The Latest SEN Fad Diagnosis: Attachment Disorder
June 21, 2015A few years ago I used to write a lot about SEN on this blog. The bloated SEN systems in mainstream schools which consisted of proliferating paperwork and amateur diagnoses were sucking money away from the main responsibilities of schools and spending it on form-filling and “interventions” that, at best, didn’t work and, at worst, undermined teachers. While a lot of bad practice still exists in the SEN world, progress has been made since then. There is far greater awareness that it is not enough to simply assign TAs to a kid labelled “SEN”; that tolerating bad behaviour does nobody any favours; that SENCOs should be properly trained and qualified, and that the genuine expertise of those in special schools has an important role to play. I don’t want to suggest the problems are solved, but I have seen fewer fashionable diagnoses being invented and greater appreciation of special schools in the last few years, and a move away from the old “SEN racket” that kept many people employed in making bogus diagnoses for perfectly unexceptional students without actually helping anybody.
However, in the last few months a new fad diagnosis has appeared. I first noticed it on blogs but have since encountered it in real-life. Here are a few examples:
I’m looking at whether the use of key adults helps children get from our turnaround class, it is designed as a short term intervention where children who are exhibiting challenging behaviour can be taught with a high ratio of very experienced staff to children… Many of the children who attend this class show behaviours which are typical of, amongst other things, an Attachment Disorder. We know these children and their backgrounds, an attachment disorder would not seem unreasonable in many cases. We have had the Educational Psychologist come and look at some of these children (with necessary parental permissions) and they have said the children need to learn to make attachments and become dependent so that they can then become independent, it sounds so easy on paper!
From a blogpost by a SENCO.
There are different types of attachment disorder, with differing ways of responding to the condition explained in the books below. At its most extreme, a student may have a statement of special educational need which specifies the condition and so staff are forewarned. More likely, are the students who have never had their behaviour and attitudes looked at through the lens of attachment, and who simply present as puzzling, challenging or unusual. These types of students are often recognised as the 5% who don’t generally respond to the usual behaviour management techniques, such as rewards and sanctions or ‘the language of choice’.
From a blogpost by an educationalist.
Young people who experience a negative attachment cycle can often end up with heavily compromised social, emotional and cognitive development. It is also important to note that the nature of attachment changes during secondary school years from child-caregiver to relationships with a romantic orientation and peer relationships. In this transitional stage, more challenging behaviours such as stress response and aggression manifest themselves, producing a different set of educational challenges in the secondary setting…
From an article in the Teaching Times
Have you had a child with Attachment disorder within your class? Suspected? How do they present?
- Violent behaviour towards staff
- Violent behaviour towards children
- Throwing objects directly and/or indirectly
- Swearing
- Spitting
…The list is endless. Children share these behaviours sometimes mindlessly, without even realising that anything was going to happen. There is a lot to be said for patience during a situation like this. It isn’t easy but knowing what situation an attachment disorder can enable is important in keeping patience.
From a blogpost by an “SLE in behaviour”.
From reading these you might be under the impression that Attachment Disorder was a recognised medical disorder, that could be diagnosed in children of any age, and often manifests itself as extreme bad behaviour.
There is a recognised medical condition called “Reactive Attachment Disorder”. You can find the list of diagnostic criteria here. This condition, a relatively rare social disorder resulting from extreme circumstances of neglect, is linked to “irritability”, but not any other form of poor behaviour, and is only diagnosed when signs of the condition have manifested themselves before the age of 5. It does not resemble the conditions described above, and the existence of RAD cannot be assumed to be evidence for the existence of the “Attachment Disorder” described in the various passages above.
A taskforce of the The American Professional Society on the Abuse of Children (APSAC) compiled a report clarifying the issues around attachment. Although it accepts the possibility of attachment disorders beyond RAD it states:
…the term attachment disorder has no broadly agreed-on or precise meaning. The term is not part of any accepted standard nosology or system for classifying behavioral or mental disorders, such as the Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases (ICD). Officially, there is no such disorder.
It notes the possibility that disorders could exist, and describes RAD and observes that attempts to apply it beyond the diagnostic criteria have taken place and that some clinicians have suggested the existence of broader attachment disorders. It warns that there is no consensus about these disorders and observes:
There are no studies examining diagnostic accuracy among the increasing numbers of children who are maltreated being described by clinicians as having an attachment disorder. It is not clear how many children described as having attachment disorders suffer from actual disorders of attachment, from transitory sequelae of maltreatment, from stress related to shifts in placements or cultures, or from other disorders with shared characteristics. The simple fact that a child may have experienced pathogenic care, or even trauma, should not be taken as an indication of an attachment disorder or any other disorder. It also is important to bear in mind that a child entering the child welfare system, foster care, adoption, or other settings is almost invariably experiencing acute stress. Behavior problems or relationship problems shown during periods of acute stress do not automatically suggest any disorder. This is a particularly important point for evaluating children in cross-cultural or international adoptions. Different cultures have different normative social behaviors, which could easily be misconstrued as a disorder. For example, failure to make eye contact is included on some checklists as a sign of attachment disorder; however, this may be a normative social behavior in many cultures (Keating, 1976). Establishing that an attachment disorder, or any other stable disorder, actually exists requires some familiarity with the child’s long-term behavior, including behavior in multiple settings, and should not be limited to behaviors occurring with a foster or adoptive parent. Assessments based on a single point in time snapshot of the child may be particularly vulnerable to misdiagnosis
The reports warns that “Mental health and related fields have a long history of diagnostic fads, when rare or esoteric diagnoses become fashionable and spread rapidly through the practice world, support groups, and the popular press” and suggests that:
The standard diagnostic aphorism that “when you hear hoof beats, think horses, not zebras” is important to bear in mind for a number of reasons. First, more prevalent conditions are less likely than rare conditions to be misdiagnosed; their criteria are better established and agreed on, sound assessment procedures are more widely available, and classification accuracy is always higher with more prevalent (i.e., higher base rate) conditions. Second, the appropriate intervention for a common disorder is likely to be different from that for an uncommon disorder. Finally, there are richer literatures and better established evidenced-based treatments for more common conditions. For example, scientifically well-supported and effective treatments exist for ADHD, oppositional-defiant disorder, and PTSD (Kazdin, 2002).
