Revision as of 18:47, 23 April 2006

It has been suggested that this article be merged with Attachment disorder. (Discuss)

Reactive attachment disorder
Specialty	Psychology

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Reactive Attachment Disorder (sometimes called "RAD") (DSM-IV 313.89) is a psychophysiologic condition (1) with markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age five years and is associated with grossly pathological care. This pathological caregiving behaviour may consist of any form of neglect, abuse, mistreatment or abandonment.

In Mental Retardation, attachments to caregivers are consistent with the level of development. In Pervasive Developmental Disorders, attachments to caregivers either fail to develop or are highly deviant, but this usually occurs in a context of reasonably supportive care.

Due to maltreatment by caregivers, RAD sufferers have difficulty forming healthy relationships with their caregivers, peers and families.

RAD can reportedly be diagnosed as early as the first month of life, but critics have charged such diagnoses are often inaccurate.

Some estimate that 10% (2) to 80% (3) of children and adolescents in adoptive families, and an unknown number of children who remain in their family of origin, suffer from RAD. (note some critics have questioned the accuracy of these percentages). There generally tend to be the same causes regardless of family setting.

A crucial defining characteristic of Reactive Attachment Disorder--explicit in DSM and ICD--is that there be pathogenic caregiving. This can be very difficult to prove, but it makes lasting effects on the children concerned.

Critics charge that actual RAD is rather rare, and that diagnoses are often incorrect, too broadly applied and are made by unqualified persons. Some critics have further charged that RAD is a fad diagnosis for any number of unrelated behaviors that parents disapprove of in their children.

Classification

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The DSM-IV specifically includes two forms of clinical presentation:

• "Inhibited" (Criterion A1), and
• "disinhibited" (Criterion A2)

These are roughly equivalent to the ICD-10, in which 94.1 represents the "inhibited" form of the disorder, and 94.2 represents the "disinhibited" form.

When either classification system is used, the inhibited form tends to have more withdrawal behaviours towards a caregiver, (4) and the disinhibited more externalising behaviours. (5)

Many popular, informal classification systems, outside the DSM and ICD, have been created out of clinical and parental experience. Some critics have charged these informal classification systems are inaccurate, too broadly defined or applied by unqualified persons.

One popular classification system is the Randolph Attachment Disorder Questionnaire. (6) The checklist includes 93 discrete behaviours, many of which overlap with other disorders, like Conduct Disorder and Oppositional Defiant Disorder.

Children who are adopted after the age of six months are at risk for attachment problems. Normal attachment develops during the child's first two to three years of life. Problems with the mother-child relationship during that time, orphanage experience, or breaks in the consistent caregiver-child relationship interfere with the normal development of a healthy and secure attachment. There are wide ranges of attachment difficulties that result in varying degrees of emotional disturbance in the child. One thing is certain; if an infant's needs are not met consistently, in a loving, nurturing way, attachment will not occur normally and this underlying problem will manifest itself in a variety of symptoms Bowlby.

When the first-year-of-life attachment-cycle is undermined, Basic Trust vs. Mistrust, in E. Erickson's framework and the child’s needs are not met, and normal socializing shame is not resolved, mistrust begins to define the perspective of the child and attachment problems result. The cycle can become undermined or broken for many reasons:

1. Multiple disruptions in care giving

2. Post-partum depression causing an emotionally unavailable mother

3. Hospitalization of the child causing separation from the parent and/or unrelieved pain. For example, stays in a NICU or repeated hospitalizations during infancy.

4. Parents who are attachment disordered, leading to neglect, abuse (physical/sexual/verbal), or inappropriate parental responses not leading to a secure/predictable relationship.

5. Genetic factors.

6. Caregivers whose own needs are not met, leading to overload and lack of awareness of the infant's needs

The child may develop mistrust, impeding effective attachment behavior. The developmental stages following these first three years continue to be distorted and/or retarded, and common symptoms emerge. Although I am listing several common symptoms it is very important to realize that when you are trying to parent a child with attachment difficulties you must focus on the cause of the behaviors and not on the symptoms or surface behaviors. It is the cause or motivation for the behaviors that must be your focus…otherwise you are like a doctor who treats a cough without figuring out whether the cough is caused by TB, an allergy, the flu, or lung cancer.

What are the underlying causes of the various symptoms? The cause is some break in the early attachment relationship that results in difficulties trusting others. The child experiences a fear of close authentic emotional relationships because early maltreatment or other difficulties has “taught” the child that adults are not trust worthy and that the child is unloved and unlovable. Fundamentally, the cause is a developmental delay. The child may be chronologically six, ten, or fifteen, but developmentally these children are much younger. It is often useful to consider, “at what age would this behavior be normal?” Frequently you will find that the child’s behavior would be normal for a toddler.

