Reactive attachment disorder

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Reactive attachment disorder
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Reactive attachment disorder (RAD) is the broad term used to describe the severe and relatively uncommon disorders of attachment characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts, beginning before the age of five. It can either take the form of a persistent failure to initiate most social interactions, or respond to them in a developmentally appropriate way, or present as indiscriminate sociability, such as excessive familiarity with relative strangers.

RAD arises from a failure to form normal attachments to primary caregiving figures in early childhood. Such a failure would result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts. Not all, or even a majority of such experiences result in the disorder.[1]

It is distinct from the less than ideal attachment 'styles' such as insecure or disorganized attachment. It is also differentiated from pervasive developmental disorder or developmental delay and from possibly comorbid conditions such as mental retardation, all of which can affect attachment behavior.

Although it was first classified in 1980, reactive attachment disorder has only been studied since the mid-1990s.[2] It is a somewhat controversial and still poorly-researched area. It is thought to grossly disturb the development of a childs internal working model of relationships leading to relationship and behavioral difficulties in later life but there are few studies of long term effects and there is a lack of clarity about presentation of the disorder beyond the age of five years.[3][4]

The opening of orphanages in Eastern Europe following the end of the Cold War in the early 1990s provided opportunities for research on infants and toddlers brought up in very deprived conditions. Such research broadened the understanding of the prevalence, causes, mechanism and assessment of disorders of attachment. This lead to efforts from the late 1990s onwards to develop treatment and prevention programs and better methods of assessment. Mainstream theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined beyond current classifications.[5]

All mainstream treatment and prevention programs which target RAD and other problematic early attachment behaviors are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver.[6] Most such strategies are in the process of being evaluated.

There is significant controversy over the diagnosis and treatment of RAD within the field of attachment therapy, which has a different theoretical basis. A range of approaches are used, some of which are physically coercive and considered to be antithetical to attachment theory.[7]


Theoretical framework

Main articles: Attachment theory and Attachment in children

The theoretical framework for reactive attachment disorder is attachment theory, based on work conducted from the 1940s to the 1980s by John Bowlby, Mary Ainsworth and René Spitz. Attachment theory is a psychological and evolutionary theory according to which initially the infant or child seeks proximity to a specified attachment figure in situations of alarm or distress, for the purpose of survival.[8] Subsequently, the child learns to use the caregiver as a 'secure base' to explore from, and return to. Attachment is not the same as love and/or affection although they often go together. Attachment and attachment behaviors tend to develop between the age of six months and three years. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time.[9] Caregiver responses lead to the development of patterns of attachment, which in turn lead to internal working models which will guide the individual's feelings, thoughts, and expectations in later relationships.[10][11] For a diagnosis of reactive attachment disorder, one or both of the attachment behaviors of seeking proximity to a specified attachment figure must be missing. (See ICD-10 and DSM-IV-TR criteria below).

There are four attachment 'styles' known as secure, anxious-ambivalent, anxious-avoidant, (all organized)[12] and disorganized.[13][14] The latter three are characterised as insecure. A securely attached toddler will explore freely while the caregiver is present, engage with strangers, be visibly upset when the caregiver departs, and happy to see the caregiver return. The anxious-ambivalent toddler is anxious of exploration, extremely distressed when the caregiver departs but ambivalent when the caregiver returns. The anxious avoidant toddler will not explore much, avoid or ignore the parent - showing little emotion when the parent departs or returns - and treat strangers much the same as caregivers with little emotional range shown. The disorganized/disoriented toddler shows a lack of a coherent style or pattern for coping. Evidence suggests this occurs when the caregiving figure is frightening thus putting the child in an irresolvable situation regarding approach and avoidance. On reunion with the caregiver children can look dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors that seem to imply fearfulness of the person who is being sought. It is thought to represent a breakdown of an inchoate attachment strategy and it appears to affect the capacity to regulate emotions.[15]

Although there are wide ranges of attachment difficulties within the styles which may result in emotional disturbance and increase the risk of later psychopathologies, particularly the disorganized style, none of the styles constitute a disorder in themselves and none are within the criteria for RAD.[16] (See ICD-10 and DSM-IV-TR criteria below). A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders.[3] There is a growing body of research on the links between abnormal parenting, disorganized attachment and risks for later psychopathologies.[17]RAD denotes a lack of attachment rather than an attachment style, however problematic that style may be, in that there is an unusual lack of discrimination between familiar and unfamiliar people in both forms of the disorder.

