Efficacy of Treatment for Reactive Attachment Disorder: A Follow-Up Study
Abstract
Purpose: Examine effectiveness of attachment- and trauma-focused treatment for children/adolescents meeting criteria for Reactive Attachment Disorder (RAD).
Sample: n = 71 participants from an outpatient treatment center; treatments delivered as an integrative trauma-informed approach.
Measures: Parents completed the Child Behavior Checklist (CBCL) and the Randolph Attachment Disorder Questionnaire (RADQ) at pre- and post-treatment.
Key findings:
Significant decreases in symptoms on all six DSM-oriented scales of the CBCL and on seven of eight syndrome scales.
No significant differences on the CBCL competence scales.
Significant decrease in attachment-related symptoms on the RADQ.
Effect sizes: Cohen’s d estimates indicate small to moderate effects on 12 of 16 measures.
Conclusion: Integrative attachment- and trauma-focused therapy delivered at an outpatient clinic can reduce RAD-related symptoms and support social change; results contribute to the empirical evidence base, though caution due to study design and lack of randomization.
Background and Context on RAD
RAD is a relatively new diagnosis in counseling/mental health; first introduced in DSM-III (1980) by Zeanah & Fox.
Root cause: disrupted attachment with primary caregiver in the first five years of life (often due to neglect or caregiver trauma) (Cassidy & Shaver, 1999).
Foundational theory:
Bowlby (1962/1982): a caregiver’s emotional availability is central to attachment; physical presence without emotional responsiveness can lead to disordered attachment.
Prolonged caregiver disruption may lead to attachment disruption and possible character/pathology development (Bowlby).
Epigenetics and intergenerational effects: maternal trauma can influence fetal nervous system development and may have transgenerational effects even when adopted into nurturing environments (Krippner & Barrett, 2019; Gapp et al., 2020).
Research implications: need to identify effective clinical interventions for RAD; historically, tensions exist about what constitutes appropriate treatment (e.g., attachment therapies vs. coercive holding therapies).
Core behavioral implications of RAD when attachment is insecure: difficulty regulating impulses, behavior, and emotions; potential risk for antisocial outcomes if untreated (Randolph, 2001).
Key definitions:
Secure attachment: consistent, appropriate caregiver responses promote healthy attachment bonds (smiling with eye contact, following, seeking comfort, etc.).
Insecure/Disordered attachment: inconsistent or absent responses leading to maladaptive beliefs like feeling “unlovable.”
RAD subtypes (DSM-IV framework cited):
Inhibited type: difficulty initiating/engaging in social interactions; limited comfort-seeking when distressed.
Disinhibited type: indiscriminate sociability with strangers.
Common RAD symptoms (selected examples):
(a) poor eye contact, (b) limited genuine affection, (c) superficial charm with strangers, (d) speech abnormalities, (e) lying, (f) stealing, (g) hoarding/gorging, (h) poor impulse control, (i) poor peer relationships, (j) lack of cause-and-effect thinking, (k) preoccupation with blood/gore, (l) preoccupation with fire, (m) lack of conscience, (n) self-destructive behavior, (o) cruelty to others/animals, (p) learning delays, (q) inappropriate clinginess, (r) frequent nonsensical questions, (s) demanding behavior, (t) difficulty asking for help, (u) need for control.
Temperament and RAD: infant temperament may influence whether inhibited or disinhibited RAD develops (Zeanah & Fox, 2004).
Brain development perspective: early neglect/abuse can affect limbic system, neocortex, orbitofrontal cortex, and R-complex, with consequences for emotion regulation and higher cognition (Garland, 2004; Hage, 2004; Levy, 2000; May, 2004).
Therapeutic shift: early “holding therapy” controversies led to a distinction between coercive holding and modern attachment- and trauma-focused treatments (Dozier, 2003; O’Connor & Zeanah, 2003; Randolph, 2001).
The study’s target setting: Attachment Institute of New England (AINE) in Worcester, MA; outpatient, integrative model combining trauma-focused family therapy, CBT, psychodynamic, object relations, biofeedback, EMDR.
Research gap: few rigorous empirical studies of RAD treatment; prior small studies and case reports with mixed methods; this study contributes a larger sample (n = 71).
Purpose and Rationale of the Study
Objective: Assess efficacy of the AINE integrative therapy for RAD by measuring symptom changes in children/adolescents and their families.
Hypothesis: Children from families participating in AINE psychotherapy would show significant reductions in CBCL and RADQ scores at the end of treatment.
Contextual note: prior research suggested potential benefits of attachment-based therapies, but results were limited and controversial; this study aims to provide more robust evidence while acknowledging ethical considerations.
Methods
Setting and treatment model:
Outpatient clinic (AINE) with an integrative, trauma-sensitive approach rooted in attachment theory.
Treatment components include trauma-focused family therapy, CBT, DBT, psychodynamic therapy, biofeedback, EMDR; sessions typically 12–16 two-hour sessions.
Participants:
Number: n = 71 families with a child diagnosed with RAD.