It goes on to describe some of the many crank “therapies” invented for attachment disorder, including a number (such as “holding therapy”) that are abusive and have even resulted in the death of children. If you have a (sceptical) interest in crank psychology and unproven interventions, I would recommend reading the whole report. I would also direct you to the excellent blog Child Myths that covers many of these issues on an ongoing basis.
While I have never heard of holding therapy or similar treatments being used in schools here, we should be aware that any material found online about “Attachment Disorder”, particularly material that claims it is the cause of poor behaviour, could well be written by advocates of such interventions. The APSAC report accepts that those children diagnosed as having “Attachment Disorder” may have genuine conditions requiring interventions and that some interventions, particularly those that are well-established in other contexts, may work. However, (non-RAD) Attachment Disorder is usually pseudo-science or speculation and if there is one thing we should have learnt as teachers during the era of the SEN racket, it’s that neither poor behaviour nor genuine mental illnesses are best dealt with by the diagnosis, particularly by amateurs, of conditions that may well not exist.
Scenes From The Battleground 
Blogged about this several times. You and I might be in broad agreement for once, OA. https://movingonfrombowlby.wordpress.com/2012/06/09/whats-wrong-with-attachment-theory/
This is an interesting post, but I feel I must correct the idea that attachment disorder is a NEW idea. Bowlby back in the 1950’s was very interested in what it was that was different about ‘juvenile delinquents’ and his study which compared ‘delinquents’ to controls he found many of them had experienced some form of break in attachment with the main giver in the first two years of life. Hodges and Tizard in the 1970’s conducted a longitudinal study where they compared children who had been in care (and then adopted before the age of two) with children who had not been in care. They interviewed the children, parents and teachers every so many years throughout childhood (at age 8 and 16) and found that children who had been in care generally reported less stable friendships, more incidence of bullying (bully and victim) and less secure attachments to care givers. Teachers often rated these children as less liked than their peers when compared with controls. There have been many, many studies since, all finding broadly similar differences. Ainsworth and her colleagues have identified attachment types that generally hold up cross-culturally which suggest attachment, like many ‘disorders’, is on a continuum from the securely attached to insecurely attached. None of this is new and there is much evidence and theoretical frameworks to explain the role early attachments play on later relationships. There is also much evidence based research. Although I agree that ‘fad’ diagnoses are unhelpful such as MMR causes autism, and ‘fad’ interventions can be damaging e.g. enemas for autism. In the case of attachment disorders, they is also a wealth of research into effective interventions.
Children with complex behaviour may well have co-morbid conditions for example social/communication difficulties or attentional problems and a history or poor attachment. It is therefore crucial that schools seek help if the usual interventions are not effective. Children with poor early attachments can have poor long term outcomes – children in care are particularly at risk. Hodges and Tizards study also compared adopted children with those who had returned to the birth parents (after time in care). They found more problems in the children who had returned to their birth parents, with the adopted children more like the controls (who had never been in care). This tells us two things 1) attachment problems can occur even if you are not physically separated from the parent e.g the parent is emotionally unavailable for a variety of reasons including depression and substance addiction and 2) that with the right environment where work is done with the child to build secure attachments, then these children can have a good future outcome.
As a trainee educational psychologist, I am glad that attachment issues are reaching beyond the confines of psychological research and that teachers, SENCO’s etc are aware that for some children this may well help to explain some of their problems and lead to interventions. Psychology is a new science and therefore its ability to inform and help is still very much in its infancy, but it is a growing field and in education has the potential to be transformative – at least that’s my plan.
Good to be able to talk about this and share the evidence base.
Worth reading paper by Barth et al on state of attachment research http://is.gd/IUPVOr – lots of papers referring to it, not so much research into it.
Also, psychology is a *new* science? Compared to…?
I will definitely read that paper. Thanks. Compared to maths and physics. We are talking about William James in 19th century as the founder of modern psychology. The scientific method in psychology only really began with behaviourism in 1940’s and 50’s.
Fechner? Wundt?
Thanks for the link to the paper. It is an interesting read, however, it is not rejecting attachment theory, rather commenting that there are some dubious interventions that have resulted from a misunderstanding about what is meant by disordered/insecure attachments and that future work lies in interventions that address the current parent-child relationship (rather than the deterministic nature of early attachment theory, which suggested once a child was damaged then there was no way of improving).
The future work it suggests, considering the paper is ten years old, is now taking place. For example it suggests that further evidence needs to be gathered on programmes designed to improve the parent/child relationship, such as The Incredible Years Parenting programme. A review was conducted recently by a trainee EP at UCL (link below): “This review found that
there was moderate evidence to suggest the effectiveness of the Incredible Years in improving positive parenting, reducing negative parenting and improving social and
emotional well-being.”
