Editing Reactive attachment disorder (section)

==Treatment==
{{Main|Attachment-based therapy (children)|Attachment therapy}}
Assessing the child's safety is an essential first step that determines whether future intervention can take place in the family unit or whether the child should be removed to a safe situation. Interventions may include psychosocial support services for the family unit (including financial or domestic aid, housing and social work support), psychotherapeutic interventions (including treating parents for mental illness, [[family therapy]], individual therapy), education (including training in basic parenting skills and child development), and monitoring of the child's safety within the family environment<ref name=Sad04/>

In 2005 the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W. Boris and C.H. Zeanah) based on its published parameters for the diagnosis and treatment of RAD.<ref name=AACAP-2005>{{cite journal |journal=Journal of the American Academy of Child and Adolescent Psychiatry |date=November 2005 |volume=44 |issue=11 |pages=1206–19 |title= Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood |last1=Boris |first1=Neil W. |last2=Zeanah |first2=Charles H. |author3=Work Group on Quality Issues |pmid=16239871 |url=http://www.jaacap.com/article/S0890-8567(09)62229-2/fulltext |doi=10.1097/01.chi.0000177056.41655.ce |doi-access=free }}</ref> Recommendations in the guidelines include the following:
# "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."
# "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."
# "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."
# "Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive (additional) treatments."

