Reactive attachment disorder

Reactive attachment disorder (also known as "RAD") is the broad term used to describe the severe and relatively uncommon disorders of attachment which are classified in World Health Organization (ICD-10) codes 94.1 and 94.2, and the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) 313.89. RAD is characterized by markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before the age of five years. This can take the form of either a persistent failure to initiate or respond in a developmentally appropriate way to most social interactions, or indiscriminate sociability such as excessive familiarity with relative strangers. It should not be confused with less than ideal attachment 'styles' or attachment difficulties which do not amount to the clinical disorder defined as RAD. RAD should also be differentiated from pervasive developmental disorder or mental retardation, both of which conditions can affect attachment behavior.

RAD arises from a failure to form normal attachments to primary care giving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about age six months but before about age three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts.

RAD was first defined in DSM in 1980 although it has been studied only recently.^[1] Important modifications have been made, but the core remains the same. The definitions in ICD-10 and DSM-IV-TR are similar but not identical and are under constant review in this somewhat controversial area. There has been considerable recent research both on maltreated toddlers and on those from very deprived conditions in East European orphanages following the end of the Cold War. Such research has broadened the understanding of disorders of attachment, and findings have opened up new areas for research. Leading theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined.^[2]

Mainstream treatment and prevention programmes target both reactive attachment disorder and other problematic early attachment behaviors. However, there is significant controversy over the diagnosis and treatment of RAD within the field of attachment therapy.

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Theoretical framework

Main articles: Attachment theory and Attachment in children

RAD arises from a failure to form normal attachments to primary care giving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about age six months but before about age three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts.

The theoretical framework for reactive attachment disorder is attachment theory, based on work from the 1940s to the 1980s by Bowlby, Ainsworth and Spitz. Attachment theory is an evolutionary theory in which the infant or child seeks proximity to a specified attachment figure in situations of alarm or distress, for the purpose of survival.^[3] 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.^[4] Caregiver responses lead to the development of patterns of attachment which in turn lead to internal working models which will guide the individuals feelings thoughts and expectations in later relationships.^[5][6] Reactive attachment disorder requires one or both of the attachment behaviors of proximity seeking to a specified attachment figure to be missing. (See ICD-10 and DSM-IV-TR criteria below).

Normal attachment develops during the child's first two to three years of life. Problems with the caregiver-child relationship during that time, orphanage experience, or breaks in the consistent caregiver-child relationship, (such as foster or adoptive placements) after the age of six months interferes with the normal development of a healthy and secure attachment.

A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders.^[7] There is a lack of consensus about the precise meaning of the term 'attachment disorder' although there is general agreement that such disorders only arise following early adverse caregiving experiences. There are also a number of attachment 'styles' namely secure, anxious-ambivalent, anxious-avoidant, (all organized))^[8] and disorganized.^[9] The latter three are characterised as insecure. Some of these styles are more problematical than others, particularly disorganized attachment. There is a growing body of research on the links between aberrant parenting, disorganized attachment and risks for later psychopathologies.^[10] However, none of the 'styles' constitute a disorder in themselves. There are wide ranges of attachment difficulties that result in varying degrees of emotional disturbance in the child but none are within the criteria for RAD.^[11] (See ICD-10 and DSM-IV-TR criteria below).

Classification and characteristics

Main articles: 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.^[12] The disorder arises from the severe lack of developmentally appropriate attachment behaviors and thus appropriate social relatedness.

RAD is classified in both ICD-10 and DSM-IV-TR. 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.
• Requires a history of significant neglect.
• Implicit lack of identifiable, preferred attachment figure.

There must be a history of 'pathogenic care' defined as 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 way to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent, or 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.

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. This somewhat controversial, being a commission rather than omission and because abuse of itself does not lead to attachment disorder.
• associated emotional disturbance.
• poor social interaction with peers.

