10.1177/1077559505283699ChaffinCHILD MALTREATMENTet al. / ATTACHMENT / FEBRUARYMONTH TASK FORCE 2006 2006 REPORT

Report of the APSAC Task Force on , Reactive , and Attachment Problems

Mark Chaffin University of Oklahoma Health Sciences Center, Center on Child and Rochelle Hanson Benjamin E. Saunders Medical University of South Carolina, Crime Victims Research and Treatment Center Todd Nichols Attachment Counseling Center Douglas Barnett Wayne State University Charles Zeanah Tulane University School of Lucy Berliner Harborview Sexual Assault Center Byron Egeland University of Minnesota Institute of Elana Newman University of Tulsa Tom Lyon University of Southern California Law School Elizabeth LeTourneau Medical University of South Carolina, Family Services Research Center Cindy Miller-Perrin Pepperdine University

Although the term attachment disorder is ambiguous, at- field, and the benefits and risks of many treatments remain tachment therapies are increasingly used with children who scientifically undetermined. Controversies have arisen about are maltreated, particularly those in or adoptive potentially harmful attachment therapy techniques used by a homes. Some children described as having attachment disor- subset of attachment therapists. In this report, the Task Force ders show extreme disturbances. The needs of these children reviews the controversy and makes recommendations for as- and their caretakers are real. How to meet their needs is less sessment, treatment, and practices. The report reflects Ameri- clear. A number of attachment-based treatment and - can Professional Society on the Abuse of Children’s (APSAC) ing approaches purport to help children described as attach- position and also was endorsed by the American Psychologi- ment disordered. Attachment therapy is a young and diverse cal Association’s Division 37 and the Division 37 Section on CHILD MALTREATMENT, Vol. 11, No. 1, February 2006 76-89 Child Maltreatment. DOI: 10.1177/1077559505283699 © 2006 Sage Publications

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Keywords: reactive attachment disorder; attachment therapists and foster or adoptive who advo- therapy cate their use. As a professional society concerned with the welfare of maltreated children, the American Professional The terms attachment disorder, attachment problems, Society on the Abuse of Children (APSAC) has a direct and attachment therapy, although increasingly used, interest in this area. In response to concerns about have no clear, specific, or consensus definitions. How- these issues, this Task Force was charged by the APSAC ever, the terms and therapies often are applied to chil- Board of Directors with examining current practices dren who are maltreated, particularly those in the related to the theory, evidence, diagnosis, and treat- foster care, kinship care, or systems, and re- ment of children described as having attachment- lated populations such as children adopted interna- related conditions and problems and with making tionally from orphanages. Some children who are recommendations for action to the Board. The Task maltreated described as having attachment-related Force also included members appointed from the conditions show genuine and occasionally extreme American Psychological Association’s Division on behavioral and relationship disturbances and may be Child, Youth and Family Services. In this article, the at risk for placement failures and other adverse out- Task Force will (a) present our summary and analysis comes. A number of attachment-based treatment and of positions taken by critics and proponents of some approaches have been developed that pur- of the controversial attachment therapies and (b) port to help these children. Attachment therapy is a make recommendations for indicated and contrain- young and diverse field, and the benefits and risks of dicated assessment, treatment, and professional prac- many attachment-related treatments remain scientifi- tices related to children described as having attach- cally undetermined. Controversies have arisen about ment disorders. a particular subset of attachment therapy techniques developed by a subset of attachment therapy practitio- ners, techniques that have been implicated in several BACKGROUND child and other harmful effects. Although fo- Research on Accepted and cused primarily on specific attachment therapy tech- Noncontroversial Attachment Interventions niques, the controversy also extends to the theories, diagnoses, diagnostic practices, beliefs, and social It is important to note that not all attachment- group norms supporting these techniques, and to the related interventions are controversial. There are patient recruitment and advertising practices used by many noncontroversial interventions designed to their proponents. The controversy deepened after improve attachment quality that are based on ac- the of 10-year-old during a cepted theory and use generally supported tech- therapy session in 2000 (Crowder & Lowe, 2000), and niques. Traditional holds that a number of child deaths occurring at the hands of qualities such as environmental stability, parents who claim that they acted on attachment ther- parental sensitivity, and responsiveness to children’s apists’ instructions (Warner, 2003). Criminal charges physical and emotional needs, consistency, and a safe have been brought against some attachment thera- and predictable environment support the develop- pists and against parents who claimed to be using what ment of healthy attachment. From this perspective, is known as . State legislative ac- improving these positive caretaker and environmen- tions banning particular treatment techniques have tal qualities is the key to improving attachment. From been proposed and passed (Gardner, 2003; Janofsky, the traditional attachment theory viewpoint, therapy 2001). Professional organizations have published for children who are maltreated and described as hav- warnings (American Academy of Child and Adoles- ing attachment problems emphasizes providing a cent , 2003). Despite these actions, and stable environment and taking a calm, sensitive, non- others, some of these concerning practices have re- intrusive, nonthreatening, patient, predictable, and mained entrenched within networks of attachment nurturing approach toward children (Haugaard, 2004a; Nichols, Lacher, & May, 2004). Moreover, gen- erally accepted theory suggests that because attach- ment patterns develop within relationships, correct- Authors’ Note: APA Division 37 (Child, Youth and Family Services) and the Section on Child Maltreatment have endorsed this report ing attachment problems requires close attention to and its recommendations. This does not imply endorsement by the improving the stability and increasing the positive American Psychological Association as a whole or endorsement by quality of the parent-child relationship and parent- any of the Association’s other Divisions or Sections. child interactions. Indeed, in a review of more than 70

