Attachment therapy

From Wikipedia, the free encyclopedia

Attachment therapy is the term most commonly used by practitioners and critics for a controversial category of alternative child mental health interventions intended to treat what practitioners describe as attachment disorders. The term generally includes accompanying parenting techniques which proponents consider as important as the therapy itself. Attachment therapy is a treatment used primarily with fostered or adopted children who are believed to have certain behavioral difficulties, including disobedience and lack of gratitude or affection for their caregivers. The children's problems are ascribed to an inability to attach to their new parents because of suppressed rage due to past maltreatment and abandonment.

This form of therapy is scientifically unvalidated and is not considered to be part of mainstream psychology either as to understanding of attachment theory, (with which it is considered incompatible),^[1][2] diagnosis or treatment, or as to the accompanying attachment parenting techniques. It is distinct from mainstream forms of therapy based on attachment theory as it is primarily based on misapplied psychoanalytic theories about suppressed rage, catharsis, regression and the breaking down of resistance and defence mechanisms. It has been described as potentially abusive and a pseudoscientific intervention, not based on attachment theory or research, that has resulted in tragic outcomes for children including at least six documented child fatalities.^[3] From the 1990s onwards there was a series of prosecutions for deaths or serious maltreatment of children, allegedly at the hands of "attachment therapists" or parents following their instructions. Two of the most well-known cases are those of Candace Newmaker in 2001 and the Gravelles in 2003-5. Following publicity for these adverse events, some advocates of attachment therapy began to alter views and practices in ways that would be less potentially dangerous to children. This change may have been hastened by the publication of a Taskforce Report on the subject in 2006, commissioned by the American Professional Society on the Abuse of Children (APSAC) which was largely critical of attachment therapy.(Chaffin et al, 2006)^[4]

Probably the most common form of attachment therapy is holding therapy, in which a child is firmly held (or lain upon) by therapists and/or parents, who then, by restraint and confrontation, seek to produce in the child a range of responses such as rage and despair for the supposed purpose of 'catharsis'. The theory is that when the child's resistance is overcome, and the rage is released, they are reduced to an infantile state in which they can be 're-parented' by methods such as cradling, rocking, bottle feeding and enforced eye contact. The aim is to promote attachment with the new carers. Control over the children is usually considered essential and the therapy is often accompanied by attachment therapy parenting techniques which emphasise obedience. These accompanying parenting techniques are based on the belief that a properly attached child should comply with parental demands 'fast, snappy and right the first time' and should be 'fun to be around'.

Variant forms or particular techniques may be known by a number of names including "rebirthing," "compression therapy," "holding therapy," "the "Evergreen model", "holding time," "rage-reduction"^[5] and "corrective attachment therapy". Some attachment therapists have also started using the term "attachment-based therapy" as opposed to "attachment therapy" although this term was previously used by some mainstream therapists in an effort to distinguish themselves from attachment therapy. Some authors critical of this approach have used the term Coercive Restraint Therapy. ^[6] This form of treatment differs significantly from mainstream attachment based therapies, talking psychotherapies such as attachment-based psychotherapy and relational psychoanalysis or the form of attachment parenting advocated by the pediatrician Sears. Further, the form of rebirthing sometimes used within attachment therapy differs from Rebirthing-Breathwork.

Contents 1 Treatment characteristics of attachment therapy 1.1 Parenting techniques 1.2 Traditional attachment theory based methods 2 History and underlying theory 2.1 Attachment theory 2.2 Underlying theoretical principles of attachment therapy 2.3 Historical roots 3 Range of attachment therapies 4 Diagnosis and Attachment Disorder 4.1 Diagnosis lists and questionnaires 4.2 Patient recruitment 5 Prevalence 6 Evidence basis and controversial therapies 7 Mainstream therapies 8 Cases 9 See also 10 Notes 11 References 12 External links

[edit] Treatment characteristics of attachment therapy

The controversy has centered most broadly on what is known as "holding therapy"^[7] and coercive, restraining, or aversive procedures such as deep tissue massage, aversive tickling, punishments related to food and water intake, enforced eye contact, requiring children to submit totally to adult control over all their needs, barring normal social relationships outside the primary caretaker, encouraging children to regress to infant status, reparenting, attachment parenting, or techniques designed to provoke cathartic emotional discharge. Variants of these treatments have carried various labels that appear to change frequently. They may be known as 'rebirthing therapy,' 'compression therapy,' 'corrective attachment therapy,' 'the Evergreen model,' 'holding time,' or 'rage-reduction therapy'.^{[7][8][9][10][11]}

Speltz (2002) describes a typical treatment taken from The Center's material (apparently a replication of the programme at the Attachment Center, Evergreen) as follows:

"Like Welsh (sic)(1984, 1989), The Center induces rage by physically restraining the child and forcing eye contact with the therapist (the child must lie across the laps of two therapists, looking up at one of them). In a workshop handout prepared by two therapists at The Center, the following sequence of events is described: (1) therapist "forces control" by holding (which produces child "rage"); (2) rage leads to child "capitulation" to the therapist, as indicated by the child breaking down emotionally ("sobbing"); (3) the therapist takes advantage of the child's capitulation by showing nurturance and warmth; (4) this new trust allows the child to accept "control" by the therapist and eventually the parent. According to The Center's treatment protocol, if the child "shuts down" (i.e., refuses to comply), he or she may be threatened with detainment for the day at the clinic or forced placement in a temporary foster home; this is explained to the child as a consequence of not choosing to be a "family boy or girl." If the child is actually placed in foster care, the child is then required to "earn the way back to therapy" and a chance to resume living with the adoptive family."^[12]

The APSAC Task Force (2006) describes how the conceptual focus of these treatments is the child's individual internal pathology and past caregivers rather than current parent-child relationships or current environment, to the extent that if the child is well behaved outside the home this is seen as manipulative. It was noted that this perspective has its attractions because it relieves the caregivers of responsibility to change aspects of their own behavior and aspirations. Proponents believe that traditional therapies fail to help children with attachment problems because it is impossible to establish a trusting relationship with them and that children with attachment problems actively avoid forming genuine relationships (Institute for Attachment and Child Development). The child's resistance to attachment and the need to break it down is emphasized. In rebirthing and similar approaches, protests of distress from the child are considered to be resistance that must be overcome by more coercion. Similar but less physically coercive approaches may involve holding the child and psychologically encouraging the child to vent anger toward her or his biological parents.^[13]

Coercive techniques, such as scheduled or enforced holding, also may serve the intended purpose of demonstrating dominance over the child and provoking catharsis or ventilation of rage. Establishing total adult control, demonstrating to the child that he or she has no control, and demonstrating that all of the child's needs are met through the adult, is a central tenet of many controversial attachment therapies. Similarly, many controversial treatments hold that children described as attachment disordered must be pushed to revisit and relive early trauma. Children may be encouraged to regress to an earlier age where trauma was experienced or be reparented through holding sessions.^[14] Other features of attachment therapy are the 'two week intensive' course of therapy, and the use of 'therapeutic foster parents' with whom the child stays whilst undergoing therapy. According to O'Connor and Zeanah,^[1] the "holding" approach would be viewed as intrusive and therefore non-sensitive and counter therapeutic, in contrast with accepted theories of attachment.

According to Advocates for Children in Therapy, an advocacy group that campaigns against attachment therapy, "Attachment Therapy almost always involves extremely confrontational, often hostile confrontation of a child by a therapist or parent (sometimes both). Restraint of the child by more powerful adult(s) is considered an essential part of the confrontation." The purported correction is described as "... to force the children into loving (attaching to) their parents; … there is a hands-on treatment involving physical restraint and discomfort. Attachment Therapy is the imposition of boundary violations – most often coercive restraint – and verbal abuse on a child, usually for hours at a time; … Typically, the child is put in a lap hold with the arms pinned down, or alternatively an adult lies on top of a child lying prone on the floor."^[15] They give a list of therapies they state are attachment therapies and a list of additional therapies used by attachment therapists which they consider to be unvalidated.^[16]

[edit] Parenting techniques

Often parents are required to follow programmes of treatment at home, for example obedience-training techniques such as "strong sitting" (frequent periods of required silence and immobility) and withholding or limiting food.^[17] Earlier authors sometimes referred to this as 'German Shepherd training'.^[10]

According to the APSAC Task Force, because it is believed children with attachment problems resist attachment, fight against it and seek to control others to avoid attaching, the child's character flaws must be broken before attachment can occur. Attachment parenting may include keeping the child at home with no social contacts, home schooling, hard labor or meaningless repetitive chores throughout the day, motionless sitting for prolonged periods of time, and control of all food and water intake and bathroom needs. Children described as attachment disordered are expected to comply with parental commands "fast and snappy and right the first time," and to always be "fun to be around" for their parents. Deviation from this standard, such as putting off of not finishing chores or arguing, is interpreted as a sign of attachment disorder that must be forcibly eradicated. From this perspective, parenting a child with an attachment disorder is a battle, and winning the battle by defeating the child is paramount.^[18]

Proper appreciation of total adult control is also considered vital and to this end information, such as how long a child will be with 'therapeutic foster parents' or what will happen to it next is deliberately withheld.^[19] It has been stated that attachment disordered children act worse when given information about what is going to occur because they will use the information to manipulate their environment and everyone in it.^[17]

In addition to this restrictive parental behavior, to create attachment parents are advised to provide daily sessions in which older children are treated as if they were babies.^[17] The child is held in the caregiver's lap, rocked, hugged and kissed, and fed with a bottle and given sweets. These sessions are carried out at the caregiver's wish and not upon the child's request. Attachment therapists believe that these reenactments of some aspects of infant care have the power to rebuild damaged aspects of early development such as emotional attachment.

