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Preventing Reactive Attachment Disorder (RAD)


While it's not known if reactive attachment disorder can be prevented with certainty, there may be ways to reduce the risk of its development:
  1. Be actively engaged with babies and kids in your care by playing with them, talking to them, making eye contact or smiling at them, for example.
  2. Don't miss opportunities to provide warm, nurturing interaction with your baby or youngster, such as during feeding, bathing or diapering.
  3. If you lack experience or skill with babies or kids, take classes or volunteer with kids so that you can learn how to interact in a nurturing manner.
  4. If your baby or youngster has a background that includes orphanages or foster care, educate yourself about attachment and develop specific skills to help your youngster bond.
  5. If you're an adult with attachment problems, it's not too late to get professional help. Getting help may prevent you from having attachment problems with your kids, who otherwise may also be at risk.
  6. Learn to interpret your baby's cues, such as different types of cries, so that you can meet his or her needs quickly and effectively.
  7. Teach kids how to express feelings and emotions with words. Lead by example, and offer both verbal and nonverbal responses to the youngster's feelings through touch, facial expressions and tone of voice.

Coping With RAD—

If you're a parent or caregiver whose baby or youngster has reactive attachment disorder, it's easy to become angry, frustrated and distressed. You may feel like your youngster doesn't love you — or that it's hard to like your youngster sometimes.

You may find it helpful to:
  • Acknowledge that the strong or ambivalent feelings you may have about your youngster are natural
  • Be willing to call for emergency help if your youngster becomes violent
  • Continue friendships and social engagements
  • Find respite care so that you can periodically have downtime if caring for your youngster is particularly troublesome
  • If your youngster was adopted, reach out to your adoption agency for attachment resources
  • Join a support group to connect with others facing the same issues
  • Practice stress management skills
  • Take time for yourself through hobbies or exercise

Parenting Defiant RAD Teens

Risk Factors for Reactive Attachment Disorder

Reactive attachment disorder is considered uncommon. It can affect kids of any race or either sex. By definition, reactive attachment disorder begins before age 5, although its roots start in infancy.

Several risk factors can contribute to the occurrence of reactive attachment disorder.

Parental or caregiver related risk factors:
  • Aggressive behavior towards kids when they request comfort
  • Being abused, neglect, and abandonment by primary caregivers
  • Being raised by parents with different psychological conditions (such as unipolar or bipolar disorder, postpartum depression, substance abuse, anger management problems, or attachment disorder)
  • Forced removal from a neglectful home
  • Frequent changes in foster care or caregivers
  • Inexperienced parents that provide inconsistent or inappropriate care
  • Maternal ambivalence toward pregnancy

Child related risk factors:
  • Being separated from parents/caregivers due to prolong hospitalization
  • Difficult temperament
  • Premature birth
  • Suffering a birth or prenatal trauma
  • Suffering from painful or undiagnosed illnesses

Environment related risk factors:
  • Being separated from birth parents as the result of divorce, death, or serious illnesses
  • Extreme poverty
  • Frequent changes in foster care or caregivers
  • Living in orphanages
  • Significant family trauma, such as death or divorce

Complications:

Without treatment for reactive attachment disorder, a kid's social and emotional development may be permanently affected.

Complications and related conditions may include:
  • Academic problems
  • Aggression
  • Anxiety
  • Bullying or being bullied
  • Depression
  • Developmental delays
  • Drug and alcohol addiction
  • Eating problems
  • Growth delays
  • Inappropriate sexual behavior
  • Lack of empathy
  • Malnutrition
  • Relationship problems in adulthood
  • Temper or anger problems
  • Trouble relating to classmates or peers
  • Unemployment or frequent job changes

Parenting Defiant RAD Teens

All About Attachment Disorder: An Overview

Attachment disorders are the psychological result of negative experiences with caretakers, usually since infancy, that disrupt the exclusive and unique relationship between kids and their primary caretaker(s). Oppositional and defiant behaviors may be the result of disruptions in attachment.

Many kids experience the loss of primary caretakers either because they are physically separated from them or because the caretaker is incapable of providing adequate care. Removal from primary caretakers can cause serious problems by breaking primary attachments, even if alternate caretakers are competent.

Attachment disorders have been described in the psychological and psychiatric literature for approximately 50 years. The condition Rene Spitz called anaclitic depression is now considered an attachment disorder. Spitz observed young kids in an orphanage who were fed and kept clean and were initially in good physical condition but who received no consistent affection from a sole caretaker. The long-standing absence of emotional warmth took an enormous toll on the kids, primarily on their emotional development but also on their physical growth and development condition. Spitz concluded that providing only for a baby's physical needs is not sufficient for normal development.

A short while later, John Bowlby, a psychoanalyst interested in the parallels between human babies and animal babies, incorporated Harlow's research on rhesus monkeys into his study of the youngster's tie to its mother. He concluded that separations during the first few months of life negatively impact a baby's psychic organization and that separation from a parental figure causes separation anxiety.

In a film entitled A-Two-Year-Old Goes to Hospital, Bowlby shows that a baby goes through several phases in reaction to separation. The baby goes from protest to crying to a sad state and, finally, to a more desolate state of resignation regarding the loss.

Bowlby, the father of attachment theory, produced a report for the World Health Organization (WHO) highlighting the importance of parental sensitivity in adequate child development. Parental sensitivity refers to the ability of a mom or dad to read internal states and emotions in his or her baby and to respond to them in a positive and supportive manner.

Attachment refers to a set of behaviors and inferred emotions that can be observed in babies. Humans need attachments with others for their psychological and emotional development as well as for their survival. Early manifestations of attachment include the unique and exclusive relationship between a baby and its moms & dads. Moms & dads and babies establish a continuous relationship that has specific features. The quality of this relationship colors the individual's relationships for the rest of his or her life.

Both caretaker and baby have biological preprogrammed instinctive equipment to foster their relationship. Most individuals have a strong attraction and desire to care for babies. In addition, a baby's crying and clinging (signaling behaviors) reinforce the baby's efforts to obtain care and attention. Moms & dads also has instinctive behaviors, such as soothing the crying baby, caressing it, making sounds that are appealing to the baby, and mirroring the baby (i.e., playfully imitating the baby's facial expressions), all of which trigger tenderness and a maternal instinct.

Attachment develops through repeatedly being looked after and appropriately responded to by the caretaker. This convinces the baby and young child that an individual is available to soothe, console, and comfort. Babies may develop attachments to other individuals who are consistent in their lives; however, the relationship with the primary caretaker(s) plays the most critical role in determining the youngster's basis for future attachments. The attachment figure(s) cannot suddenly be replaced by any other caretaker because that relationship is unique and stable.

Based on the nature and quality of early attachments, kids develop an internal working model of relationships that serves as a template for future relationships. These working models of relationships can be positive (i.e., individuals can be trusted, confided in, helpful in distress) or negative (i.e., no one can be trusted, individuals are not caring, one is all alone in the world). Babies internalize their moms & dads (and other attachment figures) as a secure base. This allows babies to feel internally safe and to confidently explore the world around them. It also allows them to experience positive interpersonal exchanges with other kids. The baby can come back to the caretaker to refuel emotionally before proceeding with further explorations.