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studies of interventions designed to improve early and children who are deprived or traumatized. Many childhood attachment, those interventions that most of these conceptualizations include a central focus on increased parental sensitivity were also the most ef- the concept of suppressed rage to explain children’s fective in improving children’s attachment security (Cline, 1991). The rage theory appears to be (Bakermans-Kranenburg, van Ijzendoorn, & Juffer, rooted almost exclusively in clinical observation 2003). In these types of attachment security interven- rather than in science or traditional attachment the- tions, the focus is primarily on the parent-child rela- ory and is not considered well supported by most at- tionship and teaching positive parenting skills rather tachment researchers (Sroufe, Erickson, & Friedrich, than on the individual child’s . Such parent- 2002). In contrast to traditional attachment theory, child relationship approaches would likely tend to the theory of attachment described by controversial favor maintaining children in their homes and attachment therapies is that young children who (either biological, kinship, foster, or adop- experience adversity (including maltreatment, loss, tive) over removing children to institutional care. separations, adoption, frequent changes in child Comparing findings across studies has resulted in care, colic, or even frequent ear ) become the initial identification of some approaches that enraged at a very deep and primitive level. As a result, appear more effective than others. In their meta- these children are conjectured to lack an ability to analytic review, Bakermans-Kranenburg et al. (2003) attach or to be genuinely affectionate with others. identified common characteristics found among Suppressed or unconscious rage is theorized to pre- more successful approaches. Shorter term, more vent the child from forming bonds with focused, and goal-directed interventions tended to and leads to behavior problems when the rage erupts yield better results than broadly focused and longer into unchecked aggression. The children are de- term interventions. This was true irrespective of the scribed as failing to develop a and as not level of problems in the family and irrespective of trusting others. They are said to seek control rather whether the program was delivered to prevention than closeness, resist the authority of caregivers, and (nonclinical) or intervention (clinical) populations. engage in endless power struggles. From this perspec- Broadly focused and more extensive interventions tive, children described as having attachment prob- sometimes produced negative effects. Other keys to lems are seen as highly manipulative in their social effectiveness identified by Bakermans-Kranenburg relations and actively trying to avoid true attachments et al. included maintaining a focused, goal-directed, while simultaneously striving to control adults and behavioral approach targeted at increasing sensitive others around them through manipulation and parental and including fathers and moth- superficial sociability. Children described as having ers in the intervention. These findings echo those attachment problems are alleged by proponents of of similar meta-analytic reviews summarizing a large the controversial therapies to be at risk for becoming body of randomized outcome trials testing interven- psychopaths who will go on to engage in very serious tions for childhood disorders in general. Across stud- delinquent, criminal, and antisocial behaviors if left ies, interventions that are focused, goal-directed, and untreated. behavioral typically yield better results (Weisz, Weiss, Proponents of controversial attachment therapies Han, Granger, & Morton, 1995). Consequently, it commonly assert that their therapies, and their thera- appears that many characteristics of effective attach- pies alone, are effective for children with attachment ment interventions are the same characteristics found disorders and that more traditional treatments are among many effective child interventions in general either ineffective or harmful (see, e.g., Becker- (e.g., including parent skills training, goal-directed, Weidman, n.d.-b; Kirkland, n.d.; Thomas, n.d.-a). behavioral focus, etc.—see Patterson, Reid, & Eddy, Proponents believe that traditional therapies fail to 2002). Thus, the arguments sometimes offered by help children with attachment problems because the proponents of controversial attachment therapies prerequisite of establishing a trusting relationship that “traditional therapies don’t work with these chil- with the child is impossible to accomplish with these dren” appear counter to the available evidence if the children. In contrast to traditional theories, the con- traditional therapies are evidence based. troversial treatments hold that children with attach- ment problems actively avoid forming genuine rela- Controversial Theories of Attachment Disorder tionships, and consequently relationship-based and Corresponding Controversial Treatments interventions are unlikely to be effective (Institute for Proponents of controversial attachment therapies Attachment and Child Development, n.d.). Propo- often offer alternative conceptualizations of attach- nents of the controversial therapies emphasize the ment problems among foster and adoptive children child’s resistance to attachment and the need to break

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down the child’s resistance (Institute for Attachment expected to comply with parental commands “fast and Child Development, n.d.). According to pro- and snappy and right the first time,” and to always be ponents, children with attachment disorders crave “fun to be around” for their parents (see, e.g., Hage, power, control, and authority; are dishonest; and n.d.-a). Deviation from this standard, such as putting have ulterior motives for ostensibly normal social off chores, incompletely executing chores, or argu- behaviors. The child with attachment disorders is de- ing, is interpreted as a sign of attachment disorder scribed by these proponents as completely self- that must be forcibly eradicated. From this perspec- centered, often exhibiting a sense of , lack- tive, parenting a child with an attachment disorder is a ing conscience, and posing a danger to other children battle, and winning the battle by defeating the child is and, ultimately, to society itself. They are labeled paramount. within some treatment or parent communities as sim- Many of the controversial attachment therapies ply “RAD’s,” “RAD-kids” or “RADishes.” Thus, the also hold that the child’s rage must be “released” for conceptual focus for understanding the child’s the child to function normally (for a critique of this behavior emphasizes the child’s individual internal theory, see Sroufe et al., 2002). A central feature of pathology and past caregivers, rather than current many of these therapies is the use of psychological, parent-child relationships or current environment. If physical, or aggressive means to provoke the child to the child is well behaved outside the home, it is con- , ventilation of rage, or other sorts of ceptualized as successful manipulation of outsiders, emotional discharge. To do this, a variety of coercive rather than as evidence of a problem in the current techniques are used, including scheduled holding, home or current parent-child relationship (Thomas, binding, rib cage stimulation (e.g., tickling, pinching, n.d.