Reactive Attachment Disorder on the Internet: Confident, but Wrong

Reactive Attachment Disorder is a genuine diagnosis, code 313.89 in the Diagnostic and Statistical Manual of the American Psychiatric Association (DSM). Young children who receive this diagnosis are either unusually friendly to strangers for their age, or unusually clingy and concerned about separation from familiar people, and they have histories of poor and inconsistent care early in their lives. Appropriate treatment for this condition involves helping caregivers increase their commitment, or investment in an enduring relationship with the child, and become more sensitive to the child’s signals of interest and affection toward the caregiver (see Bernard, K., & Dozier, M. [2011]. This is my baby: Foster parents’ feelings of commitment and displays of delight. Infant Mental Health Journal, 32, 251-262). Interestingly, although parents are often very concerned about “disinhibited attachment”-- the child’s willingness to approach strangers-- by the time they reach adolescence, many “disinhibited” children receive social approval for their good social skills and ease of engagement with other people. You’d never know any of this if you got your information about attachment and mental health from http://www.attachtrauma.org. Although this web site lists the DSM criteria for Reactive Attachment Disorder, it also provides a checklist for something else called “Attachment Disorder”. This problem (not to be found in DSM) is said to include the following, among other things: poor eye contact, firesetting, cruelty to animals, toileting issues, unusual speech patterns, and lack of cause and effect thinking. Attachtrauma.org attributes angry moods and behavior to a failure to experience something they call the “bonding cycle”, a series of events in which a caregiver calms, helps, or gratifies a child. This “bonding cycle”, which is almost never mentioned in modern conventional discussions of attachment, resembles the original Freudian view of attachment as “cupboard love”-- a positive emotional response to being fed. As I mentioned earlier, effective treatment for attachment problems of young children focuses on their caregivers’ emotional skills and behavior. The child’s emotional development is considered to depend to a considerable extent on the quality of social interactions and communications with the parent. The attachtrauma approach is much more concerned with treating the child himself or herself, although it includes strong resistance to the idea that the child might receive any treatment without the parents’ involvement. My concern today is with the parts of attachtrauma.org that reject conventional psychological interventions in favor of unconventional approaches like Attachment Therapy, cranial-sacral therapy, neurofeedback, and EMDR-- all methods with weak or no evidence supporting their effectiveness. But attachtrauma.org does not spend time arguing why these unorthodox practices are desirable, which would be hard to do. Instead, the site presents claims against “traditional psychotherapies” (by which they mean “talk” therapies) and against behavioral therapies. In each case, the rejection of the treatment is argued not in terms of systematic evidence but in terms of what would be the case, if certain assumptions happened to be correct. Here’s what the attachtrauma site says about traditional psychotherapies: “[they] don’t work [by the way, “working” is undefined-- JM] with children with RAD [Reactive Attachment Disorder]. The reason is that traditional therapies all depend on a relationship of trust between the child and therapist and/or child and parent. A child with RAD is by definition a child without trust. Therapies that involve the parents and work toward building the trust between parent and child are the kinds of therapies that work. Therapies that don’t involve the parents are WRONG [caps sic] for and usually damaging to a child with RAD.” Let’s look closely at this statement. As I pointed out, what it means for a treatment to “work” or not remains unstated. I can only assume that the desired outcome is what is stated on another attachtrauma page as indicating attachment-- that the child is obedient but not overly submissive, etc., etc. In other words, the focus is not on the attachment relationship at all, but on the child’s obedient behavior, including affectionate actions when desired by the parent. Conventional therapies would not necessarily share these goals and would consider appropriate goals to be different for different ages and circumstances. To go on: do traditional therapies depend on a relationship of trust? No, of course they do not assume that the child or adult patient comes in prepared to hand over trust to a therapist. Building a therapeutic relationship and establishing trust are part of the process. As for the idea that a child with RAD is by definition a child without trust-- this is the definition attachtrauma.org has created for its own purposes. If anything, children with the RAD diagnosis who show disinhibited attachment could easily be described as too trusting, as they are willing to behave toward every adult as they do toward familiar people. But in the next sentence I believe we get to the crux of this matter, as the anonymous author goes on to refer to “therapies that involve the parents”. Conventional therapies like Parent-Child Interaction Therapy do involve parents, of course, and there is much evidence that PCIT (for instance) “works”. However, it’s not at all clear that those are the kinds of treatments attachtrauma is referring to. Is not their concern that a child may talk to or work with a therapist independently and establish a relationship which, however beneficial to the individual, does not give priority to the parents’ needs and wishes? Surely such a relationship would be most helpful in the cases in which parents have difficulty processing the child’s feelings or past history; this might well apply to Russian-adopted children who before adoption had received weekly visits from parents they knew very well. As a final glance at the claims about “traditional” therapies, it’s important to look at the unsupported statement that such therapies are “usually damaging” to children diagnosed with RAD. This is an exceedingly strong statement and goes far outside the normal boundaries of professional criticism, particularly when no systematic evidence is offered to support the argument. There is no doubt that some psychological interventions are ineffective, and even that some are potentially harmful treatments. But this claim, made without evidence, and with the apparent purpose of attracting clients to an unconventional form of treatment, is a shocking departure from ethical conduct in either the medical or the mental health area. There is no meaningful information presented here; on the contrary, as my mother used to say, it’s all an old saying that they just made up. Similar issues appear in the attachtrauma.org statement about behavioral methods, in which we see that “Children with RAD do not respond to rewards”. This is indeed a remarkable statement and suggests that the children in question (either the clingy ones or the ones who follow strangers) function differently from any other known animal right down to flatworms. Attachtrauma also says “Some children see these rewards as another way to trick their parents and prove how stupid adults are”. Here we have an internally inconsistent argument that claims simultaneously that the children cannot respond to a reward, and that they are rewarded by an opportunity to “trick” others. Once again, the author of this material has presented a set of claims based only on unsupported assumptions and has relied on proof by assertion of most unlikely and even paradoxical statements. If you’ve been reading www.attachtrauma.org, or any other website supporting Attachment Therapy, do use your own critical cognitive ability. And, while you’re at it, take a look at the list of therapists approved by that site. If they’ve been willing to have their names associated with the confident assertion of incorrect statements, maybe you should do a little critical thinking about them too.