Reactive attachment disorder—

Reactive attachment disorder (RAD), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), requires etiologic factors, such as gross deprivation of care or successive multiple caretakers, for diagnosis.
  • In dis-inhibited RAD, the youngster participates in diffuse attachments, indiscriminate sociability, and excessive familiarity with strangers. The youngster has repeatedly lost attachment figures or has had multiple caretakers and has never had the chance to develop a continuous and consistent attachment to at least one caretaker. Disruption of one attachment relationship after another causes the baby to renounce attachments. The usual anxiety and concern with strangers is not present, and the baby or youngster superficially accepts anyone as a caretaker (as though individuals were interchangeable) and acts as if the relationship had been intimate and life-long.
  • In inhibited RAD, the youngster does not initiate and respond to social interactions in a developmentally appropriate manner. It is a disorder of nonattachment and is related to the loss of the primary attachment figure and the lack of opportunity for the baby to establish a new attachment with a primary caretaker. Also, a nonattachment disorder may develop because the baby never had the opportunity to develop at least one attachment with a reliable caretaker who was continuously present in the baby's life.

Attachment disorders independent of DSM-IV –
  • In angry attachment, a strong relationship exists between mom or dad and baby that is unique and exclusive; however, the relationship is marked by angry features and exchanges. The dyad members are angry with each other but not with other individuals around them.
  • In reversed attachment, the youngster becomes the source of comfort to the mom or dad, who is insecure and vulnerable; the relationship is inverted and the baby, although unable to reassure the parent completely, provides the security.

Mary Ainsworth developed an attachment classification based on the behavior of babies (typically aged 10-13 mo) in the presence of a stranger during and after a short separation from their primary caretakers.
  • Approximately 65% of American middle-class kids are thought to have secure attachments with primary caretakers, whereas 35% exhibit an insecure attachment style. Not all kids who show an insecure attachment to primary caretakers are diagnosed with RAD, either because they did not receive pathological care or because their insecure attachment is not severe. The lack of a secure attachment style affects the youngster throughout life; however, an insecure attachment should not be confused with a disorder. The Ainsworth attachment study is only a suggestion of an internal state of the youngster. It is not a diagnostic tool for attachment disorders.
  • Behavioral patterns associated with insecure attachments, such as avoidant and ambivalent styles, include lack of distress upon separation and avoidance of, or anger toward, mother upon reunion.
  • Behavioral patterns associated with secure attachments include some distress at separation, preference for a mom or dad over a stranger, and a search for comfort from the mom or dad upon reunion.

Pathophysiology—

Inhibited RAD:

If caretakers are not reliably or consistently present or if they respond in an unpredictable and uncertain way, babies are not able to establish a pattern of confident expectation. One result is insecure attachment, or a less than optimal internal sense of confidence and trust in others, beginning with caretakers. The kid then uses psychological defenses (e.g., avoidance or ambivalence) to avoid disappointments with the caretaker. This is thought to contribute to a negative working model of relationships that leads to insecurity for the rest of the youngster's life.

Dis-inhibited RAD:

Young kids exposed to multiple caretakers simultaneously or sequentially do not easily experience the sense of security associated with unique and exclusive long-standing relationships. No opportunity exists to trust one individual because past relationships were interrupted, disrupted, or consistently unreliable. Kids with dis-inhibited attachment resort to psychological defense mechanisms (e.g., relying only on themselves and not expecting to be soothed, cared for, or consoled by adults) to survive. Instead of relying on one individual, any sense of fear or loneliness is inhibited and the kids develop a pseudo-comfort with whoever is available. The youngster is thought to suppress the conscious experience of fear only as a result of a psychological defense. The youngster is afraid of trusting anyone and being further disappointed. This pattern can continue into adult life and adversely affect adult relationships.

Frequency—

United States:

No epidemiologic studies of frequency or prevalence of attachment disorders in kids exist; however, statistical data regarding adoptions and foster care placement are available. One might estimate, based on the number of foster care placements and disruptions in relationships, approximately how many kids can have attachment disorders.

International:

Many kids, examples being certain kids from Romania and China, have lived in orphanages and have had little opportunity for attachment or they have lived in bleak conditions with multiple caretakers and are emotionally and cognitively deprived. In the midst of such deprivation and so many disruptions in relationships, determining exactly what causes a youngster to have difficulties in relating and communicating, in development of trust, and in linguistic and cognitive development can be difficult.

Race:

No evidence suggests greater prevalence of attachment disorders in a particular racial or ethnic group unless as noted above in specific countries with unusual youngster care practices.

Sex:

No information in the scientific literature suggests a sex predilection exists.

Age:

Onset of attachment disorders is in kids younger than 5 years. Typically, the disorder has its roots in infancy. The more serious effects of disruptions in attachment relationships tend to persist and manifest themselves in the preschool and school years. In more muted forms (e.g., mistrust and difficulties in establishing supportive, sensitive, and intimate relationships), they last into adolescence and adulthood.

Clinical—

History:

Rene Spitz noted that the kids in the orphanage were prone to physical illness and had decreased appetites. They exhibited some stereotyped movements, self-stimulation, and an empty look in their eyes. They lacked normal responses of interest when individuals came close. They cried vaguely or softly many times a day and seemed unhappy. Many of these kids seemed depressed and unresponsive to initiatives for interaction, as if they were resigned to their situation of affective deprivation. These kids also had a much higher mortality rate than non-institutionalized pediatric populations.

A history of gross neglect, lack of contingent responses, and little or no attention, interaction, and affection are required to establish a diagnosis of inhibited RAD. For a diagnosis of dis-inhibited RAD, a history of multiple caretakers, sequential changes in caretaker, disruptions in relationships, and placement with different individuals for considerable periods must exist. The youngster does not develop preferential attachments and secure base behavior toward a specific individual but instead develops an undifferentiated closeness with anyone who approaches the youngster.

1. Inhibited RAD-
  • Blank expression, with eyes lacking the luster and joy that is usually observed
  • Failure to thrive
  • May appear bewildered, unfocused, and under-stimulated
  • No evidence of the usual responses to interpersonal exchanges
  • Poor hygienic condition
  • Underdevelopment of motor coordination and a pattern of muscular hyper-tonicity because of diminished holding
  • Appearance of not knowing body language
  • Does not approach or withdraw from another individual
  • Does not pursue, initiate, or follow up on cues for an exchange or interaction.
  • May avoid eye contact and protest or fuss if an individual comes too close or attempts to touch or hold them (have developed avoidant behaviors because they do not expect interaction and have learned not to interact when an adult approaches)
  • No exploration of another individual's face or facial expression

2. Dis-inhibited RAD-
  • Can give hugs to anyone who approaches them and go with that individual if asked
  • Instead of caution, excessive familiarity or psychological promiscuousness with unknown individuals
  • May approach a complete stranger for comfort, food, to be picked up, or to receive a toy

Physical—

No specific physical signs of attachment disorder exist. Nevertheless, indirect indicators may be present, such as the following:
  • A syndrome characterized by excessive appetite in kids who have been in several foster homes
  • Effects of under-nutrition and rashes because of not changing diapers frequently
  • Excessive appetite and excessive thirst in kids who experience severe stress
  • Flattened back of the head because left in bed much of the time in cases of nonattachment
  • If severe, growth retardation
  • Signs of physical maltreatment, such as old fractures or bruises

Causes—

Multiple situations can lead to attachment disorders.

