Talk:Reactive attachment disorder

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Contents 1 Footnotes 2 Introduction 3 Cleanup 4 Introduction being too long? 5 Jean Mercer and the problem of fringe groups more generally 6 Fringe Groups...do we really need to list every nut? 7 Please see "Overdiagnosis" 8 Mercer 9 MEDIATION 10 Start over! 11 Removed merge tag 12 Article is about the Diagnostic Category 13 The experience section 14 Criticisms 14.1 Disorder? What disorder 15 References for est of incidence 16 Unclear 17 DDP 18 Overlap 19 Parent's comments 20 Diagnosis 21 Odd paragraph 22 Research 23 Tag 24 Why Reactive? 25 GA on Hold 26 GA PASS 27 Template for citations 28 WP:MEDMOS 29 Cultural references 30 Causes and genetics 31 Disorganised attachment 32 Stuff to add or subtract (post Fac application) 33 Article has improved! 34 example 35 1996 36 Speculation? 37 References to attachment therapy 38 Differential diagnosis 39 Update 40 Update 2 41 Treatment - basic stuff (remember who's reading the article) 42 Lack of attachment behaviors? 43 Missing piece 44 Checkup 45 Lead 46 AT source 47 A note about FAC commentary 48 Sadock 49 Links to Attachment therapy 50 Memo 51 The introduction lacks an example 52 Incorrect reversion 53 Moved down from up amongst the 2006 stuff! 53.1 Disorder? What disorder?

[edit] Footnotes

do we need all of those footnots? -- from cleanup

my persional oppinion is yes, yes, YES. infact i would go as far to sa that this is what most wikipedia articals lack tooto 22:20, 23 Aug 2004 (UTC)

I agree. Footnotes add veracity to the material and allows readers to delve more deeply into the subject AWeidman 25 Dec 2005

[edit] Introduction

The first paragraph of this article is overly complex and does not give a clear description of this disorder that would be accessible to many people who do not have a background in the subject.

Reactive Attachment Disorder (sometimes called "RAD")(DSM-IV 313.89, ICD-10 F94.1/2) is a psychophysiologic condition[1] secondary to pathogenic behaviour from a caregiver during the first three years of life which would, in the absence of such pathogenic behaviour, normally meet well-timed milestones, so that the developmental trajectory is qualitatively different from the superficially similar failures or deviances in Mental retardation and Pervasive developmental disorders). This pathogenic caregiving behaviour constitutes any form of neglect, abuse, mistreatment and abandonment.

The DSM-IV intro is much clearer.

The essential feature of Reactive Attachment Disorder is markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 years and is associated with grossy pathological care.

May I suggest this replacement:

Reactive Attachment Disorder (sometimes called "RAD")(DSM-IV 313.89, ICD-10 F94.1/2) is a psychophysiologic condition[1] with markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age five years and is associated with grossly pathological care. This pathological caregiving behaviour may consist of any form of neglect, abuse, mistreatment and abandonment.

In Mental retardation attachments to caregivers are consistent with the level of development. In Pervasive developmental disorders attachments to caregivers either fail to develop or are highly deviant, but this usually occurs in a context of reasonably supportive care.

--CloudSurfer 22:19, 7 Oct 2004 (UTC)

Thank you, CloudSurfer.

Imagine that, to have written a first paragraph to an article in an online encyclopedia that is much less clear than the DSM-IV. And that book is not a piece of obscurantist dogma, or it shouldn't be.

Still, four big words in the middle clause (the one that begins with 'so that'...)- I am not doing that again in a big hurry! The four were 'developmental' 'trajectory' (might have just said 'path', but that might have connoted spirituality), 'qualitiatively' and 'superficial'.

The lack of clarity was in part due to political correctness: or, more simply, not wanting to offend anybody in the three diagnostic categories mentioned. As you might see, 'markedly disturbed' and 'developmentally inappropriate' are very loaded words (though usually not meant so in the medical context), as when discussing Pervasive Developmental Disorders as being 'highly deviant' in this area. This is well-balanced by the 'reasonably supportive care'.

Apart from these points, I do agree with the replacement and the editing of the first paragraph. I suppose 'pathogenic' would be a loaded word too (as psychogenic had been), as compared to pathological, in terms of how things are caused.

As to the background thing would this 'markedly disturbed' and 'developmentally appropriate' be obvious to doctors, to parents, and/or to you and me?

Your edits make much better that point that Reactive Attachment Disorder is different, especially to the ordinary reader.

Just a little point: it is five years, not three, according to the DSM-IV?

EuropracBHIT

Thanks for that, so it seems you are happy with the suggestions so I have put it in, with 5 not 3 years. I just wanted to check that I wansn't missing anything crucial. --CloudSurfer 05:11, 9 Oct 2004 (UTC)

Hi, I don't know what 'grossly pathological care'/pathogenic caregiving means... would it be useful to have a link to a definition, or include the definition here? Nao* 14:50, 7 September 2005 (UTC)

Hi, I noted the thing about Randalph Questionnaire. But I saw a site that mentioned that this Questionnaire is ONLY used for attachment disorder. Reactive attachment disorder and ODD/CD togheter in one person are not common. However, the real Questionnaire can only be used for Attachment disorder (AD) and not RAD...

Actually, most children with a clinical diagnosis of Reactive Attachment Disorder would also meet the DSM IV criteria for ODD and/or CD. That is because DSM IV diagnoses are usually made solely based on the presence of absence of certain behaviors. RAD is one of the few diagnoses in the DSM that relies on cause or etiology. AWeidman 25 Dec 2005

[edit] Cleanup

The section under "Classification" that begins with "SUBTLE AND NOT SO SUBTLE SIGNS OF ATTACHMENT PROBLEMS" looks like it comes from a parent's manual on attachment disorder, not an encyclopedia article. I've listed this article under "inappropriate tone" cleanup to deal with that. Quinnanya 16:37, 1 March 2006 (UTC)

[edit] Introduction being too long?

I think we need to cut out the last two paragraphs of the introduction.

How long are introductions in regard to the major developmental disorders of infancy and adolescence, assuming an equal amount of development and time has been put in to this article?

Just would like a ballpark estimate.

--Bronwyn Gannan 03:37, 23 April 2006 (UTC).

[edit] Jean Mercer and the problem of fringe groups more generally

In medicine and psychiatry, there will always be fringe groups questioning the effiacy of a treatment or intervention. I think Children in Therapy is right on myself, particularly in view of the deaths and that they look down more generally on coercive therapy. Even the best attachment therapy is not evidence/research based. Where are the case studies? I read my first case study back in September 1998 in the Margaret Talbot article from the New York Times which was subsequently published in the Sydney Morning Herald/The Age magazine Good Weekend. Why are the few known case studies plagiarised from Milton Erickson? And it is not right to be discrediting a clinician because xe is a transsexual (female to male). It would be like discrediting John Money who was a very well known sexologist. To mainstream medical practice the fringe groups would appear to be ATTACh and the individual therapists and so-called 'attachment centres'. Thank you very much, I would welcome all your opinions on this matter. --Bronwyn Gannan 20:29, 23 April 2006 (UTC).

The section on fringe groups that stated "Jean Mercer, PhD, AKA Gene Lester. Mr. Lester/Mercer ... " seemed problematic because of concerns about defamation. It appears to imply that Jean Mercer is transsexual, transgendered, or something similar, which she is not. So, I reverted to the earlier version of this page that did not contain the defamation.

[edit] Fringe Groups...do we really need to list every nut?

Children is Therapy is an advocacy group and is not recognized by any mainstream group (AMA, APSAC, NASW, etc.) They have a specific agenda to attack all attachment based treatment. They state that there is no such thing as Reactive Attachment Disorder.

In all fields there will be pratcitioners who are unethical or who practice bad medicine or psychology. The deaths cited were all caused by unlicensed individuals or persons using "methods" that no professional group would sanction. But that is no reason to continue to debase a field because of a few bad apples. After all, medical malpractice does not prevent us from seeking medical care or considering research. It does lead us to be sure our physician is licensed, Board certified if a specialist, and related issues.

To "mainstream medical practice" ATTACh is seen as a leader in the field of treating children with severe difficulties. There is a substantial amount of research published in peer-reviewed professional journals about evidence-based approaches to the prevention and treatment of attachment disorders. See, for example, The Circle of Security Program (Dr. Robert Marvin, U. of VA.) or Dyadic Developmental Psychotherapy (Child and Adolescent Social Work Journal) or Theraplay, etc. A review of such professional journals as Developmental Psychology, Infant Mental Health Journal, Attachment and Human Behavior, just to name a few, will yield a significant number of evidence and research based effective prevention and treatment approaches. --User:AWeidman16:51, April 23, 2006

They say there is no such thing as Attachment Disorder beyond the confines of the DSM-IV diagnosis Reactive Attachment Disorder.

And don't you mean Attachment and Human Development if that's the journal you're thinking of?

They are recognised by people like New Jersey Infant Development. --Bronwyn Gannan 08:49, 25 April 2006 (UTC).

I think as in the report for Child Maltreatment Journal from Feb. 2006, the thing that people are not getting is that dozens of kids have died from RAD therapy, a lot of it consists of hold the child down for hours... people don't realize that. very desperate parents go in hope of helping their very mentally ill children, who were often adopted. Many of these adopted children were exposed to drugs and etc... in utero, and also lack of food etc. after birth, and this actually causes brain damage itself. Hence, why so many of them have some major problems. A lot of the RAD therapist are out making a lot of money off some very desperate parents. —Preceding unsigned comment added by 141.152.143.254 (talk) 21:50, 13 October 2007 (UTC)

[edit] Please see "Overdiagnosis"

It seems very clear that not only do we "label every nut," but some seem to need a flavor of the month--every month. The pathology that flows from such universal and useless over-use of pathological nomenclature constitutes a major cause of iatrogenesis.

[edit] Mercer

I don't know what gender Jean Mercer/Gene Lester is or was. But Jean Mercer's C.V. clearly states that Jean Mercer and Gene Lester are one and the same person. Gene Lester had a name change to Jean Mercer. Jean Mercer's resume lists publications by Gene Lester and states that Jean Mercer was Gene Lester. So, this is not defamation, merely a statement of fact.

Jean Mercer's CV states that her previous name was Gene Lester. Her current name is Jean Mercer. At all times, Jean Mercer/Gene Lester was female. So, she should not be referred to as "Mr." and there is no need to say "AKA" because her current name is Jean Mercer. When someone who knows she is female intentionally refers to as "Mr.", is potentially defamatory.

I don't know if Jean Mercer is male or female. I do know from reading the bio's of Gene Lester on those books and articles that Gene Lester was male. So, Mr. may or may not be correct at this time. The material on the website at the school (Richard Stockton College) in NJ where Mercer is at is silent on gender.

Gene Lester was not male. You read the bio incorrectly. Regardless of whether you knew her gender before, you are now put on notice: She is and has always been female. If you had a question about her gender, you should have asked her about it instead of making an assumption.

An interesting exchange. Who are these people? Aren't we supposed to sign our talk references and edits? Anyway, obviously there are strong feelings here and we should be sensitive to them. I'm not sure what difference Dr. Mercer's gender makes anyway to this page or the content. I'd suggest we focus on the material at hand and not be side tracked. --User:AWeidman9:52, April 24, 2006

[edit] MEDIATION

Because of these continued Ad Hominem attacks I have turned this over to mediation. It would be helpful if you would identify yourself.

Given your past history of defamation, I prefer to remain anonymous. I think mediation is a great idea. The Wikipedia moderators should have a fun time reviewing the original edits you made implying that Jean Mercer was a "Mr."

The correct spelling is "ad hominem", and the remarks AWeidman has been making are "ad feminam." Jean Mercer

Jean, would you mind getting a Wikipedia account? We'd all benefit from your professional expertise, as well as Dr Weidman's.

I can't follow. Who has the past history of defamation? --Bronwyn Gannan 08:51, 25 April 2006 (UTC).

Whoever keeps referring to Jean Mercer as "Mr." -- which appears to be AWeidman in some cases and an unidentified person in others -- has the history of defamation.

[edit] Start over!

This entire piece, as well as the other material about attachment and attachment disorders, need to be scrapped and started over by serious professionals who have no commercial interest in these matters. These pieces have become a mish-mosh of unsubstantiated opinions and claims without an acceptable evidentiary basis. I note that my comments about EBT status have been deleted. As soon as this semester is over, I hope to offer some possible replacements. In the mean time, I hope readers will be cautious about what they read here. Jean Mercer

When will the semester finish at your university? --Bronwyn Gannan 10:11, 26 April 2006 (UTC).

Hi Bronwyn-- I have started an account, as you suggested, but when I tried to e-mail you separately it didn't seem possible. I could probably start to work on this toward the end of May and would like to hear your opinion on the direction it should go. Thanks for your earlier rebukes on the "transgendering" front-- if you'll look at the mediation page you'll see an explanation, but obviously the whole thing is irrelevant. I will say once again that EBT status for DDP is highly questionable, a point that my statement "EBT or not EBT?" on www.childrenintherapy.org examines in detail. Jean Mercer

I have a proposal for re-organizing the articles on attachment theory. The main attachment theory article will contain a brief introduction followed by sections that have summaries and links to related articles. I have already created a draft of the main article at User:Kc62301/Attachment Draft. The links on this draft are valid and take you to the actual proposed articles...not just stubs. I plan to finish the article on adult attachment by no later than July 4th. If the Reactive attachment disorder article could be merged into the Attachment disorder article, it would fit nicely into the scheme. I did something similar with the Monogamy article, and it has been well-received, since no one has objected or made major changes. What do you think? kc62301

Reactive Attachment disorder is a psychiatric diagnosis. It probably makes more sense to integrate material from attachment disorder into this article on reactive attachment disorder. However, if this is going to lead to problems with whether or not to include material on such reputable approaches as Floor Time, Theraplay, or Dyadic Developmental Psychotherapy as is going on with the Bowlby article, then I'd let sleeping dogs...sleep. MarkWood 15:03, 28 June 2006 (UTC)

I see your point after reading the discussion page on Bowlby. I decided to take your advice and have two main sections on the User:Kc62301/Attachment Draft page. One for basic attachment theory, and one for attachment theory in clinical practice. (I'm open to suggestions for alternative heading names, by the way.) I included both the Attachment disorder article and the Reactive attachment disorder articles on the main page...as well as two therapeutic interventions. I did not write the article on attachment of children to caregivers, so that has some clinical info that I don't feel comfortable moving without consensus. It might be okay as is. kc62301

[edit] Removed merge tag

There is serious disgreement between contributors about material that would no doubt be included in a merged article. Currently there appears to be consensus on how the Attachment disorder article and the Reactive attachment disorder article are written. I think anyone who wants to merge the articles should write a draft and get consensus on the draft. kc62301

I don't think that there is serious disagreement between contributos about material in this article...it appears to be only one contributor and I don't think that one loud voice should disrupt consensus. SamDavidson 17:18, 1 July 2006 (UTC)

Okay. You don't mind the merge tag being removed, though, do you? Please feel free to put it back if you prefer. I'll leave it alone. kc62301

I'd agree with SamDavidson that there isn't serious disagreement among contributors. I think the removal of the merge tag is fine, as far as I am concerned. I appreciate your work here. It's very good!! DPeterson 00:03, 2 July 2006 (UTC)

• • • Once again, this whole piece has been written from the viewpoint of practitioners far outside the mainstream. The reference to the RADQ and to "Attachment Disorders" ("tout court")indicates that the writers belong to the school of thought that has brought us a number of highly commercialized treatments sold to parents who are supplied with a checklist to demonstrate that their child needs treatment.Are readers aware that Elizabeth Randolph, developer of the RADQ (on the basis of an old checklist that would help you detect if your child was masturbating), claims that she can diagnose an attachment disorder if the child does not crawl backward on command or execute a cross-crawl movement? The only diagnosis against which the RADQ is validated is Randolph's own opinion; there is no independent assessment and certainly no double-blind design.As a result, using the RADQ as a way to evaluate treatment is a matter of garbage-in/garbage-out. This is only one of many problems with this page, and I think it is shameful to put this kind of disinformation out where the unsuspecting public can be influenced by it. Please understand that Candace Newmaker, the child who was asphyxiated by holding therapists some years ago, was diagnosed over the telephone by a practitioner who used the RADQ.

