Attachment Interventions (Child & Adolescent)

Attachment Interventions (Child & Adolescent) are defined by the CEBC as those interventions developed for the treatment of children and adolescents with a diagnosis or symptoms of a severe attachment disturbance such as Reactive Attachment Disorder (RAD) or Disinhibited Social Engagement Disorder (DSED). A severe attachment disturbance includes symptoms such as lack of seeking out a specific caregiver when it would be expected (e.g., when hurt) [RAD] and willingness to seek comfort from or show "overly familiar" behavior toward strangers [DSED]. Almost exclusively, these symptoms appear in children who have not had opportunities to develop typical attachments with a specific caregiver. This may be because of institutional care (e.g., children raised in orphanages), severe and profound neglect, or frequent changes in caregiving arrangements. Recognizing RAD and DSED as distinct diagnoses means that they should be considered separate from a range of often co-occurring behaviors in these children, including hoarding, inattention, lack of empathy, severe aggression, pathological lying, and other oppositional or conduct problems that are not part of the DSM-5 diagnostic criteria. It is important to consider, for example, oppositional behaviors as additional problems that need to be appropriately addressed, rather than as a component of the attachment disorder. The prevalence of attachment disorders is difficult to estimate as few rigorous studies have been conducted in populations in which this would be detectable. However, studies of children adopted from orphanages and other depriving institutional settings report that only a small minority of the children have severe attachment disturbances.

Cautionary Notes:

1. Interventions for attachment disorders have not been without controversy. Following several child deaths in the early 2000s after the use of attachment therapy methods such as holding therapy and rebirthing, specific practices have been banned by state legislatures and condemned by Congress. In addition, professional organizations, such as the American Academy of Child & Adolescent Psychiatry (AACAP), the American Professional Society on the Abuse of Children (APSAC), the American Psychiatric Association, and the American Psychology Association, have published warnings regarding these treatments. 2. The CEBC is utilizing the APSAC and AACAP recommendations to identify attachment interventions that are potentially harmful and meet the criteria for a rating of Level 5: Concerning Practice on the CEBC. These recommendations are shown below:

• APSAC: 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. (Chaffin et al., 2006, p. 86.)
• AACAP: Interventions Designed to Enhance Attachment that Involve Noncontingent Physical Restraint or Coercion (e.g., "˜Therapeutic Holding" or "˜Compression Holding"), "Reworking" of Trauma (e.g., "˜Rebirthing Therapy"), or Promotion of Regression for "Reattachment" have no Empirical Support and have been Associated with Serious Harm, Including Death [NE- Not endorsed refers to practices that are known to be ineffective or contraindicated] (Boris, Zeanah, & Work Group on Quality Issues, 2005, p. 1216.)

References: Chaffin, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., Zeanah, C., Berliner, L., Egeland, B., Newman, E., Lyon, T., Letourneau, E., & Miller-Perrin, C. (2006). Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. Child Maltreatment, 11(1), 76–89. https://doi.org/10.1177/1077559505283699 Boris, N. W., Zeanah, C. H., & Work Group on Quality Issues. (2005). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 44(11), 1206-1219. https://doi.org/10.1097/01.chi.0000177056.41655.ce

3. Child welfare systems often indicate that they are struggling with how to assess and intervene with children who are presenting with attachment problems of the kind described in DSM-5. However, there are not established clinical or laboratory assessments to rule in a diagnosis of any of the DSM-5 defined attachment disorders, and the materials that have been developed through research studies or adaptations of existing psychiatric instruments have not yet been incorporated into clinical practice. It is important to consider that the symptoms that may co-occur with attachment disturbances may be best treated by an evidence-based practice that focuses on the specific symptoms that are being manifested (e.g., aggression, oppositional behaviors, anxiety, etc.), rather than using a practice developed for attachment problems. Programs reviewed in other topic areas such as: Anxiety Treatment (Child & Adolescent), Behavioral Management Programs for Adolescents in Child Welfare, Depression Treatment (Child & Adolescent), Disruptive Behavior Treatment (Child & Adolescent), and Trauma Treatment (Child & Adolescent) should be considered as possible ways to address the specific symptoms that are being manifested. In addition, for concerns about developing secure attachments in younger children, see the Infant and Early Childhood Mental Health Programs topic area.

