Myths and Facts About Reactive Attachment Disorder Part 3 - Treatment
(Note: this is part 3 of a three part series. You can read part 1 here, or part 2 here.)
Reactive Attachment Disorder/Disinhibited Social Engagement Disorder is a serious problem, interfering with the child's ability to get close to others and in some cases putting the child's safety at risk. (DSED especially, since these children are overly trusting and easy to take advantage of.) In addition, many RAD/DSED children also experience a range of other psychiatric issues which - although not useful for diagnosis - are still a cause for concern, such as conduct problems, emotional distress, social skill impairments, and learning or self-care delays.
However, for kids who have already been placed in a good home environment and still need more help, there's only a small pool of studies into potential treatments. But what studies have been done suggest a few potentially beneficial approaches.
In the following section, I'll review several treatments that have been studied in children with RAD symptoms or children meeting criteria for pathogenic care (ie history of neglect, placement changes or institutional care between 6 months to 5 years), who are living with nonbiological parents; and have been found effective in reducing either RAD symptoms, attachment insecurity, or externalizing behavior. (Externalizing behavior - aggression, rule-breaking, etc - because it's the most commonly reported concern by parents and caregivers of RAD children, and has serious implications for success in adult life.)
Child-Parent Relational Therapy/Parent-Child Interaction Therapy
Child-parent relational therapy (CPRT) trains parents to perform play therapy sessions with their child in the hopes that this will build a stronger emotional bond between the parent and child, and therefore improve attachment.
Unfortunately, the three studies I found did not examine attachment directly. However, in all three studies, there was evidence of a decrease in externalizing behavior in at least some of the children treated.
The best-designed study was Carnes-Holt (2012), which randomly assigned 61 adopted children aged 2 to 10 years with behavior problems (most of whom were adopted after age 1) to either child-parent relational therapy (32 children) or a control group (29 children). (This design controls for the possibility that the child may have improved regardless of treatment.) Compared to the control group, the treatment group showed reduced externalizing behavior and overall behavior concerns (as measured by the CBCL, a commonly-used and well-validated parent rating scale for behavioral and emotional problems). In addition, parents reported feeling less stress and more empathy for their adoptive children.
Sergeant (2011)'s study had a much poorer design, but was still encouraging. This study reported on 34 children with symptoms of RAD, but did not specify how old the children were. The children were randomly assigned to treatment or control, but 10 children dropped out of treatment, resulting in 15 treatment and 17 control children (treatment drop-outs are concerning because they did not occur at random, and therefore bias the results - also, why did so many families drop out?). In addition, this study used the RADQ, which as I mentioned in one of my earlier posts, is not a valid assessment of RAD. However, it does seem to be a decent measure of generalized behavior problems, and they also used the BASC-2, which is a well-validated measure. Their results were promising - the treatment group scored lower than controls on both the RADQ and the BASC-2 externalizing scale (internalizing behavior - such as anxiety and depression - was unchanged). The decrease on the BASC-2 externalizing scale was still significant when the drop-outs were lumped in with the treatment group (which restores random assignment). So, although this study is flawed, it still supports use of CPRT in this group.
Soulounias-Arriaga (2009) reported on two case studies - two boys in the process of being adopted by foster parents, aged 5 and 6 and both diagnosed with RAD. Both kids also carried a diagnosis of ODD, and the younger boy also had OCD while the older boy had a whole laundry list of psychiatric diagnoses (which is very common in RAD children). Both boys received Parent-Child Interaction Therapy, which as far as I can gather, is the same as CPRT. Both sets of parents showed improvements in their parenting behavior, but only the younger boy showed an improvement in ECBI behavior problems. (The ECBI is also a well-validated scale for externalizing behavior.) However, this is the weakest study of the three, with no control group and only two children studied. Still, even a case study can suggest a potential treatment approach.
Overall, these studies together provide encouraging evidence in support of using CPRT/PCIT to reduce externalizing behavior in RAD children.
Attachment and Biobehavioral Catch-up
The Attachment and Biobehavioral Catch-up (ABC) program is a 10-session training program designed for foster parents of infants and toddlers, which teaches these parents about attachment theory and provides direct advice on how to improve parental sensitivity and avoid being misled by the child's miscuing due to insecure attachment.