There is no clearly-described diagnostic entity known as Attachment Disorder. The symptoms of the DSM category called Reactive Attachment Disorder are rather general and certainly don't include anything about eye contact or disobedience. The DC: 0-3, a set of categories designed to use with children of the age when attachment develops, does not even include any form of attachment disorder.

"Everyone knows" all about attachment, but few people know much that is correct, especially about disorders of early development. (N.B. The bizarre statement about 80% of some groups being diagnosed with RAD is a typical contribution of the Practitioners Formerly Known as Holding Therapists-- they are fond of this proportion.) This whole piece needs re-writing. Is there anyone out there who would like to work together on this? You must know what you're talking about or be willing to do some reading. Keep in mind that there is a responsibility here to parents who might make some decisions based on material they read on Wikipedia. Jean Mercer

Removal of the merge tags is fine. The previous comments mirror those of Mercer's articles on the ACT website. I will have to see if there is a relevant citation for that 80% figure. I seem to recall reading it in an article by Dr. Dante Cicchetti, but don't hold me to that as I must check the reference...MarkWood 17:47, 9 July 2006 (UTC)

The reference is right there on the page, number 4, if you both would take a look. The reference by D.C. should be found in any library...at least ours has a copy. JonesRD 20:51, 9 July 2006 (UTC)

I have added some introductory material that I believe clarifies some issues. Disorders of attachment are not like chickenpox-- they my occur in many forms and may even amount to normal variations-- and this point should be included in the article.Jean Mercer 15:37, 10 July 2006 (UTC)

It might be better to put the material you suggest into a separate section labeled critics or something like that. Neutral point of view is generally preferred in articles, but critics should also have a clearly labeled place to put in their two cents. Also, self-promotion is to be avoided as well. JohnsonRon 20:01, 10 July 2006 (UTC)

Okay, good idea.Jean Mercer 21:49, 11 July 2006 (UTC)

[edit] Article is about the Diagnostic Category

I removed a section that probably belongs better in an article about treatment. In fact the material can be found in the article Attachment Therapy DPeterson^talk 12:19, 11 August 2006 (UTC)

I added it back, as the article does contain a section on controv. and so references also belong. DPeterson^talk 12:23, 11 August 2006 (UTC)

An improvement! Dr. Becker-Weidman ^Talk 14:25, 27 August 2006 (UTC)

[edit] The experience section

I am not sure that this section belongs in this article. It does not have an encyclopedia sound to it...reads more like a first person account by a parent. In addition, a number of the "symptoms" or "behaviors" listed are value-laden terms and not part of any recognized diagnostic scheme, such as the DSM-IV. I'd suggest removal of the "diagnostic" paragraph of this section, or removal of the entire section, or at least substantial editing. What do others think? DPeterson^talk 12:42, 30 August 2006 (UTC)

I suggest removing the section with the list of symptoms/behaviors and editing the remaining material to conform to encyclopedia format and form. Dr. Becker-Weidman ^Talk 15:50, 30 August 2006 (UTC)

In re-reading the section, I now think it should be deleted...It requires very extensive editing. My problems with the section as written is that the description of the child, the child's motivation, and the child's behavior is negative and perjorative. It does not address or even consider the underlying cause of behaviors. So, for example, to describe a child as manipulative is to ascribe a level of sophistication and motivation to the child that is just not usually present. Most often children who have Reactive Attachment Disorder are significantly developmentally younger than their chronological age (as measured by some standardized instrument such as the Vineland-II). Often what appears to be "manipulative" is actually driven by fear...fear of being hurt or abandoned. I hate to delete material wholesale, but in this instance I think it would be the right thing to do. What is the opinion of other editors? Dr. Becker-Weidman ^Talk 15:56, 30 August 2006 (UTC)

Unless there is strong disagreement, I will delete the section later today or tomorrow...COMMENTS??? RalphLender^talk 18:50, 30 August 2006 (UTC)

[edit] Criticisms

I have trouble with a diagnosis based on causation. I think it is stacking the deck a bit. Since one of the criteria for RAD is a history of bad caregivers it seems like a self-fullfilling prophecy. In my experience a child from that kind of history will often be assumed to have RAD. Where others exhibiting the same behavior without the history will not.

Also the 10 to 80% stat seem disingenuous. The range is too broad. It means nothing and does not have a citation.

raspor 14:40, 21 December 2006 (UTC)

[edit] Disorder? What disorder

And further: forgive me if I’m being thick, but after reading and re-reading this article several times, I’m unable to discover any evidence that the symptoms described constitute a disorder at all.

True, the dictionary I have to hand (Webster’s) defines disorder as “an abnormal physical or mental condition”, but in those terms high intelligence and extreme muscularity are both disorders. To be worthy of the name, a disorder must cause a problem.

The behaviour I see described is labelled “Disturbed” and “Developmentally inappropriate”, when as far as I can see,it is merely “statistically abnormal”. The assumption seems to be that anyone who doesn’t behave like everyone else must have something wrong with them.

“RAD arises from a failure to form normal attachments to primary caregivers in early childhood.”

It appears from the Causes section that this is a definition, i.e. if these symptoms are not attributable to such failure, then they do not constitute RAD. But whether actual symptoms are so attributable is a question for empirical verification, not prior stipulation; and no evidence appears to be offered. Even if the correlation were perfect, it is not necessarily causal in the direction indicated: RAD and failure to form caregiver attachments could both be caused by a third factor.

The number of occurrences of such words as could, may, presumed etc. is quite alarming. Why could the symptoms of RAD not result from (just to take a few examples):

a) A child’s dislike or distrust of the caregiver (most of us can think of relatives we don’t like even though we wouldn’t accuse them of being bad people).

b) Extreme introversion (or extroversion in the case of DAD).

c) Precocious self-sufficiency

d) Disinterest in the available peer-group—for example, if the child is either much more or much less intelligent.

I see no mention of any effort to ascertain whether all such children are in fact unhappy, or whether they make other children unhappy. In short, if “RAD is one of the least researched and most poorly understood disorders in the DSM”, why are children that are apparently merely unusually unsocial (or excessively social) being (apparently) viewed as antisocial (or rather, “inappropriate”), and—more to the point—since no evidence of later probems is adduced, why should they be ‘treated’ for anything?

It’s otherwise an informative article, and I see several contributors here who evidently know what they’re talkng about, so I hope someone can address these concerns for me.

Paul Magnussen (talk) 23:13, 21 April 2008 (UTC)

[edit] References for est of incidence

Very good references. It is important that statements with estimates have some sources to support the statement..thank you FCYTravis. JohnsonRon 19:26, 16 March 2007 (UTC)

[edit] Unclear

I added an unclear template tag to this article, because after reading through it, I can't figure out for the life of me what it's trying to say in general or what the symptoms are - only what supposedly causes it or who it occurs in. 76.202.58.168 04:21, 22 June 2007 (UTC)

[edit] DDP

I have removed Dyadic Developmental Psychotherapy from this page. This little known therapy has been extensively advertised on Wiki as evidence based, sometimes the only evidence based treatment for a variety of disorders affecting attachment. (Theraplay, also little known and not evidence based has also been advertised in this way.) A range of attachment articles including attachment therapy are currently before ArbCom. In the course of ArbCom it has transpired that of the 6 users promoting DDP and Theraplay and controlling these pages, User:DPeterson, User:RalphLender, User:JonesRD, User:SamDavidson, User:JohnsonRon, and User:MarkWood, the latter four are definitely socks and have been blocked, and the other two have been blocked for one year. The attachment related pages are in the course of being rewritten. Fainites ^barley 20:14, 1 August 2007 (UTC)

Update - all 5 are now indefinitely blocked as sockpuppets of DPeterson, and DPeterson has been banned for 1 year by ArbCom.[1] Fainites ^barley 19:41, 5 September 2007 (UTC)

Update 2 - User:AWeidman, AKA Dr. Becker-Weidman ^Talk and Dr Art has now also been indef. banned for breach of the ban on his sockpuppet DPeterson. Fainites ^barley 17:37, 10 November 2007 (UTC)

[edit] Overlap

This article has extensive overlap with the piece on Attachment Disorder-- is it necessary for more than a definition and a link to exist?Jean Mercer 00:12, 8 August 2007 (UTC)

I think there's a place for a decent article on RAD. The description in attachment disorder is fairly brief. Why don't we get this article up to scratch, see how long it is and then see if the two can be sensibly merged. Fainites ^barley 11:46, 12 August 2007 (UTC)

I have started rewriting this article by putting a great deal more information on its subject and removing information which would be duplicated, or which properly belongs in attachment disorder. Fainites ^barley 15:31, 14 August 2007 (UTC)

What did the editor who wrote the introduction mean by using the term "psychophysiological"? There might be many reasons to refer to the physiological aspects of an emotional disturbance, but there are also many implications of doing so (e.g., causal events, treatment, genetic factors). If this word is to be used at all, the implications should be spelled out-- or it might be better not to use the term, but unpack some of its baggage and use whatever was intended. If it was only put in to allude to brain functions and therefore stress that the disorder is "real", not just bad behavior, then I think the term should be removed as adding nothing, but raising questions.Jean Mercer 17:58, 14 August 2007 (UTC)

What about the Erikson material? Is someone suggesting that Erikson's work is an influence on attachment theory? I don't see this, especially in the light of Erikson's view of constant reworking of personality development, and Bowlby's stress on critical periods.Jean Mercer 18:13, 14 August 2007 (UTC)

There's alot of stuff that needs removing from this article jean, as the article was written to promote a non-mainstream viewpoint as the norm. I have removed the most glaring anomolies. Feel free to remove the rest! I don't really know what is meant by psychopyisiological. As for Erikson, is that Milton or Erik? (Ha!) It also seems to be running two separate ref. lists. However, it was a key note of the socks that he did not know how to do ref lists for a long time and when he did often didn't create one or remove the old ref lists which were in aphabetical order. Fainites ^barley 09:05, 15 August 2007 (UTC)

The refs for the 'psychophysiological' bit is John Alston. Fainites ^barley 17:46, 15 August 2007 (UTC)

[edit] Parent's comments

As the adoptive parent of a child diagnosed with RAD, it would be helpful if this article was less medically technical, finding that more layman's terms would be appropriate. Citing typical symptoms of RAD sufferers, diagnostic tools and psychological methods to ease the symptoms and reintegrate the patient to societal normalcy would be beneficial as well.

Because the feedback comments include a reference to substantiating the requirement that a patient have a history of pathological care, I find it compelling to relate that of the children and families I am affiliated with in which an adopted child exhibits RADS, all have histories of abuse, neglect or depravity from a first caregiver or foster home before being safely placed with the families that are able to provide appropriate care.

I may not be a psychologist but since I am 24/7 responsible for the care and therapy of a child with RADS, it is my hope that my opinion is considered equally valuable.

— moved from portal rater's comments to here; originally posted by 216.186.222.2 at 21:31, 22 July 2007

Hi 216.186.222.2. May I call you 216? This article needs an extensive rewrite which has only just begun. For the last year or so it (and most articles relating to attachment)have been controlled by a group of sockpuppets promulgating a particular set of non-mainstream views. They have only recently been banned. All the articles have bneeded, and still need alot of work. All contributions therefore are welcome! Feel free to plunge in. I agree with you absolutely that it needs to be written in an accessible way. Have you had a look at the attachment disorder article? Fainites ^barley 09:09, 15 August 2007 (UTC)

The current proposal is to greatly expand the child psychotherapy article to include all major treatments, what they're for, theoretical base, evidence base etc etc. This seems better than people either putting in their pet therapies or arguing for hours over what 'evidence based' means over a dozen articles. Fainites ^barley 19:17, 22 August 2007 (UTC)

[edit] Diagnosis

Another odd thing I notice is that the article says that the diagnosis of RAD is often done by Social Workers. That certainly wouldn't be the case over here. Social Workers would be expected to pick up on and be aware of attachment issues but certainly wouldn't be 'diagnosing' anything, particularly something as rare and extreme as RAD. Fainites ^barley 09:15, 15 August 2007 (UTC)

Where is "over here"? Paul Magnussen (talk) 23:48, 21 April 2008 (UTC)

I've rewritten diagnosis and aded a section on prevalence. There was too much material here that really belongs in a discussion on attachment styles, not RAD. Fainites ^barley 18:08, 21 August 2007 (UTC)

I've also added extensive passages from ICD and DSM as to what RAD actually is, and a brief section on attachment theory as that is its theoretical base. Fainites ^barley 19:24, 22 August 2007 (UTC)

[edit] Odd paragraph

I took this out as it didn't seem to fit, intending to move it to attachment disorder but it doesn't seem to fit there either so I'm putting it here for now.