There is a lack of consensus about the precise meaning of the term 'attachment disorder' and the term is sometimes loosely and confusingly used to denote problematic attachment styles or, within the field of attachment therapy, a range of problematic behaviors not related directly to attachment difficulties.

Classification and characteristics

See also: Attachment theory and attachment disorder

The core feature is that the style of social relating by affected children involves either indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers (older children and adolescents may also aim attempts at peers), or extreme reluctance to initiate or accept comfort and affection, even from familiar adults and especially when distressed.[18] The disorder arises from the severe lack of developmentally appropriate attachment behaviors and thus appropriate social relatedness.

Reactive attachment disorder is classified in the World Health Organization's ICD-10 and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR).[19] It was first defined in the DSM in 1980. ICD-10 describes reactive attachment disorder of childhood, known as RAD, and disinhibited disorder of childhood, less well known as DAD. DSM-IV-TR also describes reactive attachment disorder of infancy or early childhood divided into two subtypes, inhibited type and disinhibited type, both known as RAD. The two classifications are similar and both include:

  • markedly disturbed and developmentally inappropriate social relatedness in most contexts
  • the disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder
  • onset before five years of age
  • a history of significant neglect, and
  • an implicit lack of identifiable, preferred attachment figure.

There must be a history of 'pathogenic care' defined as persistent disregard of the child's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to account for the disorder. For this reason, part of the diagnosis is the child's history of care rather than observation of symptoms.

In DSM-IV-TR the inhibited form is described as:

  • "Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness)", (hypervigilance while keeping an impassive and still demeanour).

Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain 'proximity', an essential element of attachment behavior.

The disinhibited form shows:

  • "Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures)"

There is therefore a lack of 'specificity' of attachment figure, the second basic element of attachment behavior. The ICD-10 descriptions are comparable save that ICD-10 includes in its description several elements not included in DSM-IV-TR as follows:

  • psychological and physical abuse and injury in addition to neglect
  • associated emotional disturbance, and
  • poor social interaction with peers.

The former of these is somewhat controversial, being a commission rather than omission and because abuse of itself does not lead to attachment disorder.

The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is more enduring.[20] Disinhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same child.[21] The question of whether there are in fact two subtypes has been raised.

Developments

Research from the late 1990's indicated that there were disorders of attachment not captured by DSM or ICD and showed that RAD could be diagnosed reliably without evidence of pathogenic care.[22] Research published in 2004 showed that the disinhibited form can endure alongside structured attachment behavior (of any style) towards the child's permanent caregivers.[21] This illustrates some conceptual difficulties with the rigid structure of the current definition of RAD. Some authors have proposed a broader continuum of definitions of attachment disorders ranging from RAD through various attachment difficulties to the more problematic attachment styles. There is as yet no consensus on this issue but a new set of practice parameters containing three categories of attachment disorder has been proposed. The first of these is disorder of attachment, in which a young child has no preferred adult caregiver. This is parallel to RAD in its inhibited and disinhibited forms, as defined in DSM and ICD. The second is secure base distortion where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, may cling to the adult, may be excessively compliant, or may show role reversals in which they care for or punish the adult. The third type is disrupted attachment. Disrupted attachment is not covered under other approaches to disordered attachment, and results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed.[23] This form of categorisation may demonstrate more clinical accuracy overall than the current DSM-IV-TR classification but more research is required.[24][5]

One paper considers there to be a significant overlap between behaviors of the inhibited form of RAD or DAD and aspects of disorganized attachment where there is an identified attachment figure.[15]

Causes and genetics

Although increasing numbers of childhood mental health problems are being attributed to genetic defects,[25] reactive attachment disorder is almost by definition based on a problematic history of care and social relationships. However, reactive attachment disorder may resemble many other emotional disorders with an etiology in which a predisposition or constitutional weakness is affected by an environmental stressor.[26] It has been suggested that types of temperament, or constitutional response to the environment, may make some individuals susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years.[27] In the absence of available and responsive caregivers it appears that some children are particularly vulnerable to developing attachment disorders.[28]

Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. Abuse is associated with developed, albeit disorganized attachment. This style is a risk factor for a range of psychological disorders although it is not in itself considered an attachment disorder under the current classification.[29][30]

There is as yet no explanation for why similar abnormal parenting produces two distinct forms of the disorder. The issue of temperament and its influence on the development of attachment disorders has yet to be resolved. RAD has never been reported in the absence of serious environmental adversity yet outcomes for children raised in the same environment vary widely.[31]

One study has reported a connection between a specific genetic marker and disorganized attachment (not RAD) associated with problems of parenting.[32] Another author has compared atypical social behavior in genetic conditions such as Williams syndrome with behaviors symptomatic of RAD.[33]

Mechanism

The mechanism by which reactive attachment disorder develops remains a matter of speculation. It is thought that social events between infant and caregiver are needed to produce typical developmental changes in attachment. The absence of such events may be part of the mechanism producing reactive attachment disorder.

Typical attachment development begins with unlearned infant reactions to social signals from caregivers. The ability to send and receive social communications through facial expressions, gestures and voice characteristics develops with social experience by seven to nine months. This makes it possible for an infant to interpret messages of calm or alarm from face or voice. At about eight months, infants typically begin to respond with fear to unfamiliar or startling situations, and to look to the faces of familiar caregivers for information that either justifies or soothes their fear. This developmental combination of social skills and the emergence of fear reactions results in attachment behavior such as proximity-seeking, if a familiar, sensitive, responsive, and cooperative adult is available. Further developments in attachment, such as negotiation of separation in the toddler and preschool period, depend on factors such as the caregiver's interaction style and ability to understand the child's emotional communications.[34]

With insensitive or unresponsive caregivers, or frequent changes, an infant may have few experiences that encourage proximity seeking to a familiar person. An infant who experiences fear but who cannot find comforting information in an adult's face and voice may develop atypical ways of coping with fearfulness such as the maintenance of distance from adults, or the seeking of proximity to all adults. These symptoms accord with the DSM criteria for reactive attachment disorder.[35] Either of these behavior patterns may create a developmental trajectory leading ever farther from typical attachment processes such as the development of an internal working model of social relationships that facilitates both the giving and the receiving of care from others.[36][37]

Atypical development of fearfulness, with a constitutional tendency either to excessive or inadequate fear reactions, might be necessary before an infant is vulnerable to the effects of poor attachment experiences.[27]

Alternatively, the two variations of RAD may develop from the same inability to develop 'stranger-wariness' due to inadequate care. Appropriate fear responses may only be able to develop after an infant has first begun to form a selective attachment. An infant who is not in a position do this cannot afford not to show interest in any person as they may be potential attachment figures. Faced with a swift succession of carers the child may have no opportunity to form a selective attachment until the possible biological-determined sensitive period for developing stranger-wariness has passed. It is thought this process may lead to the disinhibited form.[38]

In the inhibited form infants behave as if their attachment system has been 'switched off'. However the innate capacity for attachment behavior cannot be lost. This may explain why children diagnosed with the inhibited form of RAD from institutions almost invariably go on to show formed attachment behavior to good carers. However children who suffer the inhibited form as a consequence of neglect and frequent changes of caregiver continue to show the inhibited form for far longer when placed in families.[39]

Additionally, the development of Theory of Mind may play a role in emotional development. Theory of Mind is the ability to know that the experience of knowledge and intention lies behind human actions such as facial expressions. Although it is reported that very young infants respond differently to humans and objects, Theory of Mind develops relatively gradually and possibly results from predictable interactions with adults. However, some ability of this kind must be in place before mutual communication through gaze or other gesture can occur, as it does by seven to nine months. Some early emotional disorders, such as autism, have been attributed to the absence of the mental functions that underlie Theory of Mind. It is possible that the congenital absence of this ability, or the lack of experiences with caregivers who communicate in a predictable fashion, could underlie the development of reactive attachment disorder.[40][41]