Chronic Maltreatment (abuse or neglect) or other disruptions to the normal attachment relationship cause:

1. Fear of intimacy

2. Overwhelming feelings of shame. (Not guilt…shame causes you to want to hide and not be seen. So, for example, some children’s chronic lying can be seen as a manifestation of this pervasive sense of shame. After all, what is a lie, but another way to hide?).

3. Chronic feelings of being unloved

4. Chronic feelings of being unlovable

5. A distorted view of self, other, and relationships based on past maltreatment.

6. Lack of trust

7. Feeling that nothing the child does can make a difference; hence, low motivation and poor academic performance.

8. A core sense of being Bad.

9. Difficulty asking for help

10. Difficulty relying on others in a cooperative and collaborative manner.

Framework

The theoretical framework for Reactive Attachment Disorder is based on work by Bowlby, Ainsworth and Spitz, from the 1940s to the 1980s. Some critics charge later therapists have misused or misrepresented Ainsworth's or Bowlby's work.

In contrast, the popular framework tends to be more eclectic, using many sources from birth/prenatal psychology (7), the human potential movement (8) (where issues of coercion and consent in treatment are especially relevant) to transactional analysis and ethology.

The development of diagnostic criteria was further operationalised by Zeanah and O’Connor throughout the 1980s and 1990s, and through greater awareness garnered from the adoption of institutionalised children from Romania, Russia and China, and also foster care in America and other nations.

Psychiatrist Michael Rutter has done an outcome study, the largest of its kind, called the Romanian Adoption Project. Victor Groza has done another outcome study, and as of 2004 there are many in process. (10)

Diagnosis

In mainstream medical practice, Reactive Attachment Disorder is most often diagnosed by social workers or psychologists. Psychiatrists may be called in when there is medication involved.

It is important to note that there are various "attachment styles" that are not pathological, and attachment issues that may run anywhere across the continuum. "Reactive Attachment Disorder" has been traditionally used to describe a "severe disturbance in the attachment between caregiver and child that is of long standing and applicable/observable in all contexts in which the child interacts."

Some of the "attachment styles" are named: "avoidant," "aggressive," "ambivalent" and "disorganised/mixed". There is often a blending of several "attachment styles" in an individual.

Reactive Attachment Disorder affects the "basic working model." Many parents report that they do not understand what their child is thinking or feeling at any given time. Some diagnosticians of RAD argue these sensations are due to the child giving inconsistent, "low-level" or mixed signals.

Intervention

Many caregivers and therapists, say, however, that "traditional therapies" do not always work on those who have Reactive Attachment Disorder.

Evidence based approaches do exist for the effective treatment of RAD. One important study found that "usual treatments" for RAD are ineffective, while the intervention under investigation, Dyadic Developmental Psychotherpay (10) (11), was effective. (see "Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy," Child and Adolescent Social Work Journal. 12(6), December 2005).

Dyadic Developmental Psychotherapy

Dyadic Developmental Psychotherapy is an effective and evidence-based treatment developed by Daniel Hughes, Ph.D., (Hughes, 2005, Hughes, 2004, Hughes, 2003; Hughes, 1997)(13-15). Its basic principals are described by Hughes (2003) and summarized as follows:

1. A focus on both the caregivers and therapists own attachment strategies. Previous research (Dozier, 2001,(16) Tyrell 1999 (17)) has shown the importance of the caregivers and therapists state of mind for the success of interventions.

2. Therapist and caregiver are attuned to the child’s subjective experience and reflect this back to the child. In the process of maintaining an intersubjective attuned connection with the child, the therapist and caregiver help the child regulate affect and construct a coherent autobiographical narrative. 3. Sharing of subjective experiences. 4. Use of PACE and PLACE are essential to healing. 5. Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships. 6. Caregivers use attachment-facilitating interventions. 7. Use of a variety of interventions, including cognitive-behavioral strategies.

PACE refers to the therapist setting a healing pace by being playful, accepting, curious, and empathic. PLACE refers to the parent creating a healing environment by being playful, loving accepting, curious, and empathic. These ideas are described more fully below.

Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines (Becker-Weidman & Shell, 2005). Attachment theory (Bowlby, 1980, Bowlby, 1988) provides the theoretical foundation for Dyadic Developmental Psychotherapy.

This treatment has been found to produce meaurable and sustained improvement in children diagnosed with Reactive Attachment Disorder (Becker-Weidman, 2005)(12). In that study it was found that other forms of treatment, such as individual therapy or play therapy did not produce any improvement; thus indicating that Dyadic Developmental Psychotheray is effective while other forms of treatment are not effective for this disorder.

Controversy

Critcs charge that some treatments for RAD are abusive and improper. As is true for nearly all therapies, there are practitioners who are not properly trained or who use unproven interventions. Medical malpractice is a significant problem. Any coercive intervention should be considered unacceptable.