-a). Proponents of this viewpoint may describe the knuckling), and/or licking. Children may be held presenting problem as a healthy family with a sick down, may have several adults lie on top of them, or child. This perspective may appeal to some. As Barth, their faces may be held so they can be forced to Crea, John, Thoburn, and Quinton (2005) noted engage in prolonged eye contact. Sessions may last “attachment therapies may be attractive because by from 3 to 5 hours, with some sessions reportedly last- locating the blame for the child’s current difficulties ing longer. In the Newmaker case, a technique called with prior carers, they appear to relieve adoptive and rebirthing was used to simulate the psychological death foster parents of the responsibility to change aspects of the angry unattached child to allow the child to be of their own behavior and aspirations” (pp. 262-263). psychologically reborn (Lowe, 2000). This technique Because children with attachment problems are involved the child being held down by several adults, conjectured to resist attachment or even fight against rolled up in blankets, and being instructed to fight it, and to control others to avoid attaching, the child’s her way free. In rebirthing and similar approaches, character flaws must be broken before attachment protests of distress from the child are considered to be can occur. As part of attachment parenting, parents resistance that must be overcome by more coercion. may be counseled to keep their child at home, bar Rebirthing has been repudiated by many practi- social contact with others besides the parent, favor tioners, including those who recommend other con- home schooling, assign children hard labor or mean- troversial techniques (Federici, n.d.). Similar but less ingless repetitive chores throughout the day, require physically coercive approaches may involve holding children to sit motionless for prolonged periods of the child and psychologically encouraging the child time, and insist that all food and water intake and to vent anger toward her or his biological parents. bathroom privileges be totally controlled by the par- Coercive techniques, such as scheduled or en- ent (for an example of some of these types of recom- forced holding, also may serve the intended purpose mendations, see Federici, 2003). We should note that of demonstrating dominance over the child, and pro- the term attachment parenting may have various mean- voking catharsis or ventilation of rage. Establishing ings. In a less controversial context, the term refers to total adult control, demonstrating to the child that he practices of maintaining close physical contact and or she has no control, and demonstrating that all of proximity between and newborns, which is the child’s needs are met through the adult, is a cen- argued to promote healthy attachment. This is not the tral tenet of many controversial attachment therapies. meaning discussed here. Here, the term refers to Similarly, many controversial treatments hold that practices similar to the controversial attachment ther- children described as attachment disordered must be apies, except that the actual practices are delivered by pushed to revisit and relive early trauma. Children parents, often in consultation with therapists, rather may be encouraged to regress to an earlier age where than by therapists themselves. In these practices, chil- trauma was experienced (Becker-Weidman, n.d.-b) dren described as being attachment disordered are or be reparented through holding sessions, diaper-

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ing, or scheduled sessions where older children are paths or violent criminals should be viewed with some nursed using pacifiers or baby bottles (see, e.g., Ward, skepticism given the results of related research. Until n.d.). sound research is conducted to test these prognos- The question of whether releasing rage or encour- tications, they must be considered speculative and aging regression is beneficial is largely untested but without scientific foundation. ought to raise concerns. When tested experimentally, encouraging physical ventilation of anger has been ASSESSMENT AND DIAGNOSIS found to increase levels of anger and aggression toward others, not diminish them (Bushman, 2002). As we have noted earlier, the term attachment disor- Furthermore, children who cope with abuse or der has no broadly agreed-on or precise meaning. The trauma by expressing or ventilating anger appear to term is not part of any accepted standard nosology or show poorer , not better (Chaffin, Wherry, system for classifying behavioral or mental disorders, & Dykman, 1997). Similarly, although many well- such as the Diagnostic and Statistical Manual of Mental supported treatments for traumatic –related Disorders (DSM)orInternational Classification of disorders (e.g., gradual exposure-based therapies) (ICD). Officially, there is no such disorder. However, involve talking about or revisiting traumatic events, neither is the term completely arbitrary. It refers to a there are fundamental differences between exposure fairly coherent domain of severe relational and be- techniques and the kinds of catharsis promoted by havioral problems. Understanding what is meant by controversial attachment therapies. The gradual attachment disorder first begins by understanding the exposure-based techniques supported in the empiri- narrower, more tightly defined, and better accepted cal literature all emphasize maintaining control over diagnosis of reactive attachment disorder or RAD, and coping with emerging connected to the which is described in the DSM-IV (American Psychi- trauma using newly learned adaptive skills (Deblinger atric Association [APA], 1994). & Heflin, 1996), rather than emphasizing ventilation Reactive Attachment Disorder (RAD) of overwhelming , emotional discharge, or revisiting supposed “preverbal” or unconscious trau- According to the DSM, the core feature of RAD is matic events. severely inappropriate social relating that begins Some controversial attachment therapies offer before age 5 years. The style of social relating among predictions that children with attachment disorder children with RAD typically occurs in one of two ex- will grow to become violent predators or psychopaths tremes: (a) indiscriminate and excessive attempts to unless they receive the controversial treatments. At receive comfort and affection from any available least one attachment therapy Web site has argued that adult, even relative strangers (older children and ado- Saddam Hussein, Adolph Hitler, and Jeffrey Dahmer, lescents may also aim attempts at peers) or (b) among others, were examples of children who were extreme reluctance to initiate or accept comfort and attachment disordered who “did not get help in time” affection, even from familiar adults and especially (Thomas, n.d.-b). These prognostications appear to when distressed (APA, 1994). RAD is one of the least fuel a sense of urgency about these children and have researched and most poorly understood disorders in been invoked by some attachment therapists to justify the DSM. There is very little systematically gathered application of aggressive and unconventional treat- epidemiologic information on RAD. In its absence, ment techniques (Hage, n.d.