Coercive Interventions for Reactive Attachment Disorder

Approved by Council November, 2003
Reviewed by the Child Maltreatment and Violence Committee May 2014
Reviewed and Approved by Council in October 2016

The Attachment Disorders (Reactive Attachment Disorder and Disinhibited Social Engagement Disorder) are complex psychiatric illnesses characterized by problems in forming and maintaining emotional attachments with others. These difficulties are usually present by 5 years of age, and may be detected during the first year of life. Children with Reactive Attachment Disorder appear detached, unresponsive, inhibited or reluctant to engage in age-appropriate social interactions; whereas children with Disinhibited Social Engagement Disorder may be overly and inappropriately social or familiar, even with strangers.

The Attachment Disorders can be difficult to diagnose. Most children with either of these disorders have had problems or severe disruptions in their early relationships. Many have been physically, sexually or emotionally abused or neglected. Others have had multiple traumatic losses or changes in their primary caretaker. Many severely traumatized children present with complex problems and symptoms, but only partially meet diagnostic criteria for Attachment Disorders. Reactive Attachment Disorder is sometimes confused with Pervasive Developmental Disorder or other neurological disorders including deafness, and genetic disorders that may mimic signs of Reactive Attachment Disorder.

Because of these diagnostic difficulties, children who exhibit signs of either of the Attachment Disorders require comprehensive psychiatric evaluation and individualized treatment plans by professionals who are expert in the differential diagnosis and treatment of these complex disorders. Treatment usually includes both individual and family interventions. In extreme cases complicated by self-endangering behavior, placement in a safe, therapeutic setting may be necessary. Nevertheless, family settings that maximize opportunities for the child to develop selective attachments are usually most helpful.

Some therapists have used so called "rebirthing techniques" or "compression holding therapy" as treatments. These, and other interventions that include physically coercive methods like adults forcibly holding a child to improve attachment, using hunger or thirst, or forcing food or water upon the child, can be dangerous. At least six documented child fatalities have occurred related to the use of these methods.

There is no scientific evidence that such coercive interventions are effective and the number of deaths associated with these practices demonstrates their danger. These techniques also violate the fundamental human rights of the children subjected to them. Therefore, AACAP urges that these coercive, dangerous and ineffective practices not be used.