Mainstream prevention programs and treatment approaches for attachment difficulties or disorders for infants and younger children are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver.<ref name=AACAP-2005/><ref>Prior &amp; Glaser (2006), p. 231.</ref><ref name="BakermansKranenburg et al. (2003)">{{cite journal |vauthors=Bakermans-Kranenburg M, van IJzendoorn M, Juffer F |year=2003 |title=Less Is More: Meta-Analyses of Sensitivity and Attachment Interventions in Early Childhood |journal=Psychological Bulletin  |volume=129 |pages=195–215 |url=http://www.childandfamilystudies.leidenuniv.nl/content_docs/agp/Publicaties/baketal03pb.pdf |access-date=2 February 2008 |doi=10.1037/0033-2909.129.2.195 |pmid=12696839 |issue=2 |s2cid=7504386 }}</ref> These approaches are mostly in the process of being evaluated. The programs invariably include a detailed assessment of the attachment status or caregiving responses of the adult caregiver as attachment is a two-way process involving attachment behavior and caregiver response. Some of these treatment or prevention programs are specifically aimed at foster carers rather than parents, as the attachment behaviors of infants or children with attachment difficulties often do not elicit appropriate caregiver responses.<ref name="Stovall &amp; Dozier (2000)">{{cite journal |vauthors=Stovall KC, Dozier M |title=The development of attachment in new relationships: single subject analyses for 10 foster infants |journal=Dev. Psychopathol. |volume=12 |issue=2 |pages=133–56 |year=2000 |pmid=10847621 |doi=10.1017/S0954579400002029 |s2cid=746807 }}</ref> Approaches include "Watch, wait and wonder,"<ref name="Cohen et al. 1999">{{cite journal |vauthors=Cohen N, Muir E, Lojkasek M, Muir R, Parker C, Barwick M, Brown M |year=1999 |title=Watch, wait and wonder: testing the effectiveness of a new approach to mother-infant psychotherapy |journal=Infant Mental Health Journal  |volume=20 |issue= 4 |pages=429–51 |doi= 10.1002/(SICI)1097-0355(199924)20:4<429::AID-IMHJ5>3.0.CO;2-Q}}</ref> manipulation of sensitive responsiveness,<ref name="van den Boom 1994">{{cite journal |author=van den Boom D |year=1994 |title=The influence of temperament and mothering on attachment and exploration: an experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants  |journal=Child Development  |volume=65 |pages=1457–77 |doi=10.2307/1131277 |pmid=7982362 |issue=5 |jstor=1131277}}</ref><ref name="van den Boom 1995">{{cite journal |author=van den Boom D |title=Do first-year intervention effects endure? Follow-up during toddlerhood of a sample of Dutch irritable infants |journal=Child Dev |volume=66 |issue=6 |pages=1798–816 |year=1995 |pmid=8556900 |doi=10.2307/1131911 |jstor=1131911}}</ref> modified "Interaction Guidance",<ref name="Benoit et al.">{{cite journal |vauthors=Benoit D, Madigan S, Lecce S, Shea B, Goldberg S |year=2002 |title=Atypical maternal behaviour toward feeding disordered infants before and after intervention |journal=Infant Mental Health Journal |volume=22 |issue= 6|pages=611–26 |doi= 10.1002/imhj.1022 }}</ref> "Clinician-Assisted Videofeedback Exposure Sessions (CAVES)",<ref>{{cite journal  |vauthors=Schechter DS, Myers MM, Brunelli SA, etal | title = Traumatized mothers can change their minds about their toddlers: Understanding how a novel use of videofeedback supports positive change of maternal attributions | journal = Infant Mental Health Journal | volume = 27 | issue = 5 | pages = 429–447 |date=September 2006 | pmid = 18007960 | pmc = 2078524 | doi = 10.1002/imhj.20101 }}</ref> "Preschool Parent Psychotherapy",<ref name="Toth et al. (2002)">{{cite journal |last=Toth |first=S |author2=Maughan A |author3=Manly J |author4=Spagnola M |author5=Cicchetti D  |year=2002 |title=The relative efficacy of two in altering maltreated preschool children's representational models: implications for attachment theory |journal=Development and Psychopathology  |volume=14 |pages=877–908 |doi= 10.1017/S095457940200411X |pmid=12549708 |issue=4 |s2cid=30792141 }}</ref> "Circle of Security",<ref name="Marvin et al. (2002)">{{cite journal |vauthors=Marvin R, Cooper G, Hoffman K, Powell B |date=April 2002 |title=The Circle of Security project: Attachment-based intervention with caregiver&nbsp;– pre-school child dyads |journal=Attachment & Human Development |volume=4 |issue=1 |pages=107–24 |url=http://www.circleofsecurity.org/docs/languages/08%20AHD%20final.pdf |access-date=2 February 2008 |doi=10.1080/14616730252982491 |pmid=12065033 |s2cid=25815919 |url-status=dead |archive-url=https://web.archive.org/web/20080227161855/http://www.circleofsecurity.org/docs/languages/08%20AHD%20final.pdf |archive-date=27 February 2008  }}</ref><ref name="Cooper et al. (2005)">Cooper G, Hoffman K, Powell B and Marvin R (2005). "The Circle of Security Intervention; differential diagnosis and differential treatment". In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (eds.) ''Enhancing Early Attachments: Theory, research, intervention, and policy''. pp. 127–51. The Guilford Press. Duke series in Child Development and Public Policy. (2005) {{ISBN|1-59385-470-6}}.</ref> "Attachment and Biobehavioral Catch-up" (ABC),<ref name="Dozier et al. (2005)">Dozier M, Lindheim O and Ackerman JP (2005) "Attachment and Biobehavioral Catch-Up: An intervention targeting empirically identified needs of foster infants". In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (Eds.) ''Enhancing Early Attachments: Theory, research, intervention, and policy''  pp. 178–94. Guilford Press. Duke series in Child Development and Public Policy. (2005) {{ISBN|1-59385-470-6}} (pbk)</ref> the New Orleans Intervention,<ref name="Zeanah & Larrieu">{{cite journal |vauthors=Zeanah CH, Larrieu JA |title=Intensive intervention for maltreated infants and toddlers in foster care |journal=Child Adolesc Psychiatr Clin N Am |volume=7 |issue=2 |pages=357–71 |year=1998 |pmid=9894069|doi=10.1016/S1056-4993(18)30246-3 }}</ref><ref name="Larrieu &amp; Zeanah (2004)">Larrieu JA, Zeanah CH (2004). "Treating infant-parent relationships in the context of maltreatment: An integrated, systems approach". In Saner A, McDonagh S and Roesenblaum K (Eds.) ''Treating parent-infant relationship problems '' pp. 243–64. New York. Guilford Press.  {{ISBN|1-59385-245-2}}</ref><ref name="Zeanah &amp; Smyke">Zeanah CH, Smyke AT (2005) "Building Attachment Relationships Following Maltreatment and Severe Deprivation". In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (Eds) ''Enhancing Early Attachments: Theory, research, intervention, and policy'' The Guilford Press. Duke series in Child Development and Public Policy. (2005) pp. 195–216. {{ISBN|1-59385-470-6}} (pbk)</ref> and parent–child psychotherapy.<ref name="Leiberman et al. 2000">Lieberman AF, Silverman R, Pawl JH (2000). "Infant-parent psychotherapy". In Zeanah CH (Ed.) ''Handbook of infant mental health'' (2nd ed.) p. 432. New York: Guilford Press. {{ISBN|1-59385-171-5}}</ref> Other treatment methods include Developmental, Individual-difference, and Relationship-based therapy (DIR, also referred to as Floor Time) by [[Stanley Greenspan]], although DIR is primarily directed to treatment of pervasive developmental disorders.<ref name="ICD">{{cite web | publisher = Interdisciplinary Council on Developmental & Learning Disorders | year = 2007 | url = http://www.icdl.com/dirFloortime/overview/index.shtml | title = Dir/floortime model | access-date = 2 February 2008 | url-status = dead | archive-url = https://web.archive.org/web/20080225132429/http://www.icdl.com/dirFloortime/overview/index.shtml | archive-date = 25 February 2008 | df = dmy-all }}</ref>

