Diagnosing Reactive Attachment Disorder: Don't Try This at Home

Rather regularly, I get blog comments, e-mails, and even phone calls from mothers who have read about RAD on the Internet and know that this is exactly what their children have. It doesn’t matter that much of the on-line information is not actually descriptive of Reactive Attachment Disorder; many of these parents are positive that they know what’s wrong, and all they need is to find someone who specializes in attachment disorders to treat the children and get rid of the disorders. Can I suggest a suitable person, they ask, because they are having trouble finding such a specialized therapist.

No, I can’t, and here’s why.

1.     1.  Unless you are looking at DSM-5, you will probably not find on the Internet much that actually describes Reactive Attachment Disorder. Most of the material that purports to do this focuses on disobedience, surliness, aggression, theft, and cruelty to others. These are all serious matters, and a family with a child or children presenting these  problems is certainly in need of good professional help. However, the behaviors are symptoms belonging to a range of other diagnoses, and not to RAD. Note: it’s possible that the children have attachment disorders in addition to these other problems, but the attachment disorders are not the cause of the very concerning behaviors, and “fixing” the attachment problems does not “fix” the antisocial behaviors.

2.    2.  Well-trained clinical psychologists may have most experience and interest in working with one problem area, but they are competent to deal with the full range of childhood mental health issues. Such a professional begins the process of diagnosis by considering all the difficulties that may be behind disturbed moods and behaviors. He or she will pay attention to the child’s cognitive and language development and to areas where the child is behind, up to, or beyond what would be expected at this age. The psychologist needs to be open to consideration of a full range of problems that may be present. To make best use of this professional help, parents need to bring in the best information they can about how the child seems to feel and to act in specific circumstances, and they too need to keep open minds about the causes of problems rather than trying to “cut to the chase” by insisting on one diagnosis or demanding that a therapist focus on a problem as the parent sees it.

3.      3. When children show disturbed relationships with others, and especially when there is antisocial behavior involved, parents need to realize that the child lives and acts within a network of family and other social connections. One possibility behind disturbed behavior is that events or actions of others in the family are making it difficult for the child to reach his best levels of thinking and behavior. These factors can range from marital tension and disagreement to sibling conflict and school pressures to inappropriate disciplinary methods. A therapist who addresses such problems is not assigning blame or pointing to anyone’s guilt, but is dealing with the fact that a child’s mental health problem is bound to be, in one way or the other, a problem of the whole family. Working with the child means working with the family, little as most stressed-out parents care for this idea. These facts also mean that the most accurate diagnosis of a child’s problems is only the beginning of the discussion.

4.      4. The assumption that many, even most, child problems are derived from attachment difficulties distracts parents from seeing the whole child, and unfortunately it can also distract some professionals in the same way.  A 2013 paper by the British psychologists Matt Woolgar and Steve Scott outlined a number of cases in which psychological staff focused on children’s attachment  issues to such an extent that they failed to notice  serious problems that were unrelated to attachment. When parents go out of their way to find professionals who state a specialty of working with attachment issues, and who also are willing to accept a parent’s statement that a child’s problem is Reactive Attachment Disorder, chances of  inappropriate exclusive concern with attachment are much increased.

When a child shows serious mood problems or frightening antisocial behavior, it’s a mistake to jump to the conclusion that Reactive Attachment Disorder is the problem. In fact, it’s a mistake to jump to any conclusions, or even to reach them without a thorough evaluation of the child and the family. Please don’t depend on a diagnosis you reached at home with the help of friends or the Internet, or search for a therapist who will concentrate on a narrow set of problems as instructed.  Look for a professional with thorough training in clinical work with children and adolescents and let that person make the complete assessment that is needed before a therapeutic plan can be created.

   

The Jackson Abuse Case: Religious Beliefs, Old-Fashioned Punishment, Nancy Thomas, or Mrs. Great Santini?

A former Army major, John Jackson, and his wife, Carolyn, were recently sentenced for child endangerment because of the injuries they caused to children in their care (whether these children were being fostered or had been adopted is not clear—media reports run about half and half). [CORRECTION: According to the indictment, available on line, one child had been adopted and the other two were in foster care.] In “disciplining” the then-toddler  or preschool-age children. who were already developmentally delayed, the Jacksons employed hot-saucing, feeding of hot pepper flakes, forced feeding of salt, and withholding of food and water for offenses like walking or eating too slowly or putting fingers into the mouth. There were broken bones, too, including a fractured spine. Further descriptions are at www.northjersey.com/news/prosecutor-army-major-wife-abused-adopted-kids.1.1111774  ; www.nydailynews.com/news/crime/ex-army-major-wife-convicted-abusing-3-n-foster-kids-article-1.2286026 ; www.nj.com/news/index.ssf/2015/former_army_major_wife_sentenced_for_torture_of_th.html .

John Jackson was given a sentence of probation and a fine, while Carolyn Jackson was sent to prison for two years. Rather ironically, it seems to me, it was argued that Major Jackson should not be taken away from his children! One of the couple’s biological children testified about the mistreatment of the foster/adoptive children, so one must wonder about the advantage to him of having his father left available to him.

Prosecutors had asked for a sentence of 15 to 19 years because of the intensity and duration of the abuse. The judge, Katharine Hayden, cited John Jackson’s military record as a reason for giving him probation only—a decision whose implications for punishment of other abusive military people are limited only by one’s imagination. Hayden did agree that Carolyn Jackson had endangered the children’s welfare, and indeed breaking someone’s spine or inducing hypernatremia can scarcely be argued to be in their best interests, even by defense lawyers.

According to the Philadelphia Inquirer, ”Defense attorneys argued during the trial that the Jacksons’ child-rearing methods might have been objectionable but they didn’t constitute crimes, and that the foster children had preexisting health problems.” Granted that desperate lawyers seek desperate arguments, this one nevertheless seems to be not just one but several pips. First, hot-saucing and forced feeding of salt certainly would be crimes if they were committed against adults. Second, let’s look at other forms of corporal punishment. Although spanking of children remains legal, the cut-off point for its legitimacy is usually considered to be the point where its intensity or duration leave physical evidence in the form of bruises or other injuries; when this occurs, this form of punishment becomes abuse. The parallel for other methods of physical discipline would reasonably be that a method that causes visible physical harm, like blistering from hot sauce or hypernatremia from forced salt ingestion, rises (or sinks) to the level of abuse and is far beyond being merely “objectionable”. I believe this argument is an adequate counter to the claim that the Jacksons’ actions did not constitute crimes.