[edit] Traditional attachment theory based methods

In contrast, traditional attachment theory holds that caregiver qualities such as environmental stability, parental sensitivity, and responsiveness to children's physical and emotional needs, consistency, and a safe and predictable environment support the development of healthy attachment. Therapy based on this viewpoint emphasizes providing a stable environment and taking a calm, sensitive, nonintrusive, nonthreatening, patient, predictable, and nurturing approach toward children. Improving these positive caretaker and environmental qualities is the key to improving attachment.^[20][21][22]

[edit] History and underlying theory

Main article: Attachment theory

Main article: Attachment in children

Attachment therapy, which aims to treat disorders of attachment, was developed in the 1960s and 1970s, mainly in the USA by Foster Cline and associates at the Attachment Center in Evergreen. Its proponents maintain that it is based on the principles of attachment theory. Its critics disagree. Like a number of other alternative mental health treatments for children, attachment therapy is based on some assumptions that differ strongly from the theoretical foundations of other attachment based therapies.^[23]

[edit] Attachment theory

Attachment theory, on which attachment therapists state their intervention is based, is an evolutionary and ethological theory according to which the infant or child, in situations of alarm or distress seeks to be close to a particular person, (called the 'caregiver'), usually but not necessarily the mother. It is not the same as love and/or affection, although they often go together, and a healthy attachment is considered to be an important foundation of all subsequent relationships. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time. Parental responses lead to the development of patterns of attachment which in turn lead lead to 'internal working models' which will guide the individuals feelings thoughts and expectations in later relationships.^[24]

[edit] Underlying theoretical principles of attachment therapy

In contrast to traditional attachment theory, the theory of attachment described by attachment therapy proponents is that young children who experience adversity (including maltreatment, loss, separations, adoption, frequent changes in child care, colic or even frequent ear infections) become enraged at a very deep and primitive level. This results in a lack of ability to attach or to be genuinely affectionate to others. Suppressed or unconscious rage is theorized to prevent the child from forming bonds with caregivers and leads to behavior problems when the rage erupts into unchecked aggression. Such children are said to fail to develop a conscience, to not trust others, to seek control rather than closeness, to resist the authority of caregivers, and to engage in endless power struggles. They are seen as highly manipulative and as trying to avoid true attachments while simultaneously striving to control those around them through manipulation and superficial sociability. Such children are to be at risk of becoming psychopaths who will go on to engage in very serious delinquent, criminal, and antisocial behaviors if left untreated.^[25] The tone in which the attributes of these children are described has been characterised as "demonising".^[26]

Advocates of this treatment also believe that emotional attachment of a child to a caregiver begins during the prenatal period, during which the unborn child is aware of the mother's thoughts and emotions. If the mother is distressed by the pregnancy, and especially if she considers abortion, the child responds with distress and anger that continue through postnatal life. If the child is separated from the mother after birth, no matter how early this occurs, the child again feels distress and rage that will block attachment to a foster or adoptive caregiver.

If the child has had a peaceful gestation, but after birth suffers pain or ungratified needs during the first year, attachment will again be blocked. If the child reaches the toddler period safely, but is not treated with strict authority during the second year, according to the so-called 'attachment cycle", attachment problems will result. Failure of attachment results in a lengthy list of mood and behavior problems, but these may not be revealed until the child is much older. According to the attachment therapist Elizabeth Randolph, attachment problems can be diagnosed even in an asymptomatic child through observation of the child's inability to crawl backward on command.^[19][27]

[edit] Historical roots

Speltz (2002)^[12] states that the roots of attachment therapy are traceable to Robert Zaslow in the 1970s.^[28] Zaslow attempted to force attachment in those suffering from autism by creating pain and rage whilst enforcing eye contact. He believed that holding someone against their will would lead to a breakdown in their defence mechanisms, making them more receptive to others. Speltz points out that these ideas have been dispelled by research into autism and that, conversely, techniques based on behavioral principles have proved effective.^[12] Zaslow had to surrender his California psychology license following an injury to a patient.^[29]

Zaslow's belief system owed much to Wilhelm Reich, the psychoanalyst who claimed to have discovered a substance related to human sexuality and health called orgone. Reich posited that lack of appropriate care and maternal attitudes, from the prenatal period, would create a muscular-psychic condition he called 'character armor". This was indicated by problems with eye contact, upper-body stiffness and emotional constriction, to be cured by physical contact including painful prodding of the body, carried out in a manner very similar to that later recommended by Zaslow. Zaslow and his 'Z-process' influenced Foster Cline and associates at his clinic in Evergreen, originally the Youth Behavior Program, subsequently renamed the Attachment Centre. ^[19]

Speltz (2002) describes "corrective attachment therapy" as ".... a therapist or parent initiates the holding process for the purpose of provoking strong, negative emotions in the child (e.g., fear, anger), and the child's release is typically contingent upon his or her compliance with the therapist's clinical agenda" (goals).^[12] Speltz cites Martha Welch and Holding Time (published in 1984 and 1989)^[7] as the next significant development. Mothers were instructed to hold their defiant child, provoking anger and rage, until such time as the child ceased to resist at which point a bonding process was believed to begin. Foster Cline and associates at the Attachment Center at Evergreen, Colorado began to promote the use of the same or similar holding techniques with adopted, maltreated children who were said to have an "attachment disorder". This was replicated elsewhere such as at "The Center" in the Pacific Northwest.^[12] A number of clinics later arose in Evergreen, Colorado, set up by those involved in or trained at the Attachment Center at Evergreen (now renamed the Institute for Attachment and Development). [14] These include one set up by Connell Watkins, formerly an associate of Foster Cline at the Attachment Centre and one of the therapists convicted in the Candace Newmaker case.

