Report
of the APSAC Task Force on Attachment Therapy,
Reactive Attachment Disorder, and Attachment Problems
Read
the ATTACh Memo
Full
report located in Child Maltreatment, Vol. 11, No. 1, February
2006, pg. 76-89 DOI: 10.1177/1077559505283699
The
following recommendations were reprinted with the permission of
Sage Publications, Inc.
RECOMMENDATIONS
1.
Recommendations regarding diagnosis and assessment of attachment
problems
a. Attachment problems, including but extending beyond RAD, are
a real and appropriate concern for professionals working with
children who are maltreated and should be carefully considered
when these children are assessed.
b. Assessment guidelines
(1) Assessment should include information about patterns of behavior
over time, and assessors should be cognizant that current behaviors
may simply reflect adjustment to new or stressful circumstances.
(2) Cultural issues should always be considered when assessing
the adjustment of any child, especially in cross-cultural or international
placements or adoptions. Behavior appearing deviant in one cultural
setting may be normative for children from different cultural
settings, and children placed crossculturally may experience unique
adaptive challenges.
(3) Assessment should include samples of behavior across situations
and contexts. It should not be limited to problems in relationships
with parents or primary caretakers and instead should include
information regarding the child’s interactions with multiple
caregivers, such as teachers, day care providers, and peers. Diagnosis
of RAD or other attachment problems should not be made solely
based on a power struggle between the parent and child.
(4) Assessment of attachment problems should not rely on overly
broad, nonspecific, or unproven checklists. Screening checklists
are valuable only if they have acceptable measurement properties
when applied to the target populations where they will be used.
(5) Assessment for attachment problems requires considerable diagnostic
knowledge and skill, to accurately recognize attachment problems
and to rule out competing diagnoses. Consequently, attachment
problems should be diagnosed only by a trained, licensed mental
health professional with considerable expertise in child development
and differential diagnosis.
(6) Assessment should first consider more common disorders, conditions,
and explanations for behavior before considering rarer ones. Assessors
and caseworkers should be vigilant about the allure of rare disorders
in the child maltreatment field and should be alert to the possibility
of misdiagnosis.
(7) Assessment should include family and caregiver factors and
should not focus solely on the child.
(8) Care should be taken to rule out conditions such as autism
spectrum disorders, pervasive developmental disorder, childhood
schizophrenia, genetic syndromes, or other conditions before making
a diagnosis of attachment disorder. If necessary, specialized
assessment by professionals familiar with these disorders or syndromes
should be considered.
(9) Diagnosis of attachment disorder should never be made simply
based on a child’s status as maltreated, as having experienced
trauma, as growing up in an institution, as being a foster or
adoptive child, or simply because the child has experienced pathogenic
care. Assessment should respect the fact that resiliency is common,
even in the face of great adversity.
2.
Recommendations regarding treatments and interventions
a. Treatment techniques or attachment parenting techniques involving
physical coercion, psychologically or physically enforced holding,
physical restraint, physical domination, provoked catharsis, ventilation
of rage, age regression, humiliation, withholding or forcing food
or water intake, prolonged social isolation, or assuming exaggerated
levels of control and domination over a child are contraindicated
because of risk of harm and absence of proven benefit and should
not be used.
(1) This recommendation should not be interpreted as pertaining
to common and widely accepted treatment or behavior management
approaches used within reason, such as time-out, reward and punishment
contingencies, occasional seclusion or physical restraint as necessary
for physical safety, restriction of privileges, “grounding,”
offering physical comfort to a child, and so on.
b. Prognostications that certain children are destined to become
psychopaths or predators should never be made based on early childhood
behavior. These beliefs create an atmosphere conducive to overreaction
and harsh or abusive treatment. Professionals should speak out
against these and similar unfounded conceptualizations of children
who are maltreated.
c. Intervention models that portray young children in negative
ways, including describing certain groups of young children as
pervasively manipulative, cunning, or deceitful, are not conducive
to good treatment and may promote abusive practices. In general,
child maltreatment professionals should be skeptical of treatments
that describe children in pejorative terms or that advocate aggressive
techniques for breaking down children’s defenses.
d. Children’s expressions of distress during therapy always
should be taken seriously. Some valid psychological treatments
may involve transitory and controlled emotional distress. However,
deliberately seeking to provoke intense emotional distress or
dismissing children’s protests of distress is contraindicated
and should not be done.
e. State-of-the-art, goal-directed, evidence-based approaches
that fit the main presenting problem should be considered when
selecting a first-line treatment. Where no evidence-based option
exists or where evidence-based treatment options have been exhausted,
alternative treatments with sound theory foundations and broad
clinical acceptance are appropriate. Before attempting novel or
highly unconventional treatments with untested benefits, the potential
for psychological or physical harm should be carefully weighed.
f. First-line services for children described as having attachment
problems should be founded on the core principles suggested by
attachment theory, including caregiver and environmental stability,
child safety, patience, sensitivity, consistency, and nurturance.
Shorter term, goal-directed, focused, behavioral interventions
targeted at increasing parent sensitivity should be considered
as a first-line treatment.
g. Treatment should involve parents and caregivers, including
biological parents if reunification is an option. Fathers, and
mothers, should be included if possible. Parents of children described
as having attachment problems may benefit from ongoing support
and education. Parents should not be instructed to engage in psychologically
or physically coercive techniques for therapeutic purposes, including
those associated with any of the known child deaths.
3.
Recommendations for child welfare
a. Treatment provided to children in the child welfare and foster
care systems should be based on a careful assessment conducted
by a qualified mental health professional with expertise in differential
diagnosis and child development. Child welfare systems should
guard against accepting treatment prescriptions based on word-of-mouth
recruitment among foster caregivers or other lay individuals.
b. Child welfare systems should not tolerate any parenting behaviors
that normally would be considered emotionally abusive, physically
abusive, or neglectful simply because they are, or are alleged
to be, part of attachment treatment. For example, withholding
food, water, or toilet access as punishment; exerting exaggerated
levels of control over a child; restraining children as a treatment;
or intentionally provoking out-of-control emotional distress should
be evaluated as suspected abuse and handled accordingly.
4.
Professionals should embrace high ethical standards concerning
advertising treatment services to professional audiences and especially
to lay audiences.
a. Claims of exclusive benefit (i.e., that no other treatments
will work) should never be made. Claims of relative benefit (e.g.,
that one treatment works better than others) should only be made
if there is adequate controlled trial scientific research to support
the claim.
b. Use of patient testimonials in marketing treatment services
constitutes a dual relationship. Because of the potential for
exploitation, the Task Force believes that patient testimonials
should not be used to market treatment services.
c. Unproven checklists or screening tools should not be posted
on Web sites or disseminated to lay audiences. Screening checklists
known to have adequate measurement properties and presented with
qualifications may be appropriate.
d. Information disseminated to the lay public should be carefully
qualified. Advertising should not make claims of likely benefits
that cannot be supported by scientific evidence and should fully
disclose all known or reasonably foreseeable risks.