Now, let’s look at the second part of the defense attorneys’ argument: the foster children had preexisting health problems. Now we are definitely in an upside-down moral universe! “The children were in poor health and developmentally delayed; therefore it was permissible—perhaps even advisable?—to brutalize them. This would teach them not to be so sick and motivate them to speed up their development.” Outrageous to state this baldly, of course, but is this not the implication of the defense argument? In fact, in reality, the children’s health and developmental problems made them especially vulnerable to the impact of abuse, and according to their present foster mother, they continue to bear the emotional scars of their time in the Jackson household.

Why did the Jacksons treat the children as they did? Evidently, they offered their biological children the explanation that it was necessary to discipline the foster children in these ways. The parents did not use the same methods with the biological children, although Carolyn Jackson apparently gave a thorough belting to her son when she discovered that he had told a family friend how the foster children were treated. Did the Jacksons believe that the methods they were using were actually a form of intervention, a “treatment” that would help the foster children get onto an improved developmental trajectory? It’s possible that they did think this; they may have been using a version of the Nancy Thomas treatment in which food and water are withheld to motivate children to comply with parental demands, or they may have believed that the children were possessed by demons and that the demons could be expelled by discomfort, allowing the children to return to normal health and development.

It’s also possible that what we see in the Jackson case is simply the perpetuation of the “good, old-fashioned” view of physical punishment as the cure for all childhood behavior problems, and the assumption that whatever punishments were familiar in one’s own early life are the best way to guide children today. This view is sometimes associated with the belief that following one’s parents’ child-rearing ways shows respect for the parents, and failing to do so shows disrespect. In families and subcultures where lack of respect for parents has a strong religious implication of disrespect for divine authority, this can be a powerful factor. There are many unanswered questions about the role of religious belief (including assumptions about demon possession) in this case, but religious positions have played such important roles in other child abuse cases that I think it is a mistake to ignore this as we try to understand what happened here.

Finally, with all due respect to the thousands of well-functioning military families, it would be absurd to ignore the part played here by authoritarian attitudes that punish deliberate and inadvertent disobedience equally. John Jackson has been administratively separated from the Army and I cannot find whether he is actually discharged, either honorably or otherwise. His military record has saved him from imprisonment in the civilian world, but there may be a limit to what even the military can tolerate, especially because this matter became public knowledge and makes the military look bad, which officers are not supposed to do—in church terms, it’s like causing scandal in the congregation.  

Many questions remain unanswered about the Jackson case. I hope further investigation will occur and be made public. The U.S attorney is apparently considering an appeal… and there remains a question about why the Jacksons were never charged with the death of one of the children. Another desirable investigation would look into the conduct of caseworkers responsible for monitoring the foster children.

How Babies Remember: A Tribute to Carolyn Rovee-Collier

Because babies can’t speak to tell us what they know, and because they don’t know how to encode whatever they have learned into language when they begin to talk, all kinds of peculiar claims have been made about their knowledge and memory of their experiences. these range from the idea that babies remember their prenatal lives right back to conception, to the belief that they remember being born and can articulate these memories later, to the assumption that they remember nothing at all even at age 2  years “because they’re too young to notice”.  It’s been pretty rare for people to figure out ways to investigate how babies learn and how their memories work.

One of the few people to create a method for looking at infant memory was Carolyn Rovee-Collier, whose death in 2014 was a great loss to the field of developmental psychology. Rovee-Collier’s work was an excellent example of something I’ve always thought to be true—that in order  to have real insights into ways to study babies, one has to have spent a whole lot of time with them. (No doubt what I am about to say will offend some readers, but I think this is a bit like what Daniel Lehrman and other comparative psychologists used to say about the study of animal behavior.) There’s a sort of total immersion that occurs when you are paying most of your attention to a baby for a long period of time. You begin to see things that were invisible to you before, just as an experienced dancer sees things in a dance performance that even the most enthusiastic non-dancer will miss.

Not all parents observe carefully, but Carolyn Rovee-Collier did while one of her children was an infant. She noticed that when her baby had discovered that by kicking his feet he could make a mobile swing, he kicked again when put back into the same setting, even though things had changed so he could not make the mobile move. At a few months of age, he had learned and remembered something he could do to make an interesting event happen.

Later on, Rovee-Collier systematically investigated the circumstances of learning and forgetting for infants of different ages. Her method—originally used to entertain her baby so Mom could get some work done!—was formalized under the name “mobile conjugate reinforcement paradigm”. The baby is put in a crib with a colorful print crib liner, a mobile is provided, and a ribbon is tied to the baby’s ankle and to the mobile so kicking will make the mobile move. (Do I need to say that babies are not left alone with the ribbon tied? This could be quite dangerous, so don’t try it at home unless you are staying nearby!) Whether the baby learns is measured by the increase in kicking; whether he or she forgets is measured by noting how long it takes for kicking to resume when the baby sees the print crib liner again. The baby learns not just that an action causes interesting results, but that the action works in certain circumstances and not in others, just like the “time, manner, place” learning that makes up so much of what we try to teach small children.

Just as you might expect if you didn’t think babies could remember their own births, younger babies learn more slowly and forget more quickly than older ones. Two-month-olds take 7 to 9 minutes to learn to make the mobile move, and forget  how it works in two days. Three-month-olds learn in 4 to 6 minutes and remember for 6 or 7 days. Six-month-olds learn the trick in 1 to 3 minutes and remember for 15 or 16 days, and after about 9 months the memory lasts for many weeks.

Now, here is the interesting thing that shows how the mobile conjugate reinforcement paradigm is relevant to ordinary real life learning. Babies remember longer when their memories are “reactivated” by letting them see (just see, not make the mobile move) either the mobile or the print crib liner at some time before they are tested. The timing of the reminder is critical, and it seems that some time must pass before the memory is affected by the repeated experience. For three-month-olds, at least 8 hours must pass before the memory is reactivated as shown by kicking in response to the crib and mobile, and it takes 3 days for the maximum effect of the reminder. A three-month-old who gets two memory reactivations (reminders) will remember what was learned for twice as long as the first learning lasted. By age 6 months, only an hour need pass before the reactivation effect is seen, and it takes only 4 hours to reach the peak effect.

