Evidence-Based Practice in Child and Adolescent Mental Health

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A RADical Idea: A Call to Eliminate “” and “” From the Clinical Lexicon

Brian Allen

To cite this article: Brian Allen (2016) A RADical Idea: A Call to Eliminate “Attachment Disorder” and “Attachment Therapy” From the Clinical Lexicon, Evidence-Based Practice in Child and Adolescent Mental Health, 1:1, 60-71, DOI: 10.1080/23794925.2016.1172945

To link to this article: http://dx.doi.org/10.1080/23794925.2016.1172945

Accepted author version posted online: 12 Apr 2016. Published online: 12 Apr 2016.

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Download by: [Penn State University], [Brian Allen] Date: 13 July 2016, At: 12:50 EVIDENCE-BASED PRACTICE IN CHILD AND ADOLESCENT MENTAL HEALTH 2016, VOL. 1, NO. 1, 60–71 http://dx.doi.org/10.1080/23794925.2016.1172945

A RADical Idea: A Call to Eliminate “Attachment Disorder” and “Attachment Therapy” From the Clinical Lexicon

Brian Allen Center for the Protection of Children, Penn State Hershey Children’s Hospital, Hershey, PA, USA

ABSTRACT “Attachment disorder” and “attachment therapy” are common terms used in applied clinical practice. However, these terms are not typically employed in research settings or published scientific papers. In this article, the author reviews the theoretical tenets and empirical research of and discusses how these two terms fail to coincide with the scientific knowledge. The historical development of these phrases is considered, as well as the potential impact they have on clinical practice. The ultimate conclusion is that the “attachment disorder” and “attachment therapy” constructs are hindrances to evidence-based clinical practice and should be eliminated from the clinical lexicon.

Most mental health clinicians are familiar with the concerns (e.g., American Academy of Child and terms “attachment disorder” and “attachment Adolescent Psychiatry, 2005; American Professional therapy.”1 Some associate these terms exclusively with Society on the Abuse of Children [Chaffin et al., 2006]). the notorious holding therapy and rage reduction These reports largely yielded similar conclusions and approaches (e.g., Cline, 1979; Zaslow & Menta, 1975), recommendations: Attachment-related problems are techniques that resulted in serious physical injury and poorly understood by many practicing clinicians, unsup- even death to some children (Mercer, Sarner, & Rosa, ported treatment techniques should be rejected, and 2003). However, other treatment approaches employing scientifically supported interventions that strengthen the ethically questionable techniques are similarly pro- parent–child relationship are preferred. Unfortunately, moted from an attachment perspective (e.g., Dyadic anecdotal reports, court cases, news articles, and empirical Developmental Psychotherapy, Theraplay; see Allen, research suggest that the recommendations of these orga- 2011b, and Mercer, 2015, for reviews), and a sizable nizations are not practiced by many professionals. minority of clinicians appear interested in these Perhaps a new approach is necessary. approaches (Allen, Gharagozloo, & Johnson, 2012). Admittedly, the title of this article may confuse and Still others understand these terms in a more pedestrian surprise many readers. The concepts of attachment way, assuming they represent a common presentation disorder and attachment therapy are well ingrained and treatment approach, respectively, for maltreated into graduate education, clinical practice, child welfare, Downloaded by [Penn State University], [Brian Allen] at 12:50 13 July 2016 children. In short, there is a lack of professional con- adoption, and continuing education programs. sensus on what exactly these terms mean and the man- However, the reader should note that I did not include ner in which they should be used. the academic arena in the list of areas where these Given the immense confusion and multiple child phrases are widely accepted. There are many reasons deaths associated with purported “attachment therapies,” for this, which are highlighted throughout this article. various professional organizations issued policy state- Suffice it to say that neither of these two concepts is ments and practice parameters for the assessment and empirically sound as commonly practiced. Again, this treatment of children displaying attachment-related may be confusing and surprising to many. However, if

