Reactive-Attachment Disorder: A Controversial Diagnosis

One Among Many

Background To This Essay

There was a period of time in the 1990’s where my primary work was court-ordered psychosocial and family assessments—about one hundred sixty in all—concerning children’s safety and well-being in suspected or substantiated cases of abuse, neglect, or simply complicated situations involving parental figures and children. The assessments were used in legal proceedings to assist judges in determining what was in the best interests of children and families. I didn’t work as an employee of the child protective system, though the state hired me many times. But so did a number of county guardian ad litem’s office (called CASA in some states), attorneys as well as parents & foster parents out of their own pocket. I was frequently called by one or another party to give a ‘second opinion’—I was known to be absolutely independent, and willing to disagree with the opinions of anyone, including professional friends and associates, as well as the people who hired me. Other times, despite the hopes of the people or agency who had paid me, I agreed with those who had gone before.

One of the things I saw over-and-over again was the power of diagnosis: how an expert’s ‘label’ could dominate an entire case—could, in fact, define reality. I am not against the medical model; diagnosis can be an essential tool to craft appropriate treatment for suffering humans. An unfounded or incorrect diagnosis can also be something that could be called ‘scientistic’—something that must be factual because it sounds so scientific. Psychiatric/psychological diagnosis, given by an expert, can be so powerful that everything the labeled person does at variance to the diagnosis is re-contextualized to fit it. To give one example, I recall a situation where a recently-widowed single mother, very young, was about to have her parental rights terminated. She definitely had significant problems as did her children, who were placed in foster care and Child Protective Services was correct in intervening. Initially, they intended to connect her and her children with various services, focused on reunification. However, a consulting psychologist, after learning that she was working as a stripper, diagnosed her with Narcissistic Personality Disorder, because, he asserted, her display of her naked body served to gratify her narcissistic ego, and was purely exploitative of lonely and vulnerable men. She was, therefore, a “predator.” He claimed that her parenting, by definition would be no different: self-centered, un-empathetic and unresponsive to who the children really were. When he later observed a visit she had with the children and had to concede that she was engaged and responsive with them, he asserted that this was a false display for his benefit, much as she did on stage while dancing naked. [I was able to counter the leviathan that was this psychologist, among the most powerful in the area, by simply asking the right questions: finding out, among other things, that she was stripping herself bare so she’d have enough money to pay rent so if/when she got her children back, they’d return to the same home they lost when they were placed in custody. What he defined as selfish was, in fact, selfless].

The essay that follows, first written in the mid-1990s, was actually the preface to a report to a judge, concerning a teenager whom several prominent specialists had diagnosed with ‘Reactive-Attachment Disorder,’(RAD) and in their use of the term, described him as a budding psychopath who needed to be removed from his family home and placed in long-term specialized care, something the father fully supported and the mother ineffectually opposed. This child-welfare case took place in the larger context of a divorce, where the father had control of the family finances and had a very skilled, high-priced attorney. The mother had few resources, financial and otherwise, and seemed to ill-equipped to manage the dangerous young man the specialists and father described. When I entered the case, the experts were all lined up, and it looked like the court decision was a slam dunk for the father.

After spending a lot of time interviewing and observing everyone involved, including the family members as well as all the involved professionals, I found myself in utter disagreement with the father and his experts. The problem, however, was the power and credentials of the latter, and how skillfully they wove their diagnostic story of who the young man was. What they wrote sounded very plausible. [And one of the paradoxes of the child welfare system, in my state at least, is judges meet everyone but the children—they only learn of them through other’s accounts]. It was not enough to simply offer an alternative hypothesis, because that would leave the judge with ‘dueling experts,’ something almost boringly typical in cases like this. Therefore, I believed I had to counter their narrative at the root, by defining what a diagnosis is, and specifically, the nature of the diagnosis they had ‘labeled’ the young man, so that the judge and involved social workers would have the tools to truly evaluate the professionals’ reports (mine among them).

I will not recount the case here, though in this rewrite of the preamble of my report, I make some references to it. Rather, I’m publishing the essay as a stand-alone piece: on science, craft (skilled or not so skilled observation and implementation of theory and assumptions) and pseudo-science. By the way: I’m happy to write that my assessment stopped things in their tracks—the young man was not institutionalized, and in fact, the father’s parental rights were curtailed, most specifically the right to participate in medical decisions regarding him. Once he was safe from his father’s hatred, and once he no longer had to witness the contemptuous psychological abuse of his mother, his behaviors that so troubled others, ceased.

I. What is a Psychiatric Diagnosis

Psychiatric diagnosis, despite wishful thinking to the contrary, cannot be termed pure science. Although the scientific method plays a considerable part, there is also a significant element of ‘human science’—making informed decisions that are validated by their utility, rather than proven by physiological evidence. In other cases, the diagnosis is validated by generally accepted theory, often poorly buttressed by research, which has become ‘common knowledge.’ [Here is one article among many on the meme of the “chemically-unbalanced” brain causing depression and warranting medications that are damaging and very often do not work]. In fact, psychiatric diagnosis is all-too-often ‘established’ by trying out medications, taking more medications to counter sometimes horrible side-effects, and when some combination seems to affect the symptoms that the person (or others) complains about, a diagnosis is dovetailed to it, either confirming what was initially assumed or changing according to the medication response.