The take-away message from Rovee-Collier’s work is that younger babies do learn, but they learn slowly and forget quickly unless they are reminded, not by having exactly the same experience as before, but by seeing the setting in which they learned. Even with a couple of reminders, three-month-olds remember the event for only two weeks. This suggests that a single experience in infancy is not likely to be remembered long, and that early learning that lasts will be likely to involve the many repetitions of familiar daily caregiving routines in familiar places. Only after about 9 months do we see quicker and longer-lasting learning. Another implication, and an important one, is that babies are motivated to learn not so much by gratification of physical or even emotional needs, but by the need to experience mastery over the environment and to make interesting things happen.  

It’s good to keep these things in mind when confronted by claims of prenatal and birth memories and their lifetime influences.

Worrying About Autism? Some Information

Two posts on this blog draw the most reads and comments week after week: these are http://childmyths.blogspot.com/2011/07/eye-contact-with-babies-what-when-why.html and http://childmyths.blogspot.com/2013/11/infants-autismand-eye-contact.html. Both of these posts have to do with infants’ eye contact with their caregivers, and by extension with symptoms of autism—readers who write comments and queries are almost always worried about autism, not about the visual impairment that might also underlie problems with eye contact. Recently, there have also been concerns about odd movements like hand-flapping that may be associated with autism, and some readers have been worried about whether some hand movements might indicate Rett syndrome.

For worried parents, one of the real problems is that they don’t actually know what “autistic movements” look like. Another is that infants are individuals who often don’t conform to averages of development that parents read in “the books” of norms for developmental milestones; they reach some milestones earlier than the average, then turn around and act a bit delayed on others. In addition, neither autistic or typically-developing children are “all autistic” or “all typical”, and their behaviors overlap quite a bit, especially during the toddler and early preschool periods. A fourth, and very real, problem is that it’s still not understood how autism can be predicted accurately for children who are still under a year old--  but this is exactly the age period when parents are most likely to start agonizing and watching for those “red flags”.

Here is a very fine video that shows behavioral differences between typically-developing toddlers and same-age children who are later diagnosed as autistic:

http://www.kennedykrieger.org/patient-care/patient-care-centers/center-autism-and-related-disorders/outreach-training/early-signs-of-autism-video-tutorial .

When you watch this, please notice that all the children are over 12 months of age. Don’t try to generalize from this information to younger infants. One of the features of autism is developmental delay, so an autistic child may act in some ways much like a younger child--  it’s important to realize that this cannot be reversed to mean that the younger child must also be autistic, or to assume that developmentally appropriate behaviors of the infant are signs of autism.

The first concept covered in the Kennedy Krieger video is the child’s ability to use play in ways that include other people, not necessarily as a formal “game”, but as part of a social interaction like pretending to eat or to feed another person. The typically-developing child in the video offers a “bite” to an observer and takes a “bite” himself. This ability develops after about a year of age, and its absence in a younger infant would be no reason for concern. He also follows what an adult does, imitating in a meaningful rather than a mechanical way. The same-age child who is showing signs of autism does none of those things, and he does not respond to his name, which is unusual at this age (though it would happen much more frequently with children some months younger). Although he acts as if he likes to be tickled by his mother, he doesn’t respond socially.

The second point is the making of social connections by typically-developing children, by looking at people and responding to gestures. The little boy in the video even makes an effort to turn and look at his mother, and he looks at an item pointed at by an adult, continuing the “conversation” by pointing at it again later. Another boy of the same age shows symptoms of autism by flapping his hands in excitement, but without looking at the adult; a typically-developing child may also flap his hands, but he looks at adults while he does so and seems to use the gesture as communication. The autistic child does not look at an object an adult points at, but instead looks at the adult’s finger (as a much younger infant might do).

The third important point in the Kennedy Krieger video is the typically-developing child’s capacity to carry out and enjoy social communication. The child in the video is fascinated by a moving toy, but frequently looks at adults and then back at the toy, while smiling. When the toy stops moving, she wordlessly communicates to the adult that she needs help to start it again. An autistic child of the same age watches the toy carefully, but does not smile at adults or look at them to create social communication. He does not respond to a gesture by which an adult asks to have the toy. His mouth and torso become tense and stiff as he handles the toy.

Watching this video may give you some hints about differences in behavior between typically-developing and less typical children, but remember, these differences do not apply to children under a year of age. There may be differences at earlier ages, but they are not yet well understood. In addition, remember that typically-developing preschool children sometimes do “autistic” things, and autistic children sometimes do “typical” things. It’s the general pattern of behavior that is of importance. Finally, keep in mind that even the children who are diagnosed as on the autistic spectrum as toddlers and preschoolers may well look much more typical as time goes on.

Social Workers Gallop Off in All Directions

I recently came across a document that stated that the National Association of Social Workers has endorsed “equine-assisted therapy” (EAT) for mental health problems. “Wha-a--?”, I said, and began to look up whether there had been such an endorsement. Now, this can be hard to do; I know NASW sometimes passes resolutions at their annual conference, and these can be hard to locate later for those of us who are out of the social work loop (e.g., the resolution against Holding Therapy some years ago). I didn’t find a resolution about EAT, but I did find that NASW had given continuing education credits for a class on this topic (naswct.org/wp-content/uploads/2015/04/NASW-Conference-2015-Brochure.pdf).

Horseback riding has been used therapeutically for many years for children with cerebral palsy and other neurological disorders that contract muscles and distort the structure and function of the limbs. Riding provides a warm and gentle stretch for leg muscles and is so enjoyable that children are distracted  from any discomfort. But, of course, this does not mean that people with other kinds of disabilities--  people who don’t need their muscles stretched—will also benefit from horseback riding. (Similarly, prescription eyeglasses that correct visual disabilities don’t help hearing impairments.)

For some time now, there has been a strong tendency to equate mental illnesses with “brain disorders”. Certainly it’s true that at some level every mental illness has a foundation in brain function and even structure, but this does not mean that it makes sense to force all mental illnesses and all results of brain injury or atypical development unto the same category. I understand the motivation to do this forced combination—everyone knows the results of an injury are not the victim’s fault, and some people still think that the mentally ill could stop being sick if they really tried, so presenting mental illness as equivalent to brain damage supports the important argument that the mentally ill should not be stigmatized.

