Some days ago I received an e-mail from one, Justin Taylor, representing Sundance Canyon Academy, a residential treatment facility in Utah that appears to treat teenagers who are said to have Reactive Attachment Disorder. Justin said that since I had been trying to educate people about this disorder, I would like to embed in this blog the Sundance infographic describing Reactive Attachment Disorder. This suggestion led me to have a look at said graphic, and I was most interested to see the amount of mis- or dis-information that could be crammed into a few pictures. You can see it too, at http://www.sundancecanyonacademy.com/reactive-attachment-disorder-infographic/. (But I'm finding that I sometimes get an error message for this; if you go to the home page and scroll all the way down, you'll see a link to this thing.)
Let’s look at this display under the usual strong light. First, in an introductory passage plagued with writing difficulties, Sundance states that “Reactive attachment disorder is a serious condition that some children and teens must live with”. This claim ignores the fact that RAD is not a diagnosis used for children of school age or older, and no diagnostic method exists for assessing such a problem after the preschool period. In addition, Sundance seems to be uncertain about whether any treatment would be helpful, otherwise why say that the children “must live with” the problem?
To continue looking at the introduction and the infographic: it’s notable that Sundance seems to have ignored the publication of DSM-5 and the change in terminology that limits the term Reactive Attachment Disorder to what used to be called the “inhibited” type, a developmentally-inappropriate emotionally-withdrawn behavior combined with irritability, sadness, and fearfulness even during nonthreatening interactions with caregivers. What used to be called the “disinhibited” type is now categorized as disinihibited social engagement disorder (DSED), and this involves a lack of preference for unfamiliar people (note that some lack of preference for familiar adult caregivers would be quite developmentally appropriate for adolescents). Sundance still references the two types, disinhibited and inhibited. Be that as it may, they provide an interesting, though somewhat notional, list of symptoms for each, apparently having read a bit of DSM-IV and a bit of DSM-5-- though not very carefully.
Here’s what Sundance says about the disinhibited type of RAD (now known as DSED): the symptoms are “being highly selective” (?), “readily interacting with strangers, rather than showing natural strangers anxiety” (copy editor to the rescue, please!), “seeking unnatural comfort from strangers” (whoa!), “exaggerating the need for help doing basic daily tasks”, “taking part in inappropriately childish behavior”, and “appearing overly anxious”. Nowhere does the infographic clarify how children of different ages might show such “symptoms” in different ways, or deal with the issue of developmentally appropriate practice and diagnosis. The “highly selective” part is a mystery to me, and certainly does not come from any edition of DSM. Ready interaction with strangers is something I would expect from any well-developed teenager, and woe betide the poor child who is sent to any residential treatment facility if he or she does not have that capacity. “Unnatural comfort”-- well, I’m sure that doesn’t mean what it might be taken to mean, but the use of the terms “natural” and “unnatural” is without meaning except as a way to scare parents. As for needing help in basic daily tasks, this “symptom” comes straight from Attachment Therapy, where it’s regarded as a way in which disturbed children manipulate and exploit credulous adults; it’s not in the DSM description. “Inappropriately childish behavior” depends on how old a particular child is, as well as on the possibilities the environment presents. Finally we have “appears overly anxious”, but wait, hasn’t the person been declared to lack “strangers anxiety” and to approach strangers, normally a source of serious anxiety for young children? Apparently the children are simultaneously anxious and not anxious (but from the Attachment Therapy viewpoint, that only shows how cunning they are).
All right, if you’re not too depressed already, let’s have a look at the statements about symptoms of the inhibited disorder (now the only type called RAD). Here we have “avoiding eye contact” (oops, is there some confusion with autism spectrum disorders?), “unresponsive or resistant to comforting”, “steer clear of physical contact” (never mentioned in DSM), “excessively holding back emotion”, “preferring to play alone”, and “detaching from others”. The DSM description considers children with this inhibited disorder as inhibited and emotionally withdrawn, with negative emotional response to interactions with others. Although eye contact might be interpreted as an emotional interaction, it is not a very useful measure because it is characteristic of other disorders and can occur because of cultural restrictions on children’s looking directly at adults.
Sundance’s infographic goes on to inform parents that children of all ages may have Reactive Attachment Disorder (their definition) if they do the following: “cruelty to animals for no reason” (perhaps there are some good reasons Sundance could suggest?), “watching others closely, but not engaging in social interaction” (school, perhaps?), “destructive to self and others”, “impulsive negative behaviors”, and “abnormal eating patterns”. Some of these, of course are matters of extreme concern, and although they may occur in typical children in the toddler and preschool period, in older children and teens they would be evidence of a serious need for treatment. However, except for a tendency to hypervigilance, they are not mentioned in DSM in descriptions of either RAD or DSED.
As you can see, Sundance Canyon Academy either does not have a very good understanding of these disorders, or may see some benefit in offering confused material to parents. Certainly some parents who have been reading about Attachment Therapy on the Internet will find some of these ideas familiar and therefore acceptable.
It’s quite a labyrinthine process to find out what treatments are used at Sundance Canyon Academy, and what their basis in empirical evidence might be. They use a method described at www.whytry.org, whose website offers claims at evidentiary support, none of which appear to have been published in peer-reviewed journals, and most of which seem to be simple before and after studies. There are some other issues, too, but this post is getting too long already.
One more point of interest: a major figure at Sundance is described as having been the owner and operator of Odyssey Youth Transport, an organization that comes into the home at night to waken sleeping teenagers and to take them away to residential treatment facilities. How this outfit worked when owned by the Sundance staff member, I have no idea. However, at present its website (www.odysseytransport.com) includes a parent handbook that speaks of transport workers as Guides and inquires whether the child knows that the Guides are coming and whether he or she has alternative or favorite routes out of the house. Parents are told that after they converse with the Guides on their arrival at the house, they are to awaken the son or daughter in his or her bedroom and introduce the Guides. They provide a letter to the child telling what is happening. They are then to leave the house and asked “Please do not return to the residence until the Guides contact you, or until the rental car has left the premises.” As I said before, I have no way of knowing whether this draconian approach was taken when the Sundance staff member owned Odyssey, but the possibility is an eyebrow-raiser.
In a second e-mail, Justin Taylor asked whether I could point out changes needed on the Sundance website. I think I’ve done so. Now let’s see whether they alter their infographic.
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