In discussing the neurobiological basis for attachment and trauma symptoms in a 7-year twin study, it has been suggested that the roots of various forms of psychopathology, including RAD and post-traumatic stress disorder (PTSD), can be found in disturbances in affect regulation. The subsequent development of higher-order self-regulation is jeopardized and the formation of internal models is affected. Consequently the 'templates' in the mind that drive organized behavior in relationships may be impacted. The potential for “re-regulation” (modulation of emotional responses to within the normal range) in the presence of “corrective” experiences (normative caregiving) seems possible. Like many other papers in this poorly-researched area many new avenues of enquiry are raised.[42]

Diagnosis

See also: Attachment measures

RAD is one of the least researched and most poorly-understood disorders in the DSM. There is little systematically gathered epidemiologic information on RAD, its course is not well established and it appears difficult to diagnose accurately.[43] Several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, PTSD and social phobia share many symptoms and are often comorbid with or confused with RAD leading to over and under diagnosis. RAD can also be confused with neuropsychiatric disorders such as autism spectrum disorders, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. Some children simply have very different temperamental dispositions. Because of these diagnostic complexities, careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential.[44][45][46]

While RAD is likely to occur in relation to neglectful and abusive childcare, automatic diagnoses on this basis alone cannot be made as children can form stable attachments and social relationships despite marked abuse and neglect.[47]

In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the DSM and ICD, were created out of clinical and parental experience within the field known as attachment therapy. These lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common features of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under DSM-IV-TR or ICD-10.[48] Many children are being diagnosed with RAD because of behavioral problems that are outside the criteria.[44] There is an emphasis within attachment therapy on aggressive behavior as a symptom of attachment disorder whereas mainstream theorists view these behaviors as comorbid, externalizing behaviors requiring appropriate assessment and treatment rather than attachment disorders. However, knowledge of attachment relationships can contribute to the etiology, maintenance and treatment of externalizing disorders.[49]

The Randolph Attachment Disorder Questionnaire or RADQ is one of the better known of these checklists and is used by attachment therapists and others.[50] Critics assert that it lacks specificity and is unvalidated. The checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment difficulties.[51] By way of comparison, a recent study comparing questionnaires and accepted assessment measures for attachment concluded that it was not possible to satisfactorily diagnose attachment styles by means of questionnaires alone.[52]

Recognized assessment methods of attachment styles, difficulties or disorders include the Strange Situation Procedure (SSP) (Mary Ainsworth),Cite error: A <ref> tag is missing the closing </ref> (see the help page). the Observational Record of the Caregiving Environment (ORCE),[53] the Attachment Q-sort (AQ-sort)[54] and a variety of narrative techniques using stem stories or pictures. For older children, actual interviews such as the Child Attachment Interview (CAI) can be used. There is as yet no universally accepted diagnostic protocol for attachment disorder, although the practice parameters for the new classification system proposed would provide the framework for such a protocol.

More recent research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah, (1999).[55] This is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely having a discriminated, preferred adult, seeking comfort when distressed, responding to comfort when offered, social and emotional reciprocity, emotional regulation, checking back after venturing away from the care giver, reticence with unfamiliar adults, willingness to go off with relative strangers, self-endangering behavior, excessive clinging, vigilance/hypercompliance and role reversal. This method is designed to pick up not only RAD but also the proposed new alternative categories of disorders of attachment.

There is a lack of clarity about the presentation of attachment disorders over the age of five years and difficulty in distinguishing between aspects of attachment disorders, disorganized attachment or the sequelae of maltreatment.[56]

According to the American Academy of Child and Adolescent Psychiatry practice parameter (2005) the question of whether attachment disorders can reliably be diagnosed in older children and adults has not been resolved. Attachment behaviors used for the diagnosis of RAD change markedly with development and defining analogous behaviors in older children is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence.[3] Assessments of RAD past school age may not be possible at all as by this time children have developed along individual lines to such an extent that early attachment experiences are only one factor among many that determine emotion and behavior.[57]

Epidemiology

Epidemiological data are limited, but reactive attachment disorder appears to be very uncommon.[58] The prevalence of RAD is unclear but it is probably quite rare, other than in populations of children being reared in the most extreme, deprived settings such as some orphanages.[59] There is little systematically gathered epidemiologic information on RAD.[44] A cohort study of 211 Copenhagen children to the age of 18 months found a prevalence of 0.9%.[60]