Metaphors based on Zaslow's original misapplication of ego defences from psychoanalytic theory were adopted by attachment therapists. These included the notions of "breaking through" a child's defences, or the child's development being "frozen" and treatment being required to "unfreeze" development.^[30] According to Prior and Glaser (2006) "there is no empirical evidence to support Zaslow's theory. The concept of suppressed rage has, nevertheless, continued to be a central focus explaining the children's behavior."^[31]

In addition it was believed that holding induced age regression enabling a child to make up for physical affection missed earlier in life.^[32] Regression is key to the holding therapy approach.^[33] Bowlby explicitly rejected the notion of regression: "present knowledge of infant and child development requires that a theory of developmental pathways should replace theories that invoke specific phases of development in which it is held a person may become fixated and/or to which he may regress."^[34][35] In attachment therapy, the breaking down of the child's resistance by confrontational techniques is thought to reduce the child to an infantile state thus making the child receptive to forming attachment by the application of early parenting behaviors such as bottle feeding, cradling, rocking and eye contact.^[36] Some, but by no means all, attachment therapists have used rebirthing techniques to aid regression.

Cline's privately-published work Hope for high risk and rage filled children also cites the hypnotherapist Milton Erickson as a source, and reprints parts of a case of Erickson's published in 1961.^[10][37] The Erickson case report, described the case of a divorced mother with a noncompliant son. Erickson advised the mother to sit on the child for hours at a time and to feed him only on cold oatmeal while she and a daughter ate appetizing food. The child did increase in compliance, and Erickson noted, with apparent approval, that he trembled when his mother looked at him. Cline commented, with respect to this and other cases, that in his opinion all bonds were trauma bonds. According to Cline it illustrates the three essential components of 1) taking control, 2) the child's expression of rage; and, 3) relaxation and the development of bonding.

According to O'Connor and Nilsen (2005), although other aspects of treatment are applied, the holding component has attracted most attention because proponents believe it is an essential ingredient. They also considered the lack of available and suitable interventions from mainstream professionals as essential to the popularization of holding therapy as attachment therapy.^[38] Critics say holding therapies have been promoted as "attachment" therapies, even though they are more antithetical to than consistent with attachment theory. They use language from attachment theory but descriptions of the practices contain ideas and techniques based on misapplied metaphors deriving from Zaslow and psychoanalysis, not attachment theory.^[39] There are many ways in which holding therapy/attachment therapy contradicts Bowlby's attachment theory, not least attachment theory's fundamental and evidence-based statement that security is promoted by sensitivity.^[40] According to Mary Dozier (2003) ”holding therapy does not emanate in any logical way from attachment theory or from attachment research”.^[41]

In 2003 an issue of Attachment & Human Development, was devoted to the subject of attachment therapy with articles by well-known experts in the field of attachment.^[42] In 2006 the American Professional Society on the Abuse of Children (APSAC) Task Force reported on the subject of attachment therapy, reactive attachment disorder, and attachment problems and laid down guidelines for the future diagnosis and treatment of attachment disorders.^[43] The Taskforce was largely critical of attachment therapy's theoretical base, practices, claims to an evidence base, non-specific symptoms lists published on the Web, claims that traditional treatments do not work and dire predictions for the future of children who do not receive attachment therapy. "Although focused primarily on specific attachment therapy techniques, the controversy also extends to the theories, diagnoses, diagnostic practices, beliefs, and social group norms supporting these techniques, and to the patient recruitment and advertising practices used by their proponents."^[44]

[edit] Range of attachment therapies

The APSAC Task Force stated that proponents of attachment therapy correctly point out that most critics have never actually observed any of the treatments they criticize or visited any of the centers where the controversial therapies are practiced. Proponents argue that their therapies present no physical risk if undertaken properly and that critics' concerns are based on unrepresentative occurrences and misapplications of techniques, or misunderstanding by parents. Holding is described as gentle or nurturing and it is maintained that intense, cathartic approaches are necessary to help children with attachment disorders. Their evidence for this is primarily clinical experience and testimonial.^[45]

There are controversies within the attachment therapy community about coercive practices. There has been a move away from coercive and confrontational models towards attunement and emotional regulation amongst some leaders in the field, notably Hughes, Kelly and Popper. A number of therapies are quite different from those that have led to the abuse and deaths of children in much publicised court cases. However, the Taskforce point out that all the therapies, including those using frankly coercive practices, present themselves as humane, respectful and nurturing, therefore caution is advised.^[46] Some practitioners condemn the most dangerous techniques but continue to practice other coercive techniques.^[47] Others have taken a public stand against coercion. The Taskforce was of the view that all could benefit from more transparency and specificity as to how the therapy is behaviourally delivered.^[46]

