.
      And secondly, as Jean Mercer pointed out, insecure-organized attachment styles, which make up most of that 40%, are within the normal range. Sure, they're at higher risk of psychological issues than securely attached people. But the majority of people with insecure-organized attachment styles are functioning just fine.
      I do think that parent training to promote secure attachment would be a good idea, but it would be more of a general preventative treatment, kind of like immunization. We certainly aren't facing a crisis because 40% of the population is insecurely attached.

    3. You probably know that Donald Winnicott used the term "good enough mother"-- maybe we need the concept of "good enough attachment style".

      It was interesting to me once to hear a rather well-known psychologist who works on attachment state that she herself would probably have tested as insecurely attached. Perhaps it's cherry-picking to look only at the downside of insecure attachment, as people usually do-- maybe there are advantages as well to having this style.

  5. The faux attachment gurus with faux "attachment disorder" criteria seem so arbitrary -- because SO much of it is, frankly, normal kid behavior. And pathologizing normal behavior does nobody any good.

    This mom is upset that her biological, adult daughter (a college sophomore) who has NO attachment disorder, who by the mom's account is a smart, successful and socially well-adjusted girl, isn't "cuddly":


    The kid is entitled to not be cuddly or to be cuddly on her own terms. The mom seems like a genuinely good mom -- whose daughter would probably like her a whole lot better if she wasn't constantly trying to manhandle her!!

    1. It seems to be very hard for people to think of what is developmentally appropriate treatment or behavior-- they seem to think that everything should be just the same at every developmental stage, and something's wrong if it isn't. On the contrary, something would be wrong if it were the same all the time.

  6. I'm off topic again, but I want to know. American adoptive parents gain knowledge about the characteristics of the children of national peculiarities from other countries? Temperament, tradition, the age of puberty have implications for American adoptive parents? Why are they fixated on RAD diagnosis and various manifestations of this diagnosis? Some children of Siberian regions may not show outward signs of love and affection (kissing, hugs etc.) But they can not eat chocolate and secretly donated put under his mother's pillow. This is a manifestation of love. Or the child is making progress in the dance, but he does not like to dance. He's doing it for mom so she smiled and was happy. The boy can not show outward signs of love for her father, but the boy secretly trained on the bar to his father saw him success and surprised and pleased. It is also a manifestation of love. Is not it so?

    1. Most American adoptive parents do pay attention to national and cultural differences and work hard to make sure they are making these part of their family life. By no means all are ready to call on the RAD diagnosis. but unfortunately a significant number have been persuaded that a frightening and dangerous mental health disorder is prevalent among adoptees. There are a variety of personal,political, and religious beliefs that make this group of people easy prey for propaganda about adoption, and I think some of those beliefs are probably more common in the U.S.

      However, it would be a mistake to think that most American adoptive parents follow this belief system-- although it may be becoming more common as TV and movies adopt the "RAD" narrative.

    2. I don't think "most" American adoptive parents fixate on RAD or self-proclaimed trauma mama faux-RAD symptoms -- but I'd hazard a guess that a TON of the bad adoptive parents, the ones MOST likely to blog private medical / behavioral troubled their adopted kid is supposedly demonstrating are OVER-REPRESENTED in the blog-o-sphere. These are the adoptive parents who blog, who organize "trauma mama" conferences like Orlando, Beta + Hope Rising -- because they've managed to alienate everybody and anybody who politely suggests that maybe they should not violate their new kid's privacy in such a blatant manner!

      I'm assuming the good (or even just the sane) adoptive parents have too much common sense to blog about their kid's "troubles" for the universe at large to see. They treat their adopted kids like decent parents treat their biokids who have health/mental health/behavior challenges -- they get the kids the treatment/help they need WITHOUT putting it up on the internet!

    3. I think Mihail's concerns are about parents who become involved with "attachment therapy". Yours, Caylee, seem to be somewhat different, although it's quite true that the authoritarian thinking of AT practitioners could well lead to nonchalance about disclosing confidential matters.

    4. I'm not trying to blame all American adoptive parents. Many thousands of successful adoptions in the United States. Thousands of orphans have found loving parents and a chance for a better life. This is indisputable. But I think some adoptive parents are vain and want to become famous. They are trying to self-actualization through foster children (written observations of a foster child, participation in television shows, educational seminars where adoptive parents disgrace adopted children and tell terrible stories ...). It makes life rich and diverse housewives. I think if these seminars in a positive way and allow adopters show off the achievements of foster children (in school, in art, in sports, etc.) .... May be less willing to shame children and invent stories about how two - year-old russian kid running around the home for 150-pound mother and tried to kill her manicure scissors. Maybe I'm wrong but I think that some adopters have the desire for fame and notoriety.
      We need to give them a chance to "glorified" but with the least damage to the child.

      Visitors from the USA at the festival tourist foster families and orphanages in the village of "White Lake"
      Festival of foster families (Siberia)

      In Russia these events not have large scale, because financial constraints ..... but in the US it might be more popular.