Let us put aside ‘molecular psychiatry,’ however, because a disorder has to be recognized (or at least assumed) before medications are proposed. Diagnoses are generally established by the observation of behavior: descriptions of certain patterns as unique, as recognizable and as pathological (that it significantly compromises or impairs people’s ability to function in this world). For example, although we can observe that kind people help old ladies across the street far more often than cruel or selfish individuals do, there is no need to make a diagnosis of “Nice Person Personality Disorder.’ However, a compulsion to wash one’s hands over-and-over, despite knowing it is patently absurd, or a need to tap the television screen seventy-seven times with the right index fingernail before brushing one’s teeth are examples of activities known as compulsions. When coupled with a set of other related behaviors, we establish a tentative diagnosis of Obsessive-Compulsive Disorder (OCD). This diagnostic category has been reworked over many decades: theoreticians and researchers cut extraneous data that is not requisite to substantiate the problem. For example, as a hypothetical, imagine that more people with OCD part their hair on the left but those who do and those who don’t present with identical behaviors—it would not be relevant data. The diagnosis could also be ‘expanded’ to cover new data; let us say that researchers notice that people with OCD show a heightened level of anxiety, apart from activities directly associated with their obsessions and compulsions—this may be very significant data. In the end, we can use the diagnosis to describe a group of people who all suffer from roughly the same symptoms due to, as far as we can tell, roughly the same reasons, and this enables us to develop therapeutic interventions that actually help them.

Often, however, several disorders can share the same symptoms. People experiencing schizophrenia, manic-depressive illness, alcoholism, severe depression, or those suffering from the after effects of severe abuse can all hear auditory hallucinations. But they do not have the same mental illness, and despite similar symptoms, may need quite different treatment strategies.

We can sometimes pinpoint a specific diagnosis by noting idiosyncratic characteristics of a symptom. For example, human figures in the visual hallucinations of those suffering from Alcohol Hallucinosis are very frequently diminutive; unlike those experiencing other mental illnesses, such people really do see ‘little green men,’ or ‘little pink elephants.’ People who experience that characteristic type of visual hallucination are far more likely to have a syndrome provoked by severe abuse of alcohol.

II. How are Diagnoses Created?

Sometimes diagnoses are established from concrete evidence. A person shows psychotic symptoms, and a spinal tap reveals that they have meningitis in their cerebral-spinal fluid. They are given high doses of antibiotics and recover.

Other times, diagnoses are created after years observing a multitude of individuals, with the development of specific assessment tools (tests and structured interviews), and when an individual shows a similar pattern of behavior, they receive the diagnosis, which then may be confirmed or discounted by the success or failure of therapeutic interventions. Diagnoses can be quite mutable, as our observations and research tools develop over the years. The criteria for schizophrenia and its subsets, for example, have changed with each new edition of the Diagnostic and Statistics Manual [currently in its fifth version—Text Revision (DSM-V-TR], as researchers and clinicians continue to more accurately (hopefully) delineate the subsets. One of the defining characteristics of a good diagnostic category is utility, with limited over-lap with other diagnoses. It does not help suffering people when they are labeled with too many diagnoses, each describing roughly the same behaviors. For example, with each edition of the DSM, the section on depression keeps expanding into more and more subsets, with no obvious utility, given that the treatments for most of the subsets are so similar. At a certain point, it is better simply to delineate a general diagnosis and then individualize the human being in narrative form rather than offering a plethora of labels of type of depression, given that another clinician might pick another sub-label to describe the same person’s condition, to no real benefit.

An individual’s diagnosis can also be ‘disproved’ when there is a generally accepted method of treatment for a particular syndrome. If the treatment doesn’t work, and there is no evidence that the clinician is incompetent, this suggests that something else (another diagnosis) is driving the behavior. For example, we once had a middle-aged man present at our clinic exhibiting florid psychosis, extreme energy and confusion. Such late-onset psychosis with no previous episodes and no family history is unusual. He denied drug abuse, and Tox screens showed no intoxicating substances in his bloodstream. A neurological exam showed nothing untoward. Over a period of several weeks, he was unresponsive to any medication that should have mediated his symptoms. He had a balanced diet of including a breakfast of orange juice, two eggs, one whole-wheat English muffin and coffee. It was only when one of my co-workers revisited his diet and asked, “How much coffee do you drink?,” that we found out this well-to-do ‘dot-com’ executive had recently bought a home espresso maker and was drinking over forty (!!!!) double shots a day. Caffeine-induced psychosis. The symptoms disappeared after a very slow taper [imagine the headache!!!!] down to four cups a day.

Still other times, one or a few clinicians assert the existence of a new diagnosis based on a theory (not research—at least not yet) they have created to explain a set of behaviors. This is often how psychiatric knowledge increases, but several problems can emerge along with the new diagnosis:

• Clinicians have enormous power in regards to their patients. For example, there is no doubt that people can forget, perhaps even repress many events in their past, including traumatic incidents. However, the theory of the ‘repressed memory of trauma’ has spawned an inchoate movement passing itself off as science, often contrary to established, research-based information on memory and trauma.¹ This has further spawned a flood of poorly trained therapists reading poorly thought-out theory and poorly researched books, attending seminars by charismatic speakers; these therapists then look for, find and treat repressed memory in both children and adults, finding it pretty much everywhere they look. [In one famous training manual, I recall reading that a dislike of brushing one’s teeth was clear evidence or oral rape]. Much of this therapy, counter to the best research we have on memory, has caused terrible harm. Because vulnerable people can be very suggestible, particularly in the face of a concerned therapist, who seems to hold all the answers to their pain and confusion, they often can end up inadvertently ‘constructing’ a memory to support the suggestions of the therapist. The best outcome studies show that the majority of people who go through this type of therapy are far worse off than when they started. Simply put, such a diagnosis can become a self-fulfilling prophecy.²

• A diagnosis can be real, but the clinician’s explanation is not. For decades, the subject of autism, a mysterious condition, which now is believed to have a neurological basis, was under the thrall of psychoanalytic theory, which claimed that autism was caused by ‘refrigerator mothers’—cold, unloving women who psychologically devastated their child. This patent nonsense destroyed families, and did nothing to help the children.