In 2001, 2003 and 2006, ATTACh, an organisation set up by Foster Cline and associates and at one time closely associated with attachment therapy, issued a series of statements in which they progressively changed their stance on coercive practices. In 2001 after the death of Candace Newmaker they stated “The child will never be restrained or have pressure put on them in such a manner that would interfere with their basic life functions such as breathing, circulation, temperature, etc.” (ATTACh, 2001).^[48] Their 2006 guideline "unequivocally state (s) our opposition to the use of coercive practices in therapy and parenting." They acknowledge ATTACh's historical links with catharsis, provocation of rage, and intense confrontation, among other overtly coercive techniques (and indeed continue to offer for sale books by controversial proponents) but state that the organization has evolved significantly away from earlier positions. They state that their recent evolution is due to a number of factors including tragic events resulting from such techniques, an influx of members practicing other techniques such as attunement and a "fundamental shift ... away from viewing these children as driven by a conscious need for control toward an understanding that their often controlling and aggressive behaviors are automatic, learned defensive responses to profoundly overwhelming experiences of fear and terror."^[49][50]

[edit] Diagnosis and Attachment Disorder

Main articles: Attachment disorder, Reactive attachment disorder

Disorders of attachment are classified in DSM-IV-TR and ICD-10 as follows: Reactive attachment disorder of Infancy or Early Childhood, divided into two subtypes, Inhibited Type and Disinhibited Type in DSM-IV-TR, and Reactive attachment disorder of childhood and Disinhibited attachment disorder of childhood in ICD-10. Both classifications are under constant discussion and both warn against automatic diagnosis based on abuse or neglect. Many "symptoms" are present in a variety of other more common and more easily treatable disorders. There is as yet no other accepted definition of attachment disorders although the term is also used to cover a variety of problematic attachment difficulties and styles and further categories have been proposed.^[51]

There are a number of attachment 'styles' namely 'secure', 'anxious-ambivalent', 'anxious-avoidant', (all 'organized') and 'disorganized', some of which are more problematical than others and may be predictive of future social or emotional problems, but none constitute a 'disorder' in themselves. The only officially classified attachment disorder, known as Reactive attachment disorder, requires one or both of the attachment behaviors of seeking to be close to a particular person (attachment figure), and avoiding strangers, to be missing.

In attachment therapy, the diagnoses of attachment disorder and reactive attachment disorder are used in a fashion not recognised in mainstream practice. Prior and Glaser (2006) describe "two discourses" on attachment disorder. One is science-based, found in academic journals and books with careful reference to theory, international classifications and evidence. They list Bowlby, Ainsworth, Tizard, Hodges, Chisholm, O'Connor and Zeanah and colleagues as respected attachment theorists and researchers in the field. The other discourse is found in clinical practice, non-academic literature and on the Internet where claims are made which have no basis in attachment theory and for which there is no empirical evidence. In particular unfounded claims are made as to efficacy of "treatments".^[52] The Internet is considered essential to the popularization of holding therapy as attachment therapy.^[53]

The APSAC Task Force describes the polarization between the proponents of attachment therapy and mainstream therapies stating, "This polarization is compounded by the fact that attachment therapy has largely developed outside the mainstream scientific and professional community and flourishes within its own networks of attachment therapists, treatment centers, caseworkers, and parent support groups. Indeed, proponents and critics of the controversial attachment therapies appear to move in different worlds.^[54]

[edit] Diagnosis lists and questionnaires

Both the APSAC Task Force and Prior and Glaser describe the proliferation of alternative "lists" and diagnoses, particularly on the Internet, by proponents of attachment therapies that are not in accord with either DSM or ICD classifications and which are partly based on the unsubstantiated views of Zaslow and Menta (1975)^[28] and Cline (1992)^[10][55][56] Neither do these lists accord with alternative diagnostic criteria discussed as mentioned above. According to the Task Force, "These types of lists are so nonspecific that high rates of false-positive diagnoses are virtually certain. Posting these types of lists on Web sites that also serve as marketing tools may lead many parents or others to conclude inaccurately that their children have attachment disorders."^[57]

Prior and Glaser describe the lists as "wildly inclusive" and state that many of the behaviors in the lists are likely to be the consequences of neglect and abuse rather than located within the attachment paradigm. Descriptions of children are frequently highly pejorative and "demonising". Lists found on the internet often include lying, avoiding eye contact except when lying, persistent nonsense questions or incessant chatter and so on. They give an example from the Evergreen Consultants in Human Behavior (2006) which offers a 45 symptom checklist including bossiness, stealing, enuresis and language disorders.^[58]