I found four articles (Benard et al, 2012; Dozier et al, 2009a; Dozier et al, 2009b; and Dozier et al, 2006) about three studies assessing the impact of the ABC intervention (the two 2009 papers refer to the same study - preliminary & full results).
All three studies involved a virtually identical design - foster parents of infants and toddlers were randomly assigned to either receive the ABC training or a different 10-session parent training program about enhancing cognitive development (which is unlikely to affect attachment). The measures used in the studies were different, though, providing a more complete picture of the impact of the ABC program. I will discuss these studies as a group.
First, on a diary measure of attachment style (which has some validation, but is not that well studied yet), the treatment group showed a significant decrease in avoidant attachment behavior, indicating less tendency to hide their distress in attachment situations. Unfortunately, they did not show a corresponding increase in secure behavior (indicating a healthy seeking of comfort and soothability), but this result is still encouraging.
In the Strange Situation, a laboratory measure of attachment security (which is extremely well-validated), the results were even better. The treatment group showed higher rates of secure attachment and lower rates of insecure (avoidant/resistant) and disorganized attachment (disorganized attachment refers to a child who falls apart in attachment situations, showing contradictory and/or dissociative behavior). Overall, this is a strong indicator that the ABC intervention is effective at improving attachment.
The third measure used was the Parent Daily Report, a diary measure of general child behavior problems over the course of several days. Mirroring the attachment data, the study that used this measure found a significantly lower rate of behavior problems in the treatment group.
Overall, this is strong evidence that the ABC program can help prevent & change insecure and disorganized attachment in very young foster children, as well as reduce their behavior problems. Although they did not directly study RAD, it seems likely that the ABC program might also reduce RAD symptoms in this group as well.
Incredible Years Program
The Incredible Years Program is a 12-session training program designed to teach parents skills for effective discipline, to support their children emotionally, and to encourage children's learning. There are different modules for different ages, focusing on the major tasks of that developmental period.
I found four studies of the impact of the Incredible Years Program on school-aged children in foster care. The results were decidedly mixed, but still somewhat encouraging.
Three of the studies randomly assigned children to treatment or control groups. One study, Linares et al (2006), administered treatment to both biological and foster parents of 3-10 year old children in foster care with biological parent visitation, with 40 children in the treatment group and 24 in the control group. Both sets of parents showed improvement in parenting behavior, but the children did not show a corresponding improvement in externalizing behavior, as measured by three different scales: CBCL externalizing, ECBI (a parent-rated measure of child conduct problems) or SESBI disruptive classroom behavior.
The other two studies found more positive results. Bywater et al (2010) administered the training to foster carers of 2-16 year old children (29 treatment, 17 control). Oddly enough, they did not find significant changes in parenting behavior, but did find reductions in foster parents' depression symptoms as well as improvements in behavior on the ECBI scale and the SDQ total and hyperactivity scales (the SDQ is a well-validated measure of general psychiatric problems, with several subscales reflecting specific areas of difficulty). It's possible that the reduction in foster parent depression directly reduced the child's behavior problems, or else that their parenting improved in some way that the parenting measure used was unable to capture adequately. Nilsen (2007) found less strong but still encouraging results. They studied a very small sample of 5-12 year old foster children (11 treatment, 7 control). On the BASC conduct subscale, the treatment group scored better than the control group, but differences on the other scales were not significant.
Lastly, McDaniel et al (2011) did not include a control group, but the thirteen 8-13 year old foster children in their study showed a significant decrease in child behavior problems from pre-treatment to post-treatment.
Overall, although the studies don't all agree, it seems like that the Incredible Years program may be effective at treating externalizing behavior and hyperactivity in preschool and school-aged foster children. They did not study RAD directly, but it's likely that a substantial proportion of the kids in these samples may have had RAD symptoms. Therefore, it seems likely that this program would help children with RAD as well.
Other Treatments
A few studies have assessed other treatments, which have less of an evidence base with this group.
