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Reactive attachment disorder
Specialty	Psychology

Reactive Attachment Disorder (sometimes called "RAD") (DSM-IV 313.89) is a psychophysiologic condition 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% to 80% 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. In actuality RAD has varying degrees unique to each child, therefore it is often misdiagnosised or left untreated but still most professionals agree it is uncommon.

Attachment disorder is based on the psychological theories that 1) normal mother-child attachment forms in the first two years of life and 2) if a normal attachment is not formed during the first two to three years, attachment can be induced later. This theory is used, for example, to explain the behavioral difficulties of adopted children. Attachment Theory was developed by John Bowlby in the 1940's and 1950's and is the leading theory used in the fields of Infant Mental Health, Child Development, and related fields. (For example, see the following: Handbook of Infant Mental Health, edited by Charles Zeanah, MD,Guilford Press, 1993, NY, or Handbook of Attachment: Theory, Research, and Clinical Applications, edited by Jude Cassidy, Ph.D., & Phillip Shaver, Ph.D, Guilford Press, NY 1999.) It is a well researched theory that describes how how the attachment relationship develops, why it is crucual to later healthy development, and what are the effects of early maltreatment or other disruptions in this process.

Attachment Therapy is a broad term that covers a multitude of interventions. It is a term that has lost utility since it is used to cover so many interventions. Reputable approaches to treatment based on theory and research evidence include Theraplay, Dyadic Developmental Psychotherapy (See: Creating Capacity for Attachment edited by Arthur Becker-Weidman, PH.D, and Deborah Shell, MA, Wood 'N' Barnes, OK 2005 or "“Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 12 #6, December 2005. However, the use of coercive interventions has no basis in theory and is not supported by any reputable professional organization, including the APSAC, APA, NASW, or AMA.

Classification

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, and the disinhibited more externalising behaviours.

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. The checklist includes 93 discrete behaviours, many of which overlap with other disorders, like Conduct Disorder and Oppositional Defiant Disorder.

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, the human potential movement (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.

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, was effective. (see “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 12 #6, December 2005. This is a study published in a professional peer-reviewed journal).

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. 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, as a means of understanding physical abnormalities in brain functionality and offering treatment solutions to these severely hurting children.

References

: Alston, John. (2000) Characteristics of Attention Deficit Disorder, Bipolar I Disorder and Reactive Attachment Disorder.
: Alston, John. (2000) op cit.
: 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%).
: 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)
: 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)
: Ames, Elinor op cit.
: Randolph, Elizabeth Marie. (1996) Randolph Attachment Disorder Questionnaire:Institute for Attachment, Evergreen CO.
: See especially Speltz (2002) Description, History, and Critique of Corrective Attachment Therapy. The APSAC Advisor 14(3), 4-8
: 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
: “Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy,” Child and Adolescent Social Work Journal. Vol. 12 #6, December 2005. Creating Capacity For Attachment, (Eds) Arthur Becker-Weidman, Ph.D., & Deborah Shell, MA, Wood 'N' Barnes, OK: 2005. : 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.

• Childhood psychiatric disorders