While it is true that certain radical and unsupervised therapies have resulted in horrific tragedy, what is considered standard treatment for disorders of attachment, such as Theraplay or Dyadic Developmental Psychotherapy today is quite different. (12) These treatments focus on addressing the underlying trauma and resulting distortions in internal working models that cause the disorder of attachment. The focus is on developing an emotionally sensitive and responseive relationship with the child within which the attachment relationship can be remediated. Current research in brain physiology has led to the introduction of new techniques and tools, such as neurofeedback and Dyadic Developmental Psychotherapy, as a means of understanding physical abnormalities in brain functionality and offering treatment solutions to these severely hurting children.

References

1. Alston, John. (2000) Characteristics of Attention Deficit Disorder, Bipolar I Disorder and Reactive Attachment Disorder.
2. Alston, John. (2000) op cit.
3. Support for the lower estimate given here: Boris N. W, Zeanah C. et al (1998) Attachment Disorders in Infancy and Early Childhood: A Preliminary Investigation of Diagnostic Criteria. American Journal of Psychiatry February 1998. (The actual figure for their preliminary report was 42%).
4. Support for the higher estimate given here: Cicchetti D, Cummings EM, Greenberg MT, & Marvin RS: An organizational perspective on attachment beyond infancy. In: Attachment in the Preschool Years. Ed. Greenberg MT, Cicchetti D, & Cummings EM, Chicago: University of Chicago Press, 1990. (Cited: Becker-Weidman , Dyadic Developmental Psychotherapy: An Effective Treatment for Children with Trauma-Attachment Disorders)
5. Ames, Elinor Recommendations from the Final Report: The Development of Romanian Orphanage Children Adopted to Canada (1997) cited in Hanlon L, Tepper T and Sanstrom S (Eds) International Adoption-Challenges and Opportunities (1999)
6. Ames, Elinor op cit.
7. Randolph, Elizabeth Marie. (1996) Randolph Attachment Disorder Questionnaire:Institute for Attachment, Evergreen CO.
8. See especially Speltz (2002) Description, History, and Critique of Corrective Attachment Therapy. The APSAC Advisor 14(3), 4-8
9. The given reference is not to demean the good work of subcommittees from the DSM-III onwards; nor their counterparts in ICD or the many others who have done clinical and research work. O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244:Taylor and Francis
10. "Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy" Child and Adolescent Social Work Journal. 12(6), December 2005.
11. Creating Capacity For Attachment, (Eds.) Arthur Becker-Weidman, Ph.D., & Deborah Shell, MA, Wood 'N' Barnes, OK: 2005.
12. As of 2004, these US states have forbidden coercive treatments. These states permit the use of non-coercive therapies for the treatment of Disorders of Attachment, such as Theraplay or Dyadic Developmental Psychotherapy: Massachusetts, New York (State), New Jersey, Pennsylvania, Texas and Utah, as indicated by action by the respective mental health authorities, including resolutions.
13. Hughes, D. (1997). Facilitating developmental attachment. NJ: Jason Aronson.
14. Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 3, 263–278.
15. Hughes, D. (2003). Psychological intervention for the spectrum of attachment disorders and intrafamilial trauma. Attachment & Human Development, 5, 271–279.Hughes, D., “The Development of Dyadic Developmental Psychotherapy.” In Becker-Weidman, A., & Shell, D., (Eds.), Creating Capacity for Attachment. OK: Wood ‘N’ Barnes, 2005, pp vii – xvii.
16. Dozier, M. Stovall, K.C., Albus, K.E., & Bates, B. (2001) Attachment for Infants in Foster Care: The Role of Caregiver State of Mind. Child Development, 70, 1467-1477.
17. Tyrell, C., Dozier, M., Teague, G.B. & Fallot, R. (1999). Effective treatment relationships or persons with serious psychiatric disorders: the importance of attachment states of mind.

Journal of Consulting and Clinical Psychology, 67, 725-733.

External links

• "Qualifications to be a registered clinician and position statement prohibiting the use of coercive interventions"
• "Center For Family Development. Information for therapists and parents on effective treatment methods and research"
• "RadKid.Org Support & Information"

Fringe Groups

A variety of zealots and fringe groups have taken to attacking "Attachment Therapy." These groups are not part of the mainstream fields of infant mental health or the accepted attachment research community such as Dr. Mary Main, Dr. Erik Hesse, Dr. Robert Marvin, and others.

• American Professional Society on Child Abuse warnings about Attachment Therapy

• "Be Wary of Attachment Therapy" by Shannon-Bridget Maloney, on QUACKWATCH

• Advocates for Children in Therapy

• "Coercive Restraint Therapies: A Dangerous Alternative Mental Health Intervention" by Jean Mercer aka Gene Lester, PhD, Mr. Lester/Mercer is a Board member of various fringe groups which are not part of the mainstream psychology or mental health community. Mr. Lester/Mercer is a fringe advocate whose attacks on treatment are not condoned by any mainstream group.

• Library of documents critical of Attachment Therapy; includes video clips

• Childhood psychiatric disorders