• When the first-year-of-life attachment-cycle is undermined (Basic Trust vs. Mistrust, in Erik Erikson's framework) and the child’s needs are not met, and normal socializing shame is not resolved, mistrust begins to define the perspective of the child and attachment problems result. ^[1]In direct consequence, the child may develop mistrust, impeding effective attachment behavior. The developmental stages following these first three years continue to be distorted and/or retarded, and common symptoms emerge. ^[2]

I suppose Erikson was developing his theory at around the same time as Bowlby, but the trust/mistrust bit only applies to the first year I think. Fainites ^barley 19:32, 21 August 2007 (UTC)

[edit] Research

I've added quite alot on recent research. (the previous version said that 'research was ongoing as of 2004!) Can somebody more knowledgable than I check it over please. Fainites ^barley 18:36, 22 August 2007 (UTC)

Also, does anybody have the RAD/Bi-Polar paper to check please? I'm afraid all old refs need checking on the attachment pages. Fainites ^barley 19:14, 22 August 2007 (UTC)

Re Alston, here's the PsychInfo printout

> PsycINFO
> TI: Title
> Correlation between childhood bipolar I disorder and reactive
> attachment disorder, disinhibited type.
> MT: Monograph Title
> Handbook of attachment interventions.
> AU: Author
> Alston, John F. (1)
> AF: Affiliation
> (1)Private Practice, Evergreen, CO, US
> SO: Source
> Levy, Terry M. (2000). Handbook of attachment interventions. (pp.
> 193-242). San Diego, CA, US: Academic Press. xiv, 289 pp.
> DE: Descriptors
> Attachment Behavior*; Behavior Disorders*; Bipolar Disorder*; Child
> Abuse*; Early Experience*; Attention Deficit Disorder; Differential
> Diagnosis; Drug Therapy; Family Background; Treatment Planning
> AB: Abstract
> (From the chapter) Describes, from substantial clinical experience, a
> new conceptualization of the role that mood disorders, specifically
> bipolar disorder, play in the lives of maltreated children who
> subsequently develop associated emotional and behavioral problems
> relating to bonding and attachment. This conceptualization takes both
> trauma and attachment theories into account and is not in opposition
> to them, but offers different perspectives in reaching certain
> conclusions. Based on clinical experience, the author describes the
> psychiatric diagnoses of abusive parents that are indicators of
> genetic vulnerability for the development of mood disorders in
> maltreated children; presents differential characteristics of
> attention deficit disorder, bipolar disorder, and reactive attachment
> disorder, disinhibited type; and reviews effective medical treatment
> plans, specifically addressing medications useful in the
> psychopharmacology of disruptive behavioral disorders associated with
> early-life maltreatment. Recognition of the correlations between
> bipolar disorder and reactive attachment disorder, disinhibited type
> leads to more effective treatment plans, resulting in greater
> emotional accessibility and receptivity, social reciprocity, self
> control, and improved mood and self-esteem. (PsycINFO Database Record
> (c) 2007 APA, all rights reserved)
> IB: ISBN
> 0124458602 (paperback)
> PB: Publisher
> San Diego, CA, US: Academic Press
> TA: Target Audience
> Psychology: Professional & Research
> LA: Language
> English
> PY: Publication Year
> 2000
> PT: Publication Type
> Book; Edited Book; Chapter; Handbook/Manual
> FC: Format Covered
> Print
> PO: Population
> Human
> AE: Age
> Childhood (birth-12 yrs)
> ID: Identifiers
> genetic vulnerability & differential diagnosis & treatment
> plans & psychopharmacology, bipolar I & reactive attachment
> & attention deficit disorder, maltreated children
> CL: Classification
> 3211 Affective Disorders; 3300 Health & Mental Health Treatment
> & Prevention
> NR: Number of References
> 1 reference(s) present, 1 reference(s) displayed
> RE: References
> American Psychiatric Association. (1994). Diagnostic and statistical
> manual of Mental disorders (4th ed.). Washington, DC: Author.
> LR: Last Revision Date
> 20000301
> UD: Update
> 20070609
> AN: Accession Number
> 2000-07048-008
> RF: RAW Data File
> PIMain2000_02.xml; PIRefs2000_02.xml
> RX: Cited by
> 2 (on Jul 14, 2007)

Looking at this, its clinical opinion by someone who appears to be notable only in the world of AT. The citation is Levy which is an attachment therapy, not a mainstream handbook. Plus only 2 citations. I propose to remove this reference. Fainites ^barley 23:02, 24 August 2007 (UTC)

I think you have the man fairly well scoped out. Shortly after the above book was published, he testified at the "rebirthing" trial. He said then that over the preceding 20 years he had experience with 2000 children with (the "very uncommon") attachment disorder and at least 1500 children as bipolar, "of which the vast majority of them have these [as] co-morbid features". In February 2001, he told the Los Angeles Times (in reaction to Candace Newmaker's therapists telling her, 'You want to die? OK, then die. Go ahead, die right now.'), "you need to use ‘paradoxical intention.’ When they say ‘I’m going to die,’ you say, ‘Go ahead and die.’ That way, you defuse the oppositional element. If you respond to it, you buy into it." Coupled with the fact that the above is not a peer-reviewed publication of research, this is unreliable. Thus, in my opinion, the statement in the article which references it is unsupported by a reliable source and should be removed, which I see you've done already. Larry Sarner 14:16, 25 August 2007 (UTC)

How did you do that thing to make the print out readable? Fainites ^barley 20:46, 25 August 2007 (UTC)

[edit] Tag

I've removed the 'confusing' tag as the article has been almost entirely rewritten since the tag was placed. However, if anyone thinks it needs a new tag, that's a different matter! Fainites ^barley 15:12, 30 August 2007 (UTC)

[edit] Why Reactive?

found this explanation

• "In a thorough critique of RAD definitions, Zeanah (1996) argues that the term ‘reactive’ was merely an attempt to differentiate RAD from Pervasive Developmental Disorder (PDD) which can present with similar symptoms. While PDD was thought to have organic causes, RAD was conceptualized as a functional impairment brought about by adverse rearing conditions. Yet, this dichotomy of organic versus functional holds very little value given research findings about the interactive nature of social factors and brain development. In this way of thinking, RAD is no more or less “reactive” than other psychiatric disorders, and children with PDD may very well also suffer from attachment disturbances." Fainites ^barley 15:57, 13 September 2007 (UTC)

I read and was told that like sexual reactivity in children who act out sexually because they were abused... Reactive Attachment Disorder is caused due to mal treatment... children reaction —Preceding unsigned comment added by 141.152.143.254 (talk) 21:56, 13 October 2007 (UTC)

I suppose that was the idea. Children 'reacting' to maltreatment relating to attachment issues. Now the name has stuck. Fainites ^barley 23:37, 24 October 2007 (UTC)

[edit] GA on Hold

Hello, and thanks for writing such an interesting and informative article! I'm putting its GA nomination On Hold for a period of up to one week. I need to apologize first — real life concerns are calling me away from the computer now. I only have a couple minutes. I might leave some details off this description. I'll come back either tomorrow or perhaps late tonight, and I may add more at that time. Again, I apologize for that. However:

1. Several books are mentioned in Harvard-style inline cites, but several of those books are not listed in any section of references. there's a discussion of how to do this properly in Wikipedia:Citing sources.
2. Cites from books need page numbers. One way to do that might be to have separate "Notes" and "References" sections. See Georg Cantor for an example of this particular implementation.
3. The formatting of the references does not look consistent. I'll try to look again tomorrow.
4. Some sections look under-referenced. I apologize for that vague, blanket stament. I promise I'll fill in the details later.
5. The lede should be a summary of the entire article (please read WP:LEDE. I didn't see anything from the "Treatment" or "Recent Research" sections in the lede. Don't go into too much detail; a sentence or at most two from each section would probably be enough: "Common treatments include xx, yy and zz. Another treatment, qq, is more controversial."
6. I may have more nitpicks later.

I'm really sorry, I need to go. I will come back here later. Cheers! Ling.Nut (talk) 11:20, 14 December 2007 (UTC)

Thanks! Fainites ^barley 13:20, 14 December 2007 (UTC)

The cites inside the parentheses need to be given full refs, eg: (Hanson & Spratt, 2000; Wilson, 2001). Ling.Nut (talk) 14:11, 14 December 2007 (UTC)

I've just added refs to everything I can find except those two (mostly under treatment/measures and theory). Those two are part of a quote from the APSAC report. Do they still need their own refs? There's no difficulty getting them - its just that they're part of another ref if you see what I mean. Fainites ^barley 14:27, 14 December 2007 (UTC)

I've also put a synopsis of treatment/controversy and research in the lead. Fainites ^barley 14:43, 14 December 2007 (UTC)

In the "diagnosis" section, the para about the RADQ, surely the [12] should reference the first part of the first sentence-- the criticisms should be referenced to [13] or some other source, yes? Randolph did not criticize her own work, at least not in this way.Jean Mercer (talk) 22:33, 14 December 2007 (UTC)

Fixed. Fainites ^barley 01:01, 15 December 2007 (UTC)

Also, in the intro, i don't think it's correct that O'Connor and others say that RAD can be reliably identified. Mainstream practitioners acknowledge the vagueness of the criteria and the great difficulty of establishing this diagnosis in school-age or older children.Jean Mercer (talk) 22:38, 14 December 2007 (UTC)

The paper does say this in relation to maltreated toddlers. Perhaps the way its put implies more than that though. I've had another go but you can probably think of a better one or two line synopsis that I can.Fainites ^barley 00:51, 15 December 2007 (UTC)

Was it intentional, saying that programs are based on established theory? This statement raises at once in my mind the question of evidence of efficacy-- to refer to theory suggests that that issue is being avoided.Jean Mercer (talk) 22:41, 14 December 2007 (UTC)

I thought you put that bit in to avoid the implications of 'evidence-based'. By all means tinker with it. Difficult to think of an appropriate designation. There needs to be a distinction between approaches based on a generally accepted theory which have some evidential base or are in the process of acquiring one, and the Others. I don't think it needs to be too complicated for this page though. They're all now described in some detail on the Child therapy page. Fainites ^barley 00:51, 15 December 2007 (UTC)

Fainites, I'm not commanding you to be the one to change these-- I will re-write if you don't object-- but since it was your work, I thought I should just comment, so you can explain or alter as fits your goals for the article. Jean Mercer (talk) 23:02, 14 December 2007 (UTC)

Fire away. Its not owned. In the next few days though.Fainites ^barley 00:51, 15 December 2007 (UTC)

Could you have a bash at the page numbers while you're at it? Fainites ^barley 01:17, 15 December 2007 (UTC)

• (undent) Hello and thanks for tracking down all those refs! There is a little problem, though. The refs are in parenthetical (in this case, Harvard) style but now have an associated footnote-style link inside the Harvard ref. Are the Harvard refs pulled directly from other text? If so then here you run into a little bit of a debate regarding WP:MOS. Some hardcore purists think that nothing, absolutely nothing, inside a quote can be changed, except in traditionally prescribed manner (ellipses, square bracketed [sic]s etc.). That means not even wikilinks... However that idea is disputed... You're just gonna hafta work this out in such a way as to avoid mixing Harvard refs and footnote-style refs. Since the entire article is in footnote style, I suggest that you omit the Harvard refs and use only the footnotes, probably in conjunction with a Notes section, even though the Harvard refs may be directly quoted from some source. The prob here is, the source you're quoting from is using a different referencing style than your article is! Please decide on an approach for fixing the problem of having mixed referencing styles... this is the most important problem I see at this moment.
• You still need page numbers, wherever applicable. I know this is tedious and time-consuming. I'm sorry.
• I added a couple ISBNs that were missing, but didn't check every single reference for missing ISBNs. Please check them all!
• The referencing format is very inconsistent. While this is not something that would fail a GA review, everything really needs to be standardized according to one method. Just one example of inconsistency 9there are many others!):
  • In C.H. Zeanah, Jr. (Ed.)
  • In [book title]. Edited by Berlin
• Ling.Nut (talk) 05:59, 15 December 2007 (UTC)

Note to all dedicated editors: First read comments above, then look at the new "Notes" and "References" sections I created. I believe this is the only way to handle adding page numbers and ameliorating the prob of mixed harvard/footnote style refs.. If you don't like this format, please don't be angry... all you need to do is go to the article history and revert back to the edit of 05:40, 15 December 2007 (which is the one immediately prior to the creation of the new sections. :-) ) I gave you a running start on the NOTES but there are many page numbers to be tracked down. Ling.Nut (talk) 07:01, 15 December 2007 (UTC)

Blimey ! I never could work out from WP:CITE how you do the page numbers bit when you cite a ref dozens of times. Now I know. Thanks Fainites ^barley 08:02, 15 December 2007 (UTC)

Sorry to plop so much work in your lap. BTW, if you have more than one cite from the same page and the same book or whatever, you can (and should) use named refs. Ling.Nut (talk) 08:07, 15 December 2007 (UTC)

What do you mean 'named refs'? In the article? Fainites ^barley 23:40, 15 December 2007 (UTC)

Another thing: the "as discussed in" format I used here is actually kinda lame, and is really only a stopgap solution. You would be much better off inding the original sources and citing them (including page number), then removing any mention of the source it was "discussed in." That's especially true of the sources that you really should have access to: the DSMV-IV, the ascap report, etc. Ling.Nut (talk) 08:52, 15 December 2007 (UTC)

I do have them all. I'll stick them in. Fainites ^barley 23:46, 15 December 2007 (UTC)

(undent) Hi, see my multiple remarks above. I guess I've done about all I can do: I reorganized the WP:LEDE and some of the article's sections, did some light-to-moderate copyediting and did extensive work on the refs (although much work is left to be done!) The rest is up to the dedicated editors of this page. :-) Drop me a line if you have any questions. Ling.Nut (talk) 14:14, 15 December 2007 (UTC)

Yeah for the hard-core-- if you don't mess with the insides of quoted material, except according to the rules, you won't deceive anyone, accidentally or on purpose. F., I will need to come back on Monday to work on this-- sorry for delay. I do think it's essential to do a read-over for substance. I don't think i said that about theory, by the way-- I figure that a syndrome's existence should be the source of theory, not the other way around. Jean Mercer (talk) 16:10, 15 December 2007 (UTC)

Wow thanks again Lingnut. I still don't really quite get the refs system though but I'll call you if we get stuck. Tell you what Jean - I'll do the page numbers for APSAC, Prior and Glaser and you do them for Zeannah, Boris etc and the measures and we'll split the treatments. I'll try Bowlby but I've got the paperback version so the page numbers may be different. On theory, are we still talking about the treatments? What wording do you suggest? Fainites ^barley 19:51, 15 December 2007 (UTC)

Okay, but I don't really have time to deal with wording today, or anything else. Do we have until next Wednesday? I won't push it till the last minute, I promise, but neither do I want to rush this-- again, I think the whole piece needs a careful read-through. We must be our own copy-editors. Incidentally, I don't know what "Harvard" citations are-- parenthetical ones? Jean Mercer (talk) 19:59, 15 December 2007 (UTC)

OK. Fainites ^barley 23:20, 15 December 2007 (UTC)

• Harvard-formatted citations are, in this case, the parenthetical ones.. I didn't simply use the term "parenthetical" to describe them because there are other types (such as MLA) which use parentheses, but are vastly different from Harvard style.
• Named refs are exactly the kind you were using before, with the "name=xxx" inside them... Here are two ref examples. The first is named; the second is not:
  • <ref name="oconzean2003">O'Connor & Zeanah 2003, p. pagenumberhere.</ref>
  • <ref>O'Connor & Zeanah 2003, p. pagenumberhere.</ref>

Ling.Nut (talk) 02:20, 16 December 2007 (UTC)

...but I've already reformatted the Harvard cites into footnotes, using the (lame! see above) "as discussed in..." note. 05:09, 16 December 2007 (UTC) —Preceding unsigned comment added by Ling.Nut (talk • contribs)

Thanks Fainites ^barley 23:11, 16 December 2007 (UTC)

I'm vastly confused by the implication that a page number needs to be given (in the citation) when there is no direct quotation.Jean Mercer (talk) 18:44, 17 December 2007 (UTC)

I'm assuming that if you are summarising a particular passage or statement, then it needs a particular page number, but if you are mentioning an entire scheme like an attachment measure, you don't. Fainites ^barley 20:09, 17 December 2007 (UTC)

On Brodzinsky - a) its a left-over from sock days. (The last one I think) This does not make me inclined to trust that it says what it says it says - none of the socks other citations ever did. b) the title is wrong. Its just 'Being Adopted'. c) Its a book. I don't have it. Amazon don't have a 'search inside' facility for it. I don't know if you have it Jean but I'm not inclined to pay money for a 1992 book to check if yet again a sock citation either doesn't exist or says the opposite to what is claimed.

