The Latest SEN Fad Diagnosis: Attachment DisorderJune 21, 2015
A 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…
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
…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 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.