1. Inhibited RAD: Young kids who are exposed to multiple caretakers simultaneously or sequentially do not easily experience the sense of security associated with unique and exclusive long-standing relationships. No opportunity exists to trust one individual because past relationships were interrupted, disrupted, or consistently unreliable.
  • Abandonment by caretaker at the peak of attachment needs (end of first year of life)
  • Gross insensitivity in the caretaker
  • Gross neglect
  • Repeated abandonment by caretaker

2. Dis-inhibited RAD: Promiscuous or dis-inhibited attachment disorders have a phenomenology opposite that of inhibited attachment disorders. This is the most common type of attachment disturbance in clinical settings. Many kids with this condition have been placed in multiple foster homes or have lived with different relatives; their moms & dads are unable to create a sense of permanency in their lives. Many of the moms & dads experience legal problems, engage in illegal drug use, abuse alcohol, or have personality disturbances, which make them unable to provide stability for the youngster.
  • Multiple caretakers sequentially or concurrently
  • Multiple disruptions in attachment relationships
  • Several changes in foster home placement

3. Risk factors: Risk factors are the same as those associated with poor parenting, maltreatment, and neglect. A number of psychosocial factors place some kids at particular risk, such as caretakers who abuse drugs, have multiple unmanageable stressors, or have been maltreated or have experienced multiple attachment disruptions themselves.

Workup—

Laboratory Studies:
  • Studies related to neglect and nutritional deprivation (e.g., anemia caused by iron deficiency, high level of lead caused by pica) exist.
  • No directly related laboratory studies exist.

Imaging Studies:
  • No imaging studies are used to diagnose this condition.

Histologic Findings:
  • No histologic findings are related to attachment disorders.

Treatment—

Medical Care:

An appropriate treatment program for a youngster with multiple challenges requires the participation of several specialists. Most of the treatment is provided by primary caretakers, such as moms & dads or substitute moms & dads, in their everyday interactions with the youngster. Hopefully, these caretakers can rely on the expertise and advice of a mental health professional who is aware of the emotional needs of kids, the phenomenology of attachment disruptions, and the need to repair and recreate the sense of security in the youngster. Referral to a mental health professional may be critical.

Play therapy with a youngster psychotherapist, particularly in the presence of the primary caretakers, may help the youngster and the caretakers to express the emotional needs, fears, and anxieties of the youngster in the context of play. Caretakers may become more sensitive to the issues (e.g., anger about having been abandoned, maltreated, left alone, or locked up) faced by their youngster. Also, kids may be able to express their dependency needs (e.g., to be a baby, to be looked after, to be soothed) through play.

Several therapeutic ingredients seem important in treating inhibited RAD and dis-inhibited RAD. When caretakers provide the ingredients described below, the youngster may experience healthy dependency, rely on someone, and trust a new individual. That is to say, the youngster may become attached.
  • Security, or a sense of psychological safety, helps promote the development of a new attachment relationship. Constant or intense stress and anxiety do not facilitate a sense of security but, rather, promote guarding behavior. To correct the scars or sequelae of attachment disruption, the clinician, parent, or caretaker must have time and be ready, without judging, to listen to the youngster. Limits must be set for the youngster, but these should be set in the context of empathy and compassion. Only when the verbal kids feel emotionally secure will they begin talking about what has happened to them and, likely, to their siblings and gradually develop trust in the new caretaker.
  • Stability refers to the permanence of the attachment figure. The youngster needs time to develop trust in a new primary caretaker. After disruption(s), these kids need to learn to recognize their needs and to learn that these needs can be met repeatedly by the same individual.
  1. Separations and disruptions may reactivate a defensive isolation on the part of the youngster.
  2. Some kids take a long time (more than a year) to trust a caretaker again; others trust a caretaker after receiving just a few months of sensitive care. This may be a temperamental feature (e.g., orientation toward others versus inwardness) or a reflection of the quality of the match between the youngster and the new caretaker.
  3. The youngster might fear that the caretaker will disappear, die, or go away, thus leading to another disruption.
  • Sensitivity, or emotional availability, refers to attentiveness to the youngster's needs and is crucial in care taking. Inform substitute caretakers that, although the youngster may or may not be mature cognitively, the youngster's emotional development is frequently delayed in areas such as emotional expression, attachment, and age-appropriate independence. Hopefully, during the course of treatment, the youngster will gradually begin to develop feelings of dependency toward the primary caretaker because the youngster learns to expect the caretaker will be physically and emotionally available at times of crisis. During this process, caution moms & dads to expect and tolerate occasional regressive behaviors and to view them as signs that the youngster is psychologically working through earlier phases in development.
  1. For instance, a youngster who typically is independent and suspicious of others may suddenly express needs for dependency, report fears, want to sleep in the moms & dads' bed, and wish to be mommy's little boy or girl. Recommend that the moms & dads, in a sensitive way, allow the youngster to express and experience that dependency. Encourage moms & dads to think of the youngster as emotionally younger and as having legitimate emotional needs appropriate for his or her emotional age.
  2. Some kids are almost frozen emotionally because, with multiple placements and relationships, expressing age-appropriate emotions has not been safe. These kids might at first appear to be obedient because they do not express anger and are not prone to emotional outbursts. As time goes by, expressing emotions, such as anger, jealousy, and neediness, becomes safe. The caretaker may observe the appearance of temper outbursts, jealousy, and anger toward him or her upon separation. Things that previously did not seem to matter to the youngster (eg, if the caretaker comes or goes) may suddenly be upsetting. For example, a youngster who never seemed to mind separations may strongly protest the parent's leaving by clinging or going to the mom or dad for comfort. Encourage caretakers to see these behaviors as positive signs that a new attachment and a deeper level of trust have formed because the youngster feels safe to express these developmentally appropriate dependency needs.

Surgical Care:
  • No surgical procedures to treat this condition exist.

Consultations:

Consult specialists about particular problems that may be associated with experiences of detachment and neglect, such as excessive eating and drinking.
  • Pediatric gastroenterologist to rule out gastroenterological problems
  • Endocrinologist or nutritionist for short stature and malnourishment

Diet—

No specific diet is indicated; however, many kids who have experienced disruptions and early neglect also have feeding disorders and may require treatment. Also, some kids may have excessive appetite and thirst.

Medication—

No pharmacologic treatment specifically for attachment disorders exists. Psychopharmacologic agents may be used to address problems such as explosive anger, hyperactivity, and difficulty focusing or sleeping. These agents are used at similar doses and with the same objectives as described in other articles. Treat ancillary problems in order to promote the optimal psychosocial functioning of the youngster; however, these treatments are not addressed specifically to the attachment disorder.