Gender distribution: 40 ext{ female}, 31 ext{ male}.
Age: Pretest M = 10.61, ext{ SD} = 3.71; Posttest M = 11.82, ext{ SD} = 3.70.
All children were adopted; recruitment from the Massachusetts area; screening confirmed RAD criteria.
Instruments:
CBCL (Achenbach, 1991): 118 items; caregiver reports; 3-point scale (0,1,2). Normative scores: M = 50, ext{ SD} = 10 on competence, syndrome, and DSM-oriented scales.
RADQ (Randolph, 1997): 30-item parent/guardian interview; 5-point Likert scale (5 = usually, 4 = often, 3 = sometimes, 2 = occasionally, 1 = rarely); used to distinguish attachment problems from disruptive behavior disorders; total score used in this study due to limited psychometric validation.
Procedure and data collection:
CBCL administered at pre- and post-treatment for all families.
RADQ administered at pre- and post-treatment as a secondary measure of attachment problems.
The authors clarify they are not part of the AINE clinical team.
Outcomes and analysis:
Primary analyses: paired-sample t-tests comparing pretreatment vs posttreatment scores on CBCL scales and RADQ total scores.
Reported results: significant decreases in most measures; some scales showed non-significant changes (CBCL competence scales).
Effect sizes: Cohen’s d reported for each measure; interpretation provided (small to moderate effects for most measures).
Ethical considerations and context:
Discussion distinguishes evidence-based attachment therapy from unethical holding practices.
Acknowledgement of past fatalities linked to rebirthing/holding therapies (Boris, 2003).
Emphasis on ethical, child-centered practice and the need for trained therapists and evidence-based approaches.
Instruments in Detail
CBCL (Achenbach, 1991):
Measures psychopathology and behavior problems in children aged 6–18.
118 items; caregiver ratings; 3-point scale (0,1,2).
Outputs: competence scales, DSM-oriented scales, syndrome scales; standard scores with M = 50, SD = 10.
Reliability: Cronbach’s alpha ranges from 0.65 to 0.86 for most subscales.
RADQ (Randolph, 1997):
30 items; caregiver/parent report; 5-point Likert scale.
Purpose: screen for attachment problems to supplement clinical interview and other measures.
Psychometrics: not fully established; used total score as a secondary index in this study.
Scales of interest in Table 1 (CBCL):
DSM-oriented scales, syndrome scales, and competence scales; note that competence scales did not show significant changes in this study.
Results
Primary findings (CBCL):
Significant decreases across six DSM-oriented scales.
Significant decreases across seven of eight syndrome scales.
No significant differences on the CBCL competence scales.
RADQ findings:
Significant decrease in RADQ scores, indicating reduced attachment-related symptoms.
Practical significance (effect sizes):
Cohen’s d indicates small to moderate effects on 12 of 16 measures.
Table 1: Pre- and post-treatment comparisons (CBCL & RADQ)
Variables and sample sizes: n = 71.
Pretreatment vs posttreatment means (M) and standard deviations (SD) shown for each variable; t-tests and Cohen’s d reported.
Examples from Table 1:
Social Problems (Social Prb): Pretreatment M = 91.18, ext{ SD} = 10.38; Posttreatment M = 84.14, ext{ SD} = 15.45; t(70) = 4.51, ext{ ** }p < .01; d = 0.53
Thought Problems (Thought Prb): Pretreatment M = 87.98, ext{ SD} = 15.19; Posttreatment M = 82.45, ext{ SD} = 19.91; t(70) = 4.57, ext{ ** }p < .01; d = 0.31
Attention Problems (Attention Prb): Pretreatment M = 92.11, ext{ SD} = 10.39; Posttreatment M = 88.95, ext{ SD} = 10.80; t(70) = 2.29, ext{ * }p < .05; d = 0.30
Externalizing: Pretreatment M = 96.00, ext{ SD} = 4.41; Posttreatment M = 87.32, ext{ SD} = 17.61; t(70) = 4.65, ext{ ** }p < .01; d = 0.68
RADQ: Pretreatment M = 67.69, ext{ SD} = 20.64; Posttreatment M = 44.46, ext{ SD} = 22.68; t(70) = 6.56, ext{ ** }p < .01; d = 1.07
Note: Some scales showed non-significant changes (e.g., Activity) with corresponding t-values indicating non-significance (e.g., t(70) = -1.38).
Overall interpretation from Table 1:
Consistent patterns of improvement in behavioral/problem domains and attachment-related symptoms after treatment.
Large effect size observed on RADQ and certain externalizing-related scales, indicating meaningful clinical change for many children.
Discussion and Interpretation
Implications of findings:
The integrative AINE approach may produce meaningful symptom reduction in RAD and related behavioral problems.
Changes observed across multiple CBCL scales suggest broad improvements in emotional/behavioral functioning and attachment-related symptoms.
Context within the attachment therapy literature:
Distinction made between evidence-based attachment therapy and unethical holding practices (e.g., rebirthing).
The authors emphasize ongoing need for ethical guidelines, rigorous training, and adherence to evidence-based procedures.