Click to access CS1Jalali.pdf
Also find a link to a review of Triple P (positive parenting programme). “This review aims to evaluate post 2010 research into the influence of Triple P on
child behavioural outcomes. Five papers were identified to address the review question. Overall results found that Triple-P was effective in reducing/preventing child conduct
problems”
Click to access CS1Hamilton.pdf
There is an acknowledgement in psychology that we need to be doing more meta-analyses and systematic reviews as well as replicating studies. One of the requirements of my doctorate is to complete a systematic review of an intervention. Hopefully, there will then be a much clearer evidence base for interventions that have a proven effect going forward. Now all we need is for government, LA’s and schools to pay attention to them.
I think we actually need to be doing some serious work on conceptual models too. Often overlooked in the race for data.
Juliet
What do you think of NICE’s draft guidance? http://www.nice.org.uk/guidance/indevelopment/gid-cgwave0675
I think the real spanner in the works is ‘nurture groups’ where the Boxall profile has been used to diagnose children with attachment disorders and then these children are removed from class and as the main article states – children have to become dependent to become independent.
Except that Boxall’s work was basically her own commentary, the ‘evidence’ for it is pithy to say the least and despite the fact that nurture groups have been run for over 40 years there is not one longitundinal study. Ofsted looked into nurture groups and to say the provision is uneven and damaging academically is worrying. Even more worrying is how the data has simply gone missing for children. Trust me if you work in a school there is no way that the data does not exist!!! https://www.gov.uk/government/publications/supporting-children-with-challenging-behaviour
It is shocking that based on one person’s ideas there are adults in school aiming to get children to become attached to them on purpose over and above their parents. I have worked in two schools with them in and I am highly disturbed by this as there is no science behind it. There is a deliberate attempt to take-over the role of the parent. This attachment is then maintained for an indeterminable period of time over years.
There is nothing healthy about this intervention, the fact that the attachment problem stems from issues with the parent surely it is that relationship that needs to be supported. There is no safeguard here, either for the adults or the children, so no one is ensuring that it is actually benefitting them and that the adults are emotionally healthy. Too often this is just an attempt to keep those children dependent and the next step rather conveniently does not arise or is seen of less importance. The fact that little critical analysis is sought and that it is tried mainly in poorer areas is also a worry. There are parents who have asked for their children to be taken out and yet still the TAs who ran it insisted on maintaining a relationship with those children.
I have not seen it do any good only harm to the most vulnerable children. Until we have real research into the circumstances that these children find themselves in and we will not be able to introduce suitable interventions at an appropriate level, As it stands there are too many interventions and training based on ideas dreamed up by well-intentioned but ultimately ignorant individuals, who do not know or seek to understand the circumstances of these children. Seeking to deliberately infantalise children based on a dodgy diagnosis is neither helpful, ethical or acceptable.
I don’t know a great deal about nurture groups, but I did have a look at what research is out there to evaluate the outcomes. A national longitudinal study was conducted by Cooper and Whitebread (2007). Their findings were evaluated by doctoral student, Jessamine Chiapella, at UCL in 2014 as part of a larger piece of research on increasing understanding of the psychological processes in the outcomes of pupils in Nurture Groups. Her thesis can be found here: https://moodle.ucl.ac.uk/pluginfile.php/2331397/mod_resource/content/4/dedpsy_2014_theses/index.html
She evaluated the Cooper and Whitebread (2007) study and acknowledged “these results do raise the question about the mechanism for change on both the NG participants and those children with SEB needs who were not in NGs but were in schools that had NGs; and whether these positive effects could be achieved without the need for a resource-intensive intervention such as a NG e.g. through whole-school training designed to develop nurturing ethos and practice in all
lessons.”
However despite reservations of the intensive nature of NG’s in terms of resources, she concluded: “The strongest conclusions to be drawn from this large scale study are that established NGs achieve significant improvements in social, emotional and behavioural functioning compared with control children without SEB needs and those with SEB needs attending schools with NG provision. In addition, schools with NGs tend to achieve better outcomes for all their pupils with SEB needs when compared with schools without NGs.”
Nurture Groups do need further research (as do most educational interventions), and care needs to be taken that they are delivered as intended (too much modification can water down the effect), however based on the evidence I can’t endorse your view that ‘there is nothing healthy about this intervention’. The paper you cite above broadly concludes NG’s have a positive effect if delivered well, which supports the above thesis interpretation of the national study conducted in 2007.
As for the Boxall Profile – I will need to do some research on the reliability and validity of the measure and will get back to you. I would hope it has a sound evidence base (i.e. that other researchers have tested it) because it is quite widely used in research into NG’s, but can’t say until I search the databases.
Just found this paper published in a peer reviewed journal on PsychInfo database:
Couture, C., Cooper, P., & Royer, E. (2011). A study of the concurrent validity between the Boxall Profile and the Strengths and Difficulties Questionnaire. International Journal of Emotional Education, 3(1), 20-29.
