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Concerned About Unconventional Mental Health Interventions?

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

Friday, February 26, 2016

Why Some People Who Should Know Better Still Assume That Reactive Attachment Disorder Involves Violent Behavior

Both professional journals and little independent blogs like this one have been stating for years that Reactive Attachment Disorder may be accompanied by aggressive behavior, but it is not the cause of that behavior, nor is aggressive behavior a symptom of the disorder. The last word about this was thought to have been said by the joint task force on Reactive Attachment Disorder of the American Psychological Association, Division 37, and the American Professional Society on Abuse of Children, headed by the late, much-respected, Mark Chaffin (Chaffin et al, 2006).  

Nevertheless, both parents and mental health professionals continue to assume that “the list” promulgated by attachment therapists, including not only aggression, but “fascination with blood and gore”, cruelty, and unwillingness to make eye contact on the parents’ terms, is an accurate description of Reactive Attachment Disorder. This is even evident in master’s and doctoral theses, which are presumably approved by a committee whose members are regarded (by someone) as knowledgeable.

Why? Why doesn’t this trailing edge pass over us? There are lots of reasons why people believe foolish things, and no doubt they all apply, but there is more to it than that. The problem I want to point to today has to do with the failure of editors and reviewers to properly monitor publications in professional journals, and the resulting publication of inaccurate and misleading claims.

Let’s look at three such publications that I stumbled across while looking for something else.

  1. Taft, R.J., Ramsay, C.M., & Schlein, C. (2015). Home and school experiences of caring for children with Reactive Attachment Disorder. Journal of Ethnographic & Qualitative Research, 9, 237-246. [these authors appear to work in special education and curriculum]
Taft et al state that “Children with RAD demonstrate significant and often dangerous behaviors..” (p.238). They follow this statement with a reference to the DSM-IV diagnosis, but without noting that none of the DSM editions refers to dangerous behavior. In a later paragraph, they reference an attachment therapy practitioner as saying (incorrectly) that children with RAD defy traditional treatment , and then go on to say that the Chaffin et al (2006) APSAC-DIV 37 task force reported that “some RAD children exhibit extreme disturbances”—whereas in fact Chaffin et al acknowledged that extremely disturbed childhood behavior is possible, but did not connect it with RAD. Later, Taft et al describe the children as “very intentional” about threatening or inappropriate behaviors, and state that concerning behaviors are purposeful and directed toward targets rather than the results of temper tantrums or responses to specific triggering circumstances. These statements were based on interviews with parents, most of whom attended a RAD support group (where presumably they told each other these stories and perhaps competed to be the bravest or most martyred parent). The paper’s reference section includes Nancy Thomas, a major promulgator of inaccuracies about Reactive Attachment Disorder, and Michael Trout, a member of APPPAH and believer in prenatal attachment.

  1. Shi, L. (2015). Treatment of Reactive Attachment Disorder in young children: Importance of understanding emotional dynamics. American Journal of Family Therapy, 42, 1-13. [this author is a marriage and family therapist]
Shi describes the case of a four-year-old boy, prenatally drug-exposed, and fostered by a sequence of five families, one of which was said to have chained him to a table. The current foster parents at the time of writing had three bio children and two other foster children in the house as well as this child; the foster mother ran a day care in her house while attending community college part-time. The father wanted to give the child up, but the mother resisted this. In spite of some obvious environmental problems past and present, Shi diagnosed the child as having Reactive Attachment Disorder. Shi stated that the child fit the “classic” RAD picture as described in DSM-IV-Tr, and then immediately proceeded to describe the child’s relevant behaviors, none of which are described in the DSM discussion.

The behaviors in question were, first, “a persistent fear state. He would eat non-stop when food was on the table and would not stop eating until he was forced to. He would steal food and hide it in his bedroom. He would eat garbage… shampoo and charcoal.” [N.B. these statement were exactly as I have given them here, with no evidence of a persistent fear state actually being given—JM].

A second category of behaviors was “dysregulation of affect. He urinated on the carpet when he was upset. …He broke toys on purpose, left holes in walls…ruined furniture, abused family pets, bounced on his two-year-old sister… He would not show emotions when hurt or injured but would cry dramatically over small, insignificant things.” The connection between urinating on the carpet and dysregulation of affect was not made, but as was the case for the fear state, neither the categories nor the specific behaviors are discussed in DSM.

A third category was “avoidance of intimacy…any attempt at physical contact would result in his screaming at the top of his lungs. He had no tolerance for anything soft or comforting. He… slept on a bare mattress. He would fake emotions from time to time yet any genuine feelings and emotions were scarcely observed.” Shi did not comment on how it could be detected that the child was faking an emotion, or how reluctance to lie on bedding was equated with avoidance of intimacy.

Treatment involved play therapy sessions, plus the prescription of ten minutes one-on-one with the foster mother every day. (The foster father also left the home, a factor that was not further discussed.) In an outcome described as “magical” and a “miracle”, after 16 sessions the child got a lot better and maintained his gains over several years, during which the foster mother worked to adopt him. Certainly the therapist and foster mother deserve full credit for their commitment and their work with this child, but the assumption that they were “treating RAD” was never justified.