Surely if those adopted after the age of 6 months are at risk for attachment difficulties there's a more up to date ref? Fainites ^barley 21:41, 17 December 2007 (UTC)

Bet its 80% of them. Fainites ^barley 22:18, 17 December 2007 (UTC)

If Brodzinsky refers to this at all, it would be by giving a primary source. He does adoption stuff, not this type of study of emotional development. I don't have it and don't think it's an important source.

There probably are no recent primary sources-- because why should there be? This is well-established, just like material about the inflation of the newborn lungs in the 24 hours after birth.Nobody's going to repeat that work unless some surprising new event occurs. If you want a more recent secondary source, you can use my "Understanding Attachment" or most (80% of) child development textbooks. Jean Mercer (talk) 00:29, 18 December 2007 (UTC)

I think its kind of repetitious anyway. The article has already said, twice, about breaks in relationships, (repeated) change of caregiver etc etc. Inother words - multiple foster placements followed by adoption. Fainites ^barley 09:44, 18 December 2007 (UTC)

Common sense can be applied to cites. Not every cite needs a page number, esp. if the info isn't particularly attributable to the cited source (as in the case of "common knowledge," which is a slippery concept)... or if the entire paper cited is about the point being made in that sentence. However, it's better to err on the side of caution and supply page numbers wherever possible. Ling.Nut (talk) 02:03, 18 December 2007 (UTC)

Yes, F., it is repetitious, but I think the important point here is the age period during which the effect is most severe. This is the issue that is most often misunderstood-- e.g., we are saying that infants adopted at birth would NOT be expected to develop RAD as a result. Jean Mercer (talk) 14:30, 18 December 2007 (UTC)

OK. It actually says in the heading 'after the age of 6 months' so that can be repeated and expanded on if necessary in the relevent part of the article. This particular passage is talking about general interference with development of secure attachment as opposed to RAD.Fainites ^barley 14:54, 18 December 2007 (UTC)

I think that's all the refs, notes and IBSN's done. Just awaiting your content check Jean. Fainites ^barley 16:32, 18 December 2007 (UTC)

I think I've found everything I'm going to find-- Jean Mercer (talk) 22:27, 18 December 2007 (UTC)

[edit] GA PASS

Congratulations on a well-written and informative article!

• As you move on through WP:LoCE, WP:PR & WP:FAC, some people might give you grief about two things: the use of bullet points in the body of the article, and the use of multiple footnotes for a single point. Bear in mind, there really is not 100% consistency about how reviewers repond to these. If reviewers' comments seem reasonable, then change things accordingly. If not, then be flawlessly polite but unyielding, and be sure to have a logical/plausible rationale ready for your decision. Good luck!
• Ling.Nut (talk) 02:04, 19 December 2007 (UTC)

Thanks for your invaluable help and advice Ling.Nut. Fainites ^barley 15:06, 19 December 2007 (UTC)

[edit] Template for citations

{{cite journal
| author = 
| title = 
| journal = 
| volume = 
| issue = 
| pages = 
| year = 
| pmid = 
| doi = 
| issn = 
}}

Fainites ^barley 00:12, 31 December 2007 (UTC)

(applied some tricks to make the template visible, so one doesn't need to go in edit mode to copy it --Francis Schonken (talk) 10:37, 31 December 2007 (UTC))

Thanks. Fainites ^barley 10:59, 31 December 2007 (UTC)

[edit] WP:MEDMOS

1. Classification
2. Signs and symptoms or Characteristics
3. Causes or Genetics
4. Pathophysiology or Mechanism
5. Diagnosis (including Characteristic biopsy findings and differential diagnosis)
6. Prevention or Screening
7. Treatment or Management
8. Prognosis (social impact may also be discussed)
9. Epidemiology
10. History (not patient history)
11. Cultural references
12. See also (avoid if possible, use wikilinks in the main article)
13. Notes
14. References
15. Further reading or Bibliography (paper resources such as books, not web sites)
16. External links (avoid if possible)

Fainites ^barley 13:01, 31 December 2007 (UTC)

Prognosis seems to be the main one missing. Fainites ^barley 13:07, 31 December 2007 (UTC)

How about using the material in 'theoretical framework' for 'mechanism' ? Fainites ^barley 15:55, 1 January 2008 (UTC)

A mechanism for development of a disorder of attachment would involve causes for typical or atypical steps in attachment, leading under certain circumstances to an internal working model of social relationships that assumed malignant expectations about people's behavior toward each other. It would be hard to posit such a mechanism without considering Theory of Mind,with its own developmental steps. In addition, because not all children respond in the same way to difficult attachment histories, temperamental characteristics would need to be included in the mechanism. These have not been thoroughly discussed in published material. In any case, the "theoretical framework" material was so much simplified that I don't see how it can substitute for "mechanism", even if you simply interpreted "mechanism" as meaning "some causal factors"... and if "pathophysiology" is the alternative term for "mechanism" I don't see how you can interpret it that way.

Perhaps you could say "possible mechanism" and then have some discussion of internal working models as well as of temperament? The only real alternative I see, if MEDMOS is used, would be simply to say that certain categories remain uninvestigated.

Some material for "epidemiology" could come out of the Rutter work, although of course that does not focus on attachment disorders in the specific sense.Jean Mercer (talk) 01:33, 2 January 2008 (UTC)

How about "theoretical mechanism" ? A sort of double meaning! Why don't you try and write something? I simplified the theoretical framework stuff for the benefit of readers who know nothing about attachment but may not click on the attachment article. Do you think I should put it back where it was - and then you write a section on "possible mechanism" ? I found this [2] we could link too. Or there's quite a long article on Theory of mind.Fainites ^barley 09:43, 2 January 2008 (UTC)

I've made various additions - primarily to highlight the ongoing nature of it all. The prognosis section is very much work in progress until tomorrow. Fainites ^barley 23:32, 2 January 2008 (UTC)

I'll try to do what I can on "possible mechanism", as soon as i can-- I have corrections to do on an article for SRMHP (the EBP one), I have to go to Texas for mother-tending purposes, and I have a book ms. that needs to be wrapped up. I tell you, though, this material is slippery stuff. Without a clear definition, how do you know what caused the things that might but don't necessarily happen? Not rocket science, much more complicated than that.

Also, there is going to be trouble sourcing this. Jean Mercer (talk) 00:24, 3 January 2008 (UTC)

OK. Fainites ^barley 12:38, 3 January 2008 (UTC)

I've added quite a lot of detail and supporting refs Jean and I'd be much obliged if you could cast the other beady eye over it. I've found what I can for outcomes - which isn't much, plus other bits in diagnosis (over diagnosis/no universally accepted protocol/older children) and treatment re co-morbidity, older children, what isn't known (sourced) etc etc. Thanks.Fainites ^barley 00:32, 4 January 2008 (UTC)

Did an attempt at genetics and mechanism-- haven't put in sources yet. Some will be Waters et al.72.73.192.55 (talk) 18:28, 11 January 2008 (UTC)

• You added your IP address to the article, where the sources belonged. Please don't do that! Instead, you should use one of the standard Wikipedia templates for referencing the articles or books that are the original sources for the material that you added. Here is a convenient page showing these templates: WP:CTT. Also, I suggest that you register with Wikipedia. Edits from registered users are trusted far more than edits from unregistered users. It also gives us a better way to have a conversation with you about Wikipedia matters and procedures. In any event, welcome to Wikipedia! — Aetheling (talk) 18:41, 11 January 2008 (UTC)

Tut tut Jean! Fainites ^barley 20:13, 11 January 2008 (UTC)

This bit (as summarised a little by me) was in the Zeanah et al twin study article. Do you think it should go into mechanism?

In discussing the neurobiological basis for attachment and trauma symptoms it is posited that the roots of various forms of psychopathology (including RAD and PTSD) can be found in disturbances in affect regulation. The subsequent development of higher-order self-regulation is jeopardized and the formation of internal models is affected. Consequently the 'templates' in the mind that drive organized behavior in relationships may be impacted. The potential for “re-regulation” in the presence of “corrective” experiences (normative caregiving) seems possible, though has not been documented at the neuronal level. Like many other papers in this poorly researched area many new avenues of enquiry were raised.

Fainites ^barley 20:21, 11 January 2008 (UTC)

Fainites, that would be fine-- if you put it right after the part about the emergence of fear and proximity-seeking, that makes sense. But-- I'd rather not see the term "corrective" experience used to refer to normative situations, as this expression has been used to refer to holding therapy. Also, maybe scratch the "neuronal level"-- even if this were possible to test in a living human being, it wouldn't answer the question.

Atheling, I apologize for forgetting to sign in, in my haste to contribute to this part. (Actually I thought i had, and when my name didn't show up I thought-- have i forgotten how to do this in the last week?) I had a choice of spending the time doing one complete para with sources, or doing several and coming back to fill in sources, and I chose the latter in order to have more continuity in the section. Personally I prefer substance over style, and that's probably the case for most people who write for print publication. I will be back in the next couple of days to do what's needed. Jean Mercer (talk) 21:01, 11 January 2008 (UTC)

I'm just jolly impressed someone noticed and acted. Fainites ^barley 22:47, 12 January 2008 (UTC)

"corrective" is the word they use - in inverted commas. Perhaps thats why they put it in inverted commas. They're clearly talking about normative caregiving though, and this is all with young children. Not AT type therapy, or indeed any therapy, with older children. Tricky. Fainites ^barley 21:56, 11 January 2008 (UTC)

I know they mean what you say--- the trouble is that certain other authors have used the term differently (in fact, if I remember correctly, one has the term corrective attachment therapy "service-marked"). I just think it would be wise to avoid the ambiguity, for the sake of readers who will probably not go and find all the sources cited. But if you really want to use it you could quote enough to make it clear what your intention is.Jean Mercer (talk) 01:38, 12 January 2008 (UTC)

Not only has that not been shown at the neuronal level, it hasn't really been shown at any other level either. I don't say it's not true, just that it's not evidentiated.Jean Mercer (talk) 01:41, 12 January 2008 (UTC)

I did add 'normative care giving' in my summary because it was clear that was what was meant. I suppose the 'neuronal level' was because they were talking about possible neurological mechanisms. I'll have another look.Fainites ^barley 19:55, 12 January 2008 (UTC)

A point to keep in mind:

"The difficulty in linking synaptic plasticity to behavior arises from trying to identify synaptic sites in the distributed neural networks of the mammalian brain that are strengthened or weakened by specific experience. In addition, many classic paradigms that induce synaptic plasticity depend on stimulation patterns that are not physiologically plausible. Even if valid conditions are used, it is still hard to show that results gleaned from brain slice preparations underlie experience-dependent changes in behavior". (M. Brecht and D. Schmitz, "Rules of plasticity", Science, 4 Jan 2008, Vol. 319, p. 39.

Also, see the Santiago Declaration.

So, to summarize, boo sucks to neuronal explanations, and let's not be drawn (sucked?) into that way of thinking when we have good evidence for what we do say.Jean Mercer (talk) 17:05, 13 January 2008 (UTC)

I can't change it because its what the source says. The options therefore are to 1) remove it altogether, or 2) add in another source (like the one you've quoted above, or 3) remove the bit after 'impacted'. Which do you think best represents the current state of play? Fainites ^barley 18:57, 13 January 2008 (UTC)

Or we could slice more brains. Where shall we start? Fainites ^barley 18:59, 13 January 2008 (UTC)

It's not a direct quote, so why not take out the clause about the neuronal level? After all, it says this has NOT been shown, so what's the point of including it at all?Jean Mercer (talk) 20:06, 13 January 2008 (UTC)

I've done as i am told--- but I made a banner for a reference and don't know how to unbanner it. Can someone either tell me or do it?Jean Mercer (talk) 21:42, 13 January 2008 (UTC)

Fantastic! Just two things. There's one sentence that needs a ref. I've put a fact tag on it so you can see it. The second thing is that the Mercer cites need a page number as its a book. (I've done the banner - the way that occurs is if you leave a space at the very beginning of the line). Fainites ^barley 22:58, 13 January 2008 (UTC)

Does your silence on my many additions (above, 4th Jan.08) mean they meet with your approval? Fainites ^barley 23:05, 13 January 2008 (UTC)

No, it means I'm aloof and emotionally unreachable.... yes, they're fine, sorry not to have spoken up before. Don't poke me under the arms please.

Will do page numbers in one second, roughly.

(F., are your newspapers following the New York case of Nixzmary Brown, whose stepfather is now on trial for beating and mistreating her to death? You might want to look at it-- I don't think it's AT, but it shows how common or garden child abuse can overlap with AT parenting.)Jean Mercer (talk) 23:56, 13 January 2008 (UTC)

Okay on page numbers and all?Jean Mercer (talk) 00:16, 14 January 2008 (UTC)

Since we're doing this MEDMOS thing, do you want to do the cultural references, or shall I, or is there anyone else looking on who wants to do it? Jean Mercer (talk) 00:18, 14 January 2008 (UTC)

I've heard of Nixzmary Brown but I'm not aware of papers following it. I'll keep an eye out. I've thought before, from the point of view of an ignorant outsider, that there's an awful lot of US cultural attitudes to child-rearing in AT. (Do you remember WifeSwap? I know they tended to select people with psychological problems or rather extreme personalities but even so, watching the US ones was fascinating as a comparison to the UK ones on child rearing).

Nixzmary Brown was one of those cases where a child was bullied and battered over a long period of time in the name of discipline wasn't it? Fainites ^barley 21:15, 16 January 2008 (UTC)

Would a cultural references section deal with popular conceptions of RAD which means AT? I suspect this section is a great deal less important that the 'medical' ones. Its more that if there are any cultural refs - the end is where they go. What did you have in mind? More AT (the popular conception) or 'Elvis does holding' (which he did). Fainites ^barley 07:08, 14 January 2008 (UTC)

Re N.Brown: Yes, she was, and there were aspects resembling AT parenting-- but I think the perpetrator was just an ordinary nut case. That's what's interesting to me about it--- I think it's important to discriminate between systematic, "theory-based" abuse on AT lines, and some similar abusive acts without systematic beliefs behind them, resulting from individual experiences or cultural considerations. (E.g., recent discussions of African immigrant families rubbing children with pepper-imbued creams as punishment.)Jean Mercer (talk) 21:27, 16 January 2008 (UTC)

[edit] Cultural references

I'm tired of scrolling down that section-- let's have a new one.

