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Section 25
Adoption & Holding Therapy:  Harmful or Helpful?

Question 25 | Test | Table of Contents

Reactive Attachment Disorder
Reactive attachment disorder (RAD) as a diagnosis relies heavily on attachment-based theories and in turn is the diagnosis that has led to the development of attachment-based therapies According to DSM, RAD is diagnosed only when there is a known history of pathogenic care, expressed as: (i) persistent disregard for basic emotional needs for comfort, stimulation, and affection; (ii) persistent disregard for basic physical needs; (iii) and/or repeated changes of primary caregivers (American Psychiatric Association 2000). Although the American Psychiatric Association (2000) indicates that RAD is ‘uncommon’, this is not the view of adoption specialists. Maldonado- Duran et al. (2003) indicate that:

In some facilities, clinicians have become very interested in attachment disturbances. As a result, they may view any behavioral disturbance in a child as caused by disruptions in attachment and therefore diagnose the behavior as an attachment disorder. This may create problems for the clinician because the current definition of the disorder implies pathogenic care (e.g. neglect or multiple caregivers in rapid succession). (p. 295)

Overemphasizing the attachment paradigm’s relationship to psychological disorders and behavior problems is perilous. Werner-Wilson & Davenport (2003) argue that conceptualizations of attachment have become muddled, as have other psychological concepts like identity and self-esteem, and that uses of attachment theory have drifted too far from their origins to retain validity as bases for intervention. They conclude – as do Zeanah (1996) and O’Connor & Rutter (2000) – that the conceptualization of attachment that has led to the over-diagnosis of RAD is only very loosely related to attachment theory. They urge family therapists who recognize that attachment is an important family dynamic to avoid pathologizing children, and instead to focus on helping families to provide a better base for secure attachments.

Prevalence of RAD
Acknowledging the limited epidemiological data, the DSM considers RAD as ‘very uncommon’ (American Psychiatric Association 2000, p. 129), but other recent sources suggest that RAD is relatively widespread, at least in the USA. Werner-Wilson & Davenport (2003) cite a range of non-peer-reviewed sources indicating that there may be as many as one million children, and half of all adopted children, diagnosed with RAD in the USA. In England, the prevalence of disorders of attachment (as defined by DSM or ICD; World Health Organization 1992) is unknown (Kurtz et al. 1996) and these disorders were subsumed into the ‘emotional disorder’ category in the most recent Office of National Statistics Survey (Meltzer et al. 2003). Nevertheless, as in the USA, troublesome behaviors among fostered or later adopted children are often attributed by practitioners to disordered attachment (Richardson & Joughin 2002).

One reason why RAD may be over-diagnosed is that it is one of the few disorders in the DSM nosology that explicitly indicates its appropriateness for children under five years old. In addition, many practitioners ignore many of the core RAD criteria (Zeanah 1996). Instead they base the diagnosis on a child’s general level of problem behavior rather than on evidence of disturbed attachment, assume ‘pathogenic care’ as an etiology for the disorder (allowing both infant adoptions and adoptions of children from well-managed orphanages to be ruled in), and overlook the criterion that the problem behaviors must not be explainable based solely on a child’s developmental delay, although, admittedly, it is unclear how one makes this determination.

Our practice experience informs us that the use of RAD is not limited to young children or to children who have had pathogenic care, but is also applied to children adopted as newborns from well-planned domestic adoptions. In essence, the over-diagnosis of RAD is generating an oversized opportunity for interventions that appear to address RAD.

