Effective Therapeutic Interventions for Reactive Attachment Disorder: A Mixed-Method Systematic Research Synthesis

Purpose: Reactive Attachment Disorder [RAD] is a serious mental health problem affecting many children in foster and adoptive care or with abuse histories. Strong attachment promotes social and educational progress, while RAD undermines social and educational gains (Karen, 2008). There is no empirically validated “best treatment” for RAD (O'Connor & Zeanah, 2003). However, a growing literature on RAD is available, including both experimental and non-experimental reports. Further, different models for synthesizing research are available for experimental versus non-experimental research. This paper employs a mixed method using Rothman and Thomas' (1994) Systematic Research Synthesis for the experimental studies coupled with Thorne and colleagues' (2004) Qualitative Meta-synthesis for other designs. This study provides a comprehensive summary of available knowledge to guide practice and research.

Literature Review: A review of online databases [Medline, PsychInfo, Social Work Abstracts, etc.] was completed to identity relevant publications. Three experimental studies and 68 non-experimental studies on RAD treatment met inclusion criteria. A range of ages, target behaviors, measures and interventions was evident in these studies. The non-experimental publications conceptualized RAD through varying theoretical models, raising a wide range of potentially useful concepts and related interventions. However, these studies typically stand as unique reports with little planned integration to maximize their utility: A synthesis is lacking and needed.

Methods: Systematic research synthesis [SRS] requires 1) structured review of the available research literature, 2) including both experimental and non-experimental designs, c) considering a wide range of conceptualization and evidence, d) to aid practice and policy development. The literature was rated using Saunders, Berliner & Hanson's (2003) treatment classification criteria, which focus on conceptual foundations of treatments, clarity of treatments and research designs employed. The 3 experimental reports were rated using this method. The non-experimental studies were analyzed via “reciprocal translation” in which interventions and concepts are reframed into the concepts of an alternative approach; as well as via “lines of argument synthesis” which seeks the most frequent categories and concepts present in the literature (Thorne et. al, 2004). Thus experimental, non-experimental and qualitative studies were included in this synthesis.

Conclusions and Implications: There is support for the effectiveness of Dyadic Developmental Psychotherapy in treating RAD (Becker-Weidman, 2004). Further, Holding Therapy reduces aggressive behavior, but employs arguably unethical methods (Myeroff, 1997; Myeroff, Mertlich, & Gross, 1999). These experimental studies, however, do not address attachment directly; better measures are needed. More outcome studies, using rigorous research designs (including random assignment, larger sample sizes and follow-up assessments) are needed. Frequent lines of argument addressed problems in social and emotional cueing by children with RAD and difficulties in emotional regulation. For parents, frequent lines of argument centered on high levels of distress, which result in parents' minimization of the child's needs and high levels of interactive miscuing. In interaction, problems in intersubjective attunement by parents were noted by more than half of the non-experimental publications. Over three quarters of the publications also emphasized the need for clear behavioral expectations and daily routines. Many implications for future research are identified in this research synthesis.