"Primal Wound" or "The Blight Man Was Born For"

Over the last week or so , discussions at http://osolomama.wordpress.com have centered around the idea of the “primal wound” (even though that was not the blogger’s plan). The “primal wound” in question is the posited emotional injury done to infants separated from their birth mothers. Those who support this idea believe that such an injury occurs even if the baby is placed with other caregivers at birth, and that the “wound” continues to cause pain all through life, unless it is resolved and healed in some way. Adult adoptees commenting at osolomama and elsewhere have made it very clear that they experience ongoing distress in close relationships, that they feel they have had this experience throughout their lives, and that they attribute their sense of distress to their history of early separation. (I am stating this simply and unemotionally for the sake of brevity, but the adult adoptees tell their stories vividly and with intense emotional engagement.)

But here’s the issue: nothing in all the careful work in developmental science done over the last century would suggest that it is possible for early separation to have a lasting effect on children who soon enter a stable, lasting adoptive family. All the information we have says that early-adopted children do very well (for example, Sharma, McGue, & Benson [1998]. The psychological adjustment of United States adopted adolescents and their non-adopted siblings. Child Development, 69, 69,791-802). Later-adopted children may have more problems, especially if they were in institutions for long periods or had risk factors that led to their being institutionalized to begin with, but often show good recovery over some years (for example, Rutter, Kreppner, O’Connor, and the English and Romanian Adoptees [ERA] Study Team of 2001.[2001]. Risk and resilience following profound early global deprivation. British Journal of Psychiatry, 179, 97-103).