Clinical and societal relevance:
Potential for reduced antisocial outcomes and decreased demand on social services/criminal justice systems if treatment efficacy is validated in broader samples.
Parenting education and involvement (two-way engagement with families) are highlighted as important components.
Limitations and cautions:
Design is not a randomized controlled trial; there is no control group to account for Hawthorne effects or spontaneous change.
Sample is treatment-seeking, adopted children at a single center (AINE); limits generalizability to broader RAD populations.
Some measures rely on caregiver reports (CBCL, RADQ), which may introduce informant bias.
Need for longer follow-up to assess durability of effects; authors suggest including a control group with alternative treatment or attention control.
Recommendations for future research:
Larger and more diverse samples; multi-site trials; randomized controlled designs.
Inclusion of additional outcome measures (e.g., teacher reports, direct behavioral observations, neurobiological markers).
Comparative studies of different attachment- and trauma-focused approaches to determine active ingredients.
Authors’ disclosures:
Authors not part of the AINE clinical team; training and dissemination efforts are ongoing to promote evidence-based practices and caregiver education.
Practical and Ethical Implications for Clinicians
Distinguish between evidence-based attachment- and trauma-focused interventions and coercive, non-therapeutic holding strategies.
Ensure treatment is child-centered, ethically conducted, and delivered by trained professionals with adherence to professional guidelines.
Engage caregivers in therapy and provide education to support at-home practices that reinforce secure attachment.
Consider the societal benefits of reducing RAD-related symptoms, including potential reductions in antisocial behavior and reduced service utilization, while maintaining rigorous ethical standards.
Key Takeaways
The study provides evidence that an integrative, attachment- and trauma-focused program can yield statistically significant improvements in RAD-related symptoms and attachment measures in a sample of 71 families.
CBCL improvements spanned most problem scales but not competence scales; RADQ scores also improved.
Effect sizes were generally small to moderate, with some measures showing large effects (RADQ, some ADHD/Conduct/Externalizing domains).
The findings support continued development of attachment-based treatments but underscore the need for rigor, ethical safeguards, and replication with control groups.
The discussion emphasizes clear differentiation from ethically problematic holding therapies and calls for broader empirical validation and responsible dissemination.
References (selected from the study’s references)
Achenbach, T. M. (1991). Child Behavior Checklist/4-18 (CBCL/4-18). University Associates in Psychiatry.
Achenbach, T.M., & Rescorla, L.A. (2001). Manual for ASEBA school-age forms & profiles. University of Vermont.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.).
Bowlby, J. (1962/1982). Attachment and Loss: Vol. 1. Attachment. Basic Books.
Zeanah, C. H., & Fox, N. A. (2004). Temperament and attachment disorders. Journal of Clinical Child and Adolescent Psychology, 33(1), 32-41.
Randolph, E. M. (2001). Broken hearts; wounded minds. Four Seasons.
Randolph, E. M. (1996). Randolph Attachment Disorder Questionnaire: Institute for Attachment, Evergreen CO.
O'Connor, T. G., & Zeanah, C. H. (2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment & Human Development, 5, 223-244.
Collected sources on attachment theory and related therapies as cited in the study.
Abstract
Purpose: This study meticulously examines the effectiveness of an integrative treatment approach, combining attachment- and trauma-focused therapies, for children and adolescents who meet the diagnostic criteria for Reactive Attachment Disorder (RAD).
Sample: The research included a cohort of n = 71 participants, drawn from an outpatient treatment center. These participants received interventions delivered through a comprehensive, integrative trauma-informed approach, developed specifically for addressing complex attachment and trauma-related issues.
Measures: Parents or primary caregivers were responsible for completing two key assessment tools at both pre-treatment and post-treatment phases: the Child Behavior Checklist (CBCL) and the Randolph Attachment Disorder Questionnaire (RADQ). These measures were selected to capture a broad spectrum of behavioral, emotional, and attachment-specific symptoms.
Key findings:
Remarkably, significant decreases were observed in symptoms across all six
DSM-oriented scales
of the CBCL, demonstrating broad improvements in clinical psychopathology.
Furthermore, significant reductions were also noted on
seven of the eight syndrome scales
of the CBCL, indicating improvements in specific behavioral problem areas such as anxiety, depression, and aggression.
Notably, there were no significant differences identified on the
CBCL competence scales
, suggesting that while problematic behaviors decreased, the children's perceived social and academic competencies did not significantly change within the treatment period.
A significant decrease in attachment-related symptoms was consistently found on the
RADQ
, directly supporting the efficacy of the therapy in addressing core RAD features.
Effect sizes:
Cohen’s d
estimates were calculated to quantify the practical significance of the observed changes, indicating small to moderate effects on 12 of the 16 measures, with some showing larger clinical impact.
Conclusion: The study concludes that an integrative attachment- and trauma-focused therapy, when delivered in an outpatient clinic setting, can effectively reduce RAD-related symptoms and foster positive social change. These results make a valuable contribution to the nascent empirical evidence base for RAD treatment, though the authors caution against overgeneralization due to study design limitations and the absence of randomization.