• Conversely, the behavior may be real, but the diagnosis is erroneous. A child hears voices, telling her to kill herself. She is diagnosed and treated for childhood schizophrenia, something incredibly rare in pre-adolescents. Then it is discovered that she is being sexually abused, or has a toxic condition in the brain due to an infection or a medication side-effect. The observation is correct—the child is manifesting psychotic symptoms. But her treatment will be useless, as anti-psychotic medication will not alleviate either toxic conditions in the brain or experiences that amount to torture.

• Diagnoses are discarded when they are found to be not clinically useful, or when there is too much overlap with other diagnoses. Sometimes, they are ‘put on ice’ until more research can either support or deny its validity. One example of the latter is ‘Passive-Aggressive Personality Disorder,’ once in diagnostic manuals, but no longer. There is no doubt that there are profoundly passive-aggressive people, but it has not been established that there is a set of individuals who have a fixed, almost unbreakable ‘habit’ of being passive-aggressive more or less independent of the circumstances that they find themselves. It may be true. It sounds like common sense. But it has not been established.

Among the limitations of the aforementioned DSM-V-TR is that there is also a political element to it. Some years ago, there was a proposal to make a diagnosis called “Sadistic Personality Disorder,” essentially encompassing those who rape. There are definitely people who are rapists: they do it repeatedly, by choice and enjoy it. But as feminist clinicians pointed out (how obvious!), the moment you medicalize a crime, a willful behavior of choice, you give every rapist and the attorneys who support them grounds for a plea for either innocence or leniency based on his ‘disorder.’

Finally, pioneers often discover new diagnoses, believing —sometimes correctly—that they have observed an unnoticed syndrome with a cause and hopefully, a treatment. For example, high-functioning autism has surely been part of our psychological diversity since we became humans, but it was first noticed as a discrete array of behaviors and deemed pathological—a diagnosis—by Hans Asperger in the mid-twentieth century. We must always question, however, if such ‘under the radar’ behaviors are truly pathological and requiring treatment or if they are simply part of the panoply of diverse behaviors that humanity can manifest. [Asperger is a particularly troubling example: he noted a number of children who were somewhat asocial (didn’t fit in well with others), obsessive, resistant to change, hyper-logical—but his recommendations for what to do with such children were fully in line with the Nazi program on racial and mental hygiene.]³

Beyond even that, not every ‘pioneer’ is accurate in his or her observations – or at least in the conclusions he or she draws from those observations. This is the case with the at least one definition of Reactive Attachment Disorder.

III. Reactive Attachment Disorder (RAD) - The Orthodox View

Reactive Attachment Disorder (RAD) is a relatively new, equivocally researched diagnosis. In orthodox psychiatry, this diagnosis is mostly given to infants and young children who show a problematic way of relating to others. They can be excessively inhibited, hyper-vigilant or may respond to caregivers with a strange mixture of avoidance, resisting comforting, and a frozen watchfulness. Paradoxically, some may manifest an uninhibited, apparently fearless approach to strangers. (NOTE: In the DSM-V-TR, this diagnosis has been further refined, the behaviors now ‘split’ into two diagnoses: Reactive-Attachment Disorder and Disinhibited Social-Engagement Disorder. Therapeutic interventions are somewhat different for each sub-type).

The general theory is that the cause of this disorder is terribly inadequate parenting, associated with neglect, abandonment or abuse. The quite reasonable assumption is that if a child is deprived of love and protection, or even worse, terrorized before they have the cognitive ability to even find an explanation for what is happening to them, their ability to love, to trust and to form solid emotional attachments will be severely impaired. As a result, the child might be either ‘indiscriminately social’ or predominantly asocial (or both, depending on the circumstances he or she is in).

• It should be noted that there is, as yet, no definitive research that has established that abuse or deprivation is the only cause of impaired attachments.

• We also do not know if some children develop this condition in the absence of abuse or neglect.

• Furthermore, we also do not know why some children develop severe attachment problems while other children, brought up in the same situation do not; one theory is that the children who survive more-or-less intact have found some person, inside or outside their family, who valued them. Through this, the child who does not display RAD has developed a sense that, being valued, they are of value. Another theory is that some children are innately more resilient than others.

Children with attachment problems may be otherwise quite ‘normal’—they can be bright and articulate. Unlike the child with high functioning autism, who has a neurological condition that affects their behavior in a ‘pervasive way,’ children with attachment problems usually do not present as otherwise odd or eccentric. Such children can be articulate, and charming—their only anomaly is relational: either inordinately affectionate behaviors with unfamiliar people, and/or a cool un-bonded distance, particularly with their caregivers. When they get older, some such children, particularly those who have not had the benefit of restorative therapy and good parenting, can engage in various anti-social and criminal behaviors.