Abstract: The aim of the study is to establish the level of concurrent validity between the Boxall Profile, a diagnostic instrument used by teachers and teaching assistants in nurture groups, and the Strengths and Difficulties Questionnaire, a widely used screening instrument in the fields of education, mental health and social work. 202 children and adolescents attending nurture groups in England, aged 3-14 years, participated in the study. These consisted of 142 boys and 60 girls and came from 25 schools in 8 LEAs. School staff completed the Boxall Profile and Strengths and Difficulties Questionnaire for all pupils. . The results show a high degree of concordance between the two instruments, with both measures appearing to identify similar behavioural characteristics in the same children. Scores in specific domains of the Boxall Profile are shown to predict performance on particular sub-scales of the Strengths and Difficulties Questionnaire. These preliminary findings support the validity claims of the Boxall Profile, indicating that it is a reliable tool for both diagnostic and research purposes.
Would need to search further to see what other papers have tested the internal reliability and other types of validity e.g. predictive, but it looks promising in terms of concurrent validity.
Firstly, in the instance of the thesis, the student already was in the process of establishing a nurture group – how does that not affect the study with all sorts of inherent biases?
Secondly, both the SDQ and Boxall Profile suffer from problems relating to self-reporting questionnaires.
Thirdly, I don’t see that a small scale study such as the one you present in support of the Boxall Profile is adequate to make the case that either it or the SDQ is a reliable tool. The Cooper and Whitebread study, while had 548 children, is still small and would not lead to statistically significant results for either the children in the nurture groups or those not in nurture groups.
Finally – since when has a 2 year study been considered longitudinal? Short term interventions can and do have an impact on children due to novelty. Also a school signing up to ‘nurture principles’ is unlikely to report the failed cases given the money spent on these interventions.
This kind of sham is precisely what concerns me about nurture groups in the first place, vested interests conducting research, no independent replication, few peer reviewed articles in the first place nevermind any critiques.
I need a lot more evidence and a proper longitudinal study to be convinced.
I think we have a different understanding of research terms such as longitudinal and adequate sample size. As someone who is currently conducting educational research in real classroom settings I can only remark that studies that last longer than a few months and have a sample size of a few hundred are certainly not considered small or insignificant. The point of statistical analysis, in particular effect sizes, are a way of understanding whether the intervention has had a meaningful impact (taking account the sample size) – but yes there is never going to be total certainty, hence why psychologists look to meta-analyses of interventions, which review all the studies done on a particular intervention so far. While I agree that we need more independent replication (and psychology as a discipline is in the process of examining how it does more of this by encouraging journals to publish replications rather than have a bias towards new research); and I also agree that biases such as social desirability must be considered in interpreting results, I do not agree that this type of research is a sham. From the many psychologists I know, I can assure you we are not being paid to carry out research by companies selling products – rather we wish to explore and build an evidence base of what really does work so we can actually make a difference to the lives of children and young people.
As for the measures we use, yes self-reports (e.g. SDQ and Boxall), can be open to bias, but most research studies overcome this by collecting data from at least 3 sources (triangulation) if these 3 different sources yield similar results then it improves the reliability of the measure.
From what I have read, and I have not carried out a systematic review (my own thesis keeps me busy enough), Nurture Groups have shown some positive effects and do not appear to be detrimental to those who engage in them. Maybe you could carry out some research yourself if you work in a school and add to the body of evidence – the more research we have the better informed we become.
Currently I don’t work in or with a school with a nurture group however even anecdotally there have been parents withdrawing their children, refusing to send their children to the nurture group and also a complete hindrance of the NG staff when it comes to reintegration. 2 years of evidence from a biased source is still only 2 years of evidence. While I appreciate no company is directly providing funding, there are still vested interests in this movement. Triangulation where none of those reporting are unbiased does not lead to reliable results. If evidence – both positive and negative were included (whereas the latter is brushed under the carpet it seems) then we would have a better idea of what is going on. The transition from primary (where those adults are still around) to secondary is a key marker. If the attachment stayed at the level of dependency then it is likely to create another attachment issue. If the issue is attachment to the parent then only a better relationship with the parent can lead to overall and long lasting improvements.
The fact that this ‘experiment’ of NG is being effectively conducted on the poorest and most vulnerable children in our society is not acceptable. Neither should any new NG’s be allowed until we have tracked the children who have been in existing nurture groups over the course of their education. It is not good enough to remove children from their entitlement to the national curriculum based on ‘attachment’ disorders which do not count as Special Needs, would not lead to a statement, additional provision or a place at a special school. Children’s futures should not be affected by the emotional needs and biases of adults working in the education field.
I think we have to disagree on this. The evidence on NG’s from my brief search is promising in my opinion. I accept you view the research differently – all good – as critical questions are vital in all applied research fields. However, I do take issue with your end paragraph – yes children in NG’s are likely to be vulnerable as that is the target population but all research conducted at UCL has to go through an rigorous ethics committee process and any decisions to remove children from mainstream classrooms is not taken lightly by anyone involved in education. I would not be in this field if I thought otherwise. We need to do research so that these interventions can either be endorsed or debunked. One of the reasons I left teaching was so that I could have the time to pursue research. I only wish classroom teachers were given the time and the resources (e.g. access to databases) so they can ensure what they do is evidence based rather than a reaction to government policy.
I agree that we are going to have to agree to disagree on this one. While I can accept as a researcher you have had to go through an ethics committee, that is simply not true for most of the NG’s set up around the country. Therefore the standards you have had to abide by are not necessarily the same for all researchers and certainly do not have to be met when LEA’s are setting up NG’s.
Parents are often struggling with their children or home lives and are vulnerable themselves. I have not come across any literature which is given to parents which informs their opinion highlighting both positives and potential negatives. We wouldn’t give children medicine without ensuring that parents are informed, so why do it when it comes to mental health issues. I don’t believe this meets the standard of duty of care or ensuring that parents can make an informed choice when consenting to their child being part of an NG.