Attachment-based Therapies
A substantial amount of the clinical writing about attachment-based therapies regards the child as the primary target of clinical intervention (Cline 1979; Levy & Orlans 1998). Treatment of RAD from this clinical perspective is based on the assumption that the child has repressed rage resulting from earlier negative experiences that interferes with the ability to form an attachment, so clinical interventions are designed to help the child release this rage and teach the child that the new parents can be trusted as caregivers. Basing their interventions on attachment theories, the approach of Dozier (2003) in the USA and Cairns (2002) in the UK is to teach the foster parents to take the lead in maintaining positive interactions with foster children who are rejecting or withdrawing. Because most attachment therapies do not routinely place adoptive and foster parents in the position of showing an overriding warmth and concern, however, the lesson they teach can be counterproductive and even hazardous. The meta-message of such interventions can be that parents do not need to accommodate to children and that the expected process of change in the adjustment of family members to each other is unidirectional.

Other practitioners of attachment therapies conclude that a break in the arousal–relaxation cycle is a source of problematic behaviors in attachment disordered children (Fahlberg 1991). If birth or substitute caregivers have failed to meet children’s emotional and physical needs in early childhood, children will cease to trust caregivers to provide these needs and will instead trust only themselves (Thomas 1997). Attachment therapists may refer to Bowlby’s contention that emotionally deprived children exhibit underdeveloped personalities and consciences, and display ‘impulsive and uncontrolled’ behavior (Bowlby 1951, p. 59). Such therapies seek to repair the break in the need cycle by confronting the child, identifying and tearing down psychological defenses, and rebuilding the trust of the child through a combination of coercive holding and nurturing touch (ATTACh, Inc. 2004). These therapies are ‘regressive, forceful, loving and confrontive’, with the ultimate goal of instilling trust in the child through forcing him/ her to accept being controlled by others (Cline 1979, p. 162).

Holding therapy, which aims to repair rapidly the relationship between a parent and child, is attachment theory’s most visible therapeutic spin-off, particularly in the USA. This approach is primarily addressed to children who have been diagnosed with RAD, either formally or by their parents. Holding therapy has been used with thousands of parents (mainly but not exclusively in the USA) without the benefit of rigorous research and includes three primary treatment components that are directed towards the child: (i) prolonged restraint for a purpose other than protection; (ii) prolonged noxious stimulation (e.g. tickling, poking ribs); and (iii) interference with bodily functions. An early UK article (Crawford et al. 1986) describes holding therapy as an act in which the child is held securely by the parent, as the child progresses through the stages of bargaining, anger, rage, acceptance, and bonding. Welch (1989) asserts that holding therapy is designed to remedy attachment disorders in children and hypothesizes that intense physical contact with the mother can break through withdrawal and create strong ties with the mother. Laibow (1988) also asserts that this process is intended to mend damaged bonds between the parent and child but goes on to state that at times, the child will recall pre- and perinatal memories. Empirical evidence to support these claims or the proposed benefits of holding therapy is lacking. To quote Howard Steele (2003) in his Editor’s introduction to the recent special issue of Attachment and Human Development:

We must acknowledge there is, as yet, no systematic evidence-based approach for treating children with attachment disorders. Moreover, the very concept of ‘attachment disorders’ is a controversial one because of the substantial remaining questions about assessment and diagnosis. Holding therapies have not been shown to be an effective clinical tool, and according to some practices may be seriously harmful and countertherapeutic. (p. 219)

Indeed, this technique has a strong potential for ‘misuse and misapplication’ (Saunders et al. 2003, p. 103) and is ethically questionable, given the prohibition in many states against physical contact between therapists and clients. For these reasons, the US Office for Victims of Crime recently released treatment guidelines that single out holding therapy as the one intervention more likely to do harm than good (Saunders et al. 2003).