There is strong evidence that severe abuse and even more so, neglect, does affect brain development, sometimes in a life-long way. This is not due to head-injury. It is simply that if certain experiences do not happen to an infant or small child at the proper time and in proper sequence, the brain is not ‘cued’ to develop certain nerve pathways, or even, in severe cases, whole areas of the brain. Karr-Morse and Wiley state in Ghosts from the Nursery:⁴

Schore . . . , believes that there are neurochemical and structural processes in a specific area of the baby’s brain - the orbitofrontal cortex that are designed to be receptive to and programmed by the interactive emotional relationship between the baby and the . . .primary caregiver. This area of the brain appears to link sensual input from the cortex. . . with the child’s emotionally reactive limbic system and with his internal physical processes . . . . By experiencing the joyful and soothing responses of the caregiver to basic needs, the baby experiences connection and pleasure and confidence in the presence of the caregiver . . . .the infant learns that strong emotional states can be entrusted to another and ultimately balanced or resolved, in the context of relationship . . . In the case of children with type D attachment patterns, instead of a sensitive “attuned” emotional exchanged, . . there is “misattunement.” Signals intended by the infant to elicit comfort have been met with pain or unpredictable responses that did not lead to pleasure and soothing for the child. . . . Not only does the child experience a lack of excitement, closeness and warmth in this early relationship, but the child’s basic brain biology shifts for self-preservation to a dampened level. . . . Over time, these children become individuals who may show little concern for relationships. . . . In extreme instances of misattunement, scientists . . .believe that the results is developmental sociopathy. If the synapses in this area of the brain are never built . . . .the individual may be left without the ability to connect, to trust and ultimately to experience empathy.

Orthodox interventions for attachment disorders include psychotherapy, and good, loving parenting. It is clear that the latter is most important. Children who have been so profoundly hurt need parents who are both strong and powerfully calm, who do not take it as a personal affront when such children maintain their distance, or only engage with them on a superficial level, perhaps for many years. They need predictable rules, firm (but not harsh) discipline. In a sense, they need parents who are as consistent and sure as the heartbeat they felt when they were in their mother’s womb, perhaps the last safe place they have ever experienced.

IV. The Expanded View of Reactive-Attachment Disorder

  (I will refer to this as ‘Nouveau-RAD’ to delineate from the orthodox diagnosis)

A cadre of individuals, both those with clinical training and those without, most notably Foster Cline, have vastly expanded the definition of RAD, in a manner that is, in some ways, congruent with the neurological data quoted above, although they clearly warp it to their own ends. They have observed what seems to be a great increase in foster and adopted children, taken into apparently nurturing homes, who begin to behave in appalling, frightening ways: calculated aggression, lying, theft, and manipulation. Since the flourishing of substance abuse in America, particularly crack cocaine, fentanyl, and methamphetamine, more and more children are being raised in unbelievably neglectful and abusive families. Within the last fifty or sixty years, we have increasing numbers of very impaired teens and young adults raising very impaired babies who become impaired teens who raise . . . . We have cascade of three or four generations of damaged and profoundly hurt children within only a few decades. In addition, we have a great increase in adoptions from abroad, and sadly, many of these children have been grossly neglected, or even beaten or raped while still infants. Love does not seem to be enough for at least some of these children. They kill family pets, try to poison family members, urinate in food (all cases which I have had some involvement), and show a number of other severely pathological behaviors.

The theorists of Nouveau RAD assert that these children, given no opportunity to love or trust—to attach to any caregiver with any assurance of reciprocal, nourishing love in return—give up on humanity. A metaphor I have heard Nouveau RAD practitioners use is this: A child falls through the ice, almost dies, but makes it to the woods to hide out on the other side of the lake. The only way back to a real home is to return over the ice. That’s so scary that they’ll do anything to stay in the woods, where they believe that they won’t utterly perish. Therefore, they view kindly parents and supportive therapists as potential seducers who will make them vulnerable, entice them back over the icy waters and let them drop again. They are filled with rage and hidden fear, and will do anything to undermine relationships, which they define as dangerous vulnerability. They will do anything possible, no matter how horrific or disgusting, to maintain their control over their own destiny, no matter how impoverished, lonely or nasty their existence might be. Their ugly and frightening behaviors cause successive caregivers to give up on them, this confirming how unlovable they are and that no one can be trusted. There has been no research to establish that this is true, although it makes logical, even poetic sense. At this time, however, it is a theory that is only proved by the information its exponents say they get from the children, or often more importantly to the researcher/clinicians, from their caregivers. They further claim that their theories are proven by the success of the treatment they provide.

I have observed a basic training tape of at least four hours by a noted figure in the field, a foster mother by the name of Nancy Thomas. As explained in the tape, and corroborated by other clinicians I have consulted over the years who either subscribe to or oppose this theoretical construct, the parent (who is often a new foster or adoptive parent) must take total control of the child’s life. This is not done through punishment, per se, but through very firm boundaries and rules, that allegedly replicate the child’s missing experience as an infant, of being utterly dependent and safe in the arms of their mother.

There are a number of procedures to accomplish this. One essential element is that this procedure is all-encompassing; there should be no moment where the child is not wrapped in psychological swaddling. Every action must be geared towards ‘reattachment.’ For example, the child must learn to sit facing a wall, without moving for two minutes, upon entry into the foster home. They will be required to do this through the day(s) until they succeed. They may be required to play in one area with Legos, and if they speak or move from the area, the toys are taken away. They have graduated chores to do, which are not deemed finished until they are ‘perfect’—one thinks of the parody of the suburban parent who scans the lawn for errant blades of grass after mowing that must be snipped one-by-one with a small pair of scissors. The child must answer questions in full sentences: “Yes, mom,” rather than “Uh huh.”