Neither are there adequate safeguards in place for the pupils or the staff. Often it is a member of the LEA in charge of pupil behaviour or a SENCo who is in charge but they are not trained to deal with some of the issues that arise.
As for judging the research adequate, it has long been known that the research relating to education is of poor quality in general. Poorly designed and executed, statistically dubious claims and misleading tables are standard parts of research I have come across. I know as a political scientist I would never have been allowed to get away with any of this. That it does happen is a shame to the educationalists and suggests a higher bar in general needs to be enforced. The main reason this is not already the case is due to the fact that teachers are not able to hold researchers to account in the same way that people in other professions can.
This means nothing in terms of you and your university but if you are truly conducting a well designed research project which is minimising the effect of biases and is prepared to report the positive and negative effects of NG’s honestly, then you are part of a minority rather than the majority.
Oh and I don’t think there is anything strange about my understanding of longitudinal studies having come from a research background. I know of no other field of study where 2 years would be considered a longitudinal study, especially as one year would be spent in a nurture group and the second year still usually involves regular time spent in the nurture group. Therefore one doesn’t even cover the extent to which it has enabled the child to develop relationships in different contexts, not is it a comparison of their ability to relate to teachers prior to and after attending a nurture group.
Personally, I’d like to see the psychology backed by neurological evidence which there well may be. It’s unlikely that’s going to become a requirement in educational psychology, however.
Some of the worst nonsense in this area is accompanied by pictures of brain scans.
Well some of the worst nonsense in cosmetics advertising is accompanied by scientific names for chemical compounds, too. I always find it very odd that people still believe that behaviour does not originate in the brain.
Would you want an x-ray of a computer in order to de-bug a computer programme? We have minds, and they may “run” on the brain, but they are not the brain. We might find “neural correlates” by looking at the brain, but not thoughts.
Rather than wasting our time with questionable diagnoses of ‘attachment disorder’, surely we should be providing them with schools that have a stable social environment–ones where rules and relationships are well-defined, and where pupils and staff can direct their energies positively. I’ve visited many such schools, and you can tell the moment you walk in the door that no one is stressed out. Invariably, these schools have a minimal SEN establishment, and very few pupils designated as such. They also have extremely low staff turnover.
Simon Marcus, who founded the London Boxing Academy, understands that pupils with serious behavioural problems need stability above all. He commented that
“Everywhere I look, I see catastrophically bad judgment from people who have been to Oxford and Cambridge who should know better. We know what works. Kids need discipline, they need boundaries, they need love, they need stability. They don’t need a bunch of crazy liberal experiments where they are told, ‘Do what you want, make your own decisions; male role models aren’t that important; there is no such thing as right and wrong; it’s everybody else’s fault.’ “.
I’m not so sure that training Sencos is a step in the right direction. As recently as two years ago, at least one Senco Award course was still stressing the need to assess pupils’ learning styles. And they would, wouldn’t they? If there is no need to differentiate instruction for children with learning difficulties, there is no need for PEPs (or whatever they are called now), and hence not much need for Sencos.
In response to Juliet. I am not sure what you mean by neurological evidence? There is a lot of research testing tentative hypotheses between the brain and behaviour/emotion e.g. MacGuire and London taxi drivers (who seem to have larger hippocampi than controls) and Raine’s work on differences in brain connectivity between murderers and non-murderers brains (less activity in the corpus callosum as well as other differences). But it is far from clear whether experience alters the function/structure of the brain or whether it has a causal influence on our experiences and behaviour. For example, are people with larger hippocampi more likely to pass ‘The knowledge’ (the test for London taxi drivers). We do cover neurological evidence in our training, but we also cover environmental and biological factors and the interplay between them.
Psychological distress/disorder cannot be easily categorised and diagnosed (often because it is a continuum of behaviour e.g. we all have an inner voice, but most of us recognise it as ourselves). However, just because we don’t fully understand the mechanisms in depression (e.g. the role serotonin and dopamine) and why we are more likely to be depressed if we have a parent with depression, or how poverty makes it more likely, we don’t dismiss people who suffer from it. There may never be unequivocal neurological evidence of attachment disorder, but that doesn’t mean we ignore its effects.
Tom, a PEP is Principal Educational Psychologist. Unfortunately schools don’t always use Educational Psychologists to deliver training to staff and that is why you end up with dubious trainers and lack of an evidence base to support the interventions. One way EP’s can help schools is by working with them to improve the social and emotional environment. We have lots of evidence of what works. However since ‘austerity’ (a whole other issue) schools have to pay extra for our time (the free core time is taken up with statutory cases, e.g. those needing a statement/ EHC plan). Unfortunately they may look for cheaper INSET.
Learning styles came out of the work of Gardner (multiple intelligences) and was a reaction to the narrowness of intelligence as defined by IQ tests. I don’t think he ever intended for his work to be used in the way it was. Merely he was recognising that we have many forms of intelligence and learn in many different ways. Equally it is good to be aware of how you learn best and then consciously work on other modalities (the more different ways you learn the better you will learn). However, I agree telling children they must learn in only one way and forcing staff to produce VAK lessons was not helpful and you ended up with kids who refused to write because ‘I’m kinesthetic, Miss.”
Juliet,
When I was writing an education plan for a Free School last year, I was told by our DfE appointed ‘adviser’ that IEP (Individual Education Plan) had been replaced by PEP (Personalised Education Plan).