Cognitive Behavioral Therapy, which is well-supported in treating kids and adults with a wide variety of other psychiatric conditions, has been assessed in a few studies with foster children, with the most promising study being GaviĊ£a et al (2012). This study involved 5-18 year old Romanian foster children with externalizing behavior (given the history of Romania, many of these children may be post-institutionalized as well), with children randomly assigned to treatment or control. Unfortunately, 18 children dropped out of treatment, leaving 44 in the treatment group and 35 in the control group, and they did not perform any intent-to-treat analyses (lumping drop-outs with the group they were originally assigned to). Nevertheless, the treatment group showed improved parenting behavior, reduced parenting stress and a decrease in the child's CBCL externalizing score. We can't be sure it was due to treatment, as opposed to traits that made dropping out less likely, but the results are encouraging. The rest of the CBT studies (Carew, 2007; Cone et al, 2009; and Cone, 2009) had very small sample sizes (all focused on adolescents) and no control group, but some children showed improvements. Based on this, it is worth trying CBT if the child has other symptoms commonly treated by CBT, has not responded well to the above-listed treatments, or those above treatments are not available or not appropriate (eg because of the child's age). Since CBT is widely available, it is likely to be offered as a front-line treatment in any case.
Behavioral therapies have also been tried in some children with RAD. These treatments involve identifying what motivates a child's problematic behavior and then providing systematic rewards for good behavior and sometimes punishments for bad behavior, gradually shaping more appropriate behavior. Unfortunately, the field of behavioral therapy for most psychiatric conditions is dominated by isolated case studies, and RAD is no exception. The three studies I found (Buckner et al, 2008; O'Reilly et al, 2001; and Sheridan & Deering, 2009) reported on a total of four children (3, 5, 7 and 12 years old), one diagnosed with RAD, two post-institutionalized and one in the foster care system. All four children improved, which is encouraging, but these results are very preliminary. Still, this treatment should be considered if other approaches have failed.
The Hope Connection summer camp, a 3 week day camp for older adopted and at-risk children, has been assessed in several studies (Purvis et al, 2013; Purvis & Cross, 2007; and Purvis et al, 2007), but none of these studies included any control group. Nevertheless, their results suggest improvements in attachment behavior (although they used unusual and poorly-studied attachment measures such as proximity in family drawings and a poorly-studied questionnaire), CBCL aggression, thought and attention problems and CDI scores (the CDI is a well-studied measure of child depression). These results are promising, and if this summer camp is available, parents of RAD children may consider sending their child to it.
Reactive Attachment Disorder/Disinhibited Social Engagement Disorder is a serious problem, interfering with the child's ability to get close to others and in some cases putting the child's safety at risk. (DSED especially, since these children are overly trusting and easy to take advantage of.) In addition, many RAD/DSED children also experience a range of other psychiatric issues which - although not useful for diagnosis - are still a cause for concern, such as conduct problems, emotional distress, social skill impairments, and learning or self-care delays.
So, how do we help these kids?
Quack Treatments
Sadly, instead of proven, effective treatments based on a solid understanding of how RAD/DSED and attachment works, many practitioners offer quack treatments. These treatments, although claiming to be 'attachment therapy', do not follow what attachment theory actually proposes. In some cases, they can even be harmful.
Candace Newmaker, a 10 year old girl, died during one such treatment, known as 'rebirthing'. In this treatment, in order to help the child leave their past behind, therapists attempted to re-enact a birth experience. They wrapped Candace in a flannel sheet and four adults sat on top of her, with the expectation that she would struggle free. She complained that she couldn't breathe and that she was dying, but they ignored her complaints. Finally, she went still, and when they unwrapped her, she was motionless and blue.
Any treatment that involves keeping an individual restrained for any substantial length of time carries the risk of causing asphyxiation, especially if any weight is put on top of the individual. But attachment theorists have also pointed out that even if the child is not physically harmed by such a procedure, it carries the potential to be psychologically harmful - especially to a child who has already suffered prior trauma.
In addition, these quack treatments often include psychologically abusive behaviour. The transcript of Candace Newmaker's last moments reveal that she was told 'You want to die? OK, then die. Go ahead, die right now.', and called a 'Quitter, quitter, quitter, quitter! Quit, quit, quit, quit. She's a quitter!'. Words may not break bones, but they do break spirits.
Sadly, such verbal abuse is common in these sorts of quack treatments, because it is believed that provoking strong emotions in the child allows them to release their inner rage - despite good evidence that focusing on anger is not effective at reducing anger. Also, there is no good evidence that RAD/DSED children are generally filled with rage to begin with. The research generally suggests that for young infants, fear and despair are more typical than rage in reaction to prolonged separation from an attachment figure.