Follow-up—

Further Inpatient Care:
  • Unfortunately, intermediate or longer-term hospitalization is no longer available in today's economic climate. Day hospital, partial hospital, or residential care in a placement skilled in treating very disruptive, poorly attached kids may be a suitable alternative to prevent further foster care placement failures.
  • No specific indication exists for treatment of attachment disorders with inpatient hospitalization; however, occasionally, some kids and, particularly, teenagers may require a period of inpatient hospitalization to address issues such as mistrust or lack of emotional involvement with others. For instance, with the teenager who has had multiple placements, foster homes, or group homes, a period of inpatient treatment may be beneficial in helping the youngster face fears of becoming close to any individual. Also, therapy during hospitalization may help the youngster work on overcoming the fear of acknowledging dependency needs and the fear of acknowledging desires for attention and affection.

Further Outpatient Care:
  • Child therapy and relational therapy (e.g., parent-child, parent-baby) may be useful for many kids and caretakers. Caretakers may struggle with disciplining the youngster while trying to foster the youngster's ability to relate and trust. Establishing a positively oriented and developmentally appropriate behavioral management program is very important to avoid further punishment or prolonged abandonment in excessive time outs. In the context of relational play, or narrative therapy, the youngster can develop a theme that describes what is in the youngster's mind. New caretakers may need considerable emotional support to deal with challenging and difficult behaviors in their kids.

Inpatient & Outpatient Medications:
  • No pharmacologic treatments specifically indicated for attachment disorders exist; however, kids with this condition may exhibit complications in their behavior, such as aggression, defiance, or attention deficit. Medications may be geared toward those symptoms. The treatment of these problems is covered in the respective articles.

Complications:
  • Disruptions in attachment tend not to occur as isolated events but coexist with a number of adverse psychosocial circumstances known to cause psychologic disturbance. These circumstances impede adequate parenting and care…giving and often result in the loss of the primary caretakers, possibly causing posttraumatic stress symptoms. They include the following:
  1. Exposure to drugs in utero
  2. Multiple stressors, such as economic hardship, family conflict or violence (e.g., physical abuse of the baby), and crowding in the house
  3. Neglect of the needs of the baby because of parental substance abuse
  • Because of the attachment disorder, kids who have experienced multiple losses tend to engage in defiant behavior, are non-cooperative with adults, experience pervasive anger and resentment, and develop an exploitative attitude toward other individuals.
  • Persistence of the nonattachment or the superficial exploitation of individuals, with fear of closeness and intimacy, is a major complication. When kids become moms & dads, they may transmit difficulties in attachment (i.e., the moms & dads may be insensitive emotionally and may be unavailable) to their own kids.
  • The youngster with disruptions of attachments faces academic difficulties related to maltreatment and to mistrust of adults. Academic difficulties may also be related to attentional problems and hyper-arousal associated with posttraumatic stress. Additionally, the youngster may have learning disabilities and language difficulties if exposed to drugs in utero or because of a genetic loading. These disabilities may have led to the difficulties the moms & dads had in caring for their youngster in the first place. Even without all of those challenges, kids with multiple placements and disruptions in their living situations are at risk of experiencing academic problems. A specific educational program designed to address those needs is necessary. If the youngster is a ward of the state and the school system does not promptly and appropriately respond, state-supported legal assistance is usually available to enforce compliance with federally mandated educational assessment and management.
  • When the youngster has experienced multiple disruptions in placements and has witnessed violence, he or she may develop conduct disorder, experience difficulties in social settings, and/or be prone to antisocial behavior because he or she lacks empathy and appropriate models of coping and caring behavior.

Prognosis:
  • Without treatment and new attachments, the chance for normal emotional development, building trusting relationships, and experiencing and tolerating intimacy and closeness with other human beings is very poor.

Miscellaneous—

Medicolegal Pitfalls:
  • Reserve diagnosis of attachment disorders for cases clearly related to nonattachment (e.g., gross neglect, separation, loss of the caretaker) or dis-inhibited superficial attachments (e.g., multiple caretakers).
  1. Many babies seem to be oblivious to their caretakers; they do not exhibit fear and are very dis-inhibited. They might not have an attachment disorder but, instead, be focused on a particular stimulus and be unaware of their surroundings. This tendency to be impulsive, focused on a stimulus, and to be somewhat oblivious to danger is not necessarily a sign of an attachment disturbance but is more a sign of attentional deficit and impulsivity. The history of disruptions in relationships with caretakers guides the diagnosis.
  2. Many kids experience disruptions in their relationships with caretakers, and many kids become aggressive, hyper-vigilant, or defiant. However, these kids do not necessarily have attachment disorders. Aggressive behavior, explosions of temper, and defiance are characteristics of several disturbances in childhood; do not assume all of these are attachment disorders.
  3. In some facilities, clinicians have become very interested in attachment disturbances. As a result, they may view practically any behavioral disturbance in a youngster as caused by disruptions in attachment and, therefore, diagnose the behavior as an attachment disorder. This may create problems for the clinician because the current definition of the disorder implies pathogenic care (e.g., neglect or multiple caretakers in rapid succession).
  4. In kids who are non-relational and unresponsive to others, rule out the presence of a pervasive developmental disorder or an autistic condition. The differential diagnosis is facilitated by the history of neglect or multiple caretakers and by the development of imaginative play and communicational intent (which are absent or grossly impaired in the youngster with a developmental disorder).

Special Concerns:
  • A frequent concern of potential adoptive moms & dads or caretakers is deciding when the youngster is unable to develop a new attachment or to warm up to new caretakers after multiple past disruptions. After the first few months of life, the concern exists of whether or not forming an attachment to a new individual as well as the old one is possible. During the school years, establishing a close and intimate bond with a new caretaker or family seems possible. Of course, the new attachment is a complex phenomenon determined by multiple factors, such as the youngster's temperament, previous experiences with caretakers, the nature of the new moms & dads, and how sensitively the new caretakers deal with the problem.


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25. Boris NW, Zeanah CH. Clinical disturbances of attachment in infancy and early childhood. Curr Opin Pediatr. 1998;10(4):368-368.
26. Boris NW, Zeanah CH, Work Group on Quality Issues. Practice parameter for the assessment and treatment of kids and teenagers with reactive attachment disorder of infancy and early childhood. J Am Acad Child Adolesc Psychiatry. Nov 2005;44(11):1206-19.
27. Boris NW, Zeanah CH, Larrieu JA, et al. Attachment disorders in infancy and early childhood: a preliminary investigation of diagnostic criteria. Am J Psychiatry. Feb 1998;155(2):295-7.
28. Boris NW, Fueyo M, Zeanah CH. The clinical assessment of attachment in kids under five. J Am Acad Child Adolesc Psychiatry. Feb 1997;36(2):291-3.
29. Ainsworth MDS, Blehar MC, Waters E, et al. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillsdale, NJ: Erlbaum;1976.