Disinhibited and inhibited are not opposites in terms of attachment disorder and can co-exist in the same child. The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, whilst the disinhibited form is more enduring.^[13]

Recent research has shown that the disinhibited form can endure alongside structured attachment behavior (of any category) towards the child's permanent caregivers.^[14] 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 has been proposed.^[15][16] In particular, Zeanah and Boris, building on the earlier work of Leiberman, propose three categories of attachment disorder. 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.^[2]

Diagnosis

Main article: Attachment measures

According to the APSAC Taskforce Report (2006), RAD is one of the least researched and most poorly understood disorders in the DSM. They make the point that there is little systematically gathered epidemiologic information on RAD, its course is not well established and it appears difficult to diagnose RAD accurately. 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. The Taskforce specifically state "Because of these diagnostic complexities, careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is a must."^[17]

In the absence of a standardised diagnosis system, many popular, informal classification systems or checklists, outside the DSM and ICD, were created out of clinical and parental experience. These 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.^[18] Many children are being diagnosed with RAD because of behavioral problems that are outside the criteria for RAD.^[19] There is an emphasis within attachment therapy on aggressive behavior as a symptom of attachment disorder whereas mainstream theorists view these behaviors as co-morbid, externalizing behaviors requiring appropriate assessment and treatment rather than attachment disorders although knowledge of attachment relationships can contribute to the etiology, maintenance and treatment of externalizing disorders.^[20]

The Randolph Attachment Disorder Questionnaire or RADQ is one of the better known of these checklists and is used by attachment therapists and others.^[21] 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.^[22] 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.^[23]

Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation Procedure (SSP) (Mary Ainsworth),^[24][25][26] the separation and reunion procedure and the Preschool Assessment of Attachment (PAA),^[27] the Observational Record of the Caregiving Environment (ORCE)^[28], the Attachment Q-sort (AQ-sort)^[29] 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. However, there is as yet no universally accepted diagnostic protocol for attachment disorder although the practice parameters for the new classification system proposed by Boris and Zeanah would provide the framework for such a protocol.^[30]

More recent research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah, (1999).^[31] 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 Zeanah et al's suggested new alternative categories of disorders of attachment.

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 analagous behaviors in older children is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence.^[32]

Epidemiology

RAD is considered to be "very uncommon" under the DSM-IV-TR criteria although there is an estimate of prevalence amongst children freed for adoption within the USA foster care system of 10%.^[33] There has been considerable recent research into prevalence amongst children cared for in orphanages, particularly in Romania, where conditions of extreme deprivation were not uncommon. As a cluster of distinctive symptoms defined under DSM and ICD it is rare and occurs in high risk populations.^[34]

There are no precise statistics on prevalence. According to the American Professional Society on the Abuse of Children (APSAC) Taskforce Report (2006), some have suggested that RAD may be quite prevalent because severe child maltreatment, which is known to increase risk for RAD, is prevalent. The Taskforce did not agree with this view, as 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. Many children experience severe maltreatment but do not develop clinical disorders. The Taskforce states that it should not be assumed that RAD underlies 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 should not serve as a benchmark for estimates of RAD. The Taskforce further point out that according to the DSM, RAD is presumed to be a “very uncommon” disorder.^[35]

Whilst RAD is likely to occur in relation to neglectful and abusive childcare, there should be no automatic diagnosis on this basis alone as children can form stable attachments and social relationships despite marked abuse and neglect. Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. It is associated with developed, albeit disorganized attachment. Attachment disorganization is a risk factor for a range of psychological disorders although it is not in itself considered an attachment disorder under the current classification.^[36][37] However, some authors consider 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.^[38] This is the form that tends to resolve once children have appropriate family based care although the indiscriminate form is more enduring.^[39] The question of whether there are in fact two subtypes has been raised.

Although 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), not all children raised in these conditions develop an attachment disorder.^[40] There is as yet no explanation for why similar aberrant 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 are very variable.^[41]

According to Prior and Glaser (2006), in the absence of available and responsive caregivers it appears that some children are particularly vulnerable to developing attachment disorders. "The prevalence is unclear but is probably quite rare, other than in populations of children being reared in the most extreme, deprived settings such as some orphanages."^[42] 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 sequalae of maltreatment.^[43]

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, changing the caregiver.^[44][45][46] These approaches are mostly in the process of being evaluated. The programs invariably include a detailed assessment of the attachment status of the adult caregiver as attachment is a two-way process involving attachment behavior and caregiver response. Some of these treatment or prevention programmes 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.^[47] Approaches include 'Watch, wait and wonder,'^[48] manipulation of sensitive responsiveness,^[49][50] modified 'Interaction Guidance,'.^[51] 'Preschool Parent Psychotherapy,'.^[52] 'Circle of Security',^[53][54] Attachment and Biobehavioral Catch-up (ABC),^[55] the New Orleans Intervention,^[56][57][58] and Parent-Child psychotherapy.^[59] Other known treatment methods include Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders.^[60]