When the child whines or is oppositional, the parent does a kind of verbal aikido, through which he or she tries to pre-empt the child’s taking control through negative behavior. For example, “You can go to your room for one-half hour by yourself, or you can help me for two hours. Oh, you are going to your room by yourself. Good. You are getting so strong! And I’m sure you’ll want to slam the door on your way. Good slam!” However, is this, in fact, an adroit blending with the child’s energy, or merely a satisfying sarcasm that enables the parent to ‘win’ the power struggle?

In the first stages of care, they cuddle three times a day, whether the child wants to or not, and the parent must require eye contact—theirs should be warm and loving. The intention is to create an environment in the home in which the child gets what they, allegedly, never received before: a sense of their parents as “Awe-some!” (their phrase). The child learns limits and trust when they have limits and rules.

There is a proper way to hug: both the parents’ arms should be over the child’s, as, thereby, the parent is in full control. Continuing this focus on control, parents must initiate all hugs; all nurturing behavior must be given by the parents, even though this is not substantiated by research on early child development where the baby does a lot initiation of the sequence of nurturance. A particular model of parenting is established that very much resembles that of 1950’s American television shows. For example, Ms. Thomas says that she teaches her children to cook only if they have grown up in her home long enough to be ready to leave; she maintains dependency rather than encourages independence, seeing the former as the missing developmental experience.

Ms. Thomas presents some effective parenting strategies. Responsibility is placed on the children. Rather than being told to do homework, the child gets natural consequences from not doing it. The child doesn’t have ‘bedtime’—they have ‘go to your room time’ at 8:00 p.m., where they can do homework, read, whatever. The idea is that the child, so out-of-touch with his or her own organic needs, learns to self-regulate, because he or she must get up at the same time every morning, no matter what time they fall asleep.

On the other hand, some of her suggestions are an open manipulation of power through the ability to use language to define reality. An unmade or poorly made bed, for example, is interpreted as a desire to sleep in, and so the child is told to get back in bed. Every fifteen minutes or so, the parent checks again, and if the bed is still unmade, back to bed they go. The child may not leave his or her room in the morning unless it is perfectly arranged and clean.

Discipline strategies generally use this ‘power to define.’ When the child breaks a rule, there are ‘consequences as privileges.’ They are awarded the chance to wash the bathroom or the kitchen floor, using a toothbrush to get the corners, perhaps, to “help them get stronger,” because they must have been feeling weak to call their brother a nasty name. The presenter has the child offer restitution for some things by giving her a foot or shoulder massage—given how many of the children who present with such behaviors were not only neglected, but abused, this ‘restitution strategy’ is particularly troubling.

The child is seen as manipulative and untrustworthy at any and every moment: incessantly striving for any advantage. The parent’s task is to “care enough” about the child to take control now, to replicate the alleged missing experiences of the earlier stages of life so that the child can move on. Parents are encouraged be strong now, setting limits for the child, because if they don’t, these children will, it is asserted, grow up to be psychopaths, criminals or marginal individuals. They are trying, in essence, to cause the child to experience his or her life as they should have as an infant and small child. It has never been established that it is possible to heal through such regressive experience, but this is the theoretical basis of this ‘therapy.’ Furthermore, there is no evidence that the definitions attached to the child’s behaviors are, in any way, congruent with early childhood experience.

The most controversial aspect of Nouveau–RAD treatment is called Holding Therapy, a method which has rather bizarre antecedents. It was first used with children manifesting schizophrenia or autism. The originator, Robert Zaslow, believed that these conditions, too, were manifestations of poor attachment, something absolutely counter to current psychological knowledge. In his Z-Process, these vulnerable, psychotic or autistic people were pinned down by a number of people who ‘loved’ them. Then, they were tormented, tickled and poked, sometimes for hours. The idea was that the core of their psychiatric disorder was rage that had to be released. When it finally was, along with fear, helplessness and panic, it supposedly replicated the birthing experience, and in that utterly dependent state, they would meet the eyes of the people who loved them, and make a reparative bond. This, it was claimed, would cure their schizophrenia or autism.

Though thankfully abandoned as an explicit treatment for those suffering from schizophrenia or on the autism spectrum, this method was adopted by the Nouveau–RAD theorists—in fact, Zaslow, who lost his license to practice psychology, was a mentor of the aforementioned Foster Cline.⁵ It has undergone gradual development over the years. However, some therapists and parental figures still use what should be regarded as torturing the child, through tickling, grinding their knuckles into their ribs, pinning them with one’s whole body weight, or pushing on their abdomen with an elbow. The caregiver looks in the child’s eyes, once the ‘break-through’ is reached, and tells the child how much he or she loves them, therefore allegedly establishing a bond while the child is in such a vulnerable state.

Others, ostensibly more humane, though still quite intrusive, make an allegedly voluntary contract with the child in which he or she agrees to be held. ‘Voluntary’ is an interesting word, under the circumstances. By their own assertions, these are children who were deprived, neglected or brutalized in their earliest years. Now the person who controls their fate: whether they will remain in the foster home, when and how they will be fed, or whether they will spend hours scrubbing the corners of the bathtub with a toothbrush, ‘requests’ that they volunteer.

The therapists and aides hold and restrain the child in their laps, and for a long period of time, attempt to evoke ‘core emotions’ and memories through insistent verbal probing. The therapists repeat over and over how miserable and unloved the child was—so they assume—in their earliest years, trying to get the child to powerfully express his or her pain, rage, fear etc. In some case accounts I have read through, the parents indulge all their frustrations and anger with verbal abuse that is claimed, in the end to be therapeutic (I read one account where a mother licked the face of the child whom she was helping to pin down). And when the child does explode into tears or rage, the parental figure (usually a foster parent, but sometimes a family member, even a birth parent) enters the room to hold them, staring into their eyes with love and caring, thereby establishing a bond imagined to be similar to that a baby and mother experience, eye-to-eye, at the moment of birth.