Reactive Attachment Disorder: Our Story

I had heard of the terms before, but until I agreed to take my 13-year-old niece in, “Reactive Attachment Disorder” (RAD), sometimes known as “detachment disorder”, or simply “attachment disorder”, held no personal significance to me.

My husband and I took our niece in to live with us in March of 2005. While we knew, and anticipated that there would be significant problems, we had no idea as to the extent of his disability.

Our niece was diagnosed with RAD, shortly after coming to live with us and, despite the fact that this is a disorder that was barely on my screen of consciousness prior to that time, my husband and I have both come to understand it quite well. Making it go away was another matter entirely.

As a counselor for more than 18 years, I had come to appreciate signs and symptoms pointing to specific diagnoses, yet I was astounded to see how closely and how clearly our niece fit the pattern for RAD. I only wish that treating the problem were as easy as diagnosing it appeared to be.

Through books, tapes, classes, and conferences, my husband and I have devoured all of the useful information we can find on attachment disorders and, as we have learned more, we’ve added to this site. If you’ve just begun your own search for ways in which you can help your child, we understand what you are looking for, and believe that this will be a good place to start. We have included links to books that may be helpful and to other useful sites we’ve found on the Internet. We’ve also created a chat-room, and you can find a link to it in our Books and Resources section, along with other support forums on the subject.

Please be careful, however. RAD is a newly recognized disorder -- and as such, some of the available information is confusing and may appear contradictory. Treatments vary from traditional therapy to centers selling a quick fix. While I cannot evaluate the efficacy of each of these claims, my best guess is that the most useful therapy for a kid with RAD will be something in between.

We’ve chosen to remain somewhat anonymous on this site -- not because we’re trying to hide anything, and certainly not because we’re ashamed -- but because we live in a fairly small town, and we don’t want any of our niece’s friends and acquaintances happening upon this site while surfing the web and making the connection between her and her disorder. Although RAD requires that she have little or no privacy within our home, outside of the home it is another matter, and it is clear to me that the reactive attachment label wouldn’t make her already difficult relationships any easier.

After more than three years of attachment therapy and RAD parenting, I am pleased to report that our niece is doing much better, so much so that his therapist recommended that she was no longer in need of regular therapy sessions.

She has learned empathy and responsibility. She has developed reasonable cause and effect thinking, and she has learned to make good choices, none of which implies that she always chooses to make the good choice. Her emotional age has become unstuck and she is developing rapidly. While she still angers easily, she has made great progress in learning to control her anger and even to make reasonable argument in the midst of it. It has been months since she has become violent; and we hope, pray, and even dare to believe that we are beyond that.

For this, I would like to thank Julie, her therapist; Dr. James, who followed his treatment carefully, even meeting with us a couple of times; the authors of the several books from which we have gleaned the answers to many of the problems we faced; my husband, who persevered even when I was weak; and especially my niece, for not giving up on herself, as she threatened to do many times.

For reasons of his privacy, I won’t go into any details but our niece is an older teenager now, and on her own - by her option. While I’d like to be able to say that she’s doing marvelous, the reality is that she still has a ways to go.

Nevertheless, I feel confident that we’ve given her the tools that she needs to take these continuing steps, and pray that she will use them.

Parenting Defiant RAD Teens

Reactive Attachment Disorder (RAD): Overview

Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon attachment disorder that can affect kids. REACTIVE ATTACHMENT DISORDER is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited" form—or can present itself as indiscriminate sociability, such as excessive familiarity with relative strangers—known as the "dis-inhibited form". The term is used in both the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10)[1] and in the DSM-IV-IV-TR, the revised fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-IV).[2] In ICD-10, the inhibited form is called REACTIVE ATTACHMENT DISORDER, and the dis-inhibited form is called "dis-inhibited attachment disorder", or "DAD". In the DSM-IV, both forms are called REACTIVE ATTACHMENT DISORDER; for ease of reference, this article will follow that convention and refer to both forms as reactive attachment disorder.

REACTIVE ATTACHMENT DISORDER arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could 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 youngster's communicative efforts. Not all, or even a majority of such experiences, result in the disorder.[3] It is differentiated from pervasive developmental disorder or developmental delay and from possibly comorbid conditions such as mental retardation, all of which can affect attachment behavior. The criteria for a diagnosis of a reactive attachment disorder are very different from the criteria used in assessment or categorization of attachment styles such as insecure or disorganized attachment.

Kids with REACTIVE ATTACHMENT DISORDER are presumed to have grossly disturbed internal working models of relationships which may lead to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years.[4][5] However, 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 and led 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.[6]

Mainstream treatment and prevention programs that target REACTIVE ATTACHMENT DISORDER 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 youngster with a different caregiver.[7] Most such strategies are in the process of being evaluated. Mainstream practitioners and theorists have presented significant criticism of the diagnosis and treatment of alleged reactive attachment disorder or attachment disorder within the complementary and alternative medicine field commonly known as attachment therapy. Attachment therapy has an unconventional theoretical base and uses diagnostic criteria or symptom lists unrelated to criteria under ICD-10 or DSM-IV-IV-TR, or to attachment behaviors. A range of treatment approaches are used in attachment therapy, some of which are physically coercive and considered to be antithetical to attachment theory.[8]

Signs and symptoms—

Pediatricians are often the first health professionals to assess and raise suspicions of REACTIVE ATTACHMENT DISORDER in kids with the disorder. The initial presentation varies according to the developmental and chronological age of the youngster, though it always involves a disturbance in social interaction. Infants up to about 18–24 months may present with non-organic failure to thrive and display abnormal responsiveness to stimuli. Laboratory investigations will be unremarkable barring possible findings consistent with malnutrition or dehydration, while serum growth hormone levels will be normal or elevated.[9]

The core feature is that the style of social relating by affected kids involves either indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers—older kids and adolescents may also aim attempts at peers—or extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed.[10] The disorder arises from a severe lack of developmentally appropriate attachment behaviors and, thus, appropriate social relatedness.

While REACTIVE ATTACHMENT DISORDER is likely to occur in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as kids can form stable attachments and social relationships despite marked abuse and neglect.[11]

Assessment tools—

There is as yet no universally accepted diagnostic protocol for reactive attachment disorder. Often a range of measures is used in research and diagnosis. Recognized assessment methods of attachment styles, difficulties or disorders include the Strange Situation Procedure (devised by developmental psychologist Mary Ainsworth),[12][13][14] the separation and reunion procedure and the Preschool Assessment of Attachment,[15] the Observational Record of the Care-giving Environment,[16] the Attachment Q-sort[17] and a variety of narrative techniques using stem stories, puppets or pictures. For older kids, actual interviews such as the Child Attachment Interview and the Autobiographical Emotional Events Dialogue can be used. Caregivers may also be assessed using procedures such as the Working Model of the Youngster Interview.[18]

More recent research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah (1999).[19] The DAI 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/hyper-compliance" and "role reversal". This method is designed to pick up not only REACTIVE ATTACHMENT DISORDER but also the proposed new alternative categories of disorders of attachment.