-b)). However, it is criti- much of what is believed about RAD is based on the- cal to note that there is no empirical scientific support ory, clinical anecdotes, case studies, and extrapolated for the idea that children with attachment problems from laboratory research on humans and animals. grow up to become psychopaths or otherwise prey on Similarly, the course of RAD is not well established. society. Much of what is known about predicting seri- Long-term longitudinal data on the outcomes of chil- ous violent adult criminality suggests that while some dren diagnosed with RAD have not been gathered violent adult criminals have a life-course persistent (Hanson & Spratt, 2000). behavior pattern, the future predictive specificity of It appears difficult to diagnose RAD accurately. No any childhood condition or trait appears to be quite generally accepted standardized tools for assessing limited (National Institute of Mental Health, 2001). RAD exist, and several interview procedures in the lit- In other words, although a few children with early or erature misdiagnose inappropriately high numbers serious behavior problems persist on a trajectory of children as having RAD who, in fact, appear to have toward severe violence, most do not. Consequently, only mild to moderate symptoms (O’Connor, Rutter, predictions that children who are described as having Beckett, Keaveney, & Kreppner, 2000). In addition, an attachment disorder will grow to become psycho- several other disorders share substantial symptom

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overlap with RAD and, consequently, are often trauma and adversity is not limited to the extremely comorbid with or confused with RAD. For example, healthy or robust. Rather, resilience is a common and disorders such as , oppositional defi- relatively normal human characteristic (Bonanno, ant disorder, and some of the disorders, in- 2004). Thus, reliance on rates of and/or cluding posttraumatic stress disorder (PTSD) and neglect or problem behaviors should not serve as a social , all share some features with RAD. benchmark for estimates of RAD. According to the Symptom overlap can lead to a failure to diagnose DSM, RAD is presumed to be a “very uncommon” dis- RAD correctly when it is present, and to overdiagnose order (APA, 1994), although it is a disorder currently RAD when it is not present. drawing considerable attention and interest. RAD also is distinct from, but may be confused Attachment Disorders as a Broader Classification with, several other neuropsychiatric disorders involv- ing severe and pervasive problems with social related- The first standardized diagnostic criteria for RAD ness, such as spectrum disorders, pervasive came in the third version of the DSM. These criteria developmental disorder, childhood , were refined in subsequent editions of the DSM (APA, and some genetic . In addition, some chil- 1980, 1994). A largely similar definition was included dren simply have temperamental dispositions toward in the ICD-10 (World Health Organization, 1992), either rapid social engagement on one hand or shy- although pathogenic care was not a diagnostic re- ness and social avoidance on the other, and neither of quirement. Some clinicians have begun to identify a these normal variants in social behavior should be broader group of novel attachment disorders diagno- confused with an attachment disorder. Some chil- ses beyond the confines of RAD, largely through anec- dren simply learn odd social habits because of living dotal reports. As of yet, formal nosologies such as the in institutions or other unnatural environments, and DSM or ICD systems have not recognized an attach- these behaviors may mimic psychiatric disorders. Be- ment disorder beyond RAD. The children’s advocacy cause of these diagnostic complexities, careful diag- organization Zero to Three (1994) included some nostic evaluation by a trained mental health expert expanded categories by describing a number of vari- with particular expertise in is a ants of “relationship disorders” on Axis II. Despite the must (Hanson & Spratt, 2000; Wilson, 2001). limitations noted in the RAD diagnostic criteria, the Exact prevalence estimates for RAD are unavail- lack of an acceptable alternative leads to its applica- able. Some have suggested that RAD may be quite tion in practice to children who do not fully meet the prevalent because severe child maltreatment, which criteria. Consequently, in practice, a child described is known to increase risk for RAD, is prevalent, and as having RAD may actually fail to meet formal diag- because children who are severely abused may exhibit nostic criteria for the disorder, and consequently the behaviors similar to RAD behaviors. However, this label should be viewed cautiously. logic is flawed, and the Task Force it is ques- Recognizing the limitations of the formal RAD cri- tionable to infer the prevalence of RAD based on the teria, alternative diagnostic criteria have been pro- types of behavior problems exhibited by children who posed to describe broader disorders of attachment, are abused or neglected. Although RAD may underlie including those by Lieberman and Pawl (1988, 1990) occasional behavior problems among children who and by Zeanah, Mammen and Lieberman (1993). are severely maltreated, several much more common Zeanah’s research group went on to describe a range and demonstrably treatable diagnoses—with sub- of attachment disturbances including disorders of stantial research evidence linking them to a history of nonattachment, secure base distortions, and disor- maltreatment—may better account for many of these ders of disrupted attachment (Boris, Zeanah, Larrieu, difficulties. Therefore, it should not be assumed that Scheeringa, and Heller, 1998; Zeanah & Boris, 2000). RAD underlies all or even most of the behavioral and In the absence of consensual and officially recognized emotional problems seen in foster children, adoptive diagnostic criteria, the omnibus term attachment disor- children, or children who are maltreated. der has been increasingly used by some clinicians to A history of maltreatment should not imply any dis- refer to a broader set of children whose behavior is order. Many children who are maltreated cope well. affected by lack of a primary attachment figure, a seri- Even those experiencing severe maltreatment may ously unhealthy attachment relationship with a pri- evidence very few or transient behavioral or emo- mary caregiver, or a disrupted attachment relation- tional problems as a consequence of their abuse (e.g., ship (e.g., Hughes, 1997; Keck, Kupecky, & Mansfield, Kendall-Tackett, Williams, & Finkelhor, 2001). Many 2002). As Zeanah and Boris (2000) argued, clinical emerge without any long-term , let experience suggests that disorders of attachment do alone a disorder as severe as RAD. Resilience to exist beyond the confines of RAD. However, the exact