Background and Context on RAD
RAD is a relatively contemporary diagnosis within the fields of counseling and mental health, having been first formally introduced in the DSM-III in 1980 by Zeanah & Fox. Its recognition underscored a growing understanding of severe attachment disturbances in children.
Root cause: The fundamental etiology of RAD is posited to be severely disrupted or absent attachment bonds with a primary caregiver during the critical first five years of life. This often stems from profound experiences of neglect, abuse, or significant caregiver trauma which impedes the formation of secure attachment (Cassidy & Shaver, 1999).
Foundational theory:
Bowlby (1962/1982) emphasized that a caregiver’s consistent emotional availability is absolutely central to the development of secure attachment. He theorized that mere physical presence without genuine emotional responsiveness or attunement can lead to profoundly disordered attachment patterns.
Prolonged and severe disruption in caregiver-child interaction may lead not only to immediate attachment difficulties but also to long-term attachment disruption and potentially the development of character pathology, impacting personality and relational functioning throughout life (Bowlby).
Epigenetics and intergenerational effects: Emerging research in epigenetics highlights how maternal trauma can significantly influence fetal nervous system development, potentially leading to transgenerational effects. This means that children may exhibit vulnerabilities even when subsequently adopted into nurturing environments, due to pre-natal programming (Krippner & Barrett, 2019; Gapp et al., 2020).
Research implications: There is an urgent need to identify and rigorously evaluate effective clinical interventions for RAD. Historically, the field has been marked by significant tensions and controversies regarding what constitutes appropriate treatment, particularly distinguishing evidence-based attachment therapies from ethically dubious practices like coercive holding therapies.
Core behavioral implications of RAD when attachment is insecure: Children with insecure attachment, particularly those with RAD, often demonstrate profound difficulties in regulating impulses, behavior, and emotions. If left untreated, these core deficits can pose a significant risk for the development of antisocial outcomes, impacting their social integration and future well-being (Randolph, 2001).
Key definitions:
Secure attachment: Characterized by consistent, appropriate, and sensitive caregiver responses to a child’s needs, which promotes the development of healthy and resilient attachment bonds. Behaviors indicative of secure attachment include smiling with eye contact, following the caregiver, and seeking comfort when distressed.
Insecure/Disordered attachment: Arises from inconsistent, unresponsive, or absent caregiver responses. This leads to the child developing maladaptive beliefs about themselves and others, such as feeling “unlovable,” unworthy of care, or fearing abandonment.
RAD subtypes (based on the DSM-IV framework cited):
Inhibited type: Children exhibit marked difficulty initiating and engaging in social interactions, often appearing emotionally withdrawn. They show limited comfort-seeking behaviors when distressed, displaying an emotional aloofness.
Disinhibited type: These children display indiscriminate sociability with strangers, showing a lack of appropriate wariness and an overly familiar approach that is not typical for their developmental stage. This can manifest as approaching and interacting with unfamiliar adults with an absence of customary caution.
Common RAD symptoms (selected examples, reflecting a wide range of behavioral and emotional challenges):
(a) poor eye contact, often avoiding direct gaze or having an unfocused stare
(b) limited genuine affection, struggling to give or receive reciprocal emotional warmth
(c) superficial charm with strangers, used to manipulate or gain attention rather than genuine connection
(d) speech abnormalities, such as repetitive phrases, tangential speech, or unusual intonation
(e) lying, often pathologically and without clear external motivation
(f) stealing, often hoarded or not for personal use, indicating deeper emotional needs
(g) hoarding/gorging behaviors related to early deprivation and insecurity
(h) poor impulse control, leading to explosive outbursts or dangerous actions
(i) poor peer relationships, characterized by difficulty forming lasting bonds or manipulative interactions
(j) lack of cause-and-effect thinking, struggling to understand consequences of actions
(k) preoccupation with blood/gore, indicating unresolved trauma or aggressive fantasies
(l) preoccupation with fire, often linked to control issues or trauma reenactment
(m) lack of conscience, showing little remorse or empathy for others
(n) self-destructive behavior, including head-banging, cutting, or risk-taking
(o) cruelty to others/animals, a severe manifestation of lack of empathy and impulse control
(p) learning delays, often due to emotional dysregulation and trauma's impact on cognition
(q) inappropriate clinginess, a desperate attempt to seek proximity without true connection
(r) frequent nonsensical questions, used to control interactions or avoid deeper engagement
(s) demanding behavior, reflecting an inability to tolerate frustration or unmet needs
(t) difficulty asking for help, rooted in distrust and a fear of vulnerability
(u) need for control, often arising from a pervasive sense of powerlessness in early life.
Temperament and RAD: It is theorized that an infant's innate temperament may play a mediating role, influencing whether an inhibited or disinhibited presentation of RAD ultimately develops (Zeanah & Fox, 2004). Individual differences in temperament can shape how a child reacts to and copes with early attachment disruptions.