The relevance of these approaches to intervention with fostered and adopted children with RAD or older children with significant histories of maltreatment is unclear.^[61]

AACAP has laid down guidelines (devised by Boris and Zeanah) based on its published parameters for the diagnosis and treatment of RAD.^[62] 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 [MS].
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 [CG].
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 [MS].
4. Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive treatments [CG].^[63]

There is considerable controversy over the diagnosis and treatment of attachment disorders including reactive attachment disorder, by attachment therapy, a form of diagnosis and treatment that is largely unvalidated and has developed outside the scientific mainstream.^[64] These therapies have little or no evidence base and vary from non-coercive therapeutic work to more extreme forms of physical 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 emphasise obedience and parental control.^[65] Critics maintain that these therapies are not within the attachment paradigm and are potentially abusive.^[66] The APSAC Taskforce Report of 2006 notes that many of these therapies concentrate on changing the child rather than the caregiver.^[67]

Prognosis/impact

The AACAP guidelines state that children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others.^[68] 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.^[69]

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.^[70] The paper explores the similarities, differences and co-morbidity of RAD, disorganized attachment and post traumatic stress disorder. The female infant showed signs of the inhibited form of RAD while the male infant showed signs of the indiscriminate form. It was noted that the diagnosis of RAD ameliorated with better care but symptoms of PSTD and signs of disorganized attachment came and went as the infants progressed through multiple placement changes. This paper also highlighted gender differences noted in earlier research, with the female infant being more prone to dissociative behaviors and the male infant more prone to aggressive behaviors with both food-stuffing and hoarding. These are within PSTD symptomology rather than RAD even though triggered by relationship disturbances, although dissociation is associated with disorganized attachment.

In discussing the neurobiological basis for attachment and trauma symptoms it is posited that the roots of various forms of psychopathology (including RAD and 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” in the presence of “corrective” experiences (normative caregiving) seems possible, though has not been documented at the neuronal level. Like many other papers in this poorly researched area many new avenues of enquiry were raised.

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. At aged three the female childs symptoms of disorganized attachment had developed into controlling behaviors - a well documented sequalae. The male child still exhibited self-endangering behaviors, not within RAD criteria but possibly within 'secure base distortion'. At aged 8 the children were assessed with a variety of measures including those designed to access representational systems, or the childs 'internal working models'. The twins symptoms where indicative of different trajectories. The female child showed externalizing symptoms (particularly deceit), contradictory reports of current functioning, chaotic personal narratives, struggles with friendships, and emotional disengagement with the caregiver she portrayed in her narratives as most nurturing, resulting in a clinical picture described as "quite concerning". The male child who had presented as socially indiscriminate as an infant still evidenced self-endangering behaviors and he showed avoidance in relationships, a tendancy to avoid emotional expression, seperation anxiety and had impulsivity and attention difficulties. The picture was complicated by family discord but it was apparent that life stressors had impacted on each child differently. The narrative measures used where considered helpful in tracking how early attachment disruption is associated with later expectations about relationships.^[71]

Findings from the studies of children from East European orphanages indicate that persistance of the inhibited pattern of RAD is rare in children adopted out of institutions into normative care-giving environments.^[72] 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^[73] 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.^[74] 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 ^[75] 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^[76]

Apart from the studies on institutionalized children, 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.^[77]

Recent research on deprived populations

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.^[78][79] 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.^[80]

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 co-exist 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.^[81]

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 organised 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.^[82]

There are two important studies relating to high risk and maltreated children in the USA. 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 programme. The children were assessed using DSM and ICD and Zeanah and Boris' alternative proposed criteria. 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 DSM or ICD classified disorder. Under DSM and ICD classifications there was little difference between the foster care and homeless shelter groups.^[83]

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. 35% were identified as having ICD RAD and 22% as having ICD DAD. 38% fulfilled the DSM criteria for RAD.^[84] 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.^[85] 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.

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.^[86]

See also

Notes

References

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