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parameters of the disorders are not yet established. clinical or scientific progress, and occasionally they It is important that clinicians remain cognizant of have resulted in demonstrable harm. For example, these diagnostic uncertainties so that the diagnosis recent history in the child abuse field has seen the rise of “attachment disorder” is not improperly reified and fall in popularity of diagnoses such as dissociative and more precise validity sacrificed. identity or multiple- disorder and con- cepts such as repressed memory. Although fashion- Potential Misapplications of able only a few years ago, some scientists now question Attachment Disorder Diagnoses whether these phenomena actually exist at all, and it is Attachment-related problems may be underdi- now generally accepted that neither is nearly as preva- agnosed, overdiagnosed, or both simultaneously. In lent as proponents once suggested. Arguably, both general, rare conditions may be missed by some clini- of these diagnostic fads harmed some patients cians simply because of unfamiliarity. They also may (Dardick, 2004). Just as it is important not to miss the be overdiagnosed by proponents. There are no stud- presence of an uncommon condition in a child, it also ies examining diagnostic accuracy among the increas- is important not to diagnose an uncommon and dra- ing numbers of children who are maltreated being matic disorder when the diagnosis of a common but described by clinicians as having an attachment disor- less exciting disorder is more appropriate. Although der. It is not clear how many children described as more common diagnoses, such as attention-deficit/ having attachment disorders suffer from actual disor- hyperactivity disorder (ADHD), conduct disorder, ders of attachment, from transitory sequelae of mal- PTSD, or may be less exciting, treatment, from stress related to shifts in placements they should be considered as first-line diagnoses or cultures, or from other disorders with shared char- before contemplating any rare condition, such as RAD acteristics. The simple fact that a child may have expe- or an unspecified attachment disorder. The standard rienced pathogenic care, or even trauma, should not diagnostic aphorism that “when you hear hoof beats, be taken as an indication of an attachment disorder or think horses, not zebras” is important to bear in mind any other disorder. It also is important to bear in mind for a number of reasons. First, more prevalent condi- that a child entering the child welfare system, foster tions are less likely than rare conditions to be misdiag- care, adoption, or other settings is almost invariably nosed; their criteria are better established and agreed experiencing acute stress. Behavior problems or rela- on, sound assessment procedures are more widely tionship problems shown during periods of acute available, and classification accuracy is always higher stress do not automatically suggest any disorder. This with more prevalent (i.e., higher base rate) condi- is a particularly important point for evaluating chil- tions. Second, the appropriate intervention for a dren in cross-cultural or international . Dif- common disorder is likely to be different from that ferent cultures have different normative social behav- for an uncommon disorder. Finally, there are richer iors, which could easily be misconstrued as a disorder. literatures and better established evidenced-based For example, failure to make eye contact is included treatments for more common conditions. For ex- on some checklists as a sign of attachment disorder; ample, scientifically well-supported and effective however, this may be a normative social behavior in treatments exist for ADHD, oppositional-defiant dis- many cultures (Keating, 1976). Establishing that an order, and PTSD (Kazdin, 2002). attachment disorder, or any other stable disorder, Many of the controversial attachment therapies actually exists requires some familiarity with the have promulgated quite broad and nonspecific lists of child’s long-term behavior, including behavior in symptoms purported to indicate when a child has an multiple settings, and should not be limited to be- attachment disorder. For example, Reber (1996) pro- haviors occurring with a foster or adoptive parent. vided a table that lists “common symptoms of RAD.” Assessments based on a single point in time snapshot The list includes problems or symptoms across multi- ofthechildmaybeparticularlyvulnerableto ple domains (social, emotional, behavioral and devel- misdiagnosis. opmental) and ranges from DSM-IV criteria for RAD Practitioners working with children who are mal- (e.g., superficial interactions with others, indiscrimi- treated must be vigilant to avoid what some have nate affection toward strangers, and lack of affection called the “allure of rare disorders” (Haugaard, toward parents), to nonspecific behavior problems 2004a). Mental health and related fields have a long including destructive behaviors; developmental lags; history of diagnostic fads, when rare or esoteric di- refusal to make eye contact; cruelty to animals and sib- agnoses become fashionable and spread rapidly lings; lack of cause and effect thinking; preoccupa- through the practice world, support groups, and the tion with fire, blood, and gore; poor peer relation- popular press. Rarely have these fads resulted in real ships; stealing; lying; lack of a conscience; persistent

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nonsense questions or incessant chatter; poor im- disorders are “manipulative” and merely “feign dis- pulse control; abnormal speech patterns; fighting for comfort” (Corrigan & Powell, 2002). Parents’ control over everything; and hoarding or gorging on assuming total control of the child’s eating and drink- food. Others have promulgated checklists that sug- ing, and forcing excessive fluid intake, were impli- gest that among , “prefers dad to mom” or cated in one fatality, again allegedly at the instruction “wants to hold the bottle as soon as possible” are indic- of therapists. The practice of some forms of these ative of attachment problems (Buenning, 1999). treatments has resulted in professional licensure Clearly, these lists of nonspecific problems extend sanctions against some leading proponents of the far beyond the diagnostic criteria for RAD and controversial attachment therapies. There have been beyond attachment relationship problems in general. cases of successful criminal prosecution and incarcer- These types of lists are so nonspecific that high rates of ation of therapists or parents using controversial false-positive diagnoses are virtually certain. Posting attachment therapy techniques and state legislation these types of lists on Web sites that also serve as mar- to ban particular therapies. Position statements keting tools may lead many parents or others to con- against using coercion or restraint as a treatment were clude inaccurately that their children have attach- issued by mainstream professional societies (Ameri- ment disorders. can Psychiatric Association, 2002) and by a profes- sional organization focusing on attachment and attachment therapy (Association for Treatment and THE ATTACHMENT THERAPY CONTROVERSY Training in the Attachment of Children [ATTACh], The attachment therapy controversy has centered 2001). Despite these and other strong cautions from most broadly on the use of what is known as “holding professional organizations, the controversial treat- therapy” (Welch, 1988) and coercive, restraining, ments and their associated concepts and founda- or aversive procedures such as deep tissue , tional principles appear to be continuing among net- aversive tickling, punishments related to food and works of attachment therapists, attachment therapy water intake, enforced eye contact, requiring chil- centers, caseworkers, and adoptive or foster parents dren to submit totally to adult control over all their (Hage, n.d.