    5. I think people's motives for adoption are poorly understood (just like their motives for choosing to have biological children), and they may well include some of the factors you mention. It seems to me to be problematic to encourage people to achieve "glory" through their children's accomplishments, but if this is what they have to have, the way you suggest might be a harmless way of gratifying that need.

  7. Intellectual maturity adopter sometimes not more than a foster child.
    But the adoption took place. If the adoptive parent reads books Attachments therapists .... it can provoke a tragedy in the family. It would be better if the child will be on view in-school, sports club, a children's theater ... should at least ensure минимальную security of the child.

    1. It's a good point that involving the child and the family in the community helps enforce community standards-- this is why AT proponents often prefer to stay only among those who agree with them.

  8. Criminal liability may warn adopters and charlatans.
    There should be no excuses for sadists and murderers. Born child in the family or in the street he was born and lived in an orphanage ......... it does not matter. Baby drinking milk from breast or he drank milk from a bottle ..... does not matter. Child likes adoptive parent or child indifferent to the adopter .. it does not matter if the adopter and charlatans committed a crime against this child.

  9. One more seriously misinformed adoptive parent claims Dr Phil is "ignorant of adoption and attachment" because he failed to cite a condition that doesn't exist ("attachment disorder") and symptoms that aren't officially part of the RAD diagnosis as a potential reason for the out of control behavior of a 24 yr old adopted young adult who appeared on yesterday's show:


    The man in question was adopted at birth and an exemplary human being until age 18 (honor student, athlete, lots of friends, no legal troubles) -- who fell apart (drugs, alcohol, addiction, violence, arrests) shortly after moving into his college dorm.

    I'm not a doctor but come from a family with a history of severe mental illness (at least 3 generations, including my sister and I) -- and falling to pieces, seemingly out of nowhere, complete with drugs/alcohol (self-medicating) is textbook behavior / timing for a person with a mood disorder.

    (It is the cruelest, most awful illness ever -- because the smart, capable, wonderful, lovely person that you've known/raised for 18 + yrs disappears. Sometimes permanently, even with truly excellent doctors, medication, family support, therapists, etc.)

    1. In addition to what you say about mood disorders, schizophrenia can also emerge in early adulthood.

      Advocates of the "attachment therapy" belief system would probably say that this young man's exemplary early life was simply his cunning way of exploiting others and making them believe he was all right. For true believers in this system, either good behavior or bad behavior can be "proof" of the notional disorder.

      It's a relief to see that "Dr. Phil" did NOT follow this way of thinking.

    2. A woman claiming to be the mom of the 24 yo featured on that episode of the Dr Phil show left a comment on the very same blog (see below).

      If it's legit, it sounds like the adopted 24 yo's problem was.... drug/alcohol addiction. Nothing related to "attachement". He went to rehab, got sober and is thriving now that he is STAYING sober.

      "Stumbled upon this website – I am Adam’s mom and want you to know that we will be forever grateful for the help Dr. Phil gave our family. We were lost and I didn’t think our family had a chance of mending – by the grace of God we were contacted by the show’s producers to air our story. This journey has been a healing process for our family and, without Dr. Phil’s help, who knows where we would be today ?? Adam is clean, sober and has just returned to complete his senior year of college. Origins Recovery Center in South Padre Island, TX was instrumental in Adam’s treatment and care and provided Adam an opportunity to address his addictions and begin the process of understanding his disease, his destructive behaviors and work through healing and focusing on his future. Please keep us in your thoughts and prayers – we are taking it one day at a time :)"

    3. This is odd in so many ways, isn't it? For one thing, I think it's not the grace of God but previous contacts with the show or other public displays that cause outfits like "Dr. Phil" to contact people.

      I don't see at all where attachment was supposed to come in here, but when I googled the Origins place I saw some peculiar things-- for example, when you click on the MAP part, it tells nothing whatever about evidence-based methods. They also offer equine therapy, which is great if you are a horse. I hope to get a chance to look into this further.

    4. There's NOTHING attachment related wrong with the 24 to yo adoptee. That's the point.

      The guy who blogs at parenting and attachment was dead wrong.

    5. I understand the point. I was just wondering whether Origins had used any treatment that purports to treat attachment difficulties.

  10. A brief historical note here: Some years ago I attended a conference at the Attachment Center at Evergreen (ACE), before it changed its name to Institute for Attachment and Child Development.

    It was there that Forrest Lien expressed his admiration for Elizabeth Randolph as a topnotch researcher. That morning Randolph presented on her "research" regarding the effectiveness of ACE's therapy. During the Q&A, I asked her why she had not published her studies, and she claimed she had decided to forego publication because the results were too important to be held up by a lengthy peer review process.