A commonly used diagnosis checklist in attachment therapy is the Randolph Attachment Disorder Questionnaire or "RADQ", emanating from the Institute for Attachment in Evergreen.^[59] It is presented not as an assessment of RAD but rather attachment disorder. The checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like Conduct Disorder and Oppositional Defiant Disorder or are not related to attachment difficulties.^[60] It is largely based on the earlier Attachment Disorder Symptom Checklist which in itself shows considerable overlap with even earlier checklists for indicators of sexual abuse. A peculiarity of the Attachment Disorder Symptom Checklist is its inclusion of statements about the parent's feelings toward the child as well as statements about the child's behavior. For example, parental feelings are evaluated through responses to such statements as "Parent feels used" and "is wary of the child's motives if affection is expressed," and "Parents feel more angry and frustrated with this child than with other children." The child's behavior is referred to in such statements as "Child has a grandiose sense of self-importance" and "Child 'forgets' parental instructions or directives." Validity of content of the RADQ was claimed by reference to the Attachment Disorder Symptom Checklist. It also purports to diagnose attachment disorder for which there is no classification.^[61] It has been stated that a major problem of the RADQ is that it has not been validated against any established objective measure of emotional disturbance.^[62]

According to the American Academy of Child and Adolescent Psychiatry practice parameter (2005) the question of whether attachment disorders can reliably be diagnosed in older children and adults has not been resolved. Attachment behaviors used for the diagnosis of RAD change markedly with development and defining analogous behaviors in older children is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence. ^[63] Assessments of RAD past school age may not be possible at all as by this time children have developed along individual lines to such an extent that early attachment experiences are only one factor among many that determine emotion and behavior.^[64]

[edit] Patient recruitment

In addition to concerns about the use of non-specific diagnostic checklists on the Web being used as a marketing tool, the Taskforce also noted the extreme claims made by proponents as to both the prevalence and effect of attachment disorders. Some suggest most or a high proportion of adopted children are likely to suffer attachment disorder. Statistics on the prevalence of maltreatment are (wrongly) used to estimate the prevalence of RAD. Problematical or less desirable styles such as insecure or disorganized attachment are conflated with attachment disorder. Children are labeled as “RAD’s,” “RAD-kids” or “RADishes.”^[65] They are seen as manipulative, dishonest, without conscience and dangerous. Some attachment therapy sites predict that attachment disordered children will grow up to become violent predators or psychopaths unless they receive the treatment proposed. A sense of urgency is created which also serves to justify the application of aggressive and unconventional techniques. One site was noted to contain the argument that Saddam Hussein, Adolf Hitler, and Jeffrey Dahmer, were examples of children who were attachment disordered who “did not get help in time”^[66] Foster Cline in his seminal work on attachment therapy Hope for high risk and rage filled children uses the example of Ted Bundy.^[10]

In answering the question posed as to how a treatment widely regarded by attachment clinicians and researchers as destructive and unethical came to be linked with attachment theory and to be seen as a viable and useful treatment, O'Connor and Nilson cite not only the use of the Internet but also ill-equipped mainstream professionals and the absence of suitable alternative interventions. They set out recommendations for both the better dissemination of understanding of attachment theory and knowledge of the more recent evidence based treatment options available.^[67]

[edit] Prevalence

It is difficult to ascertain the prevalence of these therapies but they are sufficiently prevalent to have prompted position statements or specific prohibitions against using coercion or restraint as a treatment by mainstream professional societies such as; American Psychological Association (Division on Child Maltreatment) [15], National Association of Social Workers [16] (and its Utah Chapter[17]), American Professional Society on the Abuse of Children,^[68] American Academy of Child and Adolescent Psychiatry,^[63] and American Psychiatric Association [18]. The Association for the Treatment and Training in the Attachment of Children, or ATTACh, an organization for professionals and families associated with attachment therapy, has also issued statements against coercive practices.^[69][70] Two American states have outlawed rebirthing. [19] There have been professional licensure sanctions against some leading proponents and successful criminal prosecutions and imprisonment of therapists and parents using attachment therapy techniques. Despite this the treatments and their associated concepts and foundational principles appear to be continuing among networks of attachment therapists, attachment therapy centers, caseworkers, and adoptive or foster parents.^[71]

The practice of holding therapy is not confined to the USA, there being at least one center in the UK.^[72] The British Association for Adoption and Fostering, BAAF, has issued an extensive position statement on the subject which covers not only physical coercion but also the underlying theoretical principles. [20] The advocacy group ACT states, "Attachment Therapy is a growing, underground movement for the 'treatment' of children who pose disciplinary problems to their parents or caregivers."