-a; Keck, n.d.). As Berliner (2002) noted, needs, barring children’s access to normal social rela- parents and caseworkers may turn to these treatments tionships outside the primary parent or caretaker, out of desperation. For many foster or adoptive par- encouraging children to regress to status, re- ents, the reality of foster or adoptive parenting may be parenting, attachment parenting, or techniques quite discrepant from their expectations. Children designed to provoke cathartic emotional discharge. may be emotionally distant or difficult to manage. On Variants of these treatments have carried various rare occasions, children may be violent. In some labels that appear to change frequently. They may be cases, radical treatments advertising dramatic suc- known as “rebirthing therapy,” “compression holding cesses may appeal to these parents. Although criticism therapy,” “corrective attachment therapy,” “the Ever- of the controversial attachment therapies has been green model,” “holding time,” or “rage-reduction widespread in mainstream professional and scientific therapy” (Cline, 1991; Lien, 2004; Levy & Orlans, circles, efforts to disseminate these criticisms and 1998; Welch, 1988). Popularly, on the Internet, concerns to the lay public have been minimal, and among foster or adoptive parents, and to case work- most foster or adoptive parents are probably unaware ers, they are simply known as “attachment therapy,” of the risks and poor foundation for some treatment although these controversial therapies certainly do claims. not represent the practices of all professionals using Controversial attachment therapies are viewed by attachment concepts as a basis for their interventions. many in the mainstream professional and research The controversy was spurred by a series of child communities as presenting a significant physical and deaths. Transcripts of sessions at the facility impli- psychological risk to children with little evidence of cated in the death of Candace Newmaker revealed a therapeutic benefit. Critics have long argued that child begging to be released and complaining of suf- these treatments are not based on sound or accepted focation before dying during the procedure. The theory, are inconsistent with the general principles death of Krystal Tibbets at the hands of her parents of effective clinical practice, and are reminiscent of reportedly involved similar “compression” tech- other unsound and sometimes dangerous fad or cult niques employed at the suggestion of therapists. therapies that periodically arise in the mental health Some proponents of these techniques have dis- treatment and self-help arenas. Critics argue that missed children’s protests of distress during the treat- most of these children have never received state-of- ment by arguing that children with attachment the-art, evidence-based traditional treatments, so pro-

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ponent’s claims that “traditional therapies don’t imperfectly is simply too dangerous under any work” are not well founded. Furthermore, they argue conditions, particularly when there is no scientific that using holding therapy or similar techniques to evidence of benefit and when safer treatments are force children who were severely maltreated to have available. close, confining physical contact is more likely to ex- Critics dismiss the anecdotal reports or testimoni- acerbate their difficulties than to help. In addition, als offered on Web sites about the controversial critics note that holding therapy and those attach- attachment therapies or endorsements offered by ment therapies that seek to demonstrate dominance former patients. They note that even quackery or and control over the child may duplicate the dy- demonstrably harmful treatments have their passion- namics of abuse experiences and reinforce rather ate adherents and can proffer many satisfied patients than ameliorate relationship problems. who describe stories of miraculous cures. This type It is argued that holding therapy or other physically of evidence simply cannot be considered persuasive coercive therapies may present a physical risk to the from a scientific perspective. Critics further note that child and others because of the use of physical force. obtaining and using client testimonials in public Children have been injured while being restrained, advertising may violate established professional ethi- and parents or therapists may be hit, kicked, or bitten. cal standards (American Psychological Association, Although the exact number of child deaths related to 2002, p. 9). the controversial treatment or parenting techniques On the other hand, proponents of holding therapy is uncertain, six or more have been alleged by some and other controversial attachment therapies argue attachment therapy critics (Advocates for Children in that the techniques present no physical risk to the Therapy, n.d; Mercer, Sarner, & Rosa, 2003) and are child, parent, or therapist if done properly, and dis- noted in the policy statement by the American Acad- miss the concerns raised by critics as misunder- emy of Child and Adolescent Psychiatry (2003). Crit- standings based on scattered and unrepresentative ics argue that the dire predictions and negative con- vignettes that have been taken out of context. They ceptualizations of children central to controversial dispute that holding therapy involves coercion or attachment therapies or attachment parenting, com- involuntary restraint. Proponents describe their ap- bined with their practitioners’ isolation from the proach to holding as gentle or nurturing rather than mainstream fields of child development, child mal- coercive or humiliating (Keck, n.d.). Moreover, pro- treatment, and child , create a fertile ponents may argue that nontraditional and intensely ground for abusive practices to develop. Critics of physical and emotional techniques, such as holding, controversial attachment therapies or attachment reparenting, or catharsis, are required to help the parenting have pointed to the child deaths as the pre- children they describe as having attachment dis- dictable result of combining (a) a in coercive orders. The primary evidence offered by proponents techniques, (b) negative conceptualizations of chil- to support these arguments is anecdotal report, dren with RAD, (c) the isolated culture surrounding patient testimonials, therapist observations, and their these practice and parenting communities, (d) des- own clinical experience of appearing to achieve suc- peration over very real child behavioral or emotional cess in cases where prior treatments have failed. problems, (e) a false sense of pessimism about the All agree that the series of child deaths is tragic; child’s long-term future, and (f) a false sense of futility however, there is disagreement as to the cause. Propo- about safer alternative approaches. Critics note that nents of controversial attachment therapies suggest one of the highest profile deaths occurred at the that the practices that caused the deaths of these chil- hands of practitioners who were well-recognized dren were either misapplications of attachment ther- attachment therapy trainers. Therefore, explanations apy techniques, atypical practices, the result of par- that the deaths involved only isolated