CONTACT Brian Allen [email protected] Center for the Protection of Children, Penn State Hershey Children’s Hospital, 500 University Drive, Hershey, PA 17033. 1The terms “attachment disorder” and “attachment therapy” are used with some frequency in multiple professions, including mental health, law, child advocacy, and social work. Although confusion regarding these terms extends to allied professions, this article discusses these terms specifically as they relate to the mental health field. It is recognized, however, that many of the points made in this article may be relevant to other professions. © 2016 Taylor & Francis EVIDENCE-BASED PRACTICE IN CHILD AND ADOLESCENT MENTAL HEALTH 61

the reader will afford me the opportunity to detail my attachment behavior and the broader context of attach- reasoning, perhaps the title of this article will be seen as ment theory. Understanding this difference is a crucial the logical conclusion. point for understanding the remainder of this discussion. Attachment behavior is any attempt, whether verbal Attachment: A clinical or developmental or nonverbal, to maintain proximity to and seek com- theory? fort from an attachment figure for the purposes of , who originally specified attachment reducing distress (Bowlby 1969/1982). Using the theory, was a trained psychoanalyst, having been paradigm with infants and toddlers, mentored by . However, Bowlby was Ainsworth (1978) and her colleagues identified three an empiricist who was disillusioned with the see- patterns of attachment behavior that they labeled as mingly widening gap between psychoanalytic theories secure, avoidant, and resistant/ambivalent. Secure of the time and emerging scientific findings from the attachment is most often fostered by consistently sen- fields of ethology, biology, cognitive development, sitive and responsive caregiving, although the strength cybernetics, and others. He also was influenced by of this relationship is moderate and other causal factors his own observations suggesting the primacy and are likely (De Wolff & van IJzendoorn, 1997; Lucassen necessity of a supportive and responsive caregiver et al., 2011). Alternatively, rejecting and dismissive for healthy development, findings most famously caregiving is associated with the development of an described in his work for the World Health avoidant attachment, whereas a resistant/ambivalent Organization (Bowlby, 1951) and his classic volume attachment is linked to inconsistent caregiving that Forty-Four Juvenile Thieves (Bowlby, 1946). Bowlby fluctuates between responsive and rejecting (Egeland explicated his thinking on adaptive and aberrant & Sroufe, 1981). Each of these patterns of attachment development with the publication of his seminal is considered an organized and coherent set of charac- “attachment trilogy” (Bowlby 1969/1982, 1973, 1980). teristic behaviors designed to accomplish the same goal: Interestingly, although Bowlby was a clinician to maintain proximity to a caregiver who can be called developing a theory to improve clinical practice, his upon to help cope with a stressful situation. Although ideas were primarily investigated by developmental this may sound contradictory in the case of the insecure scientists. Readers will likely recall the formative forms (i.e., avoidant, resistant/ambivalent), consider work of (1958)withrhesusmonkeys, that a child displaying avoidant attachment behaviors, demonstrating that the availability of a caregiver who for example, actually is able to maintain proximity to a provides contact comfort and felt security is more rejecting caregiver by not displaying approach beha- crucial to emotional well-being than a caregiver viors that may prompt the caregiver to respond by who provides oral stimulation (note the direct test moving away. of attachment versus psychoanalytic ideas). and Solomon (1990) identified a number of Ainsworth (1967), after studying with Bowlby in children who displayed fearful, odd, contradictory, or London, traveled to Uganda to conduct detailed otherwise bizarre behaviors during the Strange Situation observations of mother–child interactions. She con- procedure. In essence, these children appeared to lack a tinued this work after securing faculty positions in coherently organized set of behaviors for maintaining