I agree that some U.S. values are embedded in AT and make it acceptable to certain groups. Some of these are related to Calvinism, some, I think, to the German "black pedagogy". The idea of exorcism comes into the picture too. But i don't think these are what is meant by cultural references-- are they? I think of the Presley "Changes of Habit", the TV movie "Child of Rage", various other semi-fact-based television shows, and the incessant repetition of AT definitions of RAD in newspaper reports of child deaths and injuries. To go farther afield, there are allusions like that of mary McCarthy in "Memoirs of a Catholic Girlhood", referring to her orphaned and neglected brother setting fires. How do you interpret cultural references?Jean Mercer (talk) 15:04, 14 January 2008 (UTC)

Mostly those are really AT cultural references. Elvis did holding therapy but was it for RAD or autism? There's that thing based on poor Candace and then there's that creepy Twilight Zone thing on Evergreen. Are media/AT misrepresentations of RAD, "cultural references"? Again - its a particular phenomenommenomm - but is it a cultural reference? Zeanah et al called it a "cottage industry". Even if someone wrote something clever combining folk beliefs about children, black pedagogy and Speltz's analysis to similarities with brainwashing, its still more of an AT thing I think. How about a short piece on the folk beliefs/misunderstandings about RADkids, RADishes as demonised potential Ted Bundy's etc? This is sourced in Chaffin, Prior and Glaser and quite possibly the others too.Fainites ^barley 20:22, 14 January 2008 (UTC)

We could just leave cultural refs out or have something along the lines of:

Representation of RAD in popular culture.

Extreme claims are made by proponents of attachment therapy on websites and elsewhere as to both the prevalence and effect of attachment disorders. Children are labeled as “RAD’s,” “RAD-kids” or “RADishes.” (Chaffin et al, 2006, p79) They are seen as manipulative, dishonest, without conscience and dangerous. Some attachment therapy sites predict that attachment disordered children will grow up to become violent predators or psychopaths unless they receive the treatment proposed. One site was noted to contain the argument that Saddam Hussein, Adolph Hitler, and Jeffrey Dahmer, were examples of children who were attachment disordered who “did not get help in time”.(Chaffin et al, 2006, p80) Similar lists appear in an attachment therapy parenting book. Foster Cline in his seminal work on attachment therapy Hope for high risk and rage filled children uses the example of Ted Bundy.(Cline 1992 p) Children are described in a demonising tone. (Prior and Glaser) Proponents published materials include claims that raping a cat or dog is not uncommon and some have raped or killed numerous animals. There is frequent mention of children who kill or have killed. A claimed favoured technique of such children is to injure themselves then claim to have been abused. Conversley, supposedly attachment disordered children killed by parents are seen as responsible for driving their parents to batter them. They are said to identify with the devil. Testimonials, supposedly written by children who have changed through attachment therapy and parenting techniques, describe themselves as having been a 'demonic queen' or a 'witch, a powerful demon' even one who has 'already killed'. One says "I feel if I didn't have a powerful attachment therapist I probably would have turned into a mass murderer or serial killer......I feel I can still be fixed because I haven't killed yet".

All this is easily sourced as you know.

Or is this just part of AT? Fainites ^barley 21:33, 14 January 2008 (UTC)

The child in the Elvis movie is represented as autistic-- at least, she's mute.

I would assume that "cultural references" refers to material from outside the AT group, or shared by AT and non-AT writers.

I replaced "typically", which i think is a meaningful addition in this case, particularly because the information that this is a turning point for most babies implies that behavior at this age may be a predictor of later problems. Jean Mercer (talk) 00:08, 15 January 2008 (UTC)

Fine. I just thought the 'typical' in the first sentence could be assumed to cover them all. I've done the last few doi's and links etc and contacted 'Colin' as suggested by SandyGeorgia for a further review. Fainites ^barley 21:09, 15 January 2008 (UTC)

[edit] Causes and genetics

I don't know that there's a way to put this in, but it may be that no two children are actually raised in the same environment. There may be some shared environmental characteristics, but there are also many nonshared factors, even for two children in "the same family". Between genetic variation and nonshared factors, it's not surprising that children don't have the same outcomes, and it's certainly always difficult to chase down the combinations of factors that cause an outcome. This is one reason why DSM and other sources remain as vague as they do.Jean Mercer (talk) 00:19, 3 February 2008 (UTC)

Is this getting a bit too complicated? I mean, I see what you're saying, but trying to work out whether different outcomes relate to genetics, temperament, position in the family, different parenting approach etc etc must be the same problem in all these areas. Twins are probably about as good as it ever gets but even then the ones in this study were different genders. We could put in a sort of 'insofaras'.Fainites ^barley 14:06, 5 February 2008 (UTC)

By the way - SandyGeorgia said to run the article past the Psychology and Medical projects before applying for FAC so I've left messages with them.Fainites ^barley 14:07, 5 February 2008 (UTC)

[edit] Disorganised attachment

Jean - is there any paper at all on the extent to which early disorganised attachment can be a risk factor for RAD? Fainites ^barley 16:06, 7 February 2008 (UTC)

I remember seeing it said somewhere - but if disorg. att. is a developed attachment and RAD is a lack of one - how can this be? Mind you, in the twin study the twins showed signs of both. Fainites ^barley 14:40, 12 February 2008 (UTC)

Sorry, no such thing as lack of attachment (WRT attachment theory). If there are caregivers, there's an attachment. period. The four subtypes in attachment theory cover all bases. cheers, Casliber (talk · contribs) 10:31, 13 February 2008 (UTC)

It says lack of developed attachment. But isn't that one of the conceptual/perceptual problems with RAD though. There is a perception that RAD means lack of attachment because essential elements of attachment behaviour are missing. But what does 'no attachment' mean compared to lack of attachment behaviours? Fainites ^barley 14:03, 13 February 2008 (UTC)

[edit] Stuff to add or subtract (post Fac application)

OK -

• Whole section on Theoretical framework is an issue for me. I forgot to check in DSM IV TR today on how RAD got its name, but there is little in the criteria which relates to Bowlby etc. as it stands - this will most liekly change in future but that is speculative. Hence para 1,2, 3, and 4 are possibly irrelevant to the diagnosis (and hence article). Para 5 actually crystallises the problem the article has in confusing definitions but badly needs a ref. I have not seen this written as most therapists would not make this error as they would be fully aware of the two different paradigms (i.e. blunt DSM classification vs. much more detailed Attachment stuff) when they were discussing diagnoses and theories etc cheers, Casliber (talk · contribs) 10:39, 13 February 2008 (UTC)

• Hmm. Those who drafted the DSM etc claim it is very firmly based on attachment theory. I did once find a bit on how it got its name - from memory it was something to do with it being 'reactive' to circumstances as opposed to arising organically in some way. I think most would agree the name may not be appropriate any more - but we're stuck with it for now.

Yep, I thought it might be and agree that we are stuck with the name. cheers, Casliber (talk · contribs) 11:19, 14 February 2008 (UTC)

• What I was trying to do in the theoretical framework bit was distinguish RAD from styles as it is not remotely obvious to non-professionals, or indeed many professionals who haven't made a particular study of it. Most of the people reading this article won't be therapists. Indeed the attachment articles as written by the attachment therapists all cited Cicchetti and Lyons-Ruth on disorganised attachment as if they were talking about RAD. (as in claiming 80% of maltreated toddlers had RAD and using Cicchetti and Lyons-Ruth as the source). One article contained the phrase "Attachment disorder (disorganised subtype)". They also lumped insecure attachment in with RAD and attachment disorder. There is a great deal of misunderstanding out there between RAD/AD/ and styles.
• I'm not very clear here what you are suggesting we do. Are you saying there is no need for a passage distinguishing RAD from attachment styles? What if this distinction were made in the diagnosis section? Or the classification section? This article is not being written for professionals only. A previous reviewer, not a mental health specialist, specifically asked for a brief description of the styles to enable him to understand where RAD fitted (ie, not same as insecure or disorg. att. etc).

• A ref for the last para would be the Taskforce, although many authors mention this confusion. I was trying to explain the confusion - not add to it! Obviously unsuccessfully. Fainites ^barley 12:30, 13 February 2008 (UTC)

Agree this is hard. As a clinician and a psychiatrist and one who has also done quite a bit on attachment theory it is easy for me. I'll have to look at it in more detail.cheers, Casliber (talk · contribs) 11:19, 14 February 2008 (UTC)

• Classification and characteristics - not bad. Needs a diagnosis section like in schizophrenia after it to detail who makes the diagnosis and how, plus allied health etc. Developments is ok.

I can shift the diagnosis section up. Fainites ^barley 12:30, 13 February 2008 (UTC)

• Causes - middle para needs a complete overhaul. Landmark study on adverse early expeirnces leading to future psychological problems is Isle Of Wight Study by Rutter. Would be good to mention there.

But is it RAD? I took out all the stuff on disorganised attachment as it wasn't RAD. Fainites ^barley 12:59, 13 February 2008 (UTC)

• Diagnosis section, should be combined with one above. Sentence 1 RAD is one of the least researched and most poorly understood disorders in the DSM. - I have a real problem with. There is loads of research in the area, just not into this recent artificial construct called RAD. Need to figure out as this needs overhaul. Para 3 is irrelevant as refers to Attachment Theory and not to RAD at all. Ditto DAI. Last para OK (I think)

Sentence 1. Thats taken directly from the Taskforce report on RAD and similar statements are made in much of the literature. There is, as you say, loads and loads of research on attachment but not on RAD. But this article is about RAD. I thought you wanted stuff that wasn't strictly about RAD removed. It may be that in the future, research discovers it doesn't exist as a separate entity for all I know. On measures; there is no one accepted protocol for diagnosing RAD. Diagnosers seem to use a whole range of measures which pick up a whole range of attachment information. The DAI is designed to pick up on disorders including RAD. Fainites ^barley 12:30, 13 February 2008 (UTC)

(groan) - this is a real can-of-worms area and starts to veer into a very complicated political area of developmental psychiatry. The reason I mention Rutter is that although there is little research on RAD as such, there is alot on child trauma and future outcomes in terms of psychopathology. However, I can't recall seeing them discussed in the same paper (though there must be I would think). I don't want to veer into OR either. cheers, Casliber (talk · contribs) 11:19, 14 February 2008 (UTC)

Maybe there's a whole separate article in that. Fainites ^barley 21:23, 14 February 2008 (UTC)

• Differential diagnosis - needs expanding and make into subsection of previous. eg. nonorganic FTT, how are autistic kids different etc.

OK. (I seem to recall seeing some research somewhere where they had a bunch of kids they thought were either autistic or RAD, treated them for RAD and counted which ones improved. I'm sure there must have been more to it than that though! Sounds a bit off put like that. I'll see if I can find it). Fainites ^barley 22:35, 14 February 2008 (UTC)

• Alternative diagnosis - I have never heard of attachment therapy outside of WP. Not sure what to do with this bit yet.

Its big on the Web. Its largely an American thing. They make extreme claims about the nature of RAD, cause, diagnosis, treatment etc. They are thought to be outside the mainstream but pretend, pretty successfully, not to be. They claim only their therapies (holding etc) work and nothing else does. They publish diagnosis lists on their sites. One of them ran the attachment pages on Wiki for over a year using 6 or 7 sock-puppets. I suggest you have a quick read of Attachment therapy. Also the Taskforce report which covers RAD, AD and attachment therapy. I can send you a copy if you don't have access to it. If you Google reactive attachment disorder most of the material you see there will be attachment therapy stuff from professional sounding clinics and organisations rather than mainstream stuff. Alot of the major works on this area include information on this, Prior and Glaser, O'Connor etc etc. The Taskforce on AT contains alot of the big players in this field. There have been practice parameters and pronouncements about it from eg APA. AAPSAC, BAAF. There was a whole special issue of Attachment and Human Development on it. It would be quite wrong in my view to ignore it on Wiki.Fainites ^barley 12:30, 13 February 2008 (UTC)

• Epidemiology - para 3 can be ditched as it refers to Attachment theory and not RAD

OK. Fainites ^barley 12:43, 13 February 2008 (UTC)

• Prognosis and impact - isn't too bad. Didn't look closely but think it is relevant.

Ooh, ta! Fainites ^barley 12:43, 13 February 2008 (UTC)

Anyway, gotta run and edit some mushrooms. Ask away though. cheers, Casliber (talk · contribs) 11:01, 13 February 2008 (UTC)

OK. Fine. Try lightly fried with a little butter and black pepper. Fainites ^barley 12:30, 13 February 2008 (UTC)

[edit] Article has improved!

The article has all of a sudden improved greatly! Kudos for that. It would be improved even more if sentences using the passive voice could be changed. For example:

1. Reactive attachment disorder (RAD) is the diagnostic term used to describe ... by whom?
2. It is thought to grossly disturb the development of a child's internal working model of relationships ...by whom?
3. In general, all sentences in the passive voice should be changed to active. I would change them myself but I do not know the subject matter well.

Also, who established the use of the term RAD? Was it used generally before it first appeared in DSM? The Zeamah article (which perhaps you reference) is very good in wading through the history and the discrepancies inherent in the concept of attachment disorders. (It may already be referenced in the article, I just could not find it.)

• Zeanah CH (1996). "Beyond insecurity: a reconceptualization of attachment disorders of infancy". J Consult Clin Psychol 64 (1). PMID 8907083. 

I really am not "against" the article. I just want it to be clear. I am a forensic psychologist and write reports for judges and lawyers, so I have a low tolerance for ambiguity. I apologize for my abruptness as in my field a practitioner has to be tough. The Zeanah article is very helpful. The writer clearly knows the subject matter and does not need to waffle. That is not to say there may be those who disagree. It is a good choice, I believe, to frame this article on the Zeanah article above. I would be happy to copy edit once the content is settled. Mattisse 01:23, 15 February 2008 (UTC)

Yep, that is a good article, succinct and informative and frames the issues well. It highlights problems with DSM and also the challenges in reconciling the two paradigms. I have a problem with the use of the word non-attachment in the end bit though. Even though it is succinct it still presupposes a fair degree of familiarity and expertise with the subject matter, so there are huge challenges in a non-psychologist/psychiartist distilling information from this article and that is where I'll try to help. cheers, Casliber (talk · contribs) 02:35, 15 February 2008 (UTC)

It is a good touchstone for me. I believe (generally) that it is possible to write a professional article that is understandable to the lay person - with the help of explaining links etc. I would like to try anyhow. DSM needs to be explained for what it is - a diagnostic tool for professionals, not the last word on any condition. In it's defense, although arbitrary, it actually is tremendously helpful for professionals. It absolutely helped me in communications with the court. Maybe it sounds manipulative, but I could control outcomes through its strategic use. Mattisse 03:28, 15 February 2008 (UTC)

I should add, it took me many years after I was licensed and practicing, to really understand what I was talking about, even though I sounded like I did. I read some simple definitions and explanations over and over for many years before it all clicked way after I was established. I do not think that there is any way to get around this difficulty of the subtlety involved in even the basic concepts in the area of psychology/psychiatry. Mattisse 03:35, 15 February 2008 (UTC)

Thanks for saying its improved Matisse. I am dead chuffed that people who practice in this area are getting involved. By the way - I recall reading that Zeanah was one of the people invloved in drafting the DSM criteria in the first place. I hadn't come across that particular Zeanah article before. I wish I had. It might have made my job easier! The sentence about "grossly disturbed internal working models" comes from the AACAP 2005 guidelines >Boris NW, Zeanah CH, 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" (PDF). J Am Acad Child Adolesc Psychiatry 44 (11): 1206–19. PMID 16239871.  Thats Boris and Zeanah. You may find this as equally helpful as the earlier Zeanah article. Fainites ^barley 18:46, 15 February 2008 (UTC)

Professionals do not want to get involved in these articles because they are a magnet for kooks, to put it bluntly, or special interest groups promoting a set of programs or books or whatever. These editors usually cannot be staved off and persist until others give up. I believe you said this article had to go to Arbitration because of such problems. The only article I worked on recently in psychology, not realizing it was controversial, was Psychopathy which was immediately was flung into Arbitration also. However, you seem flexible in your attitude and willing to be open minded while using good source material. So I have hope. I compliment you on the way you are handling all of this. If Zeanah was involved in drafting the criteria, that is good because it is essential to understand the thinking that went into the decisions regarding criteria selection and wording. Mattisse 19:25, 15 February 2008 (UTC)

In case you're interested, heres an example of what the article used to look like.[3]. Note the wonderful cure-all therapy and the links to attachment therapy sites. Multiply that by a few dozen articles - all run by the same sock army. Its enough to make anyone give up in despair. I'm hoping that if the attachment related articles get GA or FAC it makes it more difficult for this kind of thing to happen again.Fainites ^barley 21:26, 15 February 2008 (UTC)

(unindent) By the way - the alternative classifications that Z is talking about in that paper you cited above appear in the development section of the article with later citations.Fainites ^barley 21:57, 15 February 2008 (UTC)

[edit] example

RAD is distinct from the more problematic of the attachment styles such as insecure or disorganized attachment.