The two things are not really exactly the same, though, and their treatments cannot be identical. Brain disorders like CP can have powerful effects on the body  and affect children’s behavior and development by damaging physical growth and abilities. Horseback riding helps corrects muscle and bone development and use; it does not cure the brain damage that caused the problems of physical development. It won’t cure any posited brain disorders that may lie behind mental illness, either.

Horseback riding, and learning to handle and care for horses, can be great fun for kids, and shared enjoyable activities are an important key to social skills, sharing, taking turns, and understanding other people. Sharing such activities with a social worker or other helping person can improve interactions and help establish a strong relationship.

But these points are a far cry from evidence that EAT in itself is an effective treatment for autism, ADHD, or other disturbances of children’s mental life. There is very little evidence to that effect.  In a recent review, Kendall et al (2014; Explore, 10(2), 81-87) described EAT as under-researched and largely anecdotal in its support. Even though there are randomized designs used in some studies of EAT, they generally fall down by having a treatment group who have elaborate social, interactive, and riding experiences, but are compared with another group who are given no new experiences at all. This failure to isolate the horseback-riding variable means that no one can know whether apparent benefits came from increased social experience, from interactions with social workers or other helpers, or from riding itself.  

In addition to the lack of empirical evidence supporting EAT as a therapy for children with developmental delays or other mental problems, there has been a strong tendency for advocates of EAT to make exaggerated, even ludicrous, arguments for the treatment. I discussed some of these  several years ago at http://childmyths.blogspot.com/2011/02/clever-hans-rides-again-equestrian.html. I was responding to claims that  horses know when a child is lying (they don’t care for this, it seems), and that a horse’s gait is “downloaded” into a child’s brain, thus apparently doing an end run around all the problems that have been blamed (wrongly) on a lack of crawling experience.  These both summon entertaining images--  a deeply disapproving horse shaking its head at a fibbing child (but why lie to a horse?), and the probable human gait that would be based on a “downloaded” horse pattern. (This last makes me think of playing horses as a little girl and being both horse and rider simultaneously.)

Perhaps NASW feels that interest in EAT by social workers can lead to some serious research about the treatment’s effectiveness, and that is possible, even though much about the treatment is implausible. Nevertheless, it would be wise to limit shows of approval like continuing education credits until better evidence is presented. It would also be a good idea to draw the line clearly between the “downloading” faction and the work of those who are interested in the actual possibilities of this proposed treatment modality.

Parental Alienation Advocates Cite-- WHO?

Like advocates of other ideas, proponents of the idea of parental alienation (PA) like to list their intellectual ancestry and show how their beliefs have a respectable history. But as I was glancing at some PA material, I came upon a citation that rather astonished me: PA advocates attributed the earliest reference to the PA idea to Wilhelm Reich! This was done in an article by the usually meticulous and cautious Richard Warshak and picked up again in a book edited by William Bernet.

Now, I would not want to fall into the trap of assuming that just because most of what a person wrote was pernicious nonsense, he or she could not have had any ideas worth following up. I’m also aware that Reich has some admirers to this day and they continue to publish the Journal of Orgonomy. However, most of Reich’s beliefs and practices were such that I can’t imagine that most psychologists or psychiatrists would care to associate themselves with them, and I can’t fathom why the PA group want to do so.

Here are some facts about Wilhelm Reich:

He was part of a group rejected as doing “wild psychoanalysis” by conventional Freudian analysts. This group, including Sandor Ferenczi, was characterized by hands-on, physical treatment methods, among other things. The “wild psychoanalysts” owed much to Georg Groddeck, who had earlier claimed, for example, that problems of childbirth, such as an awkward positioning of the fetus, resulted from the mother’s psychological reluctance to give birth.

Reich believed that an energy form called “orgone” was involved in sexuality and physical health, and that sitting in a box insulated against the escape of orgone would cure cancer and other diseases. His insistence on continuing to sell orgone boxes led to charges and conviction of fraud, and he died in prison.

Reich claimed that through hands-on treatment he had cured his infant son of the Moro (“startle”) reflex; this reflexive movement pattern largely disappears by about five months of age, as voluntary movement patterns take over, and this is presumably what happened in the case of the Reich baby. Why Reich, a M.D., would not recognize a normal infant movement pattern and would try to “cure” it is a difficult question to answer.

Reich’s theory of personality involved “character armor”, a stiffening of muscles accompanied by rigid thinking, emotion, and behavior, and caused by birth and other early experiences. Relaxing the muscles was claimed to restore flexibility of thinking and feeling to a normal and desirable level; without such restoration, a person could not experience life fully. (I should note that in the 1940s and ‘50s, this belief, although not widely accepted, was not considered necessarily to be a “fringe” notion, and was described briefly in an abnormal psychology textbook published about 1960.)

Reich’s treatment for “character armor” as a psychological disability involved a semi-nude patient and therapist. The therapist treated the stiff muscles that were thought to cause psychological rigidity by thrusting his fingers or hand into the patient’s armpits or against the ribs. (Does anyone remember Rolfing? How about Holding Therapy?) Bruising and considerable pain resulted.

None of these disturbing beliefs and practices indicates that Reich never made a correct statement in his life. However, it’s hard to belief that PA advocates really wanted to take on the Reichian baggage just in order to claim an early reference to their ideas. Could this have been like Darwin’s fox terrier—the reference was cited again and again until no really knew how big a fox terrier was or how peculiar Reich had been?

Whatever the rationale for citing Reich, I would think that PA advocates would do well to delete these references and concentrate on determining the incidence and prevalence of the family issues that concern them, not to speak of assessing the efficacy of the interventions proposed as treatment. 

The "RAD" Explanation: 20/20 Improves It

 In the Nov.9 and Nov. 11 posts on this blog, I  talked about a show that appeared last month on the ABC 20/20 program, and about the trailer that preceded it. The program itself was an examination of an Arkansas case from last Spring, involving the Arkansas state legislator Justin Harris and his wife, and their adoption of three little girls whom they declared to have Reactive Attachment Disorder; after various treatment efforts, including exorcism, the Harrises “rehomed” the girls by giving them to a household where one was raped.  