rogue practitio- ents misusing certain practices, the application of ners who were simply not knowledgeable or skilled in techniques that simply are not a part of most attach- these techniques seem unlikely. Deaths allegedly due ment therapy protocols anymore, or are misrepre- to attachment parenting may be more difficult to sentations by parents who are abusive attempting to assess and sometimes involve disputes over what was defend or excuse their own abusive behavior by blam- and was not actually recommended by the therapists. ing it on therapists. In other words, proponents argue However, even if the deaths did involve misapplica- that these child deaths had nothing to do with hold- tion of treatment techniques, or misapplication of ing or other controversial attachment therapies as parenting recommendations, critics argue that any they are currently practiced. Proponents suggest that psychological treatment or parenting approach that critics are misrepresenting what attachment therapy is so volatile that it can result in child death if done actually involves (Cascade Center for Family Growth,

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n.d.). Proponents correctly point out that most critics lists of indicators. Some proponents have claimed have never actually observed any of the treatments that research exists that supports their methods, or they criticize or visited any of the centers where the that their methods are evidence based, or are even the controversial therapies are practiced. Other propo- sole evidence-based approach in existence, yet these nents have suggested more personal reasons for crit- proponents provide no citations to credible scientific ics’ positions, suggesting that critics are motivated by research sufficient to support these claims (Becker- their own “unresolved issues” or are simply psycholog- Weidman, n.d.-b). This Task Force was unable to ically uncomfortable with strong emotions (Institute locate any methodologically adequate clinical trials in for Attachment and Child Development, n.d.). the published peer-reviewed scientific literature to This polarization is compounded by the fact that support any of these claims for effectiveness, let alone attachment therapy has largely developed outside the claims that these treatments are the only effective mainstream scientific and professional community available approaches. Most of the data offered on and flourishes within its own networks of attachment these Web sites is so methodologically compromised therapists, treatment centers, caseworkers, and par- that the Task Force believes it could not support any ent support groups. Indeed, proponents and critics of clear conclusion. For example, perhaps the most the controversial attachment therapies appear to widely cited study in the holding therapy literature, move in different worlds. Moreover, the sides do not and possibly the only empirical study on the topic agree on the rules for determining the risks and bene- available in a mainstream peer-reviewed journal, suf- fits of psychological treatments or how questions fered from a number of major limitations. The study about risks and benefits should be resolved. Critics used a very small sample (12 in the treatment group, tend to rely on the well-established and accepted prin- 11 in the comparison group), participants were self- ciples of clinical science. Central to the clinical sci- selected into treatment and comparison groups, ence perspective is testing outcomes using rigorous and the statistical analysis did not include any di- scientific research designs and methods that control rect test of group differences in change over time for well-known confounds such as spontaneous re- (Myeroff, Mertlich, & Gross, 1999). covery, the placebo effect, patient expectancy effects, Critics have questioned the ethical appropriate- investigator effects, and other forces that may influ- ness of directly advertising controversial approaches ence the perceived outcomes of any clinical interven- to groups of foster parents, adoptive parents, case- tion. Critics tend to rely on scientific peer-review of workers, and other lay audiences who usually do not research findings, publishing results in the scien- have the training or background to evaluate the credi- tific literature for wider scrutiny and review, and in- bility of the claims made. It is argued by critics that any dependent replication of findings before labeling a practice that is this controversial or volatile should not treatment as efficacious with an acceptable level of be marketed directly to the lay public, and that mak- risk. ing claims of exaggerated or exclusive benefit is Proponents, although not necessarily averse to sci- inconsistent with established ethical standards and ence, appear to rely more on their own personal expe- the available scientific evidence. Presumably, most rience for determining what is beneficial, emphasiz- proponents do not agree with these concerns. Propo- ing what they see clinically and qualitatively and the nents seem to place great importance on their view testimonials of their clients (see Hage, n.d.-b). They that they are treating or parenting children who are operate more as advocates and believers than as skep- seriously disturbed, and that they have special per- tics or scientists. Most literature on controversial at- sonal knowledge about these children and the strug- tachment therapies has not been vetted through any gles involved in raising them that outsiders and critics recognized scientific, independent peer-review pro- do not. Proponents emphasize that unless one has cess. Even less scientifically rigorous outlets such as actually attempted to parent a child with an at- published books and treatment manuals are difficult tachment disorder, it is impossible to fully grasp the to find. Much of the available information is found on situation. the Web sites of organizations or centers that deliver Ultimately, continued separation between the the treatment, or in-house and self-published materi- worlds of attachment therapy and mainstream clinical als. These Web sites often appear to serve as market- science is not conducive to resolving these differences ing tools and providing information about the treat- or promoting safe and effective clinical practices. The ments used. Critics have noted that these Web sites Task Force believes that the ultimate benefit of chil- make exaggerated claims of effectiveness without ade- dren will be best served by increased dialogue and quate supporting scientific evidence and promote the information sharing between child abuse profession- diagnoses of attachment disorders with overly broad als, scientific researchers, and the attachment therapy