Although there is value in voicing unspoken thoughts so that they can be countered by more encouraging thoughts (a primary component of many evidence-based treatments), there's an important difference between expressing emotion and creating emotion. And merely venting emotion, without any effort to analyse, redirect or reinterpret it, does not provide much benefit. Otherwise, simply having a tantrum would make a child's psychological health improve.
Evidence-Based Treatments
Unfortunately, very little research has been done on effective treatment of RAD/DSED. While several hundred studies have analysed treatments for conditions like PTSD and borderline personality disorder, I was only able to find a small number of studies assessing treatments for RAD/DSED. Even insecure attachment styles, despite not being severe enough to be called a 'disorder', have received much more research into effective interventions.
The best-studied 'treatment' for RAD/DSED is to remove the child from the cause. Many studies have shown that children who have been removed from institutional care or an neglect home or placed with a permanent family do much better than children who continue to experience institutional care, neglect or placement changes. The improvement can in some cases be truly remarkable - in the Bucharest Early Intervention Project, a study assessing foster care versus institutional care, children transferred into foster care showed dramatic improvements in virtually all aspects of development, even head growth!
However, for kids who have already been placed in a good home environment and still need more help, there's only a small pool of studies into potential treatments. But what studies have been done suggest a few potentially beneficial approaches.
In the following section, I'll review several treatments that have been studied in children with RAD symptoms or children meeting criteria for pathogenic care (ie history of neglect, placement changes or institutional care between 6 months to 5 years), who are living with nonbiological parents; and have been found effective in reducing either RAD symptoms, attachment insecurity, or externalizing behavior. (Externalizing behavior - aggression, rule-breaking, etc - because it's the most commonly reported concern by parents and caregivers of RAD children, and has serious implications for success in adult life.)
Child-Parent Relational Therapy/Parent-Child Interaction Therapy
Child-parent relational therapy (CPRT) trains parents to perform play therapy sessions with their child in the hopes that this will build a stronger emotional bond between the parent and child, and therefore improve attachment.
Unfortunately, the three studies I found did not examine attachment directly. However, in all three studies, there was evidence of a decrease in externalizing behavior in at least some of the children treated.
The best-designed study was Carnes-Holt (2012), which randomly assigned 61 adopted children aged 2 to 10 years with behavior problems (most of whom were adopted after age 1) to either child-parent relational therapy (32 children) or a control group (29 children). (This design controls for the possibility that the child may have improved regardless of treatment.) Compared to the control group, the treatment group showed reduced externalizing behavior and overall behavior concerns (as measured by the CBCL, a commonly-used and well-validated parent rating scale for behavioral and emotional problems). In addition, parents reported feeling less stress and more empathy for their adoptive children.
Sergeant (2011)'s study had a much poorer design, but was still encouraging. This study reported on 34 children with symptoms of RAD, but did not specify how old the children were. The children were randomly assigned to treatment or control, but 10 children dropped out of treatment, resulting in 15 treatment and 17 control children (treatment drop-outs are concerning because they did not occur at random, and therefore bias the results - also, why did so many families drop out?). In addition, this study used the RADQ, which as I mentioned in one of my earlier posts, is not a valid assessment of RAD. However, it does seem to be a decent measure of generalized behavior problems, and they also used the BASC-2, which is a well-validated measure. Their results were promising - the treatment group scored lower than controls on both the RADQ and the BASC-2 externalizing scale (internalizing behavior - such as anxiety and depression - was unchanged). The decrease on the BASC-2 externalizing scale was still significant when the drop-outs were lumped in with the treatment group (which restores random assignment). So, although this study is flawed, it still supports use of CPRT in this group.
Soulounias-Arriaga (2009) reported on two case studies - two boys in the process of being adopted by foster parents, aged 5 and 6 and both diagnosed with RAD. Both kids also carried a diagnosis of ODD, and the younger boy also had OCD while the older boy had a whole laundry list of psychiatric diagnoses (which is very common in RAD children). Both boys received Parent-Child Interaction Therapy, which as far as I can gather, is the same as CPRT. Both sets of parents showed improvements in their parenting behavior, but only the younger boy showed an improvement in ECBI behavior problems. (The ECBI is also a well-validated scale for externalizing behavior.) However, this is the weakest study of the three, with no control group and only two children studied. Still, even a case study can suggest a potential treatment approach.