I’ve worked with a lot of Ed Psychs in my day, and found that many of them were very knowledgeable, and some of them (especially the late Martin Turner) have made a real impact upon illiteracy (which is my special field). Educational Pscyhologists in Gloucestershire conducted trials of the Wave 3 literacy materials I wrote, and the results put us on the map. See http://www.gloucestershire.gov.uk/schoolsnet/CHttpHandler.ashx?id=34381andp=0
We delude ourselves if we think that schools will ever have enough time to meaningfully design a bespoke education for every SEN pupil. When I was engaged to teach remedial literacy skills at a Norwich comp, I had 5 minutes per week to devote to each pupil who was two or more years behind in reading or spelling. We were able to make a considerable impact, but only by using SRA materials, which are the antithesis of individualised learning. They were simple enough to be used by TAs and parents–and parents made all the difference. I wrote up our results for the Dyslexia Review in 1998.
Our programme developed many of the ideas used by SRA, but oriented them more to pupils with learning difficulties. They are focused on the skills pupils need to learn, with no concessions whatever to individual differences (other than the severity of the learning difficulty). They provide more distributed practice than any other materials we have seen. Sales have continued to grow over the last ten years, and now well over 1,000 UK schools use them. The Sencos we talk to value it because it addresses the simple reality that I faced 19 years ago.
Hi Tom, acronyms! The link above is not working above. I wouldn’t be interested to take a look. Also what is SRA? The intervention you developed may be useful to me. Thanks.
NICE are currently developing guidance for professionals working with looked after children who have or at risk of developing attachment problems and RAD. They already have an evidence base and welcome contributions to the development of this resource. http://www.nice.org.uk/guidance/indevelopment/gid-cgwave0675
This is more than a little odd. It’s not directly produced by NICE and the team compiling it are mainly not doctors. Worrying if this is what NICE are now funding.
The team are multi-disciplinary, which is a much better approach than just one group of professionals. A number of them are professors in their field, which means they should have expert knowledge and also the ability to systematically evaluate research and outcomes. It also includes the voices of care leavers, which is so important. Not read the document yet, but thanks for the link Leigh, it is definitely worth a read and will hopefully provide some recent evidence based examples of what works. I am slightly biased, but UCL have an international reputation for the rigour of their research. I am also impressed that it is a collaborative work between psychiatry and psychology – these two professional groups have not always had an easy relationship in the past (see R.D. Laing and the anti-psychiatry movement).
“This guideline has been commissioned by NICE and developed within the National Collaborating Centre for Mental Health (NCCMH). The NCCMH is a collaboration of the 13 professional organisations involved in the field of mental health, national service user and 14 carer organisations, a number of academic institutions and NICE. The NCCMH is funded by NICE and is led by a partnership between the Royal College of Psychiatrists and the British Psychological Society’s Centre for Outcomes Research and Effectiveness, based at University College London”
Thanks Juliet,
NICE guidance often gives a very useful overview of many ‘special needs disorders and difficulties ‘, from a medical and social point and I have found it to be robust and pragmatic. Their teams are balanced and broad and collaboration across fields to inform professionals who work with children is to be welcomed, so that teaching, like other areas, doesn’t become rather insular.
Reblogged this on The Echo Chamber.
This is so depressing. Desperate, pointless people trying to justify their employment in a field so discredited that it really makes you wonder how it continues to exist. Then you take a look at the wider picture and it all becomes clear: it’s a huge industry whose purpose is to reclassify the manifestations of inadequate parenting as instances of medical conditions; conditions, coincidentally, whose symptoms are indistinguishable from the typical behaviours of spoiled, self-centred, attention-seeking, bone-idle, disruptive children with little or no self-control and no concept at all of the rights and feelings of others. These aren’t ‘conditions’: they’re how children turn out when nobody has ever given them appropriate barriers.
The answer is to impose barriers and socialise them to the point where they can learn and allow others to learn. Instead we have decided that what they really need is to wallow in a stew of self-serving victimology served up by vacuous ‘professionals’ who need to keep seeking out and pushing ever more unlikely diagnoses which might just convince a credulous few that the butt-naked imperial bag of blubber is actually wearing clothes.
Although the tone of your post is very negative, I agree with you that children who are not raised in a stable, loving environment with consistent rules, can present with behavioural issues. Children who are in care are much more likely to be excluded from school for example. Poor parenting is often not a choice, rather those parents were themselves poorly parented – there is much good work that goes on in Children’s centres across the country to help parents develop the skills they lack. I also don’t disagree that if there is money to be made, then someone will be making it. There are many dubious interventions sold to parents and schools that lack an evidence base and are delivered by non-psychologists. I know of a number of educational companies that offer study skills sessions to schools, where the presenter is an out of work actor, who is spouting out of date psychology.
However, you are certainly misrepresenting my profession. As a Trainee Educational Psychologist I do not diagnose and I certainly do not look for ‘medical labels’ to attach to a child. My role is to test hypotheses for a child’s difficulties and seek appropriate interventions (using psychological theory and research). For example, a child is constantly getting into conflict with teachers at school. I will gather a detailed picture of the child’s development so far, what has happened within the family, were there early development concerns, do conflicts arise in other settings e.g. home. I will also interview parents, teachers and the child themselves (if they are old enough) as well as observing them at school and possibly conducting some assessments e.g. if the child is struggling with literacy, I may conduct a dynamic or standardised assessment to explore what aspects of literacy they find most difficult. Or I may explore their personal constructs, for example the attributions they make about adults in authority ‘they all hate me’, or ‘they just want me to conform’. By testing hypotheses I can rule out ones that are not useful and focus on ones where change is possible. Sometimes those improvements involve the adults around the child changing their behaviour e.g. differentiation in the classroom, or using behavioural techniques to help parents develop a consistent bed time routine. More often than not it will involve changes at many levels e.g. the child may need some help with spellings, or a short course of CBT to help them deal with anxiety. The school may need help with recognising mental health issues and dealing with bullying.