    Randolph told the audience there that children with "AD" not only can't crawl backwards, but they can't look behind when in the crawl position. She further claimed these children can't swing their arms when walking, but that the arms will stay pinned to their sides. Randolph brought a girl of about 13 years of age to the stage. She had been diagnosed with "AD" and demonstrated these phenomena. But after the lunch break, the lawyer sitting next to me leaned over, saying, "Remember that girl? I just saw her outside swinging her arms as she walked."

    1. There certainly would be a lengthy review process, when the reviewers recommended against publication!

      That's fascinating about the arm movement. These things all seem to connect back to "patterning", don't they?

  11. If there is no reliability or validity then attempts to correlate it to valid measures should fail, as they do here: http://link.springer.com/article/10.1007/s10560-005-2556-2

  12. I found your article while searching for RAD and attachment disorder. I was looking at parenting help for the toddler I'm legally responsible for. His parents were drug addicts. We've only had him two months and have been extremely perplexed by his behavior, mood swings, general lack of love, & odd anti- toddler behavior.

    I consider myself intelligent and I'm educated; I mention this bc I' thought only less than smart people couldn't raise a kid. It's not rocket science. And, less than smart people fall for less than smart psychological BS. And, that's true for most kids. Which, your studies are pointing out. But, then, I was in charge of this child and I realized something was wrong. He doesn't run me, he isn't just 'harder.' He has severe attachment issues that are beyond his control and need definite help before he becomes older, and before he does reach adulthood.

    In reading about Ainsworth, I found it interesting the different toddler attachment characteristic securities for normal toddlers. What I find lacking in most of your insights and your commenters is a general understanding of the kids with a disruption in normal development, which is what you seem a bit cold in dealing with. Albeit, an understanding I wouldn't have understood unless I dealt with it. The research, the studies, are not taking large samples from adoptive homes and orphanages.

    I'm in a bit of a different situation with this child versus most adopted parents because I wasn't praying for a child. So, in dealing with issues from him- like hitting/biting me, anger when you say no or don't constantly give attention- I am able to simply be wavering; some would say cold. However, most parents have a very difficult time because they love them so much (which is normal). And, I will say, it's a battle even for myself and my partner. It's not fun having a non- loving child in your home who is constantly battling for control 24/7.

    To simply say a child who has been severely neglected and has emotional issues can have a 'good enough attachment style' is perplexing to me. You are diminishing the struggle that has been brought on because of a break in normal development.

    I did find Forrest Lien's site and while I didn't partake in the test because I was confused about the lack of backing and the fact it wasn't in the DSM, I did 100% understand many of his points. I have been trying to pinpoint what has been going on with this child since he entered my home. I have tried many techniques. And out of two, no-nonsense women, we've randomly done many of the items that are recommended by professionals for children with disrupted attachment. Blind luck? Common sense? I don't know. But, we are still searching and changing and adapting. It is a daily struggle. It isn't normal. And we will never be able to simply be 'a good enough mother' because if we aren't able to fix him by a certain age he will be unfixable.

    I guess I felt like writing because while I understand a main point of your article was to explain Lein's misuse of the RADQ, I feel you also undercut his work and the legitimacy of attachment disorder. I guess I'm a little embarrassed to say I maybe would have to just months ago. I'm the type of person who usually says suck it up and get over it. Enough coddling. Stop being lazy. I hate entitlement. Work and reward is how I said I'd raise my children. I'm not person who thinks every ailment and bad behavior needs a disorder.

    But, I do think you are missing the mark on children who have been bounced around, severely neglected and abused at extremely important early developmental times in their childhood. I think as time goes on, there will be a better test and better data. These children are hard to raise, hard to live with, and I can see normal families not being able to handle them without proper education, instincts, money, or common sense.

    My two cents.

  13. Thanks for your comments, but I don't understand why you are perplexed that a neglected,possibly abused, toddler, who may have been exposed to drugs prenatally, is not coping as you expected with a radical change in care setting, especially since it appears that at least one caregiver does little more than tolerate him.

    This child may indeed have poor attachment organization, but the behaviors you describe are aspects of conduct disorder, not of attachment disorder. I understand that everywhere you look you see people telling you that problems of attachment are seen in disobedience, aggressiveness, etc., but this is not the case. Attachment has been only one of many issues as such children have lacked gentle guidance toward better socialization. In addition, although I am not sure how you define toddler, I would point out that well-cared-for children in the 2-4 age range nevertheless require a great deal of help with regulation and with learning how to be autonomous without hurting other people.

    If you wish to commit to this child, which I am not at all sure that you do, I would advise you to seek Child-Parent Psychotherapy or ABC (Attachment and Biobehavioral Catch-up). These are evidence-based treatments that help adults learn to read and respond more effectively to children's needs. You might also look at Parent-Child Interaction Therapy (PCIT), which works on the parent-child relationship to improve both its pleasant aspects and the need for the parent to give effective guidance. I am not saying to "suck it up", but to use methods of established effectiveness. Limiting you search to treatments that include the word "attachment" is not going to help you or the child.

    However, if you don't want to commit, perhaps it's time to discuss this with your partner.