Thursday, May 17, 2018
A Rose By Any Other Name May Be More Difficult to Treat: Mistaking Other Disorders for Attachment Disorders
Over the last couple of years, a number of psychologists, both British and American, have called attention to the excessive current emphasis on attachment and trauma as causes of mental and behavioral problems. The emphasis has generally been on diagnosis and treatment of adopted children, for whom any behavioral problems are so often attributed to their histories of separation and possible abuse and neglect. Matt Woolgar and Stephen Scott (Woolgar, M. & Scott, S.  The importance of comprehensive formulations The negative consequences of over-diagnosing attachment disorders in adopted children. Clinical Child Psychology and Psychiatry. : DOI: 10.1177/1359104513478545) gave examples of British cases where children were evaluated as having problems caused by attachment disorders when in fact their major difficulties stemmed from treatable issues like learning disabilities. The American psychologist Brian Allen, whom I mentioned in a recent post, has argued strongly against the view that conduct disorders and callous-unemotional traits should be considered to result from difficult attachment histories or from the posited “developmental trauma”.
There are certainly childhood disorders that seem to stem from problematic experiences with early care, and because such problematic experiences are likely to lead to termination of parental rights and subsequent adoption, it is true that adopted children are more likely than others to have these difficulties. However, it is a great mistake to assume that all problems of adopted children (or of nonadopted children, for that matter) are caused by experiences of separation, abuse, or neglect. The evidence at this point is that attachment problems in children involve either Reactive Attachment Disorder, a matter of sadness, social withdrawal, and difficulty in seeking comfort from familiar adults, or Disinhibited Social Engagement Disorder, a matter of unusually easy rapport with strange adults and failure to prefer familiar adults over strangers (in contrast, with most young children, who seek familiar people and are wary of strangers). Aggressive behavior, callous-unemotional traits, precocious sexuality, unusual tantrums, and learning difficulties—all serious problems-- are not included here.
Adoption has been called the most effective treatment for attachment disorders, and most children who have been adopted and stayed with a family for some years will begin to show more normal social behaviors. Adoptive families may benefit from therapeutic support, but treatment is likely to focus on the adults and their parenting behavior rather than directly on the children.
But like nonadopted children, adopted children may have a range of psychological issues in addition to or instead of attachment disorders. All human beings are subject to psychological disorders that are influenced by biological factors like genetic influences. Although there are many rare and serious problems that are genetically determined, the most commonly-diagnosed genetically-caused psychological difficulty is autism, now known to exist in a wide range of severities (the “autistic spectrum”).
The British psychologist Joshua Carritt-Baker has recently commented on the frequency of autistic disorders among adopted children and the mistaken assumption that these children are suffering from attachment disorders. This assumption has led to the treatment of numbers of adopted children with non-evidence-based methods that claim to treat attachment problems (for example, Dyadic Developmental Psychotherapy as practiced by Daniel Hughes and Kim Golding). Carritt-Baker has created a video explaining the problems that have not been solved by the activities of the British Adoption Support Fund, which can be seen at
Carrit-Baker notes, by the way, the fact that the United Nations has warned France that its approaches to treatment of autistic children are violating those children’s human rights, and points out that the same warning is due to British organizations. The over-diagnosis of attachment disorders in the United States may deserve a similar caution.
What has brought about this difficult situation in which autism as well as other problems gets confused with attachment disorders?
One source may be the historical one, whose “trailing edge” still influences thinking about children’s mental health. At the time when autism was first clearly identified as different from speech pathologies or mental retardation, psychology and psychiatry put an enormous emphasis on experience and learning as sources of mental illness. That autism was caused by aloof, overly-intellectual “refrigerator mothers”, and was related to a lack of attachment, was taken for granted in the 1940s. Genetic factors were unknown (even the chromosomal causes of Down syndrome were not identified until the 1950s), and it was not until much later that it was demonstrated that autistic children had ordinary attachment behavior. The same stress on experience (as opposed to biology) created an emphasis on early childhood attachment experiences as the most important—even the only—factor in determining personality and mental health. This view has lingered with us and is especially obvious in non-evidence-based alternative therapies.
No one would deny that attachment is important. But other factors are also important. Children’s development is determined in complicated ways; biological and experiential factors interact with each other and have different influences at different ages. We have learned a lot about this in the last 60 years and should be able to do better than seems to be the case right now. Choosing the right kinds of treatments requires us to consider more than one possible problem and more than one possible treatment. Otherwise we waste public and family resources and do many children a distinct disservice.