Out of interest, do you work with children? If so, what do you do when a child presents with complex behavioural problems? What has worked? and how do you decide what approach to take?
“By testing hypotheses I can rule out ones that are not useful and focus on ones where change is possible. Sometimes those improvements involve the adults around the child changing their behaviour…”
I think I’ve been on the receiving end of some of these putative ‘hypotheses’ produced by various professionals and I have to say that, in almost all cases they have proved less than efficacious and generally only serve to bolster the child’s conviction that they have a God given right to maintain their regime of anomie and general disruption since they are, in fact, the unfortunate victims of a cruel and unfeeling society which lacks the nuance and insight required to fully comprehend their ‘illness’. Although I have to agree that, as you state, many of these ‘hypotheses’ do indeed require adults to alter their approach and rarely suggest that the answer may lie with a change in the child’s own behaviour. Why is that?
“Out of interest, do you work with children? If so, what do you do when a child presents with complex behavioural problems? What has worked? and how do you decide what approach to take?”
Generally speaking when ‘complex behavioural problems’ manifest themselves I’m prone to disregard them and simply consistently apply the same set of sanctions I use with other students. If this doesn’t appear to work I let the child know that whatever they get up to elsewhere they can forget about trying it with me. This solves 95%+ of such issues. Naturally, I get a certain amount of grief from the SEN department for failing to buy into their pseudo-scientific claptrap but:
a) My results are outstanding; even with those tortured souls whose ‘complex needs’ are pandered to elsewhere.
b) Our Senco is prone to make statements in quasi-technical jargon which are logically incoherent, entirely inconsistent with the known universe and are easily discounted as the ramblings of an intellectually deficient imposter…who isn’t likely to challenge me publicly again.
As for the tone of my post, I can only apologise if I came across as brusque. I can only think I must have some sort of attachment disorder…or possibly I need a course of fish oil or Ritalin or whatnot. Please don’t take it personally…I deserve sympathy…I’ve got a condition.
Many years late, but I couldn’t agree more, Rainbow Warrior! I have lost count of the complex behavioural manifestations that are miraculously “cured” when the pupils learn that they need to leave this complexity at the door. Occasionally, when the apparatus of “support” follows them around they have no opportunity to experience normative expectations and try their hand at making it easy for themselves and others to learn.
[…] needs – not their ‘labels’. This requires well-developed assessment skills which are sceptical of fads and which identify learning goals broken down into small, achievable steps. Such provision should […]
[…] The Latest SEN Fad Diagnosis: Attachment Disorder […]
Very alarming that a teacher has written this and the level of ignorance on this subject is shocking.
Go onto Adoption UK forums and read up on the subject before dismissing this as a fad. If nothing else understand that a child who is neglected in early life will have a neurologically different brain, not a fad an actual physical difference, to a child from a stable background. These children will tend to have attachment disorders and won’t know have to love others, receive love, form social relationships, understand behavioural boundaries and so on because the ‘flight’ element of he brain has developed beyond any other part of the brain.
Very, very sad that a British teacher dismisses this as a fad in the face of all known evidence on the subject.
You appear to have ignored the actual content of my post. The claim is not that no harm could come from neglect, the claim is simply that the “attachment disorder” being diagnosed by non-clinicians in schools has no basis in mainstream medicine.
Beyond that, please do not confuse neural correlates for particular experiences, with the idea that people have a different type of brain for life. Yes, what we experience and learn changes our brain at that time, this does not mean that doctors can scan somebody’s brain and know whether or not that person suffered early neglect.
Hi, apologies if I caused offence.
I am not a teacher but stumbled across this blog whilst reading up on attachment.
I’ve just reread your original post and early on you refer to a ‘new fad diagnosis’ and go onto refer to ‘pseudo science’. As an adoptive parent I just find that mindset really surprising from a teacher and being honest disappointing and outdated.
For most adoptive parents attachment disorders are very real. Our 2 children were diagnosed as having Disorganized Attachment Disorder long before we adopted them and I can assure you they are extremely challenging to parent.
Whilst they are doing ok in school, they undoubtedly need (and luckily get) additional support.
In reply to other responses to your original post, It just doesn’t work to think that kids like these will respond to good old fashioned strict boundaries, routine and being treated like all other children. As an example, you absolutely shouldn’t do ‘time out/naughty steps/ traffic lights’ or similar to discipline kids like this as it will just increase their underlying feelings of self shame and can surface memories of early neglect. ‘Time in’ with a teacher or adult e g. during break time, works much better as they experience a consequence of their action but in the presence of a loving adult.
These kids have often experienced real trauma in their early life and as a result are often extremely insecure, controlling, angry, violent and will not easily form loving relationships, even with people who show lots of love towards them.
Personally I don’t know whether attachment disorders are now definitively considered a medical condition or not. I understand there are different views out there in scientific communities. We have had several sessions with a child psychologist who certainly regards it as a real condition and I would suggest that the vast majority of adoptive parents would consider attachment disorder as real as ADHD, Aspergers, Autism or other conditions that I don’t think any teacher would ever these days dismiss as a fad.