Overall, these studies together provide encouraging evidence in support of using CPRT/PCIT to reduce externalizing behavior in RAD children.
Attachment and Biobehavioral Catch-up
The Attachment and Biobehavioral Catch-up (ABC) program is a 10-session training program designed for foster parents of infants and toddlers, which teaches these parents about attachment theory and provides direct advice on how to improve parental sensitivity and avoid being misled by the child's miscuing due to insecure attachment.
I found four articles (Benard et al, 2012; Dozier et al, 2009a; Dozier et al, 2009b; and Dozier et al, 2006) about three studies assessing the impact of the ABC intervention (the two 2009 papers refer to the same study - preliminary & full results).
All three studies involved a virtually identical design - foster parents of infants and toddlers were randomly assigned to either receive the ABC training or a different 10-session parent training program about enhancing cognitive development (which is unlikely to affect attachment). The measures used in the studies were different, though, providing a more complete picture of the impact of the ABC program. I will discuss these studies as a group.
First, on a diary measure of attachment style (which has some validation, but is not that well studied yet), the treatment group showed a significant decrease in avoidant attachment behavior, indicating less tendency to hide their distress in attachment situations. Unfortunately, they did not show a corresponding increase in secure behavior (indicating a healthy seeking of comfort and soothability), but this result is still encouraging.
In the Strange Situation, a laboratory measure of attachment security (which is extremely well-validated), the results were even better. The treatment group showed higher rates of secure attachment and lower rates of insecure (avoidant/resistant) and disorganized attachment (disorganized attachment refers to a child who falls apart in attachment situations, showing contradictory and/or dissociative behavior). Overall, this is a strong indicator that the ABC intervention is effective at improving attachment.
The third measure used was the Parent Daily Report, a diary measure of general child behavior problems over the course of several days. Mirroring the attachment data, the study that used this measure found a significantly lower rate of behavior problems in the treatment group.
Overall, this is strong evidence that the ABC program can help prevent & change insecure and disorganized attachment in very young foster children, as well as reduce their behavior problems. Although they did not directly study RAD, it seems likely that the ABC program might also reduce RAD symptoms in this group as well.
Incredible Years Program
The Incredible Years Program is a 12-session training program designed to teach parents skills for effective discipline, to support their children emotionally, and to encourage children's learning. There are different modules for different ages, focusing on the major tasks of that developmental period.
I found four studies of the impact of the Incredible Years Program on school-aged children in foster care. The results were decidedly mixed, but still somewhat encouraging.
Three of the studies randomly assigned children to treatment or control groups. One study, Linares et al (2006), administered treatment to both biological and foster parents of 3-10 year old children in foster care with biological parent visitation, with 40 children in the treatment group and 24 in the control group. Both sets of parents showed improvement in parenting behavior, but the children did not show a corresponding improvement in externalizing behavior, as measured by three different scales: CBCL externalizing, ECBI (a parent-rated measure of child conduct problems) or SESBI disruptive classroom behavior.
The other two studies found more positive results. Bywater et al (2010) administered the training to foster carers of 2-16 year old children (29 treatment, 17 control). Oddly enough, they did not find significant changes in parenting behavior, but did find reductions in foster parents' depression symptoms as well as improvements in behavior on the ECBI scale and the SDQ total and hyperactivity scales (the SDQ is a well-validated measure of general psychiatric problems, with several subscales reflecting specific areas of difficulty). It's possible that the reduction in foster parent depression directly reduced the child's behavior problems, or else that their parenting improved in some way that the parenting measure used was unable to capture adequately. Nilsen (2007) found less strong but still encouraging results. They studied a very small sample of 5-12 year old foster children (11 treatment, 7 control). On the BASC conduct subscale, the treatment group scored better than the control group, but differences on the other scales were not significant.
Lastly, McDaniel et al (2011) did not include a control group, but the thirteen 8-13 year old foster children in their study showed a significant decrease in child behavior problems from pre-treatment to post-treatment.
Overall, although the studies don't all agree, it seems like that the Incredible Years program may be effective at treating externalizing behavior and hyperactivity in preschool and school-aged foster children. They did not study RAD directly, but it's likely that a substantial proportion of the kids in these samples may have had RAD symptoms. Therefore, it seems likely that this program would help children with RAD as well.