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community. Nonetheless, the Task Force believes that vigilant about the allure of rare disorders in it is important to take a stand on harmful or question- the child maltreatment field and should be alert to the possibility of misdiagnosis. able practices and theories, while encouraging in- (7) Assessment should include family and care- creased dialogue and research in these areas. The fol- giver factors and should not focus solely on lowing practice recommendations are made by the the child. Task Force: (8) Care should be taken to rule out conditions such as disorders, perva- sive developmental disorder, childhood RECOMMENDATIONS schizophrenia, genetic syndromes, or other conditions before making a diagnosis of 1. Recommendations regarding diagnosis and assess- attachment disorder. If necessary, special- ment of attachment problems ized assessment by professionals familiar a. Attachment problems, including but extending with these disorders or syndromes should be beyond RAD, are a real and appropriate concern considered. for professionals working with children who are (9) Diagnosis of attachment disorder should maltreated and should be carefully considered never be made simply based on a child’s sta- when these children are assessed. tus as maltreated, as having experienced b. Assessment guidelines trauma, as growing up in an institution, as (1) Assessment should include information being a foster or adoptive child, or simply about patterns of behavior over time, and because the child has experienced patho- assessors should be cognizant that current genic care. Assessment should respect the behaviors may simply reflect adjustment to fact that resiliency is common, even in the new or stressful circumstances. face of great adversity. (2) Cultural issues should always be considered 2. Recommendations regarding treatments and when assessing the adjustment of any child, interventions especially in cross-cultural or international a. Treatment techniques or attachment parenting placements or adoptions. Behavior appear- techniques involving physical coercion, psycho- ing deviant in one cultural setting may be logically or physically enforced holding, physical normative for children from different cul- restraint, physical domination, provoked cathar- tural settings, and children placed cross- sis, ventilation of rage, age regression, humilia- culturally may experience unique adaptive tion, withholding or forcing food or water intake, challenges. prolonged social isolation, or assuming exagger- (3) Assessment should include samples of behav- ated levels of control and domination over a child ior across situations and contexts. It should are contraindicated because of risk of harm and not be limited to problems in relationships absence of proven benefit and should not be with parents or primary caretakers and used. instead should include information regard- (1) This recommendation should not be inter- ing the child’s interactions with multiple preted as pertaining to common and widely caregivers, such as teachers, day care provid- accepted treatment or behavior manage- ers, and peers. Diagnosis of RAD or other ment approaches used within reason, such as attachment problems should not be made time-out, reward and punishment contin- solely based on a power struggle between the gencies, occasional seclusion or physical parent and child. restraint as necessary for physical safety, (4) Assessment of attachment problems should restriction of privileges, “grounding,” offer- not rely on overly broad, nonspecific, or ing physical comfort to a child, and so on. unproven checklists. Screening checklists b. Prognostications that certain children are des- are valuable only if they have acceptable tined to become psychopaths or predators should measurement properties when applied to never be made based on early childhood behav- the target populations where they will be ior. These beliefs create an atmosphere condu- used. cive to overreaction and harsh or abusive treat- (5) Assessment for attachment problems ment. Professionals should speak out against requires considerable diagnostic knowledge these and similar unfounded conceptualizations and skill, to accurately recognize attachment of children who are maltreated. problems and to rule out competing diag- c. Intervention models that portray young children noses. Consequently, attachment prob- in negative ways, including describing certain lems should be diagnosed only by a trained, groups of young children as pervasively manipu- licensed mental health professional with lative, cunning, or deceitful, are not conducive to considerable expertise in child development good treatment and may promote abusive prac- and differential diagnosis. tices. In general, child maltreatment profession- (6) Assessment should first consider more com- als should be skeptical of treatments that describe mon disorders, conditions, and explana- children in pejorative terms or that advocate tions for behavior before considering rarer aggressive techniques for breaking down chil- ones. Assessors and caseworkers should be dren’s defenses.

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d. Children’s expressions of distress during therapy Claims of relative benefit (e.g., that one treat- always should be taken seriously. Some valid psy- ment works better than others) should only be chological treatments may involve transitory and made if there is adequate controlled trial scien- controlled emotional distress. However, deliber- tific research to support the claim. ately seeking to provoke intense emotional dis- b. Use of patient testimonials in marketing treat- tress or dismissing children’s protests of distress is ment services constitutes a dual relationship. contraindicated and should not be done. Because of the potential for exploitation, the e. State-of-the-art, goal-directed, evidence-based Task Force believes that patient testimonials approaches that fit the main presenting problem should not be used to market treatment services. should be considered when selecting a first-line c. Unproven checklists or screening tools should treatment. Where no evidence-based option ex- not be posted on Web sites or disseminated to lay ists or where evidence-based treatment options audiences. Screening checklists known to have have been exhausted, alternative treatments with adequate measurement properties and pre- sound theory foundations and broad clinical ac- sented with qualifications may be appropriate. ceptance are appropriate. Before attempting d. Information disseminated to the lay public novel or highly unconventional treatments with should be carefully qualified. Advertising should untested benefits, the potential for psychological not make claims of likely benefits that cannot be or physical harm should be carefully weighed. supported by scientific evidence and should fully f. First-line services for children described as having disclose all known or reasonably foreseeable attachment problems should be founded on the risks. core principles suggested by attachment theory, including caregiver and environmental stability, child safety, patience, sensitivity, consistency, and REFERENCES nurturance. Shorter term, goal-directed, fo- cused, behavioral interventions targeted at Advocates for Children in Therapy. (n.d.). Victims of attachment ther- increasing parent sensitivity should be consid- apy. Retrieved July 2, 2004, from www.childrenintherapy.org/ victims/index.html ered as a first-line treatment. American Academy of Child and Adolescent Psychiatry. (2003). g. Treatment should involve parents and caregivers, Policy statement: Coercive interventions for reactive attachment disor- including biological parents if reunification is an der. Washington, DC: Author. option. Fathers, and mothers, should be included American Psychiatric Association. (1980). 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