Brain development perspective: Early experiences of neglect and abuse can have profound and lasting effects on brain development, particularly impacting crucial areas such as the limbic system (involved in emotion), the neocortex (higher cognition), the orbitofrontal cortex (social behavior and decision-making), and the R-complex (primitive survival responses). These alterations can lead to persistent difficulties in emotion regulation, cognitive processing, and social interaction (Garland, 2004; Hage, 2004; Levy, 2000; May, 2004).
Therapeutic shift: The severe controversies surrounding early approaches like “holding therapy,” which sometimes employed coercive and abusive techniques, led to a critical distinction. Modern therapeutic understanding now clearly separates these harmful practices from ethical, evidence-based attachment- and trauma-focused treatments (Dozier, 2003; O’Connor & Zeanah, 2003; Randolph, 2001).
The study’s target setting: This research focused on the Attachment Institute of New England (AINE) in Worcester, MA. AINE employs an empirically informed, outpatient, integrative model that synthesizes various therapeutic modalities including trauma-focused family therapy, cognitive behavioral therapy (CBT), psychodynamic approaches, object relations therapy, biofeedback, and Eye Movement Desensitization and Reprocessing (EMDR).
Research gap: Prior to this study, there was a significant dearth of rigorous empirical studies investigating the effectiveness of RAD treatment. Existing evidence primarily consisted of small-scale studies and qualitative case reports with mixed methodologies. This study aimed to address this gap by contributing a larger sample size (n = 71), thereby strengthening the empirical foundation for RAD interventions.
Purpose and Rationale of the Study
Objective: The primary objective of this study was to systematically assess the efficacy of the AINE integrative therapy program for children diagnosed with RAD. This assessment was conducted by measuring significant changes in relevant symptomology in both the children/adolescents themselves and within their family systems.
Hypothesis: The researchers hypothesized that children participating in the AINE psychotherapy program, alongside their families, would demonstrate significant reductions in scores on both the CBCL and RADQ measures by the conclusion of their treatment regimen.
Contextual note: Historically, prior research efforts had suggested potential benefits for attachment-based therapies in treating RAD, but these results were often limited in scope, methodologically controversial, or associated with unethical practices. This study aimed to provide more robust and ethically sound evidence, while explicitly acknowledging the critical ethical considerations inherent in treating RAD and its associated challenges.
Methods
Setting and treatment model:
The study was conducted at an outpatient clinic, the Attachment Institute of New England (AINE), known for its integrative, trauma-sensitive therapeutic philosophy. This model is deeply rooted in attachment theory, seeking to address core relational deficits.
The comprehensive treatment components include a blend of modalities: trauma-focused family therapy, utilizing systemic approaches to heal family dynamics; Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) to address maladaptive thoughts and behaviors; psychodynamic therapy and object relations to explore early relational patterns and unconscious processes; biofeedback for physiological self-regulation; and Eye Movement Desensitization and Reprocessing (EMDR) for processing traumatic memories. Treatment typically consisted of 12–16 intensive two-hour sessions, designed to provide concentrated intervention.
Participants:
Number: The study included a total of n = 71 families, each with a child who had a confirmed diagnosis of Reactive Attachment Disorder.
Gender distribution: The participant group comprised 40 ext{ female} and 31 ext{ male} children, indicating a relatively balanced representation of genders.
Age: The mean age of the children at pretest was M = 10.61 years with a standard deviation of ext{SD} = 3.71 years. At posttest, the mean age had slightly increased to M = 11.82 years with a standard deviation of ext{SD} = 3.70 years, reflecting the duration of treatment.
All participating children had been adopted, a demographic characteristic highly relevant to RAD development. Recruitment was primarily from the broader Massachusetts area, and meticulous screening procedures were implemented to ensure all participants met the established diagnostic criteria for RAD, guaranteeing a homogenous sample for the study's focus.
Instruments:
CBCL (Achenbach, 1991): The Child Behavior Checklist is a widely recognized and extensively validated caregiver-report questionnaire consisting of 118 items. Caregivers rate the child’s behaviors over the past 6 months on a 3-point scale (0 = not true, 1 = somewhat true/sometimes, 2 = very true/often). Standardized normative scores are used, with a mean of M = 50 and a standard deviation of ext{SD} = 10 for competence, syndrome, and DSM-oriented scales, allowing for comparison to a general population sample.
RADQ (Randolph, 1997): The Randolph Attachment Disorder Questionnaire is a 30-item parent/guardian interview designed to specifically assess attachment-related problems. Parents respond on a 5-point Likert scale (5 = usually, 4 = often, 3 = sometimes, 2 = occasionally, 1 = rarely). Its primary purpose is to help clinicians differentiate attachment difficulties from other behavioral disorders. In this particular study, the total score from the RADQ was utilized as a global indicator of attachment-related symptoms, primarily due to the instrument's limited psychometric validation for its subscales at the time.
Procedure and data collection:
The CBCL was systematically administered to all participating families at two key time points: upon entry to treatment (pre-treatment) and at the conclusion of the treatment program (post-treatment).