Downloaded by [Penn State University], [Brian Allen] at 12:50 13 July 2016 the United States and trained a generation of attach- proximity to a caregiver and were thus identified as ment researchers. Although theconsiderablequantity displaying a disorganized attachment. Subsequent and quality of work accomplished by these research- research demonstrated that child maltreatment, particu- ers resulted in attachment theory becoming the most larly physical abuse, was a primary causal factor widely accepted theory of socioemotional develop- (although not the only causal factor) in the development ment, comparatively little research examined its clin- of disorganized attachment behavior (Cyr, Euser, ical applications. Indeed, near the end of his life, Bakermans-Kranenburg, & van IJzendoorn, 2010). Bowlby (1988) expressed disappointment that his Conceptually, disorganized behavior is believed to dis- ideas were so rarely studied for clinical purposes. play the approach-avoidance conflict inherent in seeking security from a caregiver who is also a significant source of fear (Main & Hesse, 1990). The distinction between attachment behavior Attachment classifications are somewhat flexible and attachment theory with 6- to 12-month stability estimates of organized First, it is important to note that Bowlby and develop- infant attachment classifications rarely noted above mental scientists draw a clear distinction between 65% (e.g., Belsky, Campbell, Cohn, & Moore, 1996; 62 B. ALLEN

Vaughn, Egeland, Sroufe, & Waters, 1979), and esti- the results of two major prospective studies examining mates of the stability of disorganized attachment are the longitudinal impact of early attachment (i.e., similarly modest (van IJzendoorn, Schuengel, & Pennsylvania Infant and Family Development Project Bakermans-Kranenburg, 1999). In addition, attachment and the NICHD Study of Early Child Care). Among the behavior is relationship specific. For instance, disorga- many findings of these studies was clear evidence that nized attachment is rarely observed with two different (a) the developmental benefits and risks associated with caregivers (van IJzendoorn et al., 1999). early attachment are contingent upon the quality of Although insecure and disorganized attachments are caregiving received later in development, and (b) an not psychiatric disorders, there are established links increasing number of risk factors (e.g., poverty, mater- between attachment classification and later mental nal depression, single-parent household) predict poorer health outcomes, with the strongest association occur- outcomes for children in areas such as behavior pro- ring between disorganized attachment and later exter- blems and social competence, even among those with nalizing problems (Fearon, Bakermans-Kranenburg, secure attachments. Other longitudinal studies yielded van IJzendoorn, Lapsley, & Roisman, 2010). As such, similar results (e.g., Sroufe, Egeland, Carlson, & Collins, infant and toddler attachment classifications are typi- 2005), and these findings help explain the moderate cally considered indicators of the quality of a bivariate associations documented between early parent–child relationship, a potent risk/protective fac- attachment and later outcomes (Fearon et al., 2010). tor for later psychopathology. In short, attachment theory proposes that later experi- Attachment theory, on the other hand, is a broader ences can alter one’s developmental trajectory in either conceptualization of development that incorporates and a negative or positive fashion regardless of the attach- emphasizes the impact of parent–child relationships on ment behavior displayed in the first years of life. psychological functioning. A central feature of attach- ment theory is the concept of the internal working Attachment ≠ parent–child relationship model (IWM) or cognitive representation (i.e., schema). Through interactions with caregivers, children develop Confusing for many is that “attachment” and “parent– and revise IWMs of themselves, others, and typical child relationship” are not synonymous terms. There social interactions (Bowlby, 1969/1982; Main, Kaplan, are multiple interconnected and overlapping character- & Cassidy, 1985). For instance, a child may develop a istics of the parent–child relationship, for instance, the model of themselves as competent and worthy of love discipline techniques utilized, the parent’s modeling of or incompetent and flawed, a model of others as trust- emotion regulation and impulse control, parental men- worthy or dangerous. Children then automatically tal illness, the cognitive stimulation afforded the child, implement these models when engaging in everyday the child’s temperament and biological constitution, circumstances, including social situations. A principle and communication skills. The child’s attachment to of these “working” models is that they are always cap- the caregiver, that is, the child’s understanding of the able of being revised in response to new information; caregiver as a “secure base” who provides safety and however, a model becomes more inflexible the longer it security, is only one specific component of the is maintained and reinforced by experience. Research parent–child relationship. One should be careful not from both the attachment and cognitive development to conflate these two concepts and ensure that respect-