Attachment disorders tend to occur in a definable set of contexts such as within some types of institutions, in the presence of repeated changes of primary caregiver or of extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, but not all children raised in these conditions develop an attachment disorder.[61] Studies undertaken on children from East European orphanages from the mid 1990's showed significantly higher levels of both forms of RAD in the institutionalized children, regardless of how long they had been there.[62][63][64] However, even among children raised in the most deprived institutional conditions the majority did not show symptoms of this disorder.[65]

It has been suggested by some within the field of attachment therapy that RAD may be quite prevalent because severe child maltreatment, which is known to increase risk for RAD, is prevalent, but many children experience severe maltreatment and do not develop clinical disorders.[66] Resilience is a common and normal human characteristic.[67] RAD does not underlie all or even most of the behavioral and emotional problems seen in foster children, adoptive children, or children who are maltreated. Rates of child abuse and/or neglect or problem behaviors are not a benchmark for estimates of RAD. Severely abused children may exhibit similar behaviors to RAD behaviors, and there are several far more common and demonstrably treatable diagnoses which may better account for these difficulties.[68]

There are two studies on the incidence of RAD relating to high risk and maltreated children in the U.S. The first, in 2004, compared ill-treated children in foster care, children in a homeless shelter and low income children in the Head Start program. The study reports that children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups, however this was mainly the proposed new classification of disrupted attachment disorder rather than the DSM or ICD classified RAD or DAD. Under the DSM and ICD classifications there was little difference between the foster care and homeless shelter groups.[69]

The second study, also in 2004, attempted to ascertain the prevalence of RAD and whether RAD could be reliably identified in maltreated rather than neglected toddlers. Of the 94 maltreated toddlers in foster care, 35% were identified as having ICD RAD and 22% as having ICD DAD, and 38% fulfilled the DSM criteria for RAD.[21] This study found that RAD could be reliably identified and also that the inhibited and disinhibited forms were not independent.

There are few data on comorbid conditions, but there are some conditions that arise in the same circumstances in which RAD arises, such as institutionalization or maltreatment. These are principally developmental delays and language disorders associated with neglect.[3] Conduct disorders, oppositional defiant disorder, anxiety disorders, post-traumatic stress disorder (PSTD) and social phobia share many symptoms and are often comorbid with or confused with RAD.[70][71] Attachment disorder behaviors amongst institutionalized children were correlated with attentional and conduct problems and cognitive levels but nonetheless appeared to index a distinct set of symptoms and behaviors.[65]

Treatment

Main articles: Child therapy and Attachment therapy

All mainstream prevention programs and treatment approaches for attachment disorder for infants and younger children are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver.[72][3][73] These approaches are mostly in the process of being evaluated. The programs invariably include a detailed assessment of the attachment status or caregiving responses of the adult caregiver as attachment is a two-way process involving attachment behavior and caregiver response. Some of these treatment or prevention programs are specifically aimed at foster carers rather than parents, as the attachment behaviors of infants or children with attachment difficulties often do not elicit appropriate caregiver responses.[74] Approaches include 'Watch, wait and wonder,'[75] manipulation of sensitive responsiveness,[76][77] modified 'Interaction Guidance,'[78] 'Preschool Parent Psychotherapy,'[79] 'Circle of Security',[80][81] Attachment and Biobehavioral Catch-up (ABC),[82] the New Orleans Intervention,[83][84][2] and Parent-Child psychotherapy.[85] Other treatment methods include Developmental, Individual-difference, and Relationship-based therapy (DIR, also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders.[86]

The relevance of these approaches to intervention with fostered and adopted children with RAD or older children with significant histories of maltreatment is unclear.[87]

In 2005 the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W.Boris and C.H.Zeanah) based on its published parameters for the diagnosis and treatment of RAD.[3] Recommendations in the guidelines include the following:

  1. "The most important intervention for young children diagnosed with reactive attachment disorder and who lack an attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an emotionally available attachment figure."
  2. "Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child, assessing the caregiver's attitudes toward and perceptions about the child is important for treatment selection."
  3. "Children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. After ensuring that the child is in a safe and stable placement, effective attachment treatment must focus on creating positive interactions with caregivers."
  4. "Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive (additional) treatments."