[edit] Evidence basis and controversial therapies

Evidence based medicine is a term used to mean that proposed medical and psychological treatments should be based upon rigorous testing and independent peer review of findings by the medical community and reviewers using meta-analysis of medical literature, risk-benefit analysis, randomized controlled trials, or other methods. There have been a number of reports on the evidence base for attachment therapy and holding therapies in general. According to the APSAC Task Force, proponents of attachment therapy commonly assert that their therapies alone are effective for attachment disordered children and that traditional treatments are ineffective or harmful.^[73] The APSAC Task Force expressed concern over claims by therapies to be "evidence based", or the only evidence-based therapy, when the Task Force found no credible evidence base for any such therapy so advertised.^[74] Nor did it accept more recent claims to evidence base in its November 2006 Reply.^[46]

Two approaches on which published studies have been undertaken are holding therapy, Myeroff et al (1999)^[75] and Dyadic Developmental Psychotherapy, Becker-Weidman (2006).^[76] Each of these nonrandomized studies concluded that the treatment method studied was effective. Both the APSAC Task Force and Prior and Glaser cite and criticize the one published study on "holding therapy" by Myeroff et al (1999) which "purports to be an evaluation of holding therapy".^[77][78][75] This study covers the "across the lap" approach, described as "not restraint" by Howe and Fearnley (2003) but "being held whilst unable to gain release."^[79] Prior and Glaser state that although the Myeroff study claims it is based on attachment theory, the theoretical basis for the treatment is in fact Zaslow.^[80]

Dyadic Developmental Psychotherapy was developed by Daniel Hughes, described by the Taskforce as a "leading attachment therapist", with the express intention of developing a therapy away from notions of physical coercion, obedience and control. Hughes states that it is based on Bowlby's principles of attachment theory.[21]^[81] Hughes website also gives a list of attachment therapy techniques specifically forsworn by him. Two studies on Dyadic Developmental Psychotherapy have been published by Dr Becker-Weidman, the second being a four-year follow up of the first. (Becker-Weidman 2006)^[76] Opinion is divided as to whether Dyadic Developmental Psychotherapy is in fact an attachment therapy with Prior and Glaser stating Hughes' therapy 'reads' as good therapy for abused and neglected children, though with 'little application of attachment theory', but the advocacy group ACT and the Taskforce placing Hughes within the attachment therapy paradigm.^[82][22] In 2004, Saunders, Berliner and Hanson developed a system of categories for social work interventions which has proved somewhat controversial.^[83][84] In their first analysis, holding therapy was placed in Category 6 as a "Concerning Treatment".

Craven & Lee (2006) undertook a literature review of 18 studies and classified them under the Saunders, Berliner, & Hanson (2004) system^[85] They considered both Dyadic Developmental Psychotherapy and holding therapy.^[86][75] They placed both in Category 3 as "supported and acceptable". This categorisation by Craven & Lee has been criticised as unduly favourable (Pignotti & Mercer 2007), a point to which Craven and Lee responded by arguments in support of holding therapy.^[87][88] Both Myeroff et al (1999) and Becker-Weidman's first study (published after the main Report) were examined in the Taskforce's November 2006 Reply to Letters and were criticised as to their methodology. Becker-Weidman (2006) was described as "an important first step toward learning the facts about DDP outcomes" but considered to fall far short of the criteria necessary to constitute an evidence base.^[46]

Some studies are still being undertaken on coercive therapies. A nonrandomized, before-and-after 2006 pilot study by Welch (the progenitor of 'holding time') et al on Welch's 'prolonged parent-child embrace therapy' was conducted on children with a range of diagnoses for behavioral disorders and claimed to show significant improvement.^[89]

[edit] Mainstream therapies

Main article: Child therapy

All mainstream interventions with an existing or developing evidential foundation focus on enhancing caregiver sensitivity, creating positive interactions with caregivers, or change of caregiver if that is not possible with existing caregivers. Some interventions focus specifically on increasing caregiver sensitivity in foster parents.^[90][91]

The American Academy of Child and Adolescent Psychiatry (AACAP), state that children who exhibit signs of reactive attachment disorder need a comprehensive psychiatric assessment and individualized treatment plan as the signs or symptoms of RAD may also be found in other psychiatric disorders and AACAP advises against giving a child this label or diagnosis without a comprehensive evaluation.^[92] AACAP, in their Practice Parameter (2005) has also laid down guidelines (devised by N.W. Boris and C.H. Zeanah) based on its published parameters for the diagnosis and treatment of RAD.^[90] Recommendations in the guidelines include the following:

1. "The most important intervention for young children diagnosed with reactive attachment disorder and who lack an attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an emotionally available attachment figure."
2. "Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child, assessing the caregiver's attitudes toward and perceptions about the child is important for treatment selection."
3. "Children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. After ensuring that the child is in a safe and stable placement, effective attachment treatment must focus on creating positive interactions with caregivers."
4. "Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive (additional) treatments."

[edit] Cases

There have been a number of cases of serious harm to children in which controversial attachment therapy techniques, theories or belief systems have been implicated. An estimated six children have died as a consequence of the more coercive forms of such treatments and/or the application of the accompanying parenting techniques.^[93][19][1]

• David Polreis 1996. A two year old adopted boy beaten to death. The adoptive mother first claimed he had beaten himself and then claimed he had attacked her and she acted in self defence. Foster Cline gave evidence for the mother claiming the child had RAD. David had been diagnosed with attachment disorder by an attachment therapist and was undergoing treatment and accompanying parenting techniques. Mourners at the funeral were asked to contribute to The Attachment Center.^{[94][95][96][97]}