In the actual program, 20/20 did an adequate job of showing the details of this case--  although for my money, not nearly as good a job as was done for the Arkansas Times by Benjamin Hardy and Leslie Peacock. However, I, as well as other people, had serious concerns about the trailer posted to advertise the program. In its original form, the trailer, entitled “RAD: Explaining Reactive Attachment Disorder”, began with two clips showing shrieking children being restrained physically. We felt this was a problematic beginning because of the implication that screaming wildly and needing restraint were particularly symptomatic of Reactive Attachment Disorder, which is not correct. The trailer continued with a view of perhaps a dozen women, not described or introduced, but rising one by one to speak about the extreme difficulty of dealing with their teenage adopted children, and their certainty that serious violence occurred because of Reactive Attachment Disorder. This last clip was problematic for several reasons: there is no method of diagnosing Reactive Attachment Disorder in older children and adolescents, there was no evidence given that there had been a professional diagnosis rather than the mothers “just knowing it was RAD”, and in any case violent behavior is not a symptom of Reactive Attachment Disorder, although of course it may be a symptom of other emotional disturbances.

After sending the multi-signer complaint letter quoted in my Nov. 9 post, I received phone calls from Miguel Sancho and Lynn Redmond, producer and assistant producer of 20/20. They told me that the two “shrieking children” clips had been provided by the residential treatment center Villa Santa Maria in Cedar Crest, New Mexico. Villa Santa Maria has for years focused on children said to have Reactive Attachment Disorder and was at one time associated with holding therapy, a physically intrusive treatment using restraint as a method of therapy (see http://poundpuplegacy.org/node/26944 ). Villa Santa Maria now uses Dyadic Developmental Psychotherapy, a non-evidence-based treatment, but shows its connection with highly authoritarian treatment forms like holding therapy by demands that children cannot be outside an adult’s eyesight without permission at any time, and that they must ask for everything they need or want so that they recognize their dependence on adults, and that they must experience non-negotiable “closeness” (www.villasantamaria.org/treatment_philosophy.asp). Assistant producer Lynn Redmond told me that she had spent a day at Villa Santa Maria, as well as receiving the video clips, so it is not surprising that the views offered at the school had considerable influence on the trailer.

Happily, Sancho and Redmond recognized the importance of what the signers of the letter were saying, and quickly agreed to make a new trailer. Dr. Anne Marie Albano of Columbia University, a clinical child psychologist, was interviewed for the trailer and made it clear that although Reactive Attachment Disorder exists, its symptoms are not those suggested by the original trailer. The new video, http://abcnews.go.com/2020/video/experts-parents-discuss-rad-reactive-attachment-disorder-34667787, begins and ends with statements by Dr. Albano and shows a much-reduced segment of comments by adoptive mothers (the statements about knives have been removed, and no shrieking or physical restraint is included).

It is really gratifying to know that a major television organization is willing to turn around when informed of a mistake. Naturally, it would be better if 20/20 had sought better information to begin with, but it’s understandable that they would be convinced by people who declare themselves “RAD experts”. It’s not very common knowledge that families don’t need a RAD expert, or an ODD expert, or an OCD expert, but that they do need a highly-trained practitioner who can treat the child and the family—not the disorder. I recommend against employing any person who claims special training in a narrow area; emotional disturbance in childhood rarely involves a single diagnosis, and families need broadly-trained professionals. The “RAD expert”, all too often, resembles the little boy who has a hammer and finds lots of things that need hammering--  having a diagnosis and a treatment, the “expert” may find reason to use the two things on people who don’t benefit in the least from being “hammered”, and even on those who suffer as a result.    

Does Trauma Stop Development?

When you explore some of the beliefs of unconventional, “alternative” therapists like Nancy Thomas, one idea that often emerges is that development stops when a child experiences psychological trauma.  This idea serves as justification for treatment methods involving ritualistic re-enactment of normal early-childhood experiences, based on the assumption that recapitulation of early experiences will cause development to “start over” and follow a desirable pathway. That assumption would be remotely plausible only if it were true that trauma stopped development--  and even if it were plausible, such treatments would have to be supported by systematic evidence in order to be truly acceptable.

But let’s look at the idea that development stops after trauma. Presumably this view of development—which is actually speaking of cognitive and emotional development, especially the latter—is based on analogies to specific aspects of development and specific types of trauma. It’s clear that serious traumatic brain injury can stop some aspects of development and slow others. For example, a child who receives radiation therapy for brain cancer can end up with such serious brain damage that she is never conscious again, although her life may continue for some time. She grows, but slowly, and unless she receives careful physical treatment her limbs become distorted into a “fetal” position. Much of her development has slowed, and some has stopped, but as long as she is alive she will continue to change in some ways over time—and that is what development is: changes with age.

Now let’s consider less drastic physical trauma. Suppose, for example, a child is nutritionally deprived in early life. The result will be slowed growth, but also some much more subtle problems. The bones will ossify (become hardened by absorbing calcium into their structure), but they will not do so in the order typical of well-nourished children. Development does not stop, but continues in a way that is distorted or “detoured”  rather than following a typical developmental pattern.

The effects of trauma and deprivation also depend on “critical periods” of development. A young baby who loses half of the brain through injury will develop largely normal cognitive and emotional abilities; an older child will be permanently handicapped by such a loss, sustained when  neuroplasticity is less. A malnourished infant or toddler may have slowed brain growth and development; he will “catch up” developmentally if nutrition is corrected by about age 4, but not after that, no matter how excellent the later diet may be. It’s a mistake to assume that an event that may be traumatic at one age--  abrupt separation from familiar people at age three, for instance--  is also traumatic at other ages; separation at birth does not in itself  cause emotional trauma (although learning about that separation years later may be distressing).

The effects of any kind of trauma or deprivation are also determined in part by a range of factors other than the one that seems most important. Babies exposed to lead in the environment develop better when their diets and general health are good, while lead exposure has a more serious impact on those who are poorly nourished. Similarly, infants and young children who are exposed to terrifying or painful events do better when competent parents and good family relationships serve to buffer the effects of the trauma. Events that influence development all work together, so an apparent trauma cannot be considered as having a predictable outcome all by itself.  