Problems with Nouveau RAD

There are a number of areas of concern regarding this diagnosis and its treatment:

1. There has been no legitimate research on this Nouveau RAD diagnosis and its treatment modality. There is anecdotal evidence from parents and clinicians on how much it helped a certain child. Even postulating that this could be true in one or another case, we don’t know how long it helps nor really why it helps. The treatment requires a very parent-intensive way of life. The Nouveau-RAD parents are far more involved with their children than most other parents are. Also, to be fair, some of their suggestions are a good model of authoritative parenting. An authoritative parent is one who does not try to break the child’s will, nor ignore his or her own parental responsibility by adopting a lese’ faire attitude. All available evidence shows that success in parenting is less due to any specific rules or methods than the assumption of strong, loving, consistent parental authority. Therefore, it may be that the children who allegedly do well in attachment therapy (I have been citing the extremes above, where it is hard to imagine anyone benefiting) do so because all the procedure advocated for the home give a parent one possible framework to take authority. It is conceivable that some loving people could use some of these techniques, and the child perceives their love and nurturance despite the methodology. However, any loving parent who can adopt a consistent authoritative stance with firm limits and boundaries could surely do far better, without adopting the procedures advocated by the Nouveau–RAD theorists. One could establish a far less bizarre set of rules that could provide all the consistency necessary without Nouveau-RAD’s controlling, even sadistic ways of interacting with the child. One example of a healthy way to parent even very troubled children can be found in the book, Transforming the Difficult Child.⁶

2. Screening - One of the primary methods of ‘diagnosing’ these children is the parental figures’ reports, coupled with the therapist’s observation of the child. Their diagnostic criteria are an inescapable Catch 22. One of the diagnostic criteria is the parent’s anger at the child; another is that these children always lie; and a third is that these children can charm outsiders so that only the parents can see the trouble. The belief in the diagnostic powers of the therapist or non-therapist—Ms. Thomas has no license or formal training whatsoever, and Foster Cline had to ‘voluntarily’ surrender his license to practice medicine—can be quite grandiose. Ms. Thomas, for example, states in her tape that she visited a school classroom and saw eight kids there with attachment disorder. Her criteria, I can only assume, must be that she saw some children acting up, sullen, or otherwise being unpleasant teen-agers. It is one thing to say that she saw a class with eight obnoxious kids, maybe even with bad hair and pierced tongues—but it is quite another to then assert that each is suffering from a condition that is more-or-less equivalent, as far as the Nouveau-RAD theorists are concerned, to childhood psychopathy. My first two questions, when a parent presents with complaints about a child, are a) Are the child’s behavior, in any way, related to the way the parent treats the child, b) Are the child’s behavior, in any way, related to how the parents treat each other.

3. This essay, as previously noted, was written in the context of a family, the father of whom was convinced that his adoptive son had attachment disorder. The son was, indeed, a somewhat sullen, un-talkative, angry kid, who had gotten in a little trouble with the law. However, within only a few interviews with the father, the mother and the young man (held separately), and observations of the mother interacting with the young man in their home (the father and son refused to meet with each other), it became clear that the father had always regarded the son as an intruder who stole his wife’s attention away from him. He hated the boy, and expressed that in a myriad of ways. His wife substantiated that to me. The father stated that on the boy’s 16th birthday, he was going to buy him the most powerful motorcycle he could find and then the ‘problem’ would take care of itself. The father displayed extremely paranoid and narcissistic ideation, so pronounced that they should have been obvious to any psychologically-trained observer—or, in fact, any lay-person, whether they could have put a name to them or not. Nonetheless, based on this father’s report and a single interview of the youth by a very well-known Nouveau-RAD therapist, who cited the boy’s sullenness towards her, a stranger, as a prime diagnostic characteristic, the boy received the Nouveau-RAD diagnosis. (On the contrary, my intervention was to support the mother in getting the father out of her home and her child’s life. The divorce was settled without the mother being impoverished, the father’s intention along with institutionalizing his son, and the young man’s behaviors and relationship with his mother subsequently improved.)

4. A child may certainly come into a home with some degree of difficulty in either loving or bonding, but if the parents do not genuinely love their child, if they see the child as an extension of or reflection on themselves, if they feel outraged and betrayed that their birth or adoptive darling turns out to have some problems, they can often become belittling, cold, insulting or abusive. And the child will respond in kind. The situation gets worse and worse, and eventually, the parents present their child a Nouveau-RAD therapist’s office. In these cases, there may certainly be an attachment disorder, but it is primarily that of the parent.

5. Inauthentic Consequences - One troubling aspect of Ms. Thomas’ tape was interventions like this: The child whines and the mother says, “I see you are whining and therefore feeling weak. You need to get strong. Do ten push-ups” (or jumping jacks). The exercises have to be done in the precise manner prescribed by the parent; if not, this shows they are still weak and need to do some more. Their theory is that the bobbing movement circulates the blood and stimulates the brain, and that it gets the kid in touch with his or her body, AND it is a natural consequence of negative manipulative behavior. However, there is no real connection between whining and jumping jacks, much less any proof that jumping jacks or push-ups improve either behavior, circulation of blood to the brain or neurological functioning. As the parent has an ulterior agenda, it is also manipulative. As I have already written, it is my firm belief that children, particularly disturbed children, need very firm structure and limits. But the parent must be absolutely authentic, and their communication must be ‘clean’—unambiguously connected in a concrete way to the problem behavior. If the parent is trying to do ‘therapy’ as opposed to being a pure parent, they are ‘doing’ the child, rather than being with the child. The parent must demonstrate to the manipulative child that there is a radically different way of communication than the one that the child is using, one that is nourishing to both parties.