• Krystal Tibbets 1997. A three year old adopted child killed by her father using holding therapy techniques he claimed had been taught to him by an attachment therapy centre (denied by the therapist and the adoptive mother). He lay on top of her, a technique known as "compression therapy", and pushed his fist into her abdomen to release "visceral rage" and to enforce bonding. When she stopped screaming and struggling he believed she had "shut down" as a form of resistance. After his release from a five-year prison sentence the father campaigned to have attachment therapy banned.^{[98][99][100][101]}

• Candace Newmaker 2000. A ten year old adopted girl killed by asphyxiation during an attachment therapy 'intensive' involving a 'rebirthing' script in 2000. The two attachment therapists, Connell Watkins (formerly of The Attachment Centre, Evergreen) and Julie Ponder were each sentenced to 16 years imprisonment for their part in the therapy during which Candace was wrapped in blankets and required to struggle to be reborn, against the weight of several adults. Her inability to struggle out was interpreted as "resistance". Her adoptive mother and the 'therapeutic foster parents' with whom she had been placed received lesser penalties.^[102][103]

• Logan Marr 2001. A five year old child fostered by a caseworker. The screaming and tantruming five year old was buckled into a highchair, wrapped with duct tape, including over her mouth, and left in a basement where she suffocated. The foster mother claimed to have used some attachment therapy ideas and techniques she had picked up when working as a caseworker.^[104][105]

• Cassandra Killpack 2002. A four year old adopted child died from complications of hyponatremia secondary to water intoxication, which apparently occurred when she was restrained in a chair and forced to drink excessive amounts of water by her parents as part of an “attachment-based” treatment using techniques they claimed had been taught to them the attachment therapy centre where Cassandra was undergoing treatment. It appears this was a punishment for having drunk some of her sister's drink.^{[106][107][108]}

• Gravelles. Michael and Sharon Gravelle adopted 11 special needs children many of whom slept in cages. The case also involved allegations of extreme control over food and toileting and severe punishments for disobedience. The children were "home schooled". Some of the children underwent holding therapy from their attachment therapist and the parents used accompanying attachment therapy parenting techniques at home. Parents and therapist were prosecuted and convicted in 2003.^[109][110]

• Vasquez. In this California case, three of four adopted children were kept in cages, fed limited diets, and permitted only primitive sanitary facilities. The mother received a prison sentence of less than a year and her parental rights were terminated in 2007. There was no therapist in this case but the mother claimed that three of her four adopted children had reactive attachment disorder.^[111]

[edit] See also

Attachment theory Attachment in children John Bowlby Mary Ainsworth Attachment disorder Reactive attachment disorder

Child development Advocates for Children in Therapy Michael and Sharen Gravelle Candace Newmaker Rebirthing-Breathwork Theraplay

[edit] Notes

[edit] References

Chaffin M, Hanson R, Saunders BE, et al (2006). "Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems.". Child Maltreat 11 (1): 76–89. doi:10.1177/1077559505283699. PMID 16382093. 

O'Connor TG and Nilsen WJ. (2005) "Models versus Metaphors in Translating Attachment Theory to the Clinic and Community". In Enhancing Early Attachments. Theory, Research, Intervention and Policy. Eds. Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT. Duke series in child development and public policy. Guilford Press ISBN-10: 1-59385-470-6

Prior V and Glaser D (2006). Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice, Child and Adolescent Mental Health Series. London: Jessica Kingsley. ISBN 1-84310-245-5. OCLC 70663735. 

[edit] External links

• A Search For Survivors – First–hand accounts of attachment therapy and its consequences for children
• Association for Treatment and Training in the Attachment of Children (ATTACh) – Self-described as "an international coalition of professionals and families dedicated to helping those with attachment difficulties by sharing our knowledge, talents and resources"
• Advocates for Children in Therapy – Advocacy group opposing attachment therapy
• "Be Wary of Attachment Therapy" from Quackwatch – medical watchdog website
• "Underground network moves children from home to home" Koch W. USAtoday article.
• ebm-first.com - evidence based medicine campaign group.
• kidscomefirst anti-attachment therapy source site

v • d • e Attachment theory Theory Affectional bond • Attachment in adults • Attachment in children • Attachment disorder • Attachment measures • Attachment parenting • Attachment theory • Human bonding • Maternal deprivation • Object relations theory • Reactive attachment disorder Notable Theorists Mary Ainsworth • John Bowlby • Erik Erikson • Sigmund Freud • Harry Harlow • Jerome Kagan • Melanie Klein • Konrad Lorenz • Tinbergen • Rene Spitz Controversy Attachment therapy • Candace Newmaker

v • d • e Human development: biological - psychological - Overview table Pre- and perinatal Prenatal development • Pre- and perinatal psychology Infancy Infant and child development (stages) • Infancy Childhood Child development (stages) Toddlerhood • Preadolescence Adolescence Youth development • Puberty Adulthood Early adulthood • Middle adulthood • Late adulthood • Ageing & Senescence Theorists-theories John Bowlby-attachment • Erik Erikson-psychosocial • Sigmund Freud-psychosexual • Lawrence Kohlberg-moral • Jean Piaget-cognitive • Lev Vygotsky-cultural-historical