Research by famous names like Michael Rutter suggests that children who have suffered from trauma and deprivation in poor care settings will in most cases develop normal cognitive and emotional abilities. Better recovery is likely to occur for those who move to family care or to enriched institutional care when they are still infants or toddlers. This situation seems analogous to what we see in children who are brain-injured or nutritionally deprived—“catch up” growth is possible up to a limited age. Because emotional and cognitive life depend on brain functions, it is plausible that emotional and cognitive development follow the same rules as brain development and allow for recovery from trauma or deprivation by intervention fairly early in life.

Finally, it’s important to realize that there are individual differences in children’s vulnerability, or its mirror image, resilience. For reasons of genetic or other factors in early development, some children “rise above” traumatic experiences relatively easily, while others have lasting and potentially serious effects.

Whatever roles all these factors may play in a child’s response to trauma, the result of traumatic experiences is a matter of distortion of development or changes in developmental trajectory, not of “stopped development”. Brain-injured children, for example, continue to grow and develop along the lines permitted by their injury; they do not simply stop and remain exactly as they were, without learning or emotional maturation proceeding at all. Treatment of trauma works by fostering positive change in areas where the child is not doing well, and exactly how that can be done depends on the child’s age and environment. Part of this process is recognition of the behavior problems that have emerged from trauma (like anxiety and anger about certain situations) as well as of those that occur for different reasons. 

It’s clear that one size of trauma does not fit all, and neither does one size of treatment help guide distorted development back onto a desirable trajectory.

"Faux-RAD" and the ABC 20/20 Video: Some Progress

There has been some interesting progress with respect to the letter to 20/20 I included in a post two days ago. I received a phone call from Miguel Sancho, a 20/20 producer, and another from his assistant Lynn Redmond. They plan to modify the video that caused so much concern, and to do this with the help of Dr. Anne Marie Albano of Columbia University, a clinical psychologist and one of the signers of the letter.

In talking to Sancho and Redmond, I realized how easy it is for people to assume that if an approach to childhood mental illness or problem behavior does not use holding therapy, it must be all right. Naturally I am pleased when the dangerous and physically-intrusive techniques of holding therapy are abandoned, but I continue to be concerned about the use of related methods without evidentiary foundations. There are a number of these methods that were historically associated with holding therapy and have persisted on their own as holding therapy has diminished. These methods include demands for “strong sitting”, assertion of adult authority by requiring children to ask an adult for permission to do anything they need (including toilet use), making sure that a child is within the line of sight of an adult at all times, and the assumption that physical contact between child and adult has a therapeutic value of its own.  These methods are not likely to do direct harm to the child, but they add to what Michael Linden has called the emotional burden of therapy, and because they are ineffective may cause indirect harm by keeping the child out of effective treatment.

I have been trying for years to find a term that will describe not only these methods, but the related diagnostic efforts, and the unconventional theory that supports the whole can of worms. I recently encountered the expression “faux-RAD”, which I think conveys the disparity between these beliefs and practices and those of the conventional, evidence-based practice of psychotherapy. Michael Shermer years ago referred to the suffocation of Candace Newmaker  by her therapists as “death by theory”, and I consider that insight to be essential to the understanding of faux-RAD. It is faux-RAD theory that allows the replacement of one harmful or ineffective treatment with another that is based on the same assumptions.

To deal with the faux-RAD problem, as exemplified by the 20/20 video, we need to understand the tenets of the theory. I am going to state them here in simple form:

1. Emotional attachment normally begins before birth and is present in basic form in newborn babies.
2. Children separated from their biological mothers are filled with rage and grief even if the separation is immediately after birth.
3. Rage and grief prevent development of attachment to new caregivers, as do later experiences of abuse and neglect.
4. Normally, in non-separated children, attachment advances in two stages during the first and second years.
5. In the first year, attachment to caregivers progresses because the child comes to recognize that the caregiver is the source of all satisfactions of needs. The repeated experience of need followed by satisfaction given by a parent (called an “attachment cycle”) establishes the authority of the caregiver.
6.  In the second year, the caregiver sets limits on the child’s behavior, further establishing authority and therefore attachment.
7. Children are obedient, compliant, and grateful when parental authority has been established in these two ways, and they are said to be attached.
8. Children who are disobedient, noncompliant, and ungrateful are not attached but have attachment disorders, and they do not recognize parental authority. This situation may occur because of persisting rage and grief, and/or because of the absence of the attachment cycle.
9. To make children obedient, compliant, and grateful, they must express their rage and grief and achieve catharsis; then, they must experience re-enactments of the attachment cycle which involve complete dependence on adults for food, drink, etc. This treatment causes obedience by establishing attachment.
10. Because infants need touch experiences, children in treatment also must experience re-enactment of frequent adult touch; this must be given at the decision of the adult and not at the request of the child, and indeed may be against the child’s wishes.
11. Children who are not attached (have attachment disorder) by faux-RAD criteria are filled with hatred and the desire for violence; if treated by conventional psychotherapies, they will get worse; if untreated, they will grow up to be serial killers or prostitutes.

The tenets of faux-RAD described here are at odds with everything known about attachment, about parent-child relationships, about sources of violent behavior, and about effective psychotherapy, as well as with established definitions of Reactive Attachment Disorder. The confusion of attachment and authority is especially noxious, as it opens the door for practices that are distressing and potentially harmful to children.

Regrettably, a look at doctoral and master’s theses written in U.S. social work schools in recent years reveals that faux-RAD ideas are sometimes taught and accepted. This  fact, together with the state-sponsored faux-RAD trainings of adoption workers in Georgia and Utah some years ago, means that the undercurrent of these potentially harmful beliefs is still very real and may have been exacerbated by the 20/20 video. However, I look forward to correction by ABC and to increased awareness of the issues on the part of psychologists, social workers, parents, and teachers.

Letter to ABC About Their Inaccurate Portrayal of Reactive Attachment Disorder

Some readers may have watched an ABC 20/20 program in late October that dealt with a very disturbing adoption story from Arkansas. While the program itself was passable, a video trailer posted as a "teaser" for the program was not. A number of psychologists and social workers have written to David Sloan at ABC and to the ABC ombudsman, outlining our concerns and asking that ABC make some positive move to undo the harm done by the trailer's misinformation.