-erm, not really. Well sort of... but the sentence is misleading. Attachment (WRT Attachemnt theory) is not pathological but all encompassing. It looks at any individual and examines their attachment to significant figures. Whereas DSM IV is looking at the (possibly arbitrary) threshold for a syndrome causing a significant disturbance in function. The bar for non-normal is in a very different place. cheers, Casliber (talk · contribs) 02:42, 15 February 2008 (UTC)

PS: I'd drop a request for LoCE for the moment as the content has to get sorted first. later cheers, Casliber (talk · contribs) 02:42, 15 February 2008 (UTC)

They have a 3 month waiting list I think. Fainites ^barley 21:22, 15 February 2008 (UTC)

Good point. I don't think it'll take that long to sort out content by any means. cheers, Casliber (talk · contribs) 21:25, 15 February 2008 (UTC)

I don't mind how its worded, as long as enables the average punter not to confuse attachment styles and RAD. Believe me the confusion not only occurs but is actively promoted by the same people who claim 80% of adopted children have RAD. Thats why I also included the very basic info. that a disorder is a disorder if you see what I mean. One of the peer reviewers actually asked me to clarify what the attachment styles were. Originally it said should not be confused with... but they don't like instructions to readers.Fainites ^barley 21:39, 15 February 2008 (UTC)

How about " the criteria for a diagnosis of reactive attachment disorder should not be confused with a description of an attachment style such as insecure or disorganized attachment" Fainites ^barley 00:42, 17 February 2008 (UTC)

Maybe "... confused with the criteria for categorization as having an attachment "style"... " to make the two phrases more parallel in their construction?Jean Mercer (talk) 00:49, 17 February 2008 (UTC)

Had a shot at it. Fainites ^barley 14:15, 18 February 2008 (UTC)

Re your point above Casliber, - Zeanah makes a distinction between what he calls disorders of attachment - "disordered attachments are always insecure attachments (or the absence of attachments altogether), but insecure attachments are likely to be disordered only at the

extremes of each type." - and "nonattached disorders of attachment" which he says are comparable to DSM/ICD. One could argue as to whether there is technically such a thing as non-attachment, except in James VI unfortunate infants who all died, but it does seem as if that is what DSM/ICD intend to mean. Fainites ^barley 14:34, 18 February 2008 (UTC)

[edit] 1996

Why source a 1996 Zeanah paper when the article already cites much more recent work by CHZ and colleagues?Jean Mercer (talk) 21:31, 15 February 2008 (UTC)

One reason is that the 1996 paper is an excellent compendium of the history of the concept and its relationship to DSM - really a very good article that is relevant to this article on RAD. The more recent work is not attempting to be a cohesive historical survey but rather seems to be an organized proposal or "practice parameter" with recommendations. It gives an abbreviated version of the history, but appears to focus more on a recent review of the literature and current proposals in light of many more years of experience with DSM. They both appear to be interesting and valuable sources but one does not replace the other in my mind. Reading the 1996 article clarified immensely for me the issues bedeviling this article on Wikipedia. The more recent article is much more interesting to me when taken in the context of the first. Since DSM has not changed regarding RAD since 1996, we benefit from learning the rationale behind it then in light of the author's more current experience using it. Mattisse 22:06, 15 February 2008 (UTC)

History yes- but theres some stuff on the proposed 'new' classifications in the developments section. Now you've read those two, would you like to read the Chaffin Taskforce paper? Its in the refs section at the bottom of the page. Or if you e-mail me I can send it by attachment. (Secure of course). Fainites ^barley 22:33, 15 February 2008 (UTC)

Yes I will check out those links. Zeanah is excellent and has totally changed my assumption that the area was dominated by quack therapy (for lack of a better term). The second paper is a very thoughtful evaluation, but it strikes me as sad that over a decade later there are still no longitudinal studies, standardized evaluations etc. Zeanah does a very good job of covering those deficits. All his/her recommendations are excellent. Mattisse 22:45, 15 February 2008 (UTC)

Oh good. Perhaps thats changed your views of the authors too? Sadly though, if you Google reactive attachment disorder you get an awful lot of quack therapy. As this article comes second on the list - all the more reason for it to be both accessible and right. On your point about lack of research, nearly every paper you read on this subject complains about it. By the way, you put a 'citation needed' tag in the lead. I don't think everything in the lead needs a citation provided its covered in the article - but I'll look this up. Fainites ^barley 22:47, 15 February 2008 (UTC)

Feel free to remove it if you want. I was glad to see though that Zeanah mentioned the comparison of the proposed etiology of RAD to the parental blame theories of autism. Although I have only briefly run through the article, does he not say that it is not quite clear that caregiver abuse is always the cause? Maybe I misread that. Also, I would like to read the Chaffin Taskforce paper. Mattisse 22:56, 15 February 2008 (UTC)

If you e-mail me I can e-mail it back. You can't attach articles to wiki e-mails. The DSM requires a history of 'pathogenic care'. The parameter says its associated with maltreatment. is that what you menat? There's a later paper from Zeanah in the article that says you can diagnose reliably without it though. Off to bed now. Fainites ^barley 23:10, 15 February 2008 (UTC)

That's what I thought. Zeanah actually brings up more problems then answers -- the confusing/ overlap between disorders. I guess we have to firmly keep in mind that a diagnosis is a construct. I will email you. Mattisse 23:19, 15 February 2008 (UTC)

There is only RAD or DAD as a classified disorder at the moment although the term 'attachment disorder' gets used more generally. Its loosely used to refer to RAD, to refer to proposed new clasifications, to refer to problematic attachment styles and within attachment therapy as a sort of all encompassing 'diagnosis' of everything about a child that may worry a parent - which then needs attachment therapy to treat it.Fainites ^barley 10:08, 17 February 2008 (UTC)

Be this all as it may, Mattisse, the 1993 and 1996 Zeanah papers offer quite a different taxonomy than DSM-IV or IV-TR, and although the more recent Zeanah et al suggestions drop out some of the earlier categories, the recent ones are not exactly congruent with the official standards, either. I suppose the question with respect to this article is whether the approach is a historical one-- tracing the development of the construct-- or a matter of presenting the most recent thought, however confused and confusing it may be.

I would certainly agree that reifying any construct is a mistake, and the existence of the whole CAM view of attachment means that such a mistake is even more serious for this diagnosis than for many others.Jean Mercer (talk) 23:27, 15 February 2008 (UTC)

By the way, if anyone wants to add material, we are presently quite short on discussion of both the role of temperament in RAD and that of parent attachment status.Jean Mercer (talk) 23:30, 15 February 2008 (UTC)

Interesting. I can't imagine there is much on this WRT RAD as opposed to attachment a la attachment theory in and of itself but I hope I am wrong....cheers, Casliber (talk · contribs) 00:03, 16 February 2008 (UTC)

I don't follow you-- are you referring to temperament and parent attachment status?Jean Mercer (talk) 01:38, 16 February 2008 (UTC)

Either really but more the latter I suppose in that transgeneratonial attachment styles are particularly noted in attachment theory. I mention this after noting there is little research into RAD per se although there is alot more WRT attachment theory. We have to be careful in terms of what research is relevant to what, and if not relevant to RAD per se then note that.cheers, Casliber (talk · contribs) 03:36, 16 February 2008 (UTC)

Dozier - who is in the article - is one of the ones about the importance of the caregivers attachment status. She devised a treatment and prevention programme specifically for foster carers aimed at assessing their attachment status and concentrating on caregiver responses as infants with attachment 'difficulties' often don't elicit appropriate caregiver responses. On lack of research, most of the research that there is highlights this. The citations in the article to this point are currently the Taskforce and the authors of the twin study. The parts about the way treatment and prevention programmes concentrate on increasing caregiver responsiveness come from the practice parameter and Prior and Glaser. The reference in the article to a paper on RAD and temperament basically says not much is known! Fainites ^barley 11:34, 16 February 2008 (UTC)

By the way, the article does try to focus on what little RAD research there is - but I would agree that one research paper does not a conclusion make! This is why the views of the likes of Zeanah, Boris and so on are important - but I would suggest that the difference needs to be made plain. (Between informed opinion and research results I mean). Fainites ^barley 00:46, 17 February 2008 (UTC)

[edit] Speculation?

I don't think it's exactly correct to say that DSM and ICD do not speculate on the etiology of RAD. DSM declares that pathogenic neglect is a criterion for the diagnosis, and this presumably implies some concept of etiology. However, the inclusion of this criterion is at best a speculation about etiology, as the diagnostic category is a vague one, making conclusive research about etiology impossible so far. Although the DSM statement is presented as non-speculative, in fact it is speculative.Jean Mercer (talk) 19:08, 16 February 2008 (UTC)

Whether DSM and ICD do or don't speculate, presumably its a matter of interest to researchers and theorists in the field. The sentence as put in looks odd. It looks as if its referring to some other argument that isn't on the article page. What DSM says is:

• "There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C)." Fainites ^barley 10:11, 17 February 2008 (UTC)

Which sentence do you mean? Jean Mercer (talk) 19:09, 17 February 2008 (UTC)

The same one you're talking about. That DSM and ICD "do not speculate on etiology". Suppose it had added 'other than to presume that pathogenic care is responsible for the disturbed behaviour'. In DSM this applies to both forms. ICD-10 says "The syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling." in relation to RAD (the inhibited form) but not DAD. Fainites ^barley 20:29, 17 February 2008 (UTC)

That sounds good. The reason I inquired is that i wasn't able to find the sentence in the actual article, but i guess it's there somewhere.Jean Mercer (talk) 00:05, 18 February 2008 (UTC)

Matisse put it in the lead. It may be a bit too detailed for the lead though because ICD and DSM are different in this regard. I have added more to the classification section.Fainites ^barley 08:42, 18 February 2008 (UTC)

[edit] References to attachment therapy

I am wondering whether the casual reader would really take in what is meant, when an idea is attributed to attachment therapy. Might it not be a good idea to say something like "attachment therapy, the complementary and alternative approach" or "attachment therapy, the non-conventional intervention rejected by several professional groups". My point is not to take the opportunity to bash AT, but simply to try to prevent the thought process I see in my crystal ball: "attachment therapy-- oh, yeah, that's therapy for attachment problems--well, that must be good."Jean Mercer (talk) 14:59, 18 February 2008 (UTC)

How about CAM ? It is CAM but then it doesn't seem to mean to be. It means to be mainstream and based on accepted theory. How about 'non-conventional intervention rejected by mainstream theorists and clinicians/ or professionals? Professional groups sounds a bit odd - like a book club.Fainites ^barley 17:07, 18 February 2008 (UTC)

How about "professional organizations and associated task forces", then?

I'm happy with CAM. I think the intention is to identify as CAM to attract parents who feel they've been snubbed by the professional world, but as mainstream to convince organizations to fund presentations and approve CEUs.I was just avoiding saying CAM so I wouldn't have to trot out sources other than myself.Jean Mercer (talk) 20:28, 18 February 2008 (UTC)

[edit] Differential diagnosis

What do you think about Caslibers view that there should be more on differential diagnosis - ie how RAD is differentiated from PDD/Autism etc. I don't feel qualified to put this in. I suppose I could look it up - but is it necessary if the different possibles are linked? Fainites ^barley 22:11, 18 February 2008 (UTC)

Also - I know the peer reviewers specifically requested a description of attachment styles, but would they be better in the notes section? Fainites ^barley 22:21, 18 February 2008 (UTC)

Perhaps Caslibers thinks this article is on the DSM diagnostic category on RAD which has a section entitled Differential Diagnosis. If this articles is on RAD, then it would be very important to have that section as it is included in the diagnostic description of RAD. However, I read the article you sent. I think you should change the name of this article, as it really is not about RAD but more about "attachment disorders" and even there, the article you sent has very little to say except not much is known and nothing is validated. The article convinced me all the more that this wikipedia article should should do one of two things. One is to model itself on the task force article which is actually very skeptical, as I read it, about anything other than mainstream treatments that we already know about, and leave RAD out (except perhaps with mentions to the degree the task force article does) and rename the article. Or cover RAD. I am becoming very uncomfortable again about this article. Are you aware of some recent research that shows that identical twins do not have exactly the same genotype? Do you know for sure that every child that has "attachment disorder" symptomatology comes from an abusive background of some sort? It was believed for a long time that a withdrawn mother was the cause of autism in a child. Perhaps I should just stay out of this -- too reminiscent of the "repressed memory" stuff. Mattisse 22:55, 18 February 2008 (UTC)

P.S. Read the talkpage on CAM. Mattisse 23:07, 18 February 2008 (UTC)

Mattisse, are you under the impression that the article does not express skepticism about non-mainstream interventions or beliefs about attachment? If this is the case, both Fainites and i need to re-think the way we have expressed ourselves.

As for the abusive background-- of course we don't know that, and the realities of this type of research mean it's not likely to be known. However, the point is that DSM defines RAD in part by reference to early experiences.71.251.135.11 (talk) 00:24, 19 February 2008 (UTC)

Yes, by definition; not through empirical findings. Read this, for examples:[4] which questions how much is the temperament of the child, how much the parent, how much the interaction etc. It is just not known. So it seems to me that it is difficult to state anything as a fact. DSM lays down arbitrary parameters, a rule book that may or may not reflect reality but does give structure to a discussion based on current observations of characteristics of children suspected of having this disorder without going off the map in terms of speculative psychodynamics. Mattisse 00:48, 19 February 2008 (UTC)

[edit] Update

OK, I added a bit on differential diagnosis and can add a bit about how no laboratory tests are diagnostic. I figured it out what irks me a little - the article launches into discussion a bit in what it is without taking a step back and having more of an introduction. Compare with schizophrenia which tries to be more encompassing on how it presents (eg waht age etc.) and who diagnoses it. Depends too on whether we see this as a condition as such or merely a DSM category, which is how the article reads a bit at the moment. I'll add some more later. I must say I am not thrilled about having a link to attachment therapy in the lead either.