Other Treatments
A few studies have assessed other treatments, which have less of an evidence base with this group.
Cognitive Behavioral Therapy, which is well-supported in treating kids and adults with a wide variety of other psychiatric conditions, has been assessed in a few studies with foster children, with the most promising study being GaviĊ£a et al (2012). This study involved 5-18 year old Romanian foster children with externalizing behavior (given the history of Romania, many of these children may be post-institutionalized as well), with children randomly assigned to treatment or control. Unfortunately, 18 children dropped out of treatment, leaving 44 in the treatment group and 35 in the control group, and they did not perform any intent-to-treat analyses (lumping drop-outs with the group they were originally assigned to). Nevertheless, the treatment group showed improved parenting behavior, reduced parenting stress and a decrease in the child's CBCL externalizing score. We can't be sure it was due to treatment, as opposed to traits that made dropping out less likely, but the results are encouraging. The rest of the CBT studies (Carew, 2007; Cone et al, 2009; and Cone, 2009) had very small sample sizes (all focused on adolescents) and no control group, but some children showed improvements. Based on this, it is worth trying CBT if the child has other symptoms commonly treated by CBT, has not responded well to the above-listed treatments, or those above treatments are not available or not appropriate (eg because of the child's age). Since CBT is widely available, it is likely to be offered as a front-line treatment in any case.
Behavioral therapies have also been tried in some children with RAD. These treatments involve identifying what motivates a child's problematic behavior and then providing systematic rewards for good behavior and sometimes punishments for bad behavior, gradually shaping more appropriate behavior. Unfortunately, the field of behavioral therapy for most psychiatric conditions is dominated by isolated case studies, and RAD is no exception. The three studies I found (Buckner et al, 2008; O'Reilly et al, 2001; and Sheridan & Deering, 2009) reported on a total of four children (3, 5, 7 and 12 years old), one diagnosed with RAD, two post-institutionalized and one in the foster care system. All four children improved, which is encouraging, but these results are very preliminary. Still, this treatment should be considered if other approaches have failed.
The Hope Connection summer camp, a 3 week day camp for older adopted and at-risk children, has been assessed in several studies (Purvis et al, 2013; Purvis & Cross, 2007; and Purvis et al, 2007), but none of these studies included any control group. Nevertheless, their results suggest improvements in attachment behavior (although they used unusual and poorly-studied attachment measures such as proximity in family drawings and a poorly-studied questionnaire), CBCL aggression, thought and attention problems and CDI scores (the CDI is a well-studied measure of child depression). These results are promising, and if this summer camp is available, parents of RAD children may consider sending their child to it.
The Role of the New Parents
It's important to note that most of the treatment approaches that seem to be helpful in children with or at risk for RAD involve the direct participation of the parents or caregivers of the child - sometimes without even involving the child directly! In general, parent-training programs, particularly ones that focus on increasing a parent's sensitive responses to their adopted or foster child's emotional needs, seem to be the most effective at helping children with RAD and children at risk of RAD.
It's important to note that this does not mean the parent is in any way to blame for the child's issues. Older adopted and foster children bring patterns of learnt behavior from their previous living situations, and often express their needs in confusing or counter-intuitive ways (such as attacking a caregiver when they need comfort from them, or seeking help from a stranger when they really need help from a caregiver). It's well-known that children can affect the parenting they receive, as parents get frustrated or confused by their child's behavior.
In addition, a child who is already at high risk may be more susceptible to adverse reactions to slightly suboptimal parenting - that is, parenting that is in the normal range, but not entirely ideal. For example, the same researchers who designed the ABC program have found that while biological parents with insecure-organized attachments tend to raise insecure-organized children, insecure-organized foster parents tend to raise foster children with disorganized attachments, as the trauma of placement changes compounds the impact of an insecure attachment in the parent.
Overall, research strongly supports an impact of normal-range variations in parental attachment style and sensitivity and their adopted or foster children's RAD symptoms and attachment behavior. Since many studies of biological families have found that parent-training interventions can increase parental sensitivity and child attachment security, it stands to reason that similar programs would help foster and adopted children as well.
Clearly, a lot more research needs to be done on evidence-based treatment for RAD and at risk children. But until such research is done, I hope this post will help guide parents to find the treatments most likely to help their children.
posted by Ettina at 7:31 AM
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