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.