There is considerable controversy over the use of attachment therapy, a form of diagnosis and treatment that is largely unvalidated and has developed outside the scientific mainstream, for supposed attachment disorders including RAD.[88] These therapies have little or no evidence base and vary from non-coercive therapeutic work to more extreme forms of physical, confrontational and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model. In general these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers. The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasize obedience and parental control.[89] Critics maintain that these therapies are not within the attachment paradigm, are potentially abusive,[90] and are antithetical to attachment theory.[7] The APSAC Taskforce Report of 2006 notes that many of these therapies concentrate on changing the child rather than the caregiver.[91] Children may be described as 'RADs' or 'Radkids' or 'Radishes' and dire predictions may be made as to their supposedly violent futures if they are not treated with attachment therapy.[92]

Prognosis and impact

The AACAP guidelines state that children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others.[3] However, the course of RAD is not well studied and there have been few efforts to examine symptom patterns over time. The few existing longitudinal studies involve only children from poorly-run East European institutions.[3]

Findings from the studies of children from East European orphanages indicate that persistence of the inhibited pattern of RAD is rare in children adopted out of institutions into normative care-giving environments. However, there was a close association between duration of deprivation and severity of attachment disorder behaviors.[65] The quality of attachments that these children form with subsequent care-givers may be compromised, but they probably no longer meet criteria for inhibited RAD.[93] The same group of studies suggests that a minority of adopted, institutionalized children exhibit persistent indiscriminate sociability even after more normative caregiving environments are provided.[42] Indiscriminate sociability may persist for years, even among children who subsequently exhibit preferred attachment to their new caregivers. Some exhibit hyperactivity and attention problems as well as difficulties in peer relationships.[94] In the only longitudinal study that has followed children with indiscriminate behavior into adolescence, these children were significantly more likely to exhibit poor peer relationships.[95]

There is one case study on maltreated twins published in 1999 with a follow-up in 2006. This study assessed the twins between the ages of 19 and 36 months, during which time they suffered multiple moves and placements.[71] The paper explores the similarities, differences and comorbidity of RAD, disorganized attachment and post traumatic stress disorder. The girl showed signs of the inhibited form of RAD while the boy showed signs of the indiscriminate form. It was noted that the diagnosis of RAD ameliorated with better care but symptoms of post traumatic stress disorder and signs of disorganized attachment came and went as the infants progressed through multiple placement changes. At age three, some lasting relationship disturbance was evident.

In the follow-up case study when the twins were aged three and eight years, the lack of longitudinal research on maltreated as opposed to institutionalized children was again highlighted. The girl's symptoms of disorganized attachment had developed into controlling behaviors—a well-documented outcome. The boy still exhibited self-endangering behaviors, not within RAD criteria but possibly within 'secure base distortion', (where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment). At age eight the children were assessed with a variety of measures including those designed to access representational systems, or the child's 'internal working models'. The twins' symptoms where indicative of different trajectories. The girl showed externalizing symptoms (particularly deceit), contradictory reports of current functioning, chaotic personal narratives, struggles with friendships, and emotional disengagement with her caregiver, resulting in a clinical picture described as "quite concerning". The boy still evidenced self-endangering behaviors as well as avoidance in relationships and emotional expression, seperation anxiety and impulsivity and attention difficulties. It was apparent that life stressors had impacted each child differently. The narrative measures used where considered helpful in tracking how early attachment disruption is associated with later expectations about relationships.[42]

One paper using questionnaires found that children aged three to six, diagnosed with RAD, scored lower on empathy but higher on self-monitoring than non-RAD children. These differences were especially pronounced based on parent ratings and suggested that children with RAD may systematically report their personality traits in overly positive ways. Their scores also indicated considerably more behavioral problems than scores of the control children.[96]

East European orphanages and maltreated children

A 1998 study showed that children adopted from poorly-run Romanian orphanages had a higher frequency of insecure patterns of attachment than control groups, although this difference improved in the follow-up study three years later.[62][97] However they continued to show significantly higher levels of indiscriminate friendliness.

