I’ve pointed out again and again that Reactive
Attachment Disorder in children is not characterized by aggressive or hostile
behavior, by lying, by lack of remorse—and certainly not by an inability to
connect cause and effect. But when people ask, “Well, then, what DOES my child
have wrong?”, it’s an impossible question for anyone to answer without seeing
the child and family in action.
Nevertheless, I want to put forward a possible set of
problems that could in fact produce some of the unwanted behaviors that are so
often attributed to RAD in Internet material. These are conduct problems and
callous-unemotional traits (CPCU). Children who show CPCU are antisocial and
oppositional, and often continue to show antisocial behavior later in their
lives. These conduct problems, which may occur alone, are in CPCU associated
with a number of other concerning traits. For example, they may not show guilt
or remorse after misbehaving, they may show no empathy when other people are in
distress, and they do not seem to care whether they themselves perform well or
poorly.
These CPCU characteristics are not simply disturbing
to teachers, parents, and other children; they evoke from the social
environment a set of responses that are likely to worsen the child’s behavior
problems. We expect children to be upset
if they do poorly at school or in sports, or even when they lose a game with
other children, and we are ready to offer comfort or at least “bracing” remarks
about how there will be another time or how the child should be a good loser.
When a child says, or shows, that he or she does not care what happened, we
tend to be at a loss for what to do—we may simply ignore the child, and then or
later we may make sarcastic remarks about how we know the child doesn’t care
what happens. It’s very difficult for us to model empathy in this unexpected
situation, so we model indifference instead. In addition, when we see that a child
“doesn’t care” about a person in distress, or “doesn’t care” about what he or
she has done wrong, we often feel confused and vaguely hostile, and again model
indifference or verbal attack—often, the same sort of behavior that we object
to in the child.
Whether these “normal” responses of adults actual
worsen CPCU behavior or not is not clear, but it certainly seems unlikely that
these responses will help the child develop in a more acceptable direction.
There is no evidence that any form of “attachment therapy” is effective in
changing CPCU traits, nor would we expect there to be, because the issue is not
about attachment-related behavior. However, it’s possible for behavior therapy
to bring about changes in CPCU behavior like disruptive behavior, disobedience,
tantrums, and inattention. But it may be that children who show CPCU respond
differently to rewards and punishments than most other children do, and
therefore behavior therapy may need to be fine-tuned to work well with them.
They may do well with responding to rewards, but less well than other children
when the therapy uses punishments.
An article by Daniel Waschbusch and his colleagues (“A
case study examining fixed versus random criteria for treating a child with
conduct problems and callous-unemotional traits”, Evidence Based Practice in Child and Adolescent Mental Health, 1(2-3),
73-85) looked at possible ways of fine-tuning behavior therapy for one child
with CPCU characteristics. They looked at the results of using one approach
with this child, then shifted to another approach, and compared the effects of
the two.
The little boy, “Juan”, was adopted at 17 months and began to show
concerning behavior at about age 2 years. (That is, of course, a time of life
when typically-developing children often begin to be resistant, to have
tantrums, and to react badly to frustration, so it can be difficult to know
whether a child’s behavior is or is not problematic with respect to later
development.) Entering school, he was
disruptive, aggressive, inattentive, and silly, and his teacher said he did not
seem to care about his school performance. His teachers also felt that he
lacked warmth and kindness.
Behavior therapists working with Juan focused on
managing his behavior with effective commands, positive reinforcement, and
immediate consequences for his behavior. They gave or took away points for
complying or failing to comply, and he could use the points to buy free time at
noon and privileges like screen time at home. In addition, a daily report card
helped to determine whether Juan could participate in a “fun field trip” on
Fridays. The focus for Juan’s behavior therapy was on his tendency to interrupt
other people, to violate classroom rules, and to tease his classmates. Juan’s
behavior did change in response to this regimen, and he did best when the behavior
change he was asked to perform was clearly stated – not just that he should
interrupt less, but how little he had to interrupt in order to be rewarded.
Waschbusch and his co-authors mentioned that there has
been less research on the effective use of punishment in behavior therapy than
on the effective use of reward. They noted that it seems plausible that
effective punishment must be mild, consistent, and predictable, but parents of
children with conduct problems often do not manage this. Instead, they ignore
bad behavior for some time, then unpredictably use serious punishment, which
does not seem effective in changing behavior. Waschbusch and his colleagues
also noted how little is known about the use of aversive events as punishments
rather than punishment by taking away points or privileges.
Although there is much still to be understood about
treatment of children with CPCU, these unwanted behaviors are apparently not
related to attachment or any version of RAD. Also, they are treatable with
standard treatments and need not destine a child for the school-to-prison
pipeline. Treatment both at school and at home seems to be a key to success,
and effective treatment requires changes in both teacher and parent behavior.
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