Ongoing Challenges in Conceptualizing and Treating Reactive Attachment Disorder
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Ongoing Challenges in Conceptualizing and Treating Reactive Attachment Disorder James W. Drisko1
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Abstract This response to Mercer’s article explores some additional ways of conceptualizing and treating reactive attachment disorder (RAD). The limitations of the DSM descriptive model are explored and alternate empirically supported models are described. One key limitation is DSM’s one person, medical approach, which fits poorly with issues of attachment that are inherently interpersonal and interactive. Differences by age in the presentation of RAD, and in how it is treated are also addressed. The challenges for parents of children who have RAD are explored, and for clinicians who lack solidly research supported treatments for this disorder. Keywords Reactive attachment disorder · RAD · Disinhibited social engagement disorder · Diagnosis · Attachment Mercer offers a descriptive summary of what she characterizes as the ‘conventional’ and ‘unconventional’ literatures on reactive attachment disorder (RAD) from 2006 to the present. She draws on two widely used databases, but the articles summarized are far from a complete, systematic review style literature search. Mercer offers a handy introduction to these two views of RAD which were evident long before her starting search date and which she shows persist into the present. Her detailed introduction to the ‘unconventional’— or holding and attachment therapy literatures that generally lack peer review—is useful. Mercer also alerts clinicians to the ways in which parents’ exposure to unconventional approaches may impact practice and how this may impact legal actions as well. One important, and odd, omission is Zilberstein’s (2006) excellent summary and critical review of the core characteristics of the RAD diagnosis. Published in a major psychiatric journal, Zilberstein offers a much more fine grained review of approaches to diagnosing and treating RAD. Zilberstein notes developmental and behavioral differences across the ages to which the RAD diagnosis is applied, differences in the populations included in studies of treatments, and differences in theoretical orientations to the disorder. The * James W. Drisko [email protected] 1
Smith College School for Social Work, 23 West St., Northampton, MA 01063, USA
‘holding’ therapists are included. Readers with interest in RAD should also read this well documented paper. I will draw on many of Zilberstein’s key ideas. The line between the conventional and the unconventional is blurry at best. Social work professional organizations provide unconventional attachment therapy links, including to Nancy Thomas parenting, prominently in their online professional support publications (e.g., Pandya, 2012). At least three client deaths, perhaps many more according to Advocates for Children in Therapy (n.d.) (which currently cites Mercer’s article), have led to concerns about holding and attachment therapies; therapies that lack meaningful research support and ra
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