A later study looked at children adopted in the UK who had suffered early severe deprivation in Romania, some 'early placed' and some 'late placed'. The 'late placed' children showed a far higher incidence of atypical insecure patterns such as displaying both strong avoidant and strong dependent attachment behavior patterns.[93]

A 2002 study of children in residential nurseries in Bucharest, using the DAI, challenged the current DSM and ICD conceptualizations of disordered attachment and showed that inhibited and disinhibited disorders could coexist in the same child. It also showed higher incidence of RAD in the standard care group in the institution than in the 'pilot group' receiving more consistent care, or in the non-institutionalized group.[63]

A 2005 study comparing institutionalized and community children in Bucharest, using the DAI, again showed significantly higher levels of both forms of RAD in the institutionalized children, regardless of how long they had been there. Further, only 22% of the institutionalized children had organized attachments, as opposed to 78% of the community children, and all the children in the community group showed clear attachment patterns as opposed to only 3% in the institutionalized group. It would appear that children in institutions like these are unable to form selective attachments to their caregivers. The study also concluded the signs of RAD related to how fully developed and expressed attachment behaviors are rather than the organization of a particular pattern.[64]

Studies of children who were reared in institutions have suggested that they are inattentive and overactive, no matter what quality of care they received. In one investigation, some institution-reared boys were reported to be inattentive, overactive, and markedly unselective in their social relationships, while girls, foster-reared children, and some institution-reared children were not. It is not yet clear whether these behaviors should be considered as part of disordered attachment.[98]

There are two studies on the incidence of RAD relating to high-risk and maltreated children in the U.S. The first, in 2004, compared ill-treated children in foster care, children in a homeless shelter with their mothers and low income children in the Head Start program. The children were assessed using DSM and ICD and Zeanah and Boris' alternative proposed criteria for attachment disorder. The study reports that children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups, however this was mainly disrupted attachment disorder rather than the DSM or ICD classified RAD or DAD. Under the DSM and ICD classifications there was little difference between the foster care and homeless shelter groups.[69]

The second study, also in 2004, was for the purposes of ascertaining prevalence of RAD, whether RAD could be reliably identified in maltreated rather than neglected toddlers and whether the two types of RAD were independent. The DAI and DSM and ICD were used. Of the 94 maltreated toddlers in foster care, 35% were identified as having ICD RAD, 22% as having ICD DAD and 38% fulfilled the DSM criteria for RAD.[21] The study found that RAD could be reliably identified and also that the inhibited and disinhibited forms were not independent. However, there are some methodological concerns with this study. A number of the children identified as fulfilling the criteria did in fact have a preferred attachment figure.[99] This study also showed that mothers with a history of psychiatric problems were more likely to have children exhibiting signs of inhibited/emotionally withdrawn RAD but mothers with a history of psychiatric problems and substance misuse had children more likely to exhibit signs of disinhibited/indiscriminate RAD.

See also

Notes

  1. ^ Prior & Glaser 2006, p. 218–219
  2. ^ a b Zeanah CH and Smyke AT (2005) "Building Attachment Relationships Following Maltreatment and Severe Deprivation" In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (Eds) Enhancing Early Attachments; Theory, research, intervention, and policy The Guilford Press, 2005 pps 195–216 ISBN 1593854706 (pbk)
  3. ^ a b c d e f g h Boris NW, Zeanah CH, Work Group on Quality Issues (2005). "Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood" (PDF). J Am Acad Child Adolesc Psychiatry. 44 (11): 1206–19. PMID 16239871. Retrieved 2008-01-25.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  4. ^ Prior & Glaser 2006, p. 228
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References

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  • Bowlby J (1980). Loss: Sadness & Depression, Attachment and Loss (vol. 3). (International psycho-analytical library no.109). London: Hogarth Press. ISBN 0-465-04238-4 (pbk). ISBN 0-70120-350-1. OCLC 59246032.
  • Chaffin M, Hanson R, Saunders BE; et al. (2006). "Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems". Child Maltreat. 11 (1): 76–89. doi:10.1177/1077559505283699. PMID 16382093. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  • Mercer, J (2006). Understanding Attachment: Parenting, child care and emotional development. Westport, CT: Praeger ISBN 0275982173
  • Prior V, Glaser D (2006). Understanding Attachment and Attachment Disorders. Theory, Evidence and Practice. Child and Adolescent Mental health series, RCPRTU, Jessica Kingsley Publishers. ISBN 978-1-84310-245-8 (pbk)
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