• Target population: Children and adolescents with a severe attachment disturbance associated with profoundly neglectful history of care, such as those captured by DSM-5 criteria for Reactive Attachment Disorder (RAD) or Disinhibited Social Engagement Disorder (DSED)
• Services/types that fit: Outpatient services including individual, group, family therapy or other services or system-level interventions, training programs, and resource materials for child welfare staff and service providers working with this population.
• Delivered by: Mental health professionals, as well as trained paraprofessionals, educators, and health care providers
• In order to be included: Program must specifically target children and adolescents with severe attachment disturbances of the kind described by RAD or DSED criteria. A formal diagnosis is not required given the inconsistent practice in applying the diagnosis and the frequent misapplication of the diagnosis. Interventions for insecure attachment are not included unless they have been specifically suggested for children showing the qualitatively different impairments denoted by an RAD or DSED disorder or symptoms of these disorders.
• In order to be rated: There must be research evidence (as specified by the Scientific Rating Scale) that examines outcomes for children and adolescents with severe attachment disturbances (e.g., improvements in appropriate social behaviors), child welfare outcomes for families involving a child or adolescent in this population (e.g., placement stability), or outcomes for providers working with this population (e.g., changes in attitudes or performance, knowledge of techniques or curricula).

The Attachment Interventions (Child & Adolescent) topic area is relevant to child welfare because so much of child welfare practice has been informed by the principles of Attachment Theory that were first articulated by Dr. John Bowlby and subsequently developed in work by Mary Ainsworth and others. Child welfare workers intervene with a large number of children and youth who exhibit a wide range of behaviors that appear to emanate from poor early attachment that has resulted from child abuse and/or neglect. While they are able to link families to services that are designed to remedy conditions of abuse and neglect, they often struggle to identify therapeutic resources that address the children's behavioral and mental health issues that they believe are related to poor attachment. Child welfare workers understand that an inability to address these matters seriously hampers their efforts to maintain children in their homes, successfully return children from foster care, or find effective permanent alternatives through Adoption and Legal Guardianship. The behaviors that they believe are related to poor early attachment, such as aggression, oppositional behavior, and anxiety, are ones that present serious barriers to achieving permanence for children in the child welfare system. In this context, it is important for child welfare workers to understand the range of disorders and behavioral issues that they may encounter and the different types of services to address these. Although the occurrences of severe attachment disturbance such as Reactive Attachment Disorder (RAD) or Disinhibited Social Engagement Disorder (DSED) are rare, these disturbances emanate from circumstances of severe neglect that they periodically encounter in their work. Less severe attachment issues may also result from other instances of abuse and neglect. It is important to note that child welfare workers need to clearly understand the difference between severe disturbances and other behavioral disorders that are amenable to different types of intervention. The Advisory Committee believes that understanding these differences is important in assisting child welfare workers in assessing what types of services are needed to address the individual needs of children and youth for whom they are striving to achieve permanency. The services described in the Attachment Interventions (Child & Adolescent) topic area are specifically for the severe disturbances. Services for other behavioral disorders may be found in the topic areas addressing specific mental health issues and parent training on the CEBC website.

Stuart Oppenheim
Executive Director
Child & Family Policy Institute of California
Sacramento Office
Sacramento, CA

The Attachment Interventions (Child & Adolescent) topic area was added in 2014. Thomas G. O'Connor, PhD was the topic expert and was involved in identifying and rating any of the programs with an original load date in 2014 (as found on the bottom of the program's page on the CEBC) or others loaded earlier and added to this topic area when it launched. The topic area has grown over the years and any programs added since 2014 were identified by CEBC staff, the Scientific Panel, and/or the Advisory Committee. For these programs, Dr. O'Connor was not involved in identifying or rating them.