Also the fist few paras of the Prognosis section aren't prospective but more retrospective and probably can go elsewhere, symptoms and signs maybe. cheers, Casliber (talk · contribs) 05:46, 19 February 2008 (UTC)

Additionally:

Some children simply have very different temperamental dispositions. - gah! really needs to be elaborated/expleined etc. cheers, Casliber (talk · contribs) 05:49, 19 February 2008 (UTC)

Thanks for extra on diff. diagnosis. I've removed the temperamental bit. There's a mention of this elsewhere in the article. Do you think the material on attachment therapy should go altogether in one paragraph? Where do you think a link should go? Fainites ^barley 07:18, 19 February 2008 (UTC)

Yes, there is some other material which is in more than one place (though the lead doesn't count as it needs to summarise salient issues). cheers, Casliber (talk · contribs) 07:47, 19 February 2008 (UTC)

The passage on signs and symptoms reads as if you would always expect to find laboratory findings for dehydration and malnutrition. Is this what you meant or should it read "possible". Fainites ^barley 14:19, 19 February 2008 (UTC)

Sorry, my bad. possible. cheers, Casliber (talk · contribs) 19:42, 19 February 2008 (UTC) —Preceding unsigned comment added by Casliber (talk • contribs)

[edit] Update 2

Sorry for being so bold but I have to log off suddenly. I am trying to make materail go under approprate headings as there is alot of subject matter which doesn't match up. What do you think? I think the developments needs to go below diagnosis over view or be a subsection at the bottom of it. cheers, Casliber (talk · contribs) 23:14, 19 February 2008 (UTC)

No its fine. i was just thinking that developments looked odd there but I see you thought the same. I think it needs to go after the descriptive part of diagnosis or it makes no sense. I'll shift it. Fainites ^barley 00:03, 20 February 2008 (UTC)

Are you sure about paediatricians and the FTT? FTT was taken out of the diagnostic criteria decades ago. Is there anything that gives any idea of how common FTT is in relation to RAD? I haven't come across anything post dating the papers about taking it out but I'll have a look.

Quite often SW's pick up the first signs that somethings wrong - though they don't 'diagnose'. Can't find a source on this though. Fainites ^barley 09:23, 20 February 2008 (UTC)

Sorry, should clarify - FTT is not a criterion, but infants (i.e. very young 'uns) may present with it which alerts the clinician to find other problems. Would be good to stick a bit about SWs, teachers and others who may be alerted early. See what I did in schizophrenia, but it needs referencing..and I don't have a child psych textbook handy, only an adult one...cheers, Casliber (talk · contribs) 10:52, 20 February 2008 (UTC) —Preceding unsigned comment added by Casliber (talk • contribs)

By the time most children are diagnosed with RAD, they may be of reduced stature but would not meet criteria for NOFT because the history would not be well known. I think care must be taken not to wander into all the developmental problems that may be (but are not well known to be) associated with a poor attachment history.Jean Mercer (talk) 14:38, 20 February 2008 (UTC)

Casliber, i think you'll find that in recent child psych-related texts, this old view of NOFT as defining RADIEC is not found, nor is RAD limited to the IEC category. For example, the publication "DC:0-3-R", a listing of diagnostic categories suitable for infants and young children, birth to 3 years of age, does not take the NOFT approach, or indeed consider RAD as a useful diagnostic category for this age group. DC:0-3's publication was supported by the organization Zero to Three and by the World Association for Infant Mental Health and it is probably a more suitable source than a textbook about adult psychiatry-- adult-oriented materials are notoriously negligent of information about early development.

I would also object to the definition of infants as under a year of age. In child development circles, the word "infant" is used in a way congruent with its Latin derivation, to include human beings from birth to 2 1/2 or even three years of age ( hence Zero to Three).Jean Mercer (talk) 19:18, 20 February 2008 (UTC)

Here on Wiki - Infant defines it as until you can walk or up to 12 months. After that you're a toddler. However Infant And Child Development puts firmly at aged 0 - 2 years. We need to decide how we're using it here in this article. Fainites ^barley 21:47, 20 February 2008 (UTC)

Talking should be the cut-off, not walking. But I'd propose that since the average age world-wide for weaning from the breast is about 18 months, we should settle on 18 months to two years. Jean Mercer (talk) 22:30, 20 February 2008 (UTC)

I'd be happy with that. Or not define it at all. FTT certainly isn't infants only anyway. Fainites ^barley 22:35, 20 February 2008 (UTC)

[edit] Treatment - basic stuff (remember who's reading the article)

My book says this in plainer english than what we have in the article currently - namely:

Assessing the child's safety is an essential first step which determines whether future intervention can take place in the family unit or that the child is removed to a safe situation.

Interventions may include psychosocial support services for the family unit (including financial or domestic aid or gaining adequate housing), psychotherapeutic interventions (including treating parents for mental illness, family therapy, inidividual therapy), education, and monitoring of the child's safety family environment.

Succinct and bread-and-butter stuff which should be a prelude to more detialed discussion. I can ref it if you want it in. cheers, Casliber (talk · contribs) 11:44, 20 February 2008 (UTC)

Yup this is fine - even better if it had social work support in there. I don't know about the US but over here SW's are expected to have a pretty broad understanding of attachment theory and therefore to be looking at attachment behaviours when they go in. They would be expected to pick up on a 'concern', but not, of course, diagnose anything. In terms of parenting support alot of it would be pretty basic stuff based around caregiver sensitivity of the ordinary variety for which there are parenting courses as well as individual SW advice. Fainites ^barley 12:22, 20 February 2008 (UTC)

How about

• ":Assessing the child's safety is an essential first step which 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, inidividual therapy), education (including training in basic parenting skills and child development), and monitoring of the child's safety within the family environment."

Or does that now need too many sources? I'd like to put in something along the lines of "often Social Workers, Health Visitors or nursery staff are alerted to difficulties leading to referrals for appropriate diagnosis and interventions" into diagnosis but I can't think of a source. Or is it too obvious to need one? Fainites ^barley 12:29, 20 February 2008 (UTC)

Your wording is ok. There is one ref to cover it so no probs with sources. Umm...I know what you mean about sources for the addendum..safe is better than sorry but rather frustrating...cheers, Casliber (talk · contribs) 19:26, 20 February 2008 (UTC) —Preceding unsigned comment added by Casliber (talk • contribs)

Ah. Good old Sadock again. Theres a new one due out any minute now you know. Interesting to see if there's been any change. Re the SW's etc, I suspect if things were bad enough for there to be RAD, there would usually be so many more obvious problems like mental health, LD, serious neglect etc you probably very rarely get referrals just on a suspicion of RAD. Fainites ^barley 21:01, 20 February 2008 (UTC)

I know, Sadock is not as good as a more scholarly peer-reviewed review or something but it's a couple of pretty basic sorta entries which I felt ok to use it with....cheers, Casliber (talk · contribs) 22:29, 20 February 2008 (UTC)

Do you think the article could be a bit more chatty about how it arises - ie give examples. eg -a grossly deprived environment, where caregivers are unavailable to form emotional and social contacts with their baby due to drug or alcohol abuse, serious mental health issues, lack of ability to understand the need to do so, or even physical unavailability. Something along those lines. Also, for example, to explain that AS disorders or other PDD have a neurological base whereas RAD does not and children with RAD retain the capacity to form normal social relationships, but have not had the opportunity to do so. Fainites ^barley 22:34, 20 February 2008 (UTC)

If somebody wants a handbook, why not the 1999 WAIMH handbook or the 2000 "Handbook of Infant Mental Health" (ed., Zeanah). Adult-focused books don't cut it.

As for the genetics part, Fainites, as you know, Minnis et al think there is a genetic component, as there presumably is in any disorder whose development follows a stress-diathesis pattern. So I wouldn't want to rush to make the distinction you suggest.Jean Mercer (talk) 22:39, 20 February 2008 (UTC)

Not so much those particular words Jean, just to be little more descriptive about the kind of circumstances in which RAD may arise. Can you give us a chunk from the Handbook then to stick in ? About the bits Sadock is currently about I mean. Fainites ^barley 23:04, 20 February 2008 (UTC)

You mean the parts about physical growth as an indicator?Jean Mercer (talk) 01:36, 21 February 2008 (UTC)

Who might pick it up initially and how. If thats an answerable question. I've only ever come across it being picked up after there have already been concerns across multiple domains - including many aspects of caregivers relationship with/care of, the child. Fainites ^barley 10:21, 21 February 2008 (UTC)

Here are two sources from the work of the leading NOFT researcher Irene Chatoor. Both comment on the fact that at one time (DSM-III) NOFT was considered to be a disorder of attachment/separation, and not only has RAD been re-defined without this issue, but NOFT is being seen as far more complex causally than was thought in those days.

Chatoor, I. (2002). Feeding disorders in infants and toddlers: Diagnosis and treatment. Child and Adolescent Psychiatric Clinics of North America, Vol 11 (2), 163-183.

Chatoor, I., Surles, J., Ganiban, J., Beker, L., Paez, L.M., & Kerzner, B. (2004). Failure to thrive and cognitive development in toddlers with infantile anorexia. Pediatrics, Vol. 113 (5), e440-e447.

In my opinion, Chatoor's remarks mean that the Sadock comments on NOFT should be omitted.Jean Mercer (talk) 01:59, 21 February 2008 (UTC)

Hmmm...interesting. Still don't have a child and adolescent handbook handy but comelling to restructure the bit. I'm not fussed if you remove it then but would think it was important to note that NOFTT had been considered a part of RAD before and then reconsidered as not. This would need to go in a history section which would also include the underlying rationale bit at the top of the article. Casliber (talk · contribs) 02:13, 21 February 2008 (UTC) —Preceding unsigned comment added by Casliber (talk • contribs)

I've been thinking of rewriting "Theoretical framework" as "History" - but without losing any of the information in it. Fainites ^barley 10:18, 21 February 2008 (UTC)

Yep. good idea. Casliber (talk · contribs) 01:26, 22 February 2008 (UTC) —Preceding unsigned comment added by Casliber (talk • contribs)

[edit] Lack of attachment behaviors?

Maybe it would be more complete and accurate to say "lack of attachment behaviors directed toward familiar persons". Following and socially approaching strangers, as in the disinhibited form, suggests some distorted version of typical attachment behavior. "Lack of attachment behaviors" suggests independence or aloofness toward everyone, unless you're very aware that the typical behavior includes discrimination between the unfamiliar and the familiar.

An interesting question would be the extent to which toddlers with atypical proximity-seeking go on to show atypical negotiation of separation-- but I don't know of anyone who's worked on this.

One other thing-- that pediatricians would pick up atypical attachment behaviors-- I doubt that this happens in the U.S., where office visits are severely limited in time. I was working with a group who wanted pediatricians to do a quick assessment of perinatal mood disorders in new mothers-- sorry, they don't have time to do that. Of course, you would hope a pediatrician would notice that a toddler didn't cling to the parent and avoid eye contact, but I have no idea whether they do.Jean Mercer (talk) 00:11, 22 February 2008 (UTC)

Well the only time I've come across it is where there have been more immediate concerns across multiple domains and the possibility of RAD has only arisen later down the line after fuller assessments. A paediatrician, SW or HV may express concerns about the relationship between infant/child and primary carer but wouldn't be making a diagnosis as such. Fainites ^barley 08:59, 22 February 2008 (UTC)

Well, you would certainly think that a SW would not be diagnosing, and maybe in the UK they don't, but in this country there's a book for SWs about using DSM (ed. Sophie Dziegielewski, pub. Wiley) which puts forth a great deal of misinformation about RAD. I don't suppose there'd be a book like this for SWs if SWs don't diagnose. Jean Mercer (talk) 15:46, 22 February 2008 (UTC)

Except that SW's need to be informed so they can spot what over here is called a 'concern' and know when and who to refer to and describe their 'concern'. However, when the article was written by USA based AT socks it did say that RAD was usually diagnosed by social workers or psychologists so the AT world presumably expects to get referrals via SW's if they're diagnosing it. I suppose that bypasses unhelpful professionals who may challenge such a diagnosis. Fainites ^barley 19:38, 22 February 2008 (UTC)

That Illinois guideline paper seems to indicate that those licensed clinical SW's (LCSW) can make an "initial evaluation" in some states at least - regardless of APA's views that it ought to be a psychiatrist or APSAC's views that it needs to be someone trained in differential diagnosis. I assume an initial evaluation is not a diagnosis but a reason for referring on for a diagnosis. It says:

• "Psychologists (Ph.D., Psy.D.) , physicians (M.D., including psychiatrists), licensed clinical social workers (L.C.S.W.), and psychiatric nurses (R.N.) have the training and background to conduct an initial evaluation for RAD." [5]Fainites ^barley 00:08, 24 February 2008 (UTC)

[edit] Missing piece

Reading through the article, what I notice is a failure to stress that attachment behaviors of all kinds occur WITHIN a relationship-- the disorder, or the secure attachment, or whatever, is only partially "in" the child, and is strongly connected with interactions between child and caregiver. Zeanah has pointed out that the disorder categories he suggested in the past might apply only to one of a child's relationships, whereas other relationships might be typical of good development. Similarly, attachment styles are influenced by the adult's contribution, as Main and Solomon stressed when they pointed out how the mothers of the disorganized children appeared frightened when approaching the child and often referred to frightening ideas.

This is difficult to put across, as we are so accustomed to the medical model of disorders, in which the child "has" RAD or SCA or chickenpox. And of course when we get around to talking about internal working models, it gets much harder to think how they are affected by ongoing social interaction. Nevertheless, if we could do a good job of stressing the attachment behavior as a type of communication, where you have to have at least two people in order for it to happen, I would think that was an important contribution.

Why talk about whether attachment is affection or not? I don't mean you shouldn't, but I don't understand the point, unless it's a phenomenological approach focused on how attachment feels to the child.Jean Mercer (talk) 01:51, 22 February 2008 (UTC)

The affection bit was really to distinguish it from understandings of 'bond' but it could easily come out if its confusing. In relation to the rest, Zeanah highlights this in his 1996 paper, and others - that DSM itself is based on the medical model. A possible side effect of this are the criteria that require inappropriate social relatedness in all contexts, not just one or some. Do we deal with this in the article and if so, how? How about in the Developments section? Fainites ^barley 09:05, 22 February 2008 (UTC)

Yes, i think Developments would be good. It is awfully hard to keep up with some of these arguments that pop up and then disappear for a while.Jean Mercer (talk) 15:45, 22 February 2008 (UTC)

OK. Are you going to have a shot at it then? Fainites ^barley 19:39, 22 February 2008 (UTC)

Yes, soon, but go ahead if you can't stand it. Jean Mercer (talk) 00:14, 23 February 2008 (UTC)

On this lack of attachment behaviours - my understanding is that is what DSM etc are trying to say. The issue of whether they are right or not and whether such a disorder should be seen in the context of a particular relationship rather than all is probably best put in developments.Fainites ^barley 15:00, 23 February 2008 (UTC)

Okay, i did it, but I don't know how to cite an edited book in this style. Help, please--Jean Mercer (talk) 16:08, 23 February 2008 (UTC)

Fine. Can I have the page numbers please. Fainites ^barley 17:39, 23 February 2008 (UTC)

161-182.