Here is the text of that letter:

David Sloan, Senior Executive Editor, ABC                                              Nov. 5, 2015

Dear Mr. Sloan:

As psychology and social work professionals concerned about public understanding of childhood mental health, we are deeply disturbed by the video clip http://abcnews.go.com/2020/video/rad-explaining-reactive-attachment-disorder-34667787. The material in this clip conveys to the public a view of Reactive Attachment Disorder (RAD)  that belongs to “fringe” therapists and is not shared by professionals with serious training in psychology. In addition, this view has been used to support the use of potentially harmful interventions with children and to argue that abused children have somehow forced their caregivers to harm them.

The opening scenes of the clip appear to show a method called “holding therapy” or “attachment therapy”, which was strongly rejected in 2006 by a joint task force of the American Psychological Association (APA) and the American Professional Society on Abuse of Children (APSAC). This method has been associated with child deaths and injuries.

A later part of the clip features women stating that their children a) had RAD, and b) were dangerous to other people and to animals, as has been suggested by “fringe” therapists. The implication was that the disorder itself is characterized by aggressive and oppositional behavior. This is not the case, as can be seen by consulting the Diagnostic and statistical manual of mental disorders of the American Psychiatric Association, 5^th edition (DSM-5). Sadness and social disengagement are in fact the leading features of RAD. In addition, it has been recommended that RAD be diagnosed in young children and not in the teenagers some of the women mentioned.

Our concerns are not simply that there was some inaccuracy in the clip, or that the discussion of RAD was insufficiently nuanced. The problem is that the content of this video supports a common misunderstanding that, among other things, can cause people to fear and reject children who have histories of abuse or abandonment, or can lead the children’s caregivers to seek “fringe” treatments that may cause real harm. In addition, this content can be used to support the “RAD defense” in abuse cases--  the argument that children who have been mistreated are so dangerous because of RAD that their caregivers were forced to hurt them.

Now that the inaccurate clip is on the Internet, it will be available for a long time. Taking it down from the ABC website will not get rid of it. For that reason, we would like to ask you to create an additional, accurate video about RAD, with our help, and to post it with a message that it is to correct the previous clip in a responsible fashion.

We hope that you will understand the reality of our concerns and respond positively to our request.

[signed by 19 professionals in psychology and social work]

Readers who are concerned about the 20/20 presentation may also want to express concerns to ABC.

A Personal Account of Attachment Therapy/Holding Therapy

The following is an account of one adopted girl's experience of attachment therapy in 1995-1997. The author, "Ann Onymous", would like readers to understand what this was like from the child's point of view. As she suggests, treatments of this type are still happening in the U.S. and other countries today.

If readers recognize what "Ann" is describing and know that they had similar experiences, I would appreciate it if they would comment or get in touch. One of the difficulties of the fight against these fringe treatments has been that victims have grown up isolated from social networks and sometimes with little education, and as a result only a few have come forward.

My thanks go to "Ann" for preparing this account:

  " My first experience with Attachment Therapy happened when I was 12 years old. These two women came to my house and my Mother called me downstairs to meet them. I walked in the living room and one of the women immediately ordered me to do jumping jacks “fast and snappy and right the first time”. I laughed and then did a few jumping jacks. She then told me that I had done the jumping jacks wrong and that I needed to clap when my hands were above my head. Because I did them wrong the first time, I was assigned 150 jumping jacks. After doing the jumping jacks, I was assigned 80 pushups, and I was made to complete them before I was allowed to go back upstairs. On my way upstairs, I overheard one of the women tell my Mother that I definitely had Attachment Disorder as evidenced by my failure to look into her eyes. My parents thought there was something wrong with me because I lied and snuck out of the house and hid food and nothing they did made much change in my behavior. After seeking support from many counselors my mother did not agree with, they sought out Attachment Therapists.

            It was after this first meeting that everything changed in my home. The same night, my parents came in my room and installed an alarm on my door. If I tried to open the door, the alarm would go off. The alarm was about the volume of a house alarm, and I think they are normally used to keep dementia patients from escaping. Also, after this meeting, my mother started keeping me out of school for long intervals and locked in my room. I was only allowed to come out to go to the bathroom or when my mother said I could. Sometimes I was allowed to eat with the family and sometimes I ate in my room. This went on for several months.

            Several months after the change, my Father came into my room one morning with a duffle bag and told me to pack it. He told me that I was going to go and stay with someone else for a while. I was not told anything other than that limited information. We got in the car and drove for two hours. During that trip I was excited. I thought living with someone else would be better and that maybe this person wanted me. I was so wrong. I was made to get out of the car, wait on the curb, and not do anything until the lady came out to get me. When she came out, I was shocked. She was an older mean looking lady and she had two other kids with her. Though her name was Mary Harless,she told me to call her “Mom Mary”. We then drove another hour to her home. During the drive she introduced the other two kids. I will call them S and D. I was very interested in S and D and so I began to talk with them. Mary then told me that she expected complete silence in the car. On the way home, Mary stopped at the grocery store and told us to remain seated and silent when she went in the store. While she was gone, S and D and I talked. When Mary returned, she said that we were all in trouble because we had not remained silent. I later found a recording device in her car while I was cleaning it.

            Life with Mary was one of unending horrible. Each day, we were woken up very early and made to go outside and run laps. She would assign laps each morning based on our “behavior” the day before. I never actually knew whether I would have many laps or only a few. Sometimes it took over an hour to run all the laps. We then had to wait in silence outside the front door for her to let us back in the house. We were not to open the door or enter the house ourselves. Mary would then let us in and assign morning work that had to be completed before we were allowed to eat breakfast. The chores included weeding the garden, washing the van, sanding a piano (more on that later). Sometimes those chores could take two to three hours and if they were not done right (which could be something as minor as leaving one weed in the flower bed) we had to either get the thing dirty and clean it again or just do another chore of equal time consumption.

            Once chores were completed, we were given a bowl of plain oatmeal (no milk, no butter, no sugar). After breakfast, we were assigned morning chores. Morning chores were similar to the before breakfast chores except that they were harder or took longer to complete. These chores had to be complete before our lunch of a piece of bread with peanut butter on it and maybe a carrot.