  1. Stinehart, M.A., Scott, B.A., & Barfield,H.G. (2012).  Reactive Attachment Disorder in adopted and foster care children: Implications for mental health professionals. The Family Journal, 20(4), 355-360. [the corresponding author is in a department of counselor education]
From the abstract onward, this paper shows serious confusion about the nature of Reactive Attachment Disorder  and about the development of attachment. The title refers to RAD, but the abstract speaks of disordered or disorganized attachment. In reality, disorganized attachment behavior is a category used when assessing toddler attachment by means of the Strange Situation. Young children with disorganized attachment behave in unusual ways when reunited with the mother after a brief separation, freezing in place, falling to the ground, or backing toward the mother. The mothers may look frightened of the children and are often suffering from traumatic experiences. This kind of behavior is by no means a positive sign or a predictor of excellent development, but neither is it a symptom of a clear-cut pathology or of Reactive Attachment Disorder. Disorganized attachment reveals a situation in which both mother and child are in need of help to recover from trauma, but it need not be associated with separations or with abusive or neglectful treatment of the child; Reactive Attachment Disorder is by definition found after situations of neglect (sometimes including abuse) or multiple separations associated with neglect.

Having gotten off to a bad start on this paper, Stinehart et al then compound the problem by stating their inaccurate position on the development of attachment. Here’s what they say: “even before birth, a fetus begins to form an attachment to the woman carrying it. After birth, an infant will display an almost biological need [?—JM] to attach to a primary caregiver, typically a mother… [this relationship] is consistently strengthened as a child is comforted when scared, fed when hungry, and in general is made to feel safe and secure. An infant will seem to seek an unbroken gaze into the caregiver’s eyes and may attempt to mirror the caregiver’s facial expressions…”. The authors next repeat their problem from the abstract, by referring in one paragraph to disorganized attachment and proceeding in the next to discuss RAD, implying without either argument or evidence that the first is to be identified with the second. Finally (for the present purposes), Stinehart et al list a series of symptoms that they declare to be part of Reactive Attachment Disorder: early feeding problems, colic, failure to thrive, food hoarding, gorging, and pica, lack of impulse control and of empathy, tantrums, depression, inattentiveness, antisocial actions, cruelty, etc., all as seen in various on-line lists but not in DSM.

To comment briefly on these claims: 1. Attachment does not begin before birth; 2. Attachment is thought to develop as a result of the enjoyable social interactions that usually accompany the caregiving routines mentioned by Stinehart et al. 3. Infants do not make a great deal of eye contact until at least 4 or 5 months of age. 4. When they do make eye contact, the unbroken gaze is only a few seconds in length, as the child looks away to other parts of the face or to other objects, then returns to mutual gaze briefly. 5. Mirroring caregiver facial expressions occurs within a day after birth in the right conditions, and is probably far more important in attracting the caregiver to the baby than in establishing the baby’s attachment. 6. Need I say again that although disorganized attachment indicates a relationship that needs support, it is not the same thing as Reactive Attachment Disorder? No one has demonstrated a connection between these two behavior patterns. 7. Once again, although children may display all the problems on the list, and need help if they do, these problems are not symptoms of Reactive Attachment Disorder.

How did these three papers get published? One reason is that professionals trained in fields that do not involve child mental health have convinced themselves that it is easy to pick up a developmental psychology background that has been missing from their studies. But, more directly and importantly,  journal editors in those fields, who cannot be expected to  know all the material relevant to every submitted paper, err by choosing reviewers who are also untrained in child development. Thus, there is approval of publication of claims that contradict established information and favor pseudoscientific views of children’s mental health. Once publication has taken place, there is no recalling the material, even when an editor revokes a published paper; it stays somewhere on the Internet as a “peer-reviewed” publication. (Unfortunately, this is all too often right, as the reviewer is apparently an equal of the author with respect to understanding the issues.)

Editors and reviewers for guilty journals  need to do a better job. Allowing misinformation to be published is harmful to children and families in ways that are difficult to undo once they have occurred.


  1. Is it likely that papers such as these could go on to influence the DSM's definition of RAD in the next edition?

    1. I doubt it, because really it's only psychiatrists and psychologists who are on those DSM committees, and the ones who are on there are pretty stringent-- see the failure to get "developmental trauma" in.

      I hope this is correct, anyway!

  2. Dear Jean Mercer
    Robert Hafetz sent me a link to a listing of its methods. I want to ask you ...... whether it makes sense to do a professional translation of this technique and use in Russian conditions? Please give professional advice.

  3. Dear Mikhail-- I would much rather see you translate different work, for example that by Mary Dozier about educating adoptive parents to do what their children need. I do not say that Haftez's techniques are harmful, at all. However, he seems to have made the mistake of thinking that all adopted children have the same problem no matter at what age they were adopted. He stated in a discussion with Pennsylvania legislators that a person who had been adopted three days after birth was depressed as an adult because of his separation from the birth mother. This is nonsense, and it opens the door to further nonsense if it is accepted-- it can even lead adoptive parents to accept cruel treatments (although once again, I see nothing inappropriate in the parental behavior Hafetz suggests).