Listen, I don't think "has been considered..." is the same thing as "may be". The first means it's a suggestion that has been offered, the second implies that there's evidence of the possibility.Jean Mercer (talk) 21:09, 23 February 2008 (UTC)

OK. I've changed it back. That last sentence is without a ref though. Also I don't think the 'we' will pass. is it something that can be subsumed under the previous ref or is it it your thinking on the subject? Fainites ^barley 23:57, 23 February 2008 (UTC)

It can't go under the previous reference-- I suppose it's my thinking, but mainly I don't know how to cite some "no evidence". Take it out if Wiki doesn't allow such a statement. Jean Mercer (talk) 14:54, 24 February 2008 (UTC)

[edit] Checkup

I popped over to see if progress was being made, and found the talk page very hard to follow since talk page guidelines on threading responses haven't been followed here, so instead, I spent my time refactoring the talk page for readability. If you all will follow Wiki conventions on threading and indenting responses, it will be easier for others to follow. I see Cas is still pitching in; it's good of him to help out when he has his own FAC to attend to. How are things going here? SandyGeorgia (Talk) 03:08, 24 February 2008 (UTC)

OK. A bit of rearranging and clarifying. A little bit of new stuff in. I'm not sure whether Casliber still thinks more needs to be done. How about it Cas? I've found some info on who diagnoses and am awaiting more from the British end of things. Oh by the way, regarding styles and RAD, here's some examples of whats on the web [6] [7]Fainites ^barley 14:05, 24 February 2008 (UTC)

Sorry, a few things have come up. I'll try to help some more presently. Casliber (talk · contribs) 19:55, 24 February 2008 (UTC) —Preceding unsigned comment added by Casliber (talk • contribs)

Thanks. I have tried to dig up some more Wikipsychs - but no go - and the ones that helped on the other psych FA's peer reviewed this one! Fainites ^barley 20:10, 24 February 2008 (UTC)

By the way Cas - can you explain whatyou mean by the first few paras of prognosis being retrospective? Fainites ^barley 08:27, 25 February 2008 (UTC)

My request to the RCP over here for guidelines on the diagnosis and treatment of RAD resulted in my being referred to DSM and ICD-10. Fainites ^barley 21:46, 25 February 2008 (UTC)

(outdent) sorry, I thought at first glance the section prognosis was more about causes rather than course. I would remove the first sentence and the 'however' and tack the sentence on the next paragraph. The first sentence doesn't add anything and is repeated elsewhere. Casliber (talk · contribs) 09:00, 27 February 2008 (UTC)

Another issue:

It has been suggested by some within the field of attachment therapy that RAD may be quite prevalent because severe child maltreatment, which is known to increase risk for RAD, is prevalent, but many children experience severe maltreatment and do not develop clinical disorders. - surely there'd be a mainstream authority to quote for this? Pretty basic concept to which many orthodox practitioners would subscribe. I am worried this legitemises Attachment Therapy. Casliber (talk · contribs) 09:48, 27 February 2008 (UTC)

It is reffed. Its from Chaffin - both the fact that attachment therapists say this and that DSM says the other. I'll try and make it clearer. The point was really to say that AT is wrong on this one. They have a tendency to use maltreatment figures as a basis on which to estimate RAD figures. 80% of maltreated, or foster, or adopted - tends to come up.Fainites ^barley 21:02, 27 February 2008 (UTC)

I've rearranged and clarified it - hopefully its clear now. I was wondering - under diagnosis there's a titled paragraph that says Alternative diagnosis which then describes the AT bit. Would it be a good idea to have alternative treatment and even alternative epidimiology ? Fainites ^barley 21:27, 27 February 2008 (UTC)

I'd put History and theoretical framework down between Diagnosis and developments. Noramlly should go at the bottom but the framework is important to know before the treatment section. I wouldn't have a whole lot of alternative x bits, I feel that invites a truckload of controversy. I think this is nearing FA standard now, great job as I didn't think ti was possible. Casliber (talk · contribs) 01:08, 28 February 2008 (UTC)

Yes. Confusion of the two is common and I didn't want people reading the whole article thinking they were reading about insecure attachment if you see what I mean. Fainites ^barley 20:39, 28 February 2008 (UTC)

[edit] Lead

How did the lead get up to eight paragraphs? See WP:LEAD, three to four is common, five is long. See autism, Asperger syndrome, Tourette syndrome and Schizophrenia. SandyGeorgia (Talk) 07:30, 27 February 2008 (UTC)

I'm working on it. There was some repetition, and I have trimmed it down to 4 paragraphs.Casliber (talk · contribs) 09:41, 27 February 2008 (UTC)

Looks fine now Cas. It got a bit split up because it kept being rearranged to see how it looked I think. Fainites ^barley 21:29, 27 February 2008 (UTC)

[edit] AT source

I do hate to see that Hall & Geher paper cited, because it has a strong AT connection and its use implies acceptance of aspects other than those discussed.Jean Mercer (talk) 01:14, 28 February 2008 (UTC)

Oh dear. Is there an alternative trustworthy source for the same point or is it a bum point? Fainites ^barley 20:35, 28 February 2008 (UTC)

[edit] A note about FAC commentary

Reivewers raise issues on the FAC because the text isn't clear; those items should be addressed in the article, not on the FAC. For example, I finally went in myself and linked to longitudinal study and included full definitions of DSM and DSM-IV-TR. But there is still, for example, a useless link to a dictionary definition of the work "inhibit" in the lead, which has nothing to do with the clinical term. Also, there is still a self-reference to "this article" in the lead. SandyGeorgia (Talk) 18:34, 28 February 2008 (UTC)

I actually think that self-reference quite helpful—along the lines of a disambiguation template. If others feel more strongly about losing it, though, that's fine. Fvasconcellos (t·c) 18:54, 28 February 2008 (UTC)

Apologies Sandy. I frankly didn't understand that argument in FAC about exactly how to set out DSM and ICD. Fainites ^barley 20:37, 28 February 2008 (UTC)

Well, I think I fixed it, but Fvasconcellos has a more discerning eye than I do, so he may adjust. While I'm here, a note about reference tags and punctuation, which I keep having to fix. No space between punctuation and ref tag. If Fv prefers the self-reference, I defer, but maybe he'll suggest a way to handle it. Whether or not the FAC succeeds, at least you're getting feedback now. SandyGeorgia (Talk) 20:41, 28 February 2008 (UTC)

A more discerning eye? One of them maybe, but surely not both of them :)

Fainites (and Cas, and everyone else working on this): about the "inhibited" and "disinhibited" definitions in the lead (or lack thereof)—I've done a little tweaking in the lead, let me know whether it was any kind of improvement. The article is looking much better. Fvasconcellos (t·c) 20:54, 28 February 2008 (UTC)

Very nice. By the way - what do you think about Mcleans POV concerns about the presentation of attachment therapy? There isn't really any secondary source on attachment therapy I've found which isn't critical. There are also mainstream commentators which call it pseudoscience and liken its processes to brainwashing! Mainstream commentators are also pretty adamant that its not based on attachment theory either.Fainites ^barley 21:31, 28 February 2008 (UTC)

[edit] Sadock

Hey, Casliber, guess who's written the section on RAD in the new Sadock and Kaplan thats about to come out "Boris N.W., Zeanah C.H. (in press) Reactive Attachment Disorder of Infancy and Early Childhood, In H. I. Kaplan and B. J. Sadock (Eds.), Comprehensive Textbook of Psychiatry/VIII, New York: Williams and Wilkins." He seems to get everywhere. Fainites ^barley 18:52, 2 March 2008 (UTC)

[edit] Links to Attachment therapy

... of which the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model.

All four of these links currently redirect to Attachment therapy. What gives? Shenme (talk) 07:05, 14 March 2008 (UTC)

They're all different names for attachment therapy. What do you suggest would be appropriate? Fainites ^barley 22:41, 16 March 2008 (UTC)

[edit] Memo

Check this one out. [8]

Look at this one again. [9] —Preceding unsigned comment added by Fainites (talk • contribs) 20:01, April 3, 2008

[edit] The introduction lacks an example

The introduction is too abstract for the average reader. You need to put in some examples of RAD to make the article more accessible. For instance: "excessive familiarity with relative strangers". Give a clear-cut example of such behaviour. --82.130.40.39 (talk) 13:34, 20 April 2008 (UTC)

Tricky to just give one. I'll have a look in various sources to see if they give any. Fainites ^barley 22:29, 20 April 2008 (UTC)

[edit] Incorrect reversion

Fainites, this is a rather alarming incorrect reversion of careful and accurate work. The other editor correctly fixed repeated, named refs. I carefully checked them, and I did not see any error. Why did you revert? SandyGeorgia (Talk) 21:58, 20 April 2008 (UTC)

Also, with one massive revert, you removed all of the other article improvements (including some typos and grammatical errors) made during the mainpage stay; pls reverse your revert, as it is not an improvement. Named refs were correctly used by the other editor, who corrected the incorrect repeat refs, and the changes made during the day all appeared good faith and accurate. SandyGeorgia (Talk) 22:00, 20 April 2008 (UTC)

Further, your edit summary indicated that Jennica removed page numbers, which is not correct; Jennica merely used named refs to cover repeats (see WP:FN, I tried to teach you to do this many times, but it appears you didn't understand). The page numbers were still there. Pls revert your incorrect removal of all of the day's improvements, back to the version before your revert. SandyGeorgia (Talk) 22:03, 20 April 2008 (UTC)

I reverted because it appeared to me that somebody went through and replaced all the refs which gave page numbers to the same ref which didn't! We discussed at peer review and at FAC what do do about a citation that is used many times with different page numbers and this was the accepted solution. After these edits, there were no page numbers at all. I suppose I could revert that and then go through each page number replacing them all individually.Fainites ^barley 22:04, 20 April 2008 (UTC)

But that is not what Jennica did, and you still haven't understood how to use named refs, per WP:FN. Jennica preserved the page (81), but combined multiple citations to that page into one. What Jennica did was correct. And, it was a lot of work. And I've watched the page all day, and you reverted several other improvements. Pls restore, back to the version before your revert. It is incorrect that there are no page numbers; click on the version just before your revert, and look at the sources at the bottom. You are misunderstanding WP:FN (which concerns me, because I tried to teach you many times :-)) NO page numbers were removed; Jennica correctly combined them into named refs, but preserved the page number. I don't know how to make this any more clear; please look at the old page, go to the bottom, you will see, for example, page 81. SandyGeorgia (Talk) 22:09, 20 April 2008 (UTC)

Already done. I haven't been around all day and when I looked at it it looked as if all the page numbers had been removed. My apologies. Fainites ^barley 22:11, 20 April 2008 (UTC)

Now it's good, but please do take advantage of Jennica's work to help you understand how to use named refs, per WP:FN. And congratulations on a very smooth mainpage day !! SandyGeorgia (Talk) 22:12, 20 April 2008 (UTC)

Well I don't think we discussed WP:FN before but I'll have a look at it. There's so many different opinions on refs and citations its a subject all by itself. (Ah - a new Wiki article!) Many thanks. Fainites ^barley 22:14, 20 April 2008 (UTC)

Now that you're on, I'm going to unwatch. Congratulations again on a fine mainpage day ! No major disruptions, discussions or issues. Best regards, SandyGeorgia (Talk) 22:15, 20 April 2008 (UTC)

Aaargh! The responsibility! Fainites ^barley 22:17, 20 April 2008 (UTC)

Mind you Sandy, the reason why there's been no comments or queries from psychs may be because it was featured on a Sunday which gets far fewer hits than weekdays. Fainites ^barley 00:15, 21 April 2008 (UTC)

[edit] Moved down from up amongst the 2006 stuff!

[edit] Disorder? What disorder?

And further: forgive me if I’m being thick, but after reading and re-reading this article several times, I’m unable to discover any evidence that the symptoms described constitute a disorder at all.

True, the dictionary I have to hand (Webster’s) defines disorder as “an abnormal physical or mental condition”, but in those terms high intelligence and extreme muscularity are both disorders. To be worthy of the name, a disorder must cause a problem.

The behaviour I see described is labelled “Disturbed” and “Developmentally inappropriate”, when as far as I can see,it is merely “statistically abnormal”. The assumption seems to be that anyone who doesn’t behave like everyone else must have something wrong with them.

“RAD arises from a failure to form normal attachments to primary caregivers in early childhood.”

It appears from the Causes section that this is a definition, i.e. if these symptoms are not attributable to such failure, then they do not constitute RAD. But whether actual symptoms are so attributable is a question for empirical verification, not prior stipulation; and no evidence appears to be offered. Even if the correlation were perfect, it is not necessarily causal in the direction indicated: RAD and failure to form caregiver attachments could both be caused by a third factor.

The number of occurrences of such words as could, may, presumed etc. is quite alarming. Why could the symptoms of RAD not result from (just to take a few examples):

a) A child’s dislike or distrust of the caregiver (most of us can think of relatives we don’t like even though we wouldn’t accuse them of being bad people).

b) Extreme introversion (or extroversion in the case of DAD).

c) Precocious self-sufficiency

d) Disinterest in the available peer-group—for example, if the child is either much more or much less intelligent.

I see no mention of any effort to ascertain whether all such children are in fact unhappy, or whether they make other children unhappy. In short, if “RAD is one of the least researched and most poorly understood disorders in the DSM”, why are children that are apparently merely unusually unsocial (or excessively social) being (apparently) viewed as antisocial (or rather, “inappropriate”), and—more to the point—since no evidence of later probems is adduced, why should they be ‘treated’ for anything?

It’s otherwise an informative article, and I see several contributors here who evidently know what they’re talkng about, so I hope someone can address these concerns for me.

Paul Magnussen (talk) 23:13, 21 April 2008 (UTC)

The article describes the current state of play - including the fact that its poorly understood, poorly researched, oddly based on a history rather than just symptoms etc etc (I think its the only one in DSM that is - and you're right - how do you then diagnose without evidence? ICD on the other hand presumes a history of neglect etc). There's only really been any research in the last decade - and still not alot. RADs been rewritten before in DSM and may well be rewritten again in the next DSM. (Did you note the bits about proposals for a different form of classification of attachment difficulties?)

However, it does exist as a classified disorder at the current time and therefore deserves a comprehensive article. It is also particularly important to have an article that is as carefully informative as is possible because the diagnosis of both RAD and attachment disorder is much overused within the field of attachment therapy (and all over the Web) for children who have a range of percieved problems that may not be related to attachment at all.

This article attempts to present what RAD is according to the DSM/ICD 10 and such research and theory as there is - warts and all - plus any relevent commentary from notable theorists in the field. There is no inherent reason however, why extreme forms of abnormal social behaviour should not constitute a disorder. Perhaps this article is rather dry and doesn't get over how disturbed and disturbing such behaviours can be. Fortunately it seems to be pretty rare. I hope this answers your points. Fainites ^barley 20:53, 23 April 2008 (UTC)