6. Beyond this, while observing the tapes of parenting techniques for such children, I was struck over and over again how the same action could be benign or hateful. Teaching a child to sit two minutes still facing a wall is the basis of meditation. Teaching a child, thereby, to follow a parent’s instruction is excellent. Requiring them to persist when they undermine one’s authority by silliness, whining, or squirming, could be good education. But it can also be a cold, punitive, controlling action. The techniques of ‘verbal aikido’ for setting limits could be an amusing, humorous way of turning the tables to the child’s benefit. It can also be a nasty, sarcastic, snide put-down, masked as caring and love, by someone who can control the definitions of reality by verbal skill. Such a theory can take parents off the hook. In both the literature and in person, I have heard parents refer to their children in terms most of us use only for vile criminals, even as they try to add a caveat that they love the child. In some of the most prominent books, they describe mini-psychopaths, and nascent serial killers, or even children with the devil inside them. Several of the most prominent authorities of Nouveau–RAD therapy have also promoted the absolutely debunked fantasy of ritual Satanic abuse, that is, they allege, endemic throughout our society, particularly in daycares.

7. A question that must be asked of proponents of the Nouveau-RAD theory, particularly when considering such a pervasive life-style change and radical therapy, must be: How are you screening the parents/foster parents? To the best of my knowledge, most Nouveau-RAD treatment facilities do not spend nearly enough time assessing how intact or impaired the parents are, and how their deficits affect their very hurt and vulnerable children. Instead, they often make the unsubstantiated assumption that the parent’s anger, frustration, even hatred and poor disciplining was evoked in nice people by these horribly disturbed, sociopathic manipulating kids.

8. The ‘religious character’ of the movement - Like any controversial area, particularly when people feel so beleaguered and misunderstood, Nouveau-RAD parents have banded together in support groups and study groups. There is often an ‘us-against-them’ attitude. For such parents, nothing that they tried for their children worked. This procedure offers hope, or at least an explanation. The worst aspects of this in-group attitude have appeared in several cases where parents or therapists killed a child, such as one case where a foster father tried to do holding therapy at home, and pushed his fist in his three-year-old’s abdomen until she died. Many Nouveau-RAD advocates, including leading ‘treatment’ specialists, have flocked to each of these people’s defense, saying that the children were attachment-disordered kids, and the loving parent was trying to save them. I’ve not read one word from these parents that expresses the slightest sympathy for the anguish that little girl must have felt being literally crushed to death by her foster father’s fist. This us-against-them stance also shuts out alternative views, including those research-based, if they are at variance with the catechism of Nouveau-RAD. One preaches to the choir and doesn’t allow access to independent opinion or information.

9. Inadequate or incorrect understanding of childhood development - The Nouveau-RAD theorists make much of eye contact between parent-and-child, and how important that is for bonding. True. But, the most current observation of infants finds that, when in a parent’s embrace, the healthy baby spends one-third of the time actively gazing in their eyes, one-third looking around, and one-third actively looking away from their caregiver (in other words, a healthy individual needs a break from constant intimacy). The method of snuggling embrace that the attachment therapy theorists advocate is constant eye contact. And this is reflected in the method of child-rearing; the child is under the gaze, so to speak of the parent at all times. This is, therefore, contrary, to how people really develop, because this 1/3, 1/3, 1/3 view of the infant shows that privacy is as essential as bonding to develop a Self. Even at the earliest stages of development, character is created by differentiation as much as by bonding. Extrapolating this to living with teenagers, many people, clinicians as well as parents, have found that they often get far more open communication with pre-teens and teens when sitting or standing side-to-side, with NO eye-contact, the youth finding it to be too intimate, too penetrating—as one youth said (not to me, thankfully): “You are always staring at me. It’s creepy, like you are trying to look in my head.” The aspect of control in at least some interpretations of the Nouveau-RAD method bears an uncanny resemblance to a 19th century theory of penology by Jeremy Bentham, called the Panopticon. The idea was that the prisoners should experience themselves twenty-four hours, exposed as naked sinners under the eye of God, as embodied by their jailers. They could not speak, could not eat, speak or move, literally could not do anything without permission. And in their case, the lights were always on. There was no privacy. I have observed something chillingly analogous in many homes following the Nouveau-RAD regimen—the child has NO psychological privacy.

10. The question of a reorganization of brain structure – returning to the quote above from Ghosts from the Nursery, if a ‘developmental sociopathy’ exists and results in actual changes in brain structure, then any therapy that works must help the child reorganize on a neurological level. This is possible, as recent research on Obsessive-Compulsive Disorder shows.⁷ I am not aware of any research, however, that attempts to correlate therapeutic outcome in Nouveau-RAD with neurological changes, or if anyone has attempted to screen children based on neurological deficits, as described above. Even if it is conceivable that Nouveau-RAD therapy does aid in neurological reorganization, a therapy this powerful would be, I believe, quite devastating to a child who does not have this (theoretical) disorder. Does one give chemotherapy to someone who doesn’t have cancer? No one in either the literature or the field has satisfactorily answered to me what the effects of an absolutely controlled and very eccentric form of communication would have on either a normal child or one with other problems. I asked a prominent therapist this question, and she blandly replied that she didn’t know; she had never used the therapeutic procedures on a normal child, nor, she said, had anyone in the field.