Similarly, the RADQ was also administered at both pre- and post-treatment assessment points. It served as a vital secondary measure, providing a focused assessment of changes in attachment problems as reported by the caregivers.
The authors explicitly clarified that they were independent researchers and not directly part of the AINE clinical team. This declaration was made to enhance objectivity and mitigate potential conflicts of interest.
Outcomes and analysis:
The primary statistical analyses involved the use of paired-sample t-tests. These were employed to compare the mean pretreatment and posttreatment scores on all relevant CBCL scales (DSM-oriented, syndrome, and competence) and the total RADQ scores. This approach allowed for the direct assessment of within-subject changes over the course of the therapy.
The reported results indicated statistically significant decreases in the vast majority of the measured problem behaviors and attachment symptoms. However, it was also noted that some specific scales, particularly the CBCL competence scales, did not show statistically significant changes.
To provide a measure of practical significance, Cohen’s d effect sizes were meticulously calculated and reported for each measure. The interpretation of these effect sizes indicated small to moderate levels of change for most measures, suggesting meaningful clinical improvement for a substantial portion of the participants.
Ethical considerations and context:
The study included a crucial discussion that meticulously distinguishes between evidence-based, ethically sound attachment therapy and the widely condemned, unethical holding practices and treatment modalities often referred to as “rebirthing” therapies. This distinction is critical given the historical controversies and risks associated with such interventions.
There was an explicit acknowledgement and condemnation of past fatalities. For instance, the death of Candace Newmaker in 2000, linked to coercive rebirthing therapy, highlighted the severe dangers of unscientific and unethical practices (Boris, 2003). Such tragic events underscore the imperative for ethical rigor in all therapeutic interventions for RAD.
The authors strongly emphasized the paramount importance of ethical, child-centered practice. This involves ensuring that all therapeutic interventions prioritize the child's safety, well-being, and developmental needs above all else. Furthermore, they stressed the necessity for treatments to be delivered by highly trained and qualified professionals who adhere strictly to established professional guidelines and utilize only evidence-based approaches.
Instruments in Detail
CBCL (Achenbach, 1991):
Measures psychopathology and a broad spectrum of behavior problems in children and adolescents typically aged 6–18. This instrument is vital for obtaining a comprehensive picture of a child’s challenges across various domains.
It comprises 118 items, which are systematically rated by a primary caregiver. Ratings are made on a 3-point Likert scale (0 = not true, 1 = somewhat true/sometimes, 2 = very true/often) to indicate the frequency or severity of behaviors observed over the past six months.
The outputs generated from the CBCL include competence scales (e.g., social, school, activities), DSM-oriented scales (e.g., anxiety problems, depressive problems, ADHD problems), and syndrome scales (e.g., withdrawn, somatic complaints, anxious/depressed, social problems, thought problems, attention problems, rule-breaking behavior, aggressive behavior). Standard scores are derived with a mean (M) of 50 and a standard deviation (SD) of 10, facilitating comparison to normative populations.
Reliability: The internal consistency (Cronbach’s alpha) for most subscales of the CBCL ranges from 0.65 to 0.86, indicating acceptable to good reliability in measuring the intended constructs.
RADQ (Randolph, 1997):
The Randolph Attachment Disorder Questionnaire consists of 30 items, completed by the caregiver or parent. Responses are recorded on a 5-point Likert scale, ranging from 1 (rarely) to 5 (usually), reflecting the child's typical behaviors related to attachment.
Purpose: This instrument serves as a specialized screening tool specifically designed to identify potential attachment problems. It is intended to supplement and inform a comprehensive clinical interview and other diagnostic measures, rather than being a standalone diagnostic tool.
Psychometrics: It is important to note that the psychometric properties of the RADQ were not fully established at the time of this study, particularly regarding the validity and reliability of its individual subscales. Consequently, in this study, only the total score was utilized as a secondary index of overall attachment problems, reflecting a cautious approach due to its evolving validation status.
Scales of interest in Table 1 (CBCL):
The study specifically focused on reporting results from the DSM-oriented scales, syndrome scales, and competence scales of the CBCL. It is noteworthy, as highlighted in the findings, that while significant improvements were seen across most problem-focused scales, the competence scales did not show significant changes in this study.
Results
Primary findings (CBCL):
Significant decreases were observed across all six DSM-oriented scales, including those for Affective Problems, Anxiety Problems, Somatic Problems, Attention Deficit/Hyperactivity Problems, Oppositional Defiant Problems, and Conduct Problems. This indicates a broad reduction in symptoms consistent with various psychiatric diagnoses.
Significant decreases were also noted across seven of the eight syndrome scales, specifically in the areas of Withdrawn, Somatic Complaints, Anxious/Depressed, Social Problems, Thought Problems, Attention Problems, and Aggressive Behavior. This demonstrates therapeutic impact on a wide range of behavioral and emotional difficulties.
However, there were no significant differences observed on the CBCL competence scales (Activities, Social, School), implying that while problematic behaviors decreased, the children's reported abilities and engagement in social, academic, and recreational activities did not significantly improve during the treatment period.