The relevance of these approaches to intervention with fostered and adopted children with RAD or older children with significant histories of maltreatment is unclear.<ref name="Newman &amp; Mares (2007)">{{cite journal |vauthors=Newman L, Mares S |title=Recent advances in the theories of and interventions with attachment disorders |journal=Current Opinion in Psychiatry |volume=20 |issue=4 |pages=343–8 |year=2007 |pmid=17551348 |doi=10.1097/YCO.0b013e3281bc0d08|s2cid=34000485 }}</ref>

===Attachment therapy===
{{main|Attachment therapy}}

The terms [[attachment disorder]], attachment problems, and attachment therapy, although increasingly used, have no clear, specific, or consensus definitions. However, the terms and therapies often are applied to children who are maltreated, particularly those in the foster care, kinship care, or adoption systems, and related populations such as children adopted internationally from orphanages.<ref>{{Cite journal|last1=Chaffin|first1=Mark|last2=Hanson|first2=Rochelle|last3=Saunders|first3=Benjamin E.|last4=Nichols|first4=Todd|last5=Barnett|first5=Douglas|last6=Zeanah|first6=Charles|last7=Berliner|first7=Lucy|last8=Egeland|first8=Byron|last9=Newman|first9=Elana|date=1 February 2006|title=Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems|journal=Child Maltreatment|language=en|volume=11|issue=1|pages=76–89|doi=10.1177/1077559505283699|issn=1077-5595|pmid=16382093|s2cid=11443880}}</ref>

Outside the mainstream programs is a [[Attachment therapy#Treatment characteristics|form of treatment]] generally known as attachment therapy, a subset of techniques (and accompanying novel diagnosis) for supposed attachment disorders including RAD. These "attachment disorders" use diagnostic criteria or symptom lists different from criteria under ICD-10 or DSM-IV-TR, or to attachment behaviors. Those with "attachment disorder" are said to lack empathy and remorse.

Treatments of this pseudoscientific disorder are called "Attachment therapy". In general, these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers. The theoretical base is broadly a combination of [[Age regression in therapy|regression]] and [[catharsis]], accompanied by parenting methods which emphasize [[Obedience (human behavior)|obedience]] and parental control.<ref name="Chaffin 2006 pp. 79">Chaffin et al. (2006), pp. 79–80. The APSAC Taskforce Report.</ref> There is considerable criticism of this form of treatment and diagnosis as it is largely unvalidated and has developed outside the scientific mainstream.<ref>Chaffin et al. (2006), p. 85. The APSAC Taskforce Report</ref> There is little or no [[Evidence based medicine|evidence base]] and techniques vary from non-coercive [[Therapy|therapeutic]] work to more extreme forms of physical, confrontational and coercive techniques, of which the best known are [[holding therapy]], [[Rebirthing (attachment therapy)|rebirthing]], [[rage-reduction]] and the [[Evergreen model]]. These forms of the therapy may well involve physical restraint, the deliberate provocation of rage and anger in the child by physical and verbal means including deep tissue massage, aversive tickling, enforced eye contact and verbal confrontation, and being pushed to revisit earlier trauma.<ref>Chaffin et al. (2006), pp. 78–83. The APSAC Taskforce Report.</ref><ref name="Speltz 2002">{{cite journal|author=Speltz ML |year=2002 |title=Description, History and Critique of Corrective Attachment Therapy |journal=The APSAC Advisor |volume=14 |issue=3 |pages=4–8 |url=http://www.kidscomefirst.info/Speltz.pdf |access-date=3 March 2008 |url-status=dead |archive-url=https://web.archive.org/web/20080414011820/http://www.kidscomefirst.info/Speltz.pdf |archive-date=14 April 2008 }}</ref> Critics maintain that these therapies are not within the attachment paradigm, are potentially abusive,<ref>Prior &amp; Glaser (2006), p. 267.</ref> and are [[wikt: antithetical|antithetical]] to attachment theory.<ref name="O'Connor & Nilsen"/> The APSAC Taskforce Report of 2006 notes that many of these therapies concentrate on changing the child rather than the caregiver.<ref>Chaffin et al. (2006), p. 79. The APSAC Taskforce Report.</ref> Children may be described as "RADs", "Radkids" or "Radishes" and dire predictions may be made as to their supposedly violent futures if they are not treated with attachment therapy.<ref name="Chaffin 2006 pp. 79"/> The Mayo Clinic, a well known U.S. non-profit medical practice and medical research group, cautions against consulting with mental health providers who promote these types of methods and offer evidence to support their techniques; to date, this evidence base is not published within reputable medical or mental health journals.<ref>{{cite web|title=Treatments and drugs|url=http://www.mayoclinic.com/health/reactive-attachment-disorder/DS00988/DSECTION=treatments-and-drugs|publisher=Mayo Clinic Staff}}</ref>