11. Holding therapy is, to me, of most concern. First of all, holding down a victim of assault, particularly sexual assault is a violation of extreme consequence. To replicate the experience of absolute helplessness is appalling cruelty. As the assault may have happened to a pre-verbal child, how can they explain that they suffered this when screened for therapy. In other words, the parents and therapists may have no idea of what the child suffered, and they are using an intense physical method that may exactly replicate experiences of abuse. There is a quite troubling parallel between the holding procedure, even in its less overtly violent form, and grooming behavior to molest children. To groom a child for molestation, one shifts between doing something that makes the child vulnerable and stressed and then offers reassurance (accompanied by abuse). This is true, whether or not the child ‘volunteers,’ given that a caregiver or trusted ‘big person’ says they should. Thus, you, the object of fear become an object of gratitude when the fear is removed—this is called a ‘trauma bond.’ And playing this back and forth, from fear to relief and back again makes the child pliable, easy to manipulate, intimidate or mold. Another example of this is the Stockholm Syndrome, where dependent and fearful hostages bond with the ‘kind’ hostage taker, who provides them with food and reassurance in the context of the dependent state that he created. In general, this should be considered a form of pseudo-religious conversion, in which an individual, in this case, a child, is subject to being made totally vulnerable, and in this state, ‘imprinted’ with a new template of relationship, like baby ducks imprinting on the first moving creature which enters their visual field. Even if this, unproved to date, were possible, something this powerful requires that all involved are totally loving towards the child, and have absolute knowledge that this and this alone is what the child needs. In sum, you have a child, held in the arms over the laps of therapist and their allies, or worse, pinned down by them. These powerful adults know a lot about the child. They probe, at least with words, to evoke the experience of loneliness, anger, fear or deprivation, which the therapists honestly believe, is ‘encapsulated’ within the child. It is no wonder that such children often call out that “I want my mommy!!!”, and collapse in their arms. The child often regresses into a dependent state, as many people do in either conversion experiences or brutal interrogations. Even worse than the possibility that such procedures will not create a bond between parent and child, there is an even more risk that a bond will be created—a traumatic bond forged of vulnerability and internal chaos created by the therapy. Sadly, many alleged positive outcomes are likely to be a manifestation of this traumatic bond, just as members of a cult proudly extol their own abuse.

Conclusion

How does one reply to anecdotal claims that severely disturbed children have been helped by these procedures? Let us imagine a child who underwent such procedures, and she or he is happier and healthier than s/he was before. Even then, we still would not know if it was the techniques or the quality of strength and love and authority that a specific parent had. If, as I believe, it is the latter, then the techniques of Nouveau-RAD would be unnecessary, rife, as they are, with misunderstandings of neurology and early childhood development, much less with an extremely high potential that they will be abusive, even violently so. Furthermore, the likelihood is very high that such parents who present with the self-fulfilling ‘diagnostic’ criteria of a) anger at the children, b) that the children always lie, and c) only the parents can see the behaviors, are very possibly not bonded or loving to the children. Nouveau RAD thereby provides sanction to a cold view of the child as damaged goods, only able to be fixed through a psychological technology that does not make the parents responsible in the slightest for their own angry or hateful feelings.

Their theory should be regarded as pseudo-science and this ‘therapy’ as quackery. What good that may be derived in individual cases is incidental, not due to the ‘therapy’ itself. The sum of this is nothing less than abuse of children under the guise of treatment.

[FINAL NOTE: Some readers may think that this essay is dated, given that it concerns a subject of discussion thirty years in the past. Unfortunately, the problems and misuse of psychiatric diagnoses are still rife today, essentially unchanged: only some of the technology of treatment (and mistreatment) may have changed. As for Nouveau-RAD, it still exists, still hurts children today].

This substack is free, and will continue to be so. As a professional writer, I do hope to have my work supported, so for those who want to do so, here’s a far less expensive way than a paid substack subscription, one that will truly be welcome - please buy one of my books. My general book website is HERE.

1. Loftus, Elizabeth, &Ketchum, Katherine, THE MYTH OF REPRESSED MEMORY: False Memories and Allegations of Sexual Abuse, St. Martins Press, New York, NY, 1994

2. Ofshe, Richard & Watters, Ethan, MAKING MONSTERS: False Memories, Psychotherapy and Sexual Hysteria, Charles Scribner’s Sons, New York, N.Y., 1994

3. https://molecularautism.biomedcentral.com/articles/10.1186/s13229-018-0208-6

4. Karr-Morse, Robin & Wiley, Meredith S. GHOSTS FROM THE NURSERY: Tracing the Roots of Violence, Atlantic Monthly Press, New York, N.Y. 1997

5. As part of my work as an assessor in cases of alleged child abuse in foster homes, a interviewed several alleged experts on Nouveau-RAD, and found their diagnostic abilities to be quite questionable. If this was close to the norm, and I’ve no doubt that it was, some children genuinely suffering from schizophrenia or on the autism spectrum were surely treated with Z-Process under the guise that they were being treated for Nouveau-RAD.

6. Glasser, Howard & Easley, Jennifer, TRANSFORMING THE DIFFICULT CHILD: The Nurtured Heart Approach, Published by Howard Glasser, Tucson Arizona, 1999 (www.difficultchild.com). The authors have continued to innovate and advance their work over the years.

7. Schwartz, Jeffrey (with Beverly Beyette) BRAIN LOCK: Free Yourself from Obsessive-Compulsive Behavior, Regan Books, New York, N.Y., 1996