RADQ findings:
A significant decrease in RADQ scores was found, providing direct evidence that the integrative therapy was effective in reducing attachment-related symptoms as reported by caregivers.
Practical significance (effect sizes):
Cohen’s d effect sizes were calculated to quantify the practical magnitude of the observed improvements. These estimates indicated small to moderate effects on 12 of the 16 measures, suggesting that the clinical changes were tangible and meaningful for many participants, even if not universally large.
Table 1: Pre- and post-treatment comparisons (CBCL & RADQ)
Variables and sample sizes: The analysis included data from n = 71 participants for all reported variables.
Pretreatment vs posttreatment means (M) and standard deviations (SD) were presented for each variable. Paired-sample t-tests were conducted to assess statistical significance, with corresponding t-values and p-values reported. Cohen’s d values were also provided to indicate the effect size for each measure.
Examples from Table 1, illustrating significant changes:
Social Problems (Social Prb): Pretreatment Mean (M) = 91.18, Standard Deviation (SD) = 10.38; Posttreatment Mean (M) = 84.14, Standard Deviation (SD) = 15.45; t(70) = 4.51, ext{**}p < .01; Cohen’s d (d) = 0.53. This indicates a moderate and statistically significant reduction in social problems.
Thought Problems (Thought Prb): Pretreatment M = 87.98, SD = 15.19; Posttreatment M = 82.45, SD = 19.91; t(70) = 4.57, ext{**}p < .01; d = 0.31. This shows a small to moderate, statistically significant decrease in thought problems.
Attention Problems (Attention Prb): Pretreatment M = 92.11, SD = 10.39; Posttreatment M = 88.95, SD = 10.80; t(70) = 2.29, ext{*}p < .05; d = 0.30. A small but statistically significant reduction in attention problems.
Externalizing: Pretreatment M = 96.00, SD = 4.41; Posttreatment M = 87.32, SD = 17.61; t(70) = 4.65, ext{**}p < .01; d = 0.68. A moderate to large and statistically significant decrease in overall externalizing behaviors.
RADQ: Pretreatment M = 67.69, SD = 20.64; Posttreatment M = 44.46, SD = 22.68; t(70) = 6.56, ext{**}p < .01; d = 1.07. This represents a large and highly statistically significant reduction in attachment disorder symptoms, indicating substantial clinical improvement.
Note: Some scales, such as Activity, showed non-significant changes, with corresponding t-values (e.g., t(70) = -1.38) indicating no statistical significance. This further highlights the specific, rather than universal, areas of improvement.
Overall interpretation from Table 1:
The data consistently revealed patterns of improvement across various behavioral and problem domains, as well as in specific attachment-related symptoms, following the integrative therapy. This offers empirical support for the program's effectiveness.
Notably, a large effect size was observed on the RADQ and certain externalizing-related scales (e.g., those related to ADHD and conduct problems), which suggests that for many children, the intervention led to meaningfully large clinical changes that are highly relevant for their daily functioning.
Discussion and Interpretation
Implications of findings:
The study’s findings strongly suggest that the integrative therapeutic approach implemented at AINE has the potential to produce meaningful and statistically significant symptom reduction in children and adolescents diagnosed with RAD, as well as in related behavioral problems. This provides empirical support for such comprehensive treatment models.
The observed changes across multiple CBCL scales (both DSM-oriented and syndrome scales) indicate broad improvements in children's emotional and behavioral functioning. This comprehensive impact extends to a reduction in core attachment-related symptoms, as evidenced by RADQ scores, suggesting a holistic improvement.
Context within the attachment therapy literature:
A critical distinction remains integral to this discussion: differentiating between ethically sound, evidence-based attachment therapy and the widely criticized, unethical holding practices, often associated with “rebirthing” therapies. The authors explicitly position their work within the former, emphasizing a commitment to responsible and empirically supported methods.
The authors’ discussion reinforces the ongoing and critical need for rigorous ethical guidelines within the field. They advocate for comprehensive training for therapists specializing in attachment and trauma, and strict adherence to evidence-based procedures. This commitment aims to prevent the recurrence of harm witnessed with discredited practices and to ensure patient safety and therapeutic efficacy.
Clinical and societal relevance:
The potential for reduced antisocial outcomes is a significant clinical and societal implication. By effectively treating RAD and associated behavioral difficulties, there is a prospect of decreasing demands on social services, foster care systems, and even the criminal justice system, leading to broader public health benefits.
The study highlights the importance of parenting education and active caregiver involvement as crucial components of effective therapy. A two-way engagement with families, where caregivers are educated and empowered to support attachment-building practices at home, is seen as essential for reinforcing therapeutic gains and promoting long-term positive change.
Limitations and cautions:
One primary limitation is that the study design was not a randomized controlled trial (RCT). The absence of a control group means that the observed improvements cannot be definitively attributed solely to the intervention, as possibilities such as Hawthorne effects (participants altering behavior due to awareness of being observed) or spontaneous developmental changes over time cannot be ruled out.