Diagnosis—

REACTIVE ATTACHMENT DISORDER is one of the least researched and most poorly understood disorders in the DSM-IV. There is little systematic epidemiologic information on REACTIVE ATTACHMENT DISORDER, its course is not well established and it appears difficult to diagnose accurately.[10] 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 consequences of maltreatment.[5]

According to the American Academy of Youngster and Adolescent Psychiatry (AACAP), kids who exhibit signs of reactive attachment disorder need a comprehensive psychiatric assessment and individualized treatment plan. The signs or symptoms of REACTIVE ATTACHMENT DISORDER may also be found in other psychiatric disorders and AACAP advises against giving a youngster this label or diagnosis without a comprehensive evaluation.[20] Their practice parameter states that the assessment of reactive attachment disorder requires evidence directly obtained from serial observations of the youngster interacting with his or her primary caregivers and history (as available) of the youngster’s patterns of attachment behavior with these caregivers. In addition it requires observations of the youngster’s behavior with unfamiliar adults and a comprehensive history of the youngster’s early care-giving environment including, for example, pediatricians, teachers, or caseworkers.[4] In the US, initial evaluations may be conducted by psychologists, psychiatrists, specialist Licensed Clinical Social Workers or psychiatric nurses.[21]

In the UK, the British Association for Adoption and Fostering (BAAF), advise that only a psychiatrist can diagnose an attachment disorder and that any assessment must include a comprehensive evaluation of the youngster’s individual and family history.[22]

According to the AACAP Practice Parameter (2005) the question of whether attachment disorders can reliably be diagnosed in older kids and adults has not been resolved. Attachment behaviors used for the diagnosis of REACTIVE ATTACHMENT DISORDER change markedly with development and defining analogous behaviors in older kids is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence.[4] Assessments of REACTIVE ATTACHMENT DISORDER past school age may not be possible at all as by this time kids have developed along individual lines to such an extent that early attachment experiences are only one factor among many that determine emotion and behavior.[23]

Diagnostic criteria—

ICD-10 describes reactive attachment disorder of childhood, known as REACTIVE ATTACHMENT DISORDER, and dis-inhibited attachment disorder, less well known as DAD. DSM-IV-IV-TR also describes reactive attachment disorder of infancy or early childhood divided into two subtypes, inhibited type and dis-inhibited type, both known as REACTIVE ATTACHMENT DISORDER. The two classifications are similar, and both include:

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

ICD-10 states in relation to the inhibited form only that the syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. DSM-IV states in relation to both forms there must be a history of "pathogenic care" defined as persistent disregard of the youngster'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 youngster's history of care rather than observation of symptoms.

In DSM-IV-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, hyper-vigilant, or highly ambivalent responses (e.g. the youngster may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit "frozen watchfulness", hyper-vigilance while keeping an impassive and still demeanor).[2] 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 dis-inhibited 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).[2] 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-IV-TR as follows:

• abuse, (psychological or physical), in addition to neglect
• associated emotional disturbance
• evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness in interactions with appropriately responsive, non-deviant adults, (dis-inhibited form only)
• poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases, (inhibited form only)

The first 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 dis-inhibited form is more enduring.[24] ICD-10 states the dis-inhibited form "tends to persist despite marked changes in environmental circumstances". Dis-inhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same youngster.[25] The question of whether there are in fact two subtypes has been raised. The World Health Organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate subdivision.[1] One reviewer has commented on the difficulty of clarifying the core characteristics of and differences between atypical attachment styles and various ways of categorizing more severe disorders of attachment. [26]
Differential diagnosis—

The diagnostic complexities of REACTIVE ATTACHMENT DISORDER mean that careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential.[27][28][29] Several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, post traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with REACTIVE ATTACHMENT DISORDER, leading to over and under diagnosis. REACTIVE ATTACHMENT DISORDER can also be confused with neuropsychiatric disorders such as autism spectrum disorders, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. Infants with this disorder can be distinguished from those with organic illness by their rapid physical improvement after hospitalization.[9] Kids with an autistic disorder are likely to be of normal size and weight and often exhibit a degree of mental retardation. They are unlikely to improve upon being removed from the home.[9][27][28][29]

Alternative diagnosis—

In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the DSM-IV and ICD, were created out of clinical and parental experience within the field known as attachment therapy. These lists are un-validated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common elements of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either DSM-IV-IV-TR or ICD-10.[30] Many kids are being diagnosed with REACTIVE ATTACHMENT DISORDER because of behavioral problems that are outside the criteria.[27] There is an emphasis within attachment therapy on aggressive behavior as a symptom of what they describe as 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.[31]

The Randolph Attachment Disorder Questionnaire or REACTIVE ATTACHMENT DISORDERQ is one of the better known of these checklists and is used by attachment therapists and others.[32] The checklist includes 93 discrete behaviors, many of which either overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment difficulties. Critics assert that it is un-validated[33] and lacks specificity.[34]

History and theoretical framework—

Reactive attachment disorder first made its appearance in standard nosologies of psychological disorders in DSM-IV-III, 1980, following an accumulation of evidence on institutionalized kids. The criteria included a requirement of onset before the age of 8 months and was equated with failure to thrive. Both these features were dropped in DSM-IV-III-R, 1987. Instead, onset was changed to being within the first 5 years of life and the disorder itself was divided into two subcategories, inhibited and dis-inhibited. These changes resulted from further research on maltreated and institutionalized kids and remain in the current version, DSM-IV-IV, 1994, and its 2000 text revision, DSM-IV-IV-TR, as well as in ICD-10, 1992. Both nosologies focus on young kids who are not merely at increased risk for subsequent disorders but are already exhibiting clinical disturbance.[35]

The broad theoretical framework for current versions of 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 framework that employs psychological, ethological and evolutionary concepts to explain social behaviors typical of young kids. Attachment theory focuses on the tendency of infants or kids to seek proximity to a particular attachment figure (familiar caregiver), in situations of alarm or distress, behavior which appears to have survival value.[36] This is known as a discriminatory or selective attachment. Subsequently, the youngster begins to use the caregiver as a base of security from which to explore the environment, returning periodically to the familiar person. Attachment is not the same as love and/or affection although they are often associated. Attachment and attachment behaviors tend to develop between the ages 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.[37] Caregiver responses lead to the development of patterns of attachment, that in turn lead to internal working models which will guide the individual's feelings, thoughts, and expectations in later relationships.[38][39] For a diagnosis of reactive attachment disorder, the youngster's history and atypical social behavior must suggest the absence of formation of a discriminatory or selective attachment.