In addition, the study of early development shows that infants do not show concern about attachment and separation until they are 6 months old or older. This does not mean that they cannot tell the differences between people, initially by smell and sound and later by looks. However, it does not seem important to the young baby to be close to a familiar person, as long as the caregivers they are with are sensitive and responsive to the baby’s needs (and of course familiar people may do a better job of reading the baby’s cues, first because they know the individual child well, and second, perhaps, because they may be highly motivated to take good care of that baby). It’s not until about 7 or 8 months that most babies will show by their behavior that they are afraid of a stranger, or temporarily disturbed by the absence of a familiar person, or deeply grieved and disturbed by an abrupt, long-term separation. It does not seem plausible that an event that a baby did not respond to at the time it happened would nevertheless cause later disturbance and grieving. The only possible argument that this could happen would seem to be based on the assumption that memories can be repressed and work some mischief from the unconscious, but the evidence is clearly against that idea.

These well-established facts suggest that there is no “primal wound”. The idea that there is such an emotional injury seems to have come out of the writings of a California marriage and family therapist named Nancy Verrier, whose thinking is strongly connected with that of William Emerson of APPPAH (Association for Pre- and Perinatal Psychology and Health). APPPAH is an organization that stresses the belief that unborn infants have conscious understanding of events going on around them, perhaps all the way back to conception or even before (you’ll have to read that part for yourselves). Verrier and her colleagues are committed to the idea that there is a biopsychological attachment between a baby and its birth mother, which when broken by separation creates a lasting emotional injury. This belief is based on some earlier views like those of Otto Rank, who suggested that birth itself is a traumatic experience for the baby; these approaches seem to be basically a reworking of the old “maternal instinct” assumption. Whatever the reasons behind the “primal wound” belief, it does not seem possible to integrate them with anything we can observe about early development.

A number of adult adoptees have found the Verrier viewpoint to make sense for them as more than a metaphor for their life situations. They feel an intense and disturbing sense of loss, which deserves to be treated with respect even though at the same time I argue against the cause they believe is behind it. People with this view of their life events ask, legitimately, “why do we feel like this if it isn’t because of our early losses?”. And of course I can’t really answer that question (certainly not to their satisfaction). I would suggest, though, that a sense of loss and loneliness is part of the experience of every thinking person. Gerard Manley Hopkins spoke of this in his poem about autumn and loss:
“Margaret, are you grieving… Over Goldengrove unleaving?.. Leaves, like the things of man you… with your fresh thoughts care for, can you?... ‘Tis the blight man was born for… It is Margaret you mourn for.”

We may not need to look to a history of early separation to explain why we human beings mourn for ourselves.

On "The Road to Evergreen"

For anyone with an interest in adoption, or in the complementary-and-alternative treatment “attachment therapy”, Rachael Stryker’s recent book The Road to Evergreen is a must-read-- although it’s also a must-criticize, with plenty to concern developmental scientists, clinicians, adoptees, and adoptive parents. Although published in 2010, The Road to Evergreen is based on a doctoral dissertation completed in the early ‘00s and approved by a committee which included Nancy Scheper-Hughes, author of the remarkable participant-observer narrative, Death Without Weeping. Stryker, an anthropologist, followed some of her mentor’s approach, but applied it to a complex topic that lacks the fascinating generalizability of the Scheper-Hughes book. It’s important to note that The Road, though published in book form in 2010, is based on observations and interviews done in the late ‘90s. The book thus gives us a detailed picture of events a decade and more ago, and it is arguable to what extent the practices described are still current. (Proponents of attachment therapy usually say they are not; critics like me cite evidence that they are ongoing.)