Downloaded by [Penn State University], [Brian Allen] at 12:50 13 July 2016 fields largely supports the concepts of cognitive repre- ing attachment theory and research does not oversha- sentations and scripts, and the impact of these auto- dow or dismiss other aspects of the parent–child matic processes on mental health (e.g., Cannon & relationship. Weems, 2010; Solomon, George, & De Jong, 1995; see This point may best be demonstrated by way of an Bretherton, 2005, for a review). Indeed, the discipline of example. The seminal Minnesota longitudinal project cognitive therapy largely concerns itself with the altera- provides numerous examples of this point. For tion of these cognitive representations, a comparison instance, as one would hypothesize, children rated as made by Bowlby (1980) himself. insecurely attached in infancy were more likely to dis- Contrary to what many believe, attachment theory play behavioral problems in preschool (Erickson, does not suggest that the first years of life and one’s Sroufe, & Egeland, 1985). However, in those instances early attachment classification determine later out- where this association was not present (i.e., secure with comes (Bowlby, 1988). Rather, attachment theory behavior problems or insecure without behavior pro- emphasizes an ongoing contextual understanding of blems), children were more likely to display problems if the child and the multiple developmental pathways their mothers were poor at setting limits on their child that may occur. For instance, Belsky (2005) reviewed and/or displayed less confidence in their ability to EVIDENCE-BASED PRACTICE IN CHILD AND ADOLESCENT MENTAL HEALTH 63

manage the child’s behavior. Conceptually, these results describe or attempt to describe disordered attachment suggest that caregivers who are emotionally supportive behavior. Rather, the intent was to describe the symp- and comforting to their distressed children may still toms of the disorder as being “reactive” to problems in confer risk for poor developmental outcomes as a result a supposed attachment relationship. The astute reader of other parenting variables. Indeed, multiple reports will note that, given the tenets of attachment theory, from the Minnesota project suggest that models includ- practically any form of emotional or behavioral pro- ing other parent–child relationship variables beyond blem could be conceptualized as “reactive” to problems attachment classification were often preferred for pre- in the primary attachment relationship. In brief, the dicting outcomes when compared to attachment classi- DSM-III unsuccessfully attempted to link a well- fication alone (Sroufe et al., 2005). One should documented clinical condition of infants (i.e., non- remember that attachment classification is a specific organic failure to thrive) to a popular and prevailing risk/protective factor that indexes certain, but not all, developmental theory. aspects of the much broader parent–child relationship. By the time the DSM-III-R (3rd ed., rev.; American Psychiatric Association, 1987) was published in 1987, it was commonly recognized that toddlers and preschoo- A brief history of Reactive Attachment Disorder lers raised in institutions (e.g., orphanages) were at risk (RAD) for displaying problematic social behavior, whether it As mentioned previously, Bowlby developed many of his be significantly withdrawn and self- isolating or “overly ideas by observing the effects of parental deprivation on friendly” behavior that lacked appropriate reticence infants and children. Evidence had existed for decades toward strangers (Tizard & Rees, 1975). In recognition that infants living in hospitals or other settings without of these findings, and to address the criticisms of RAD consistent parental interaction would display depressive- as found in the DSM-III, the diagnosis was radically like behaviors, many times resulting in the death of the changed in the DSM-III-R to reflect “markedly dis- child, what Rene Spitz (Spitz & Wolf, 1946) termed turbed social relatedness in most contexts. ” This pre- “anaclitic depression.” By the late 1970s, Bowlby’s theory sentation could manifest as either “persistent failure to on the importance of the parent–child relationship for initiate or respond to most social interactions (inhib- development, Harlow’s research with rhesus monkeys, ited)” or “indiscriminate sociability (disinhibited),” and and Ainsworth’s observational studies were well known. there was a required presumption that the condition Within this scientific and clinical climate, the Diagnostic was caused by “grossly pathogenic care” (p. 91). In and Statistical Manual of Mental Disorders (3rd ed.; addition, the condition was described as RAD of DSM-III) was published in 1980 (American Psychiatric Infancy or Early Childhood, as the aberrant social beha- Association, 1980). vior could now be diagnosed as RAD if present before DSM-III included the first codification of a disorder the age of 5 years. Although few doubted that the purportedly based in attachment theory. This presenta- problems described by RAD in the DSM-III-R were tion, termed Reactive Attachment Disorder of Infancy, linked to severe early negle