            My chore that I had for several weeks was to sand a piano. This was an upright piano that had been painted green. Mary found this piano and brought it home just for me to sand as my chore. I had to sand the entire piano with small pieces of sand paper. In order for it to be done, there had to be no green left on the piano. Morning, noon, and night, I would sit and sand this piano. Like I said, it took several weeks.

            There were punishments if we did something wrong. Something wrong would be anything but complete and total compliance and completing tasks fast and snappy and right the first time. For a minor infraction, we would be assigned exercise like 300 jumping jacks, 100 push ups, or 150 squats. For major infractions we had to do wall sitting, which is where we would sit cross legged in front of a wall with our hands at our sides and our nose touching the wall. We would sit there for hours, and sometimes even days. My longest time of wall sitting was two weeks. If I was given food, I was allowed to relax my position only long enough to eat. If I relaxed my position or my nose wasn’t on the wall, Mary would come up behind me and grab the back of my neck and squeeze hard until I straightened back to position. The other form of sitting we did was called cookie sheet sitting. We would sit facing the wall with our legs outstretched and feet flat against the wall. Mary would place the cookie sheet upright against our ankles, and we were to sit holding the cookie sheet up with the tips of our fingers. This would also be for hours or days depending on how much trouble we were in. This one was particularly painful for me because I am not flexible and I dreaded it.

            Another particularly tough punishment was to have cold showers. We were told to get into the bathtub with our clothing on, and then she would turn on the cold water. We were not allowed to get out of the shower. We would stand there in the water for a while, then she would turn the water off so we had to stand in our wet clothes. Then she would come back in and turn on the cold water etc… The longest I saw a kid in the shower was S, and she was in the bathtub for a week. She was made to sleep in the tub. At the end of the week S was very ill, but was not taken to receive medical care.

            The most brutal punishment was food deprivation. If we were in minor trouble, we missed two meals and were only given oatmeal once, and if we were in major trouble, we did not eat. The longest I went with no food was either three or four days. The longest I went with oatmeal only once per day was three months. One week, I stole pickles. I was so very hungry and I saw the pickles and I took the bottle and hid it behind my bed. When was caught, I was made to eat the entire jar and then went without food for two days. Another time I stole food, I stole marshmellows from an open bag on the counter. When Mary found out, I was made to eat an entire large bag in one sitting and then did wall sitting for the next week. I stole the food because I was hungry, but soon learned that stealing food caused me to be even hungrier. 

            After a while of living with Mary, we began “homeschooling”. Homeschooling consisted of writing sentences in a notebook. These were done in the afternoon between chores and usually consisted of something awful about ourselves. I once had to write “I hate myself” 5,000 times.

            After living with Mary for a few months, maybe three or four, we moved to Evergreen Colorado. S and D were sent to residential treatment facilities and I was the only foster kid to actually move with her. When we arrived in Colorado, we were greeted by a woman named Connell Watkins. Connell was a therapist that Mary travelled to Colorado to work with. Once again, I held onto hope that things would get better in Colorado and that Connell would be nicer, but not so.

            I started therapy twice a week with Mary, Connell, and sometimes another lady named Deborah Hage. Therapy was bizarre. I was wrapped from head to toe and blankets, and then all three women (who were not small) would sit on top of me and I had to get out of the blanket. It was horrible and sometimes I couldn’t breathe. They would make fun of me as I struggled. They called me a quitter. They said I must not want to be born or live. They told me I should just give up because that is what I always did. Sometimes during therapy, they would hold me across their laps. I would have one arm behind Connell’s back and be laying across two or three laps. They would ask me questions (usually shaming questions about me) and if I answered wrong they would put their faces really close to mine and yell at me. If I answered right, I had to yell the thing I had just said over and over. It was usually something bad about myself. If I was not compliant, they would make me lie down on the couch and kick my legs for long periods of time, and sometimes they would wrap me completely in a blanket and lay there for long periods of time. I would get really hot and sweaty and I felt like I couldn’t breathe. There was a lot of yelling and anger involved with therapy, and in order to do a good job, I had to be angry. They were always looking for anger. If I did not get angry, they would dig their fingers into my ribs until I screamed. They called this hassling.

            During the time I lived in Colorado, I had two very severe punishments. The first punishment happened because I started giving Mary and Connell sassy looks. They bought me a pair of sunglasses, and for several weeks, unless it was therapy time, I had to wear the glasses because they said that other people shouldn’t have to look at me. Once, I took the glasses off. Mary came up behind me and grabbed the back of my neck and led me to the mirror. She made me stand for hours in front of it until I had shouted out all the horrible things I could think of about what I saw when I looked at myself in the mirror. She then explained that all those things were why no one else should have to look at me. I didn’t remove the glasses again.

            For the other extreme punishment, I was locked in my room for three months. I got to come out of my room to go to therapy and that was it. I was given plain oatmeal once a day unless I tried to escape, and if I did that, I was not fed. The room was stripped of everything but the mattress, a bucket for me to urinate in, and a journal and pen. Mostly, I wrote about how I wanted to get out.

            I lived with Mary Harless for a year and a half from the ages of 12 to 14 years old. I spent a Christmas and two birthdays there. I was Connell Watkins client for a year. The abuse I suffered was extreme and horrible. I actually did have some attachment insecurity growing up due to foster care and a negative adoption experience. When I was a child, I lied and snuck around and got bad grades. My Mother (adoptive) and I did not get along. I was absolutely sure she was disappointed over having adopted me at all, and I behaved accordingly. If I was already a disappointment, I figured I could just do what I wanted. I was also angry because I didn’t get a family I “fit” with. Even with all my behaviors, I did not deserve abuse. My Mother took me to several different counselors when I was a child, but each time, as soon as the counselor suggested any changes to her behavior, she would get angry and we would never go back. My Mother wanted to believe that she had just received a defective child and she didn’t want to shoulder responsibility in fixing me. When these women came and told her what she wanted to hear (I was defective and it must be so hard for her), she latched on. It is, for me, the biggest rejection of my life. Not only did she not want me, she paid someone to openly and blatantly abuse me. If parents are still doing this to adoptive children, it needs to stop."

Please, readers, if you have other information like this and are ready to join the fight against this type of treatment--  which is certainly still in existence--  please get in touch!

Once again, my thanks to "Ann" for coming forward--  JM