Stryker’s interest in her subject matter began with investigation of institutions and adoption in Russia following the collapse of the Soviet system and the beginnings of systematic adoption of Russian children by Westerners. Subsequently, the author became intrigued with the functioning of adoption agencies and the behavior and motives of prospective and actual adoptive parents. These interests led her to the small town of Evergreen, Colorado, then, as now, operating a cottage industry for treatment of children whose behavior and attitudes were uncomfortable for their parents. Most of the children in treatment in Evergreen were adopted, and the intervention most likely to be used with them was “holding therapy” or “attachment therapy”. This physically-intrusive technique was claimed to remove the emotional attachments of adoptees to their birth parents, to create attachments to adoptive parents, and (it was argued,”therefore”) to make the children obedient, respectful, cheerful, and grateful.

Stryker is probably the only person other than attachment therapists, adoptive parents, or children to have witnessed attachment therapy sessions. Other information about these practices has come from descriptions by therapists and adult memories of treated children (see http://stopchildtorture.org), from news reports’ films of children in treatment, and from the 30 hours of videotape showing the treatment that ended in the asphyxiation of the ten-year-old patient Candace Newmaker in 2000 (see Mercer, Sarner, and Rosa, Attachment Therapy on Trial). Stryker’s description matches the other information and confirms the general accuracy of previous descriptions of attachment therapy.

Stryker’s real contribution is in her interviews with adoption staff and adoptive parents. She was able to establish rapport with those individuals, who presumably trusted her as they would not have trusted critics of attachment therapy methods. The material Stryker collected led her to a conclusion that may trouble many, although for different reasons: that the strongest motive for adoption was for the parents to feel like a family, and to be able to play the honored role of parents. In return for the care and material goods offered by the adoptive parents, the children had the job of behaving in ways that supported the adults’ actions and affirmed that they were respected and successful members of the adult community. Attachment therapy at Evergreen offered an assurance of bringing about this desired end in one way or another. If a child did not “improve” or “heal” to the point of going back to the adoptive home, he or she was placed in some other form of care, and this was described as “loving at a distance”. Whatever the outcome for the child, the adoptive parents were guaranteed support for their perceived position as parents of a family.

Stryker presents three cases, with one child “reunited” and the others placed for care outside the family. These families and their treatment are described in some detail. However, some important information is missing. At the time of this study, as today, children receiving attachment therapy were often placed in a “respite family” who provide a milieu reflecting the beliefs behind attachment therapy. The respite home experience includes complete control by adults over the child’s food, drink, and toilet access. Bedrooms are stripped of most furniture and decorations and have an alarm on the door. Children are required to sit immobile for long periods and to carry out tedious, unnecessary tasks like moving stones from one side of the yard to the other, and back again. But Stryker gives little description of these methods or their goals.

Although developmental scientists and clinicians would be interested to see Stryker discuss the poorly-designed outcome research that has examined the effects of attachment therapy, it’s obvious that such topics have no real place in her participant-observer work. However, given the time that passed between the initial observations and publication of The Road, Stryker would have done well to follow up her three reported cases and to note whether there were long-term differences between the “successful” and “unsuccessful” cases. The memories and beliefs of the now-adult adoptees would also have provided a rich source of further investigation.

My great hope, on picking up The Road, was that Stryker would examine any changes in attachment therapy beliefs and practices that followed reports of a number of associated child deaths, the most dramatic being that of Candace Newmaker at the hands of her therapists. The organization ATTACh (Association for the Treatment and Training of Attachment in Children) followed that tragedy within a couple of years by policy statements rejecting physical restraint for therapeutic purposes unless the child is willing (and of course it is highly arguable whether a child can give informed consent to such a procedure).However, some practitioners of attachment therapy apparently continue to use physical restraint, and no practitioner has stepped forward to provide a rationale supporting the change or explaining whether an entire belief system has altered.

Once again, I consider The Road to Evergreen a must-read for people interested in adoption and the attachment therapy issue, or indeed in many aspects of parenting and of complementary-and-alternative mental health interventions. But readers will be disappointed if they expect the book to give an up-to-date picture of attachment therapy or to outline the tortuous history of this unconventional practice.