The pathological absence of a discriminatory or selective attachment needs to be differentiated from the existence of attachments with either typical or somewhat atypical behavior patterns, known as styles. There are four attachment styles ascertained and used within developmental attachment research. These are known as secure, anxious-ambivalent, anxious-avoidant, (all organized)[12] and disorganized.[13][14] The latter three are characterized as insecure. These are assessed using the Strange Situation Procedure, designed to assess the quality of attachments rather than whether an attachment exists at all.[4]

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 care-giving figure is also an object of fear, thus putting the youngster in an irresolvable situation regarding approach and avoidance. On reunion with the caregiver, these kids can look dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors implying fear 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.[40]

Although there are a wide range 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 equate to criteria for REACTIVE ATTACHMENT DISORDER as such.[41] A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders.[4] Reactive attachment disorder denotes a lack of typical attachment behaviors 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. Such discrimination does exist as a feature of the social behavior of kids with atypical attachment styles. Both DSM-IV-IV and ICD-10 depict the disorder in terms of socially aberrant behavior in general rather than focusing more specifically on attachment behaviors as such. DSM-IV-IV emphasizes a failure to initiate or respond to social interactions across a range of relationships and ICD-10 similarly focuses on ambivalent social responses that extend across social situations.[35] The relationship between patterns of attachment in the Strange Situation and REACTIVE ATTACHMENT DISORDER is not yet clear.[42]

There is a lack of consensus about the precise meaning of the term "attachment disorder".[43] The term is frequently used both as an alternative to reactive attachment disorder and in discussions about different proposed classifications for disorders of attachment beyond the limitations of the ICD and DSM-IV classifications.[35] It is also used within the field of attachment therapy, as is the term reactive attachment disorder, to describe a range of problematic behaviors not within the ICD or DSM-IV criteria or not related directly to attachment styles or difficulties at all.[44]

Developments—

Research from the late 1990s indicated there were disorders of attachment not captured by DSM-IV or ICD and showed that REACTIVE ATTACHMENT DISORDER could be diagnosed reliably without evidence of pathogenic care, thus illustrating some of the conceptual difficulties with the rigid structure of the current definition of REACTIVE ATTACHMENT DISORDER.[45] Research published in 2004 showed that the dis-inhibited form can endure alongside structured attachment behavior (of any style) towards the youngster's permanent caregivers.[25]

Some authors have proposed a broader continuum of definitions of attachment disorders ranging from REACTIVE ATTACHMENT DISORDER 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 by C.H. Zeanah and N. Boris. The first of these is disorder of attachment, in which a young youngster has no preferred adult caregiver. The proposed category of disordered attachment is parallel to REACTIVE ATTACHMENT DISORDER in its inhibited and dis-inhibited forms, as defined in DSM-IV and ICD. The second category is secure base distortion, where the youngster has a preferred familiar caregiver, but the relationship is such that the youngster cannot use the adult for safety while exploring the environment. Such kids may endanger themselves, cling to the adult, be excessively compliant, or show role reversals in which they care for or punish the adult. The third type is disrupted attachment. Disrupted attachment is not covered under ICD-10 and DSM-IV criteria, and results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed.[46] This form of categorization may demonstrate more clinical accuracy overall than the current DSM-IV-IV-TR classification, but further research is required.[6][47] The practice parameters would also provide the framework for a diagnostic protocol.

Some research indicates there may be a significant overlap between behaviors of the inhibited form of REACTIVE ATTACHMENT DISORDER or DAD and aspects of disorganized attachment where there is an identified attachment figure.[40]

An ongoing question is whether REACTIVE ATTACHMENT DISORDER should be thought of as a disorder of the youngster's personality or a distortion of the relationship between the youngster and a specific other person. It has been noted that as attachment disorders are by their very nature relational disorders, they do not fit comfortably into noslogies that characterize the disorder as centered on the person.[48] Work by C.H. Zeanah[25] indicates that atypical attachment-related behaviors may occur with one caregiver but not with another. This is similar to the situation reported for attachment styles, in which a particular parent's frightened expression has been considered as possibly responsible for disorganized/disoriented reunion behavior during the Strange Situation Procedure.[49]

Causes—

Although increasing numbers of childhood mental health problems are being attributed to genetic defects,[50] reactive attachment disorder is by definition based on a problematic history of care and social relationships. Abuse can occur alongside the required factors, but on its own does not explain attachment disorder.[51] 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.[52] In the absence of available and responsive caregivers it appears that some kids are particularly vulnerable to developing attachment disorders.[53]

There is as yet no explanation for why similar abnormal parenting may produce the two distinct forms of the disorder, inhibited and dis-inhibited. The issue of temperament and its influence on the development of attachment disorders has yet to be resolved. REACTIVE ATTACHMENT DISORDER has never been reported in the absence of serious environmental adversity yet outcomes for kids raised in the same environment vary widely.[54]

In discussing the neurobiological basis for attachment and trauma symptoms in a seven-year twin study, it has been suggested that the roots of various forms of psychopathology, including REACTIVE ATTACHMENT DISORDER 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 care-giving) seems possible. Like many other papers in this poorly-researched area many new avenues of enquiry are raised.[55]

Epidemiology—

Epidemiological data are limited, but reactive attachment disorder appears to be very uncommon.[56] The prevalence of REACTIVE ATTACHMENT DISORDER is unclear but it is probably quite rare, other than in populations of kids being reared in the most extreme, deprived settings such as some orphanages.[53] There is little systematically gathered epidemiologic information on REACTIVE ATTACHMENT DISORDER.[27] A cohort study of 211 Copenhagen kids to the age of 18 months found a prevalence of 0.9%.[57]


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 youngster's basic attachment needs, but not all kids raised in these conditions develop an attachment disorder.[58] Studies undertaken on kids from Eastern European orphanages from the mid-1990s showed significantly higher levels of both forms of REACTIVE ATTACHMENT DISORDER and of insecure patterns of attachment in the institutionalized kids, regardless of how long they had been there.[59][60][61] It would appear that kids in institutions like these are unable to form selective attachments to their caregivers. The difference between the institutionalized kids and the control group had lessened in the follow-up study three years later, although the institutionalized kids continued to show significantly higher levels of indiscriminate friendliness.[59][62] However, even among kids raised in the most deprived institutional conditions the majority did not show symptoms of this disorder.[63]

A 2002 study of kids in residential nurseries in Bucharest, in which the DAI was used, challenged the current DSM-IV and ICD conceptualizations of disordered attachment and showed that inhibited and dis-inhibited disorders could coexist in the same youngster.[60]

There are two studies on the incidence of REACTIVE ATTACHMENT DISORDER relating to high risk and maltreated kids in the U.S. Both used ICD, DSM-IV and the DAI. The first, in 2004, reported that kids from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than kids from the other groups, however this was mainly the proposed new classification of disrupted attachment disorder rather than the DSM-IV or ICD classified REACTIVE ATTACHMENT DISORDER or DAD.[64] The second study, also in 2004, attempted to ascertain the prevalence of REACTIVE ATTACHMENT DISORDER and whether it could be reliably identified in maltreated rather than neglected toddlers. Of the 94 maltreated toddlers in foster care, 35% were identified as having ICD REACTIVE ATTACHMENT DISORDER and 22% as having ICD DAD, and 38% fulfilled the DSM-IV criteria for REACTIVE ATTACHMENT DISORDER.[25] This study found that REACTIVE ATTACHMENT DISORDER could be reliably identified and also that the inhibited and dis-inhibited forms were not independent. However, there are some methodological concerns with this study. A number of the kids identified as fulfilling the criteria for REACTIVE ATTACHMENT DISORDER did in fact have a preferred attachment figure.[65]