Reasons Parents Pursue Attachment Therapies
Although there is little direct research on adoptive or foster parents’ reasons for pursuing the ‘attachment therapies’ described above, reading of case studies and journalistic accounts provides some insight. Attachment therapy appears to provide a radical intervention to address behaviors that parents believe predict negative and even horrific outcomes for their children. Also, parents often feel increasingly distant from children whom they view as actively destructive and antisocial (Mercer et al. 2003) and sense that children are moving beyond parental control into a world of sociopathy. This may be so even though teachers and other adults do not view their child so negatively (Mercer 2001). This pessimistic view of their children’s future is sometimes encouraged by attachment therapists who point to Ted Bundy, Jeffrey Dahmer, Saddam Hussein and Adolf Hitler as being attachment disordered (Thomas 1997). In the case of Candace Newmaker, the adoptive mother was told that her child might be expected to grow up and become a psychopath and murder her (Mercer et al. 2003). Europeans have less of a homicidal tradition, and probably fewer fears of matricide, but scholars there have also argued that children with attachment disorder may grow up and experience ‘psychic homelessness’ (Hoksbergen & ter Laak 2000). Such predictions promote negative parental expectations and often initiate desperate attempts to achieve rapid change in their children. Moreover, these predictions are not founded in empirical evidence based on causal linkages between early attachment problems and future behaviors (Sroufe et al. 1999; Weinfield et al. 2000).

Parents are often given a dramatic view of the meaning of attachment and the trauma that their children may have experienced with biological parents, a view which sets parents up to take drastic preventive or rehabilitative action. For example, Levy & Orlans (1998) begin their volume on treating attachment disorders ominously:

There is a time bomb ready to explode . . . More and more children are failing to develop secure attachments to loving protective caregivers – the most important foundation for healthy development. They are flooding our child welfare system with an overwhelming array of problems . . . (p. 1)

Commenting on the attractions of attachment therapies to adoptive and foster parents, O’Connor & Zeanah (2003) remind us that they often feel inadequate or rejected when their children do not turn to them for comfort when distressed. There may be additional confusion or frustration when parents have been successful in raising other ‘securely attached’ children. Feeling hopeless, parents may conclude that they are not up to raising such children (Lieberman 2003). Several authors note that adoptive and foster parents frequently express high need for support and that these needs are likely to be unrecognized and unmet in generic mental health services (Thoburn et al. 2000; Boris 2003; Lieberman 2003; O’Connor & Zeanah 2003). Writing about the situation in the UK, Jonathan Green (2003) points out that:

Intensive and dramatic therapies . . . have intuitive appeal for serious disorders; they seem a fitting response somehow, like intensive care units for life threatening illness or intrusive behavioral treatments for autism. (p. 263)
- Barth, Richard, Crea, Thomas, John, Karen, Thoburn, June & David Quinton; Beyond attachment theory and therapy: towards sensitive and evidence-based interventions with foster and adoptive families in distress; Child & Family Social Work; Nov 2005; Vol. 10; Issue 4.

Personal Reflection Exercise #11
The preceding section contained information about reactive attachment disorder.  Write three case study examples regarding how you might use the content of this section in your practice.

Update
Adopted Children can Face Many Challenges,
such as the Impact of Early Trauma.
What can Parents Do to Support Them?

- Fergusson, B., (December 6, 2022). Adopted children can face many challenges, such as the impact of early trauma. What can parents do to support them?. BBC Future, 1-8.

Peer-Reviewed Journal Article References:
Tener, D., Lusky, E., Tarshish, N., & Turjeman, S. (2018). Parental attitudes following disclosure of sibling sexual abuse: A child advocacy center intervention study. American Journal of Orthopsychiatry, 88(6), 661–669.

Palacios, J., Adroher, S., Brodzinsky, D. M., Grotevant, H. D., Johnson, D. E., Juffer, F., Martínez-Mora, L., Muhamedrahimov, R. J., Selwyn, J., Simmonds, J., & Tarren-Sweeney, M. (2019). Adoption in the service of child protection: An international interdisciplinary perspective. Psychology, Public Policy, and Law, 25(2), 57–72.

Kranz, D. (2020). The impact of sexual and gender role orientation on heterosexuals’ judgments of parental competence and adoption suitability. Psychology of Sexual Orientation and Gender Diversity, 7(3), 353–365.

QUESTION 25
What is the DSM criteria for RAD? To select and enter your answer go to Test.

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