The sample consisted exclusively of treatment-seeking, adopted children from a single outpatient center (AINE). This specificity limits the generalizability of the findings to broader and more diverse RAD populations, such as children in foster care, those with different etiologies of attachment disruption, or those from varying socioeconomic backgrounds.
Some key measures, specifically the CBCL and RADQ, rely solely on caregiver reports. This introduces the potential for informant bias, where caregivers' perceptions of their child's behavior might be influenced by their hopes for treatment or their own emotional states, rather than purely objective observation.
There is a critical need for longer-term follow-up studies to assess the durability and sustainability of the observed effects beyond the immediate post-treatment period. The authors recommend including control groups in future research, potentially involving an alternative active treatment or an attention-control group, to strengthen causal inferences.
Recommendations for future research:
Future research should aim for larger and more diverse samples, encompassing a greater variety of demographic and clinical characteristics, to enhance the generalizability of findings.
Implementing multi-site trials would allow for validation of the intervention across different clinical settings and populations, reducing the potential bias of a single-center study.
Moving towards randomized controlled designs is crucial for definitively establishing causality and minimizing the influence of confounding variables.
The inclusion of additional outcome measures is recommended, such as teacher reports, direct behavioral observations in various settings, and potentially neurobiological markers (e.g., physiological stress responses, brain imaging). These would provide objective and multi-informant data, reducing reliance on single-source reports.
Comparative studies of different attachment- and trauma-focused approaches are needed to identify the most effective clinical ingredients and optimal therapeutic strategies, moving beyond broad integrative models to delineate specific beneficial components.
Authors’ disclosures:
The authors explicitly disclosed that they were not direct members of the AINE clinical team. Their involvement was as independent researchers. They also noted their ongoing efforts in training and dissemination to promote evidence-based practices and caregiver education both within and outside AINE, emphasizing their commitment to advancing ethical and effective RAD treatment.
Practical and Ethical Implications for Clinicians
Distinguish between evidence-based attachment- and trauma-focused interventions (which are ethical and supported by a growing empirical base) and coercive, non-therapeutic holding strategies (which are unethical, dangerous, and have led to tragic outcomes).
Ensure treatment is child-centered, meaning that all interventions prioritize the child’s safety, autonomy, and developmental needs. Therapy must be ethically conducted, and delivered only by trained and competent professionals who strictly adhere to professional guidelines and regulatory standards.
Engage caregivers actively in the therapy process and provide comprehensive psychoeducation. This empowers families to understand RAD, implement therapeutic strategies at home, and reinforce positive behaviors and secure attachment patterns.
Consider the broader societal benefits of effectively reducing RAD-related symptoms, which can include potential reductions in antisocial behavior, improved family stability, and decreased utilization of costly social services and the criminal justice system. These benefits must always be pursued while maintaining the most rigorous ethical standards in practice.
Key Takeaways
The study provides compelling evidence that an integrative, attachment- and trauma-focused program can yield statistically significant improvements in RAD-related symptoms and attachment measures within a specific sample of 71 families. This marks an important step in building an empirical foundation for such complex interventions.
CBCL improvements were broad, spanning most problem scales (DSM-oriented and syndrome scales), but notably, competence scales (e.g., social, academic) did not show significant changes, indicating that the focus was primarily on reducing problematic behaviors.
Effect sizes were generally small to moderate across various measures, suggesting tangible clinical improvements. However, some measures, particularly the RADQ and certain ADHD/Conduct/Externalizing domains, showed large effect sizes, pointing to substantial and clinically meaningful changes for a significant portion of the children.
Significantly, the findings support the continued development and refinement of ethical, attachment-based treatments. However, they equally underscore the critical need for continued scientific rigor, robust ethical safeguards, and systematic replication with well-designed control groups to confirm causality and generalizability.
The discussion critically emphasizes a clear differentiation between evidence-based attachment interventions and ethically problematic holding therapies, advocating for broader empirical validation and responsible dissemination of effective practices to ensure child safety and well-being.
References (selected from the study’s references)
Achenbach, T. M. (1991). Child Behavior Checklist/4-18 (CBCL/4-18). University Associates in Psychiatry.
Achenbach, T.M., & Rescorla, L.A. (2001). Manual for ASEBA school-age forms & profiles. University of Vermont.
American Psychiatric Association. (1994). Diagnostic and Statistical Manual of Mental Disorders (4th ed.).
Bowlby, J. (1962/1982). Attachment and Loss: Vol. 1. Attachment. Basic Books.
Zeanah, C. H., & Fox, N. A. (2004). Temperament and attachment disorders. Journal of Clinical Child and Adolescent Psychology, 33(1), 32-41.
Randolph, E. M. (2001). Broken hearts; wounded minds. Four Seasons.
Randolph, E. M. (1996). Randolph Attachment Disorder Questionnaire: Institute for Attachment, Evergreen CO.
O'Connor, T. G., & Zeanah, C. H. (2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment & Human Development, 5, 223-244.
Collected sources on attachment theory and related therapies as cited in the study.