It has been suggested by some within the field of attachment therapy that REACTIVE ATTACHMENT DISORDER may be quite prevalent because severe youngster maltreatment, which is known to increase risk for REACTIVE ATTACHMENT DISORDER, is prevalent and because kids who are severely abused may exhibit behaviors similar to REACTIVE ATTACHMENT DISORDER behaviors.[29] The APSAC Taskforce consider this inference to be flawed and questionable.[29] Severely abused kids may exhibit similar behaviors to REACTIVE ATTACHMENT DISORDER behaviors but there are several far more common and demonstrably treatable diagnoses which may better account for these difficulties.[66] Further, many kids experience severe maltreatment and do not develop clinical disorders.[66] Resilience is a common and normal human characteristic.[67] REACTIVE ATTACHMENT DISORDER does not underlie all or even most of the behavioral and emotional problems seen in foster kids, adoptive kids, or kids who are maltreated and rates of youngster abuse and/or neglect or problem behaviors are not a benchmark for estimates of REACTIVE ATTACHMENT DISORDER.[29]

There are few data on comorbid conditions, but there are some conditions that arise in the same circumstances in which REACTIVE ATTACHMENT DISORDER arises, such as institutionalization or maltreatment. These are principally developmental delays and language disorders associated with neglect.[4] Conduct disorders, oppositional defiant disorder, anxiety disorders, post-traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with REACTIVE ATTACHMENT DISORDER.[29][68] Attachment disorder behaviors amongst institutionalized kids are correlated with attention and conduct problems and cognitive levels but nonetheless appear to index a distinct set of symptoms and behaviors.[63]

Treatment—

Assessing the youngster's safety is an essential first step that determines whether future intervention can take place in the family unit or whether the youngster should be removed to a safe situation. Interventions may include psychosocial support services for the family unit (including financial or domestic aid, housing and social work support), psychotherapeutic interventions (including treating moms & dads for mental illness, family therapy, individual therapy), education (including training in basic parenting skills and youngster development), and monitoring of the youngster's safety within the family environment[9]

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 REACTIVE ATTACHMENT DISORDER.[4] Recommendations in the guidelines include the following:

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

Mainstream prevention programs and treatment approaches for attachment difficulties or disorders for infants and younger kids are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the youngster with a different caregiver.[4][69][70] These approaches are mostly in the process of being evaluated. The programs invariably include a detailed assessment of the attachment status or care-giving 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 moms & dads, as the attachment behaviors of infants or kids with attachment difficulties often do not elicit appropriate caregiver responses.[71] Approaches include "Watch, wait and wonder",[72] manipulation of sensitive responsiveness,[73][74] modified "Interaction Guidance",[75] "Preschool Parent Psychotherapy",[76] "Circle of Security",[77][78] "Attachment and Bio-behavioral Catch-up" (ABC),[79] the New Orleans Intervention,[80][81][82] and Parent-Youngster psychotherapy.[83] 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.[84]

The relevance of these approaches to intervention with fostered and adopted kids with REACTIVE ATTACHMENT DISORDER or older kids with significant histories of maltreatment is unclear.[85]

Outside the mainstream programs is a form of treatment generally known as attachment therapy, a subset of techniques (and accompanying diagnosis) for supposed attachment disorders including REACTIVE ATTACHMENT DISORDER. In general, these therapies are aimed at adopted or fostered kids with a view to creating attachment in these kids 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.[86] There is considerable criticism of this form of treatment and diagnosis as it is largely un-validated and has developed outside the scientific mainstream.[87] There is little or no evidence base and techniques 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. These forms of the therapy may well involve physical restraint, the deliberate provocation of rage and anger in the youngster by physical and verbal means including deep tissue massage, aversive tickling, enforced eye contact and verbal confrontation, and being pushed to revisit earlier trauma.[88][89] Critics maintain that these therapies are not within the attachment paradigm, are potentially abusive,[90] and are antithetical to attachment theory.[8] The APSAC Taskforce Report of 2006 notes that many of these therapies concentrate on changing the youngster rather than the caregiver.[91] Kids may be described as "REACTIVE ATTACHMENT DISORDER kids" and dire predictions may be made as to their supposedly violent futures if they are not treated with attachment therapy.[92]

Course—

The AACAP guidelines state that kids with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others.[4] However, the course of REACTIVE ATTACHMENT DISORDER is not well studied and there have been few efforts to examine symptom patterns over time. The few existing longitudinal studies (dealing with developmental change with age over a period of time) involve only kids from poorly run Eastern European institutions.[4]

Findings from the studies of kids from Eastern European orphanages indicate that persistence of the inhibited pattern of REACTIVE ATTACHMENT DISORDER is rare in kids adopted out of institutions into normative care-giving environments. However, there is a close association between duration of deprivation and severity of attachment disorder behaviors.[63] The quality of attachments that these kids form with subsequent care-givers may be compromised, but they probably no longer meet criteria for inhibited REACTIVE ATTACHMENT DISORDER.[93] The same group of studies suggests that a minority of adopted, institutionalized kids exhibit persistent indiscriminate sociability even after more normative care-giving environments are provided.[55] Indiscriminate sociability may persist for years, even among kids 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 kids with indiscriminate behavior into adolescence, these kids were significantly more likely to exhibit poor peer relationships.[95]

Studies of kids 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 kids, and some institution-reared kids were not. It is not yet clear whether these behaviors should be considered as part of disordered attachment.[96]

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.[68] The paper explores the similarities, differences and comorbidity of REACTIVE ATTACHMENT DISORDER, disorganized attachment and post traumatic stress disorder. The girl showed signs of the inhibited form of REACTIVE ATTACHMENT DISORDER while the boy showed signs of the indiscriminate form. It was noted that the diagnosis of REACTIVE ATTACHMENT DISORDER 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 kids 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 REACTIVE ATTACHMENT DISORDER criteria but possibly within "secure base distortion", (where the youngster has a preferred familiar caregiver, but the relationship is such that the youngster cannot use the adult for safety while exploring the environment). At age eight the kids were assessed with a variety of measures including those designed to access representational systems, or the youngster's "internal working models". The twins' symptoms were indicative of different trajectories. The girl showed externalizing symptoms (particularly deceit), 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, separation anxiety and impulsivity and attention difficulties. It was apparent that life stressors had impacted each youngster differently. The narrative measures used were considered helpful in tracking how early attachment disruption is associated with later expectations about relationships.[55]

One paper using questionnaires found that kids aged three to six, diagnosed with REACTIVE ATTACHMENT DISORDER, scored lower on empathy but higher on self-monitoring (regulating your behavior to "look good"). These differences were especially pronounced based on ratings by moms & dads, and suggested that kids with REACTIVE ATTACHMENT DISORDER may systematically report their personality traits in overly positive ways. Their scores also indicated considerably more behavioral problems than scores of the control kids.[97] 

* References provided by request.

Parenting Defiant RAD Teens