As mentioned before if you have time read some Adoption UK articles on the subject or I highly recommend reading Dan Hughes.
As mentioned before, am not a teacher but I do sympathise with teachers being asked to adapt teaching for a range of individual circumstances which must be very difficult and almost impossible. However, I think you are asking for problems if you think that a child with a diagnosis of Disorganised Attachment Disorder from a child psychologist can be taught and engaged with just like any other child. I remember in the early days with our children both we and our kids teachers struggled with the fact that our kids wouldn’t do simple tasks when asked or told to do so. The child psychologist told us that it wasn’t that they won’t, it was because they can’t. It makes a big difference to think of it that way.
Just to be clear, I am talking about fad diagnoses in schools. These are not usually made by people with any clinical training. I gave examples which came from people with no background in anything other than education. While I understand that some psychologists might be prone to diagnose outside of recognised medical conditions, that is part of the problem rather than the solution. There is a reason that diagnostic manuals exist. When the conditions are not well-defined and not studied clinically, then there is very little way to debate over how to treat, mediate, or support those with, the condition. This does not mean that a child has no problems, just that the diagnosis tells us nothing useful about those problems. Aspergers is a case in point; it has now been removed as a diagnosis from the main diagnostic manual that took it seriously, not because none of the children diagnosed with it had problems, but because it was not a useful description of those problems.
I do not mean to deny the existence of Reactive Attachment Disorder or some related conditions, but I see no reason to accept diagnoses that have not been recognised or ways to deal with them that have no evidence base. I linked above to the Child Myths website which tirelessly debunks dangerous and harmful treatments that people have sold for attachment disorder, and misinformation about such conditions. I would suspect your claim that attachment disorder is real “for most adoptive parents” to be in that latter category.
By the way, kids being disobedient is definitely not a medical condition. It’s the human condition. If they always did what they were told that would probably be more worrying.
Asperger’s wasn’t removed from the Diagnostic and Statistics Manual, rather it was incorporated under one heading Autistic Spectrum Disorder – mainly because the distinction between Autism and Asperger’s wasn’t useful. Educational Psychologists use the new term ASD and the older term Asperger’s depending on which one is more meaningful to the parents/school, it does not affect the work they do with children. Diagnostic labels in the DSM are not based on biological markers, rather on a set of signs/ symptoms (behavioural) that cluster in a meaningful way (statistics) to describe a person’s difficulties. As we gain a better understanding through research, so these definitions are improved upon and the Diagnostic Manual updated. Interestingly, the ICD-10 the manual that tends to be used in UK and Europe has retained ‘Asperger’s’ as a separate diagnosis. This further reveals how woolly these labels are (unlike biological illness where a specific gene or protein etc can be tested for). But woolly labels or not the difficulties faced are very real. Attachment difficulties have a profound impact on a child’s progress – and there is a growing evidence base on both how it impacts on children and what interventions are effective. As the evidence base grows so our understanding of underlying psychological process and the response to these improves.
Does the word Aspergers still appear in the DSM. Also, last time I looked, Aspergers was only mentioned in the ICD -10 as a condition of “doubtful nosological validity” or something similar.
I think we are arguing semantics here. ASD covers those who have a particular set of difficulties in social and communication and restricted, repetitive stereotyped behaviours (with or without intellectual deficiency). One of the reasons why Asperger’s has been incorporated into the ASD definition is because there was not enough clinical evidence that it was an entirely separate condition (as many of the symptoms/signs are the same as ‘classic’ autism) – hence nosological validity of the diagnosis. However, I would not worry too much about what it is called and focus on what interventions will help a child/person to be able to lead a fulfilling and independent life. Educational Psychologists do not make diagnoses for this very reason as a diagnosis tells us little about a child’s specific strengths and weaknesses – however, we will use a ‘label’ if it is meaningful to the adults (school and parents) we are working with.
It’s semantic in as much as it is about the labels. But it is not trivial. Teachers are told to make all sorts of allowances, exceptions and interventions based on amateur diagnoses. If those demanding this do not even know what the conditions are called then it is a cause for concern. What actual basis is there for trusting the diagnosis or the response to it? In two different schools, I saw kids who swore at teachers labelled as having possible Tourette’s, by people who had no idea what that actually meant and could not even spell it. Amateur diagnoses are a very real problem in schools, and the basis of an SEN industry that generates lots of paperwork but actually fails those with genuine needs, and I would suggest that the first step to dealing with amateur diagnoses is to restrict ourselves to looking at well-defined conditions that appear in the diagnostic manuals.
I am afraid there are no well defined conditions when it comes to mental wellbeing – Diagnostic Manuals are written by a consensus (an expert consensus, but consensus none the less). It is not about making allowances for conditions, rather finding out what works for a particular child to ensure they make progress. If a child has ASD but is coping within the normal classroom environment then that is great. Equally if a child without and official ASD diagnosis is struggling within the normal classroom environment then an intervention is needed – it might be as simple as making the front wall of the room less distracting, or providing support in play at lunchtimes. Diagnoses are affected by all sorts of factors e.g. parents desire to seek one, the paediatrician they happen to see and what the predominant symptoms are (for example ADHD and ASD are often seen together, but it might that the attention symptoms are more obvious). Rather than getting hung up on diagnoses focus on the child, what is their view of the world, how can we help them to be the best we can be.