Reactive attachment disorder (RAD) is an attachment disorder characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. RAD primarily affects children, although these issues do occasionally persist into adulthood.DSM-IV-TR (2000) American Psychiatric Association p. 129. 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". In the DSM-5, the "disinhibited form" is considered a separate diagnosis named "disinhibited social engagement disorder".
RAD 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 changes of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts. It is differentiated from pervasive developmental disorder or developmental delay and from possibly comorbid conditions such as intellectual disability, all of which can affect attachment behavior. The criteria for a diagnosis of reactive attachment disorder are very different from the criteria used in assessment or categorization of attachment styles, such as insecure or disorganized attachment.
Children with RAD are presumed to have grossly disturbed internal working models of relationships that 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.Prior & Glaser (2006), p. 228. 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, mechanisms 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.
Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver.Prior & Glaser (2006), p. 231. Most such strategies are in the process of being evaluated. Mainstream practitioners and theoristswho? have presented significant criticism of the diagnosis and treatment of alleged reactive attachment disorder or the theoretically baseless "attachment disorder" within the controversial form of psychotherapy commonly known as attachment therapy. Attachment therapy has a scientifically unsupported theoretical base and uses diagnostic criteria or symptom lists markedly different from criteria under ICD-10 or DSM-IV-TR, or to attachment behaviors. A range of treatment approaches are used in attachment therapy, some of which are physically and psychologically coercive, and considered to be antithetical to attachment theory.O'Connor TG, Nilsen WJ (2005). "Models versus Metaphors in Translating Attachment Theory to the Clinic and Community". In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (eds.). Enhancing Early Attachments: Theory, Research, Intervention, and Policy. pp. 313–26. The Guilford Press. Duke series in Child Development and Public Policy. .
Signs and symptoms
Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the disorder. The initial presentation varies according to the child's developmental and chronological age, although 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.
The core feature is severely inappropriate social relating by affected children. This can manifest itself in two ways:
Indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers (older children and adolescents may also make attempts at peers). This may often appear as a denial of comfort from anyone as well. Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed.Chaffin et al. (2006), p. 80. The APSAC Taskforce Report
While RAD occurs in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can, although this is rare, form stable attachments and social relationships despite elevated abuse and neglect.
The name of the disorder emphasizes problems with attachment but the criteria include symptoms such as failure to thrive, a lack of developmentally appropriate social responsiveness, apathy, and onset before 8 months.
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), the separation and reunion procedure and the Preschool Assessment of Attachment, the Observational Record of the Caregiving Environment, the Attachment Q-sortWaters E, Deane K (1985). "Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behavior in infancy and early childhood". In Bretherton I and Waters E (Eds.) Growing pains of attachment theory and research: Monographs of the Society for Research in Child Development 50, Serial No. 209 (1–2), pp. 41–65. and a variety of narrative techniques using stem stories, puppets or pictures. For older children, 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 Child Interview.
More recent research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah (1999).Smyke A, Zeanah CH (1999). "Disturbances of Attachment Interview". Available on the Journal of the American Academy of Child and Adolescent Psychiatry website at www.jaacap.com via Article plus. Retrieved on 3 March 2008. 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/hypercompliance" and "role reversal". This method is designed to pick up not only RAD but also the proposed new alternative categories of disorders of attachment.
Causes Although increasing numbers of childhood mental health problems are being attributed to genetic defects,Mercer (2006), pp. 104–05. 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.Prior & Glaser (2006), p. 218. 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. In the absence of available and responsive caregivers it appears that most children are particularly vulnerable to developing attachment disorders.Prior & Glaser (2006), p. 219.
While similar abnormal parenting may produce the two distinct forms of the disorder, inhibited and disinhibited, studies show that abuse and neglect were far more prominent and severe in the cases of RAD, disinhibited type. 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 the same.
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 RAD, borderline personality disorder (BPD), and post-traumatic stress disorder (PTSD), can be found in disturbances in affect regulation. The subsequent development of higher-order self-regulation is jeopardized and the formation of internal models is affected. Consequently, the "templates" in the mind that drive organized behavior in relationships may be impacted. The potential for "re-regulation" (modulation of emotional responses to within the normal range) in the presence of "corrective" experiences (normative caregiving) seems possible.
Diagnosis
RAD is one of the least researched and most poorly understood disorders in the DSM. There is little systematic epidemiologic information on RAD, its course is not well established and it appears difficult to diagnose accurately. 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.
According to the American Academy of Child and Adolescent Psychiatry (AACAP), children who exhibit signs of reactive attachment disorder need a comprehensive psychiatric assessment and individualized treatment plan. The signs or symptoms of RAD may also be found in other psychiatric disorders and AACAP advises against giving a child this label or diagnosis without a comprehensive evaluation.Reactive Attachment Disorder. American Academy of Child & Adolescent Psychiatry, Facts for Families, No. 85; Updated December 2002. Retrieved on 13 February 2008. Their practice parameter states that the assessment of reactive attachment disorder requires evidence directly obtained from serial observations of the child interacting with their primary caregivers and history (as available) of the child's patterns of attachment behavior with these caregivers. It also requires observations of the child's behavior with unfamiliar adults and a comprehensive history of the child's early caregiving environment including, for example, pediatricians, teachers, or caseworkers. In the US, initial evaluations may be conducted by psychologists, psychiatrists, Licensed Marriage and Family Therapists, Licensed Professional Counselors, specialist Licensed Clinical Social Workers or psychiatric nurses.For examples see Reactive Attachment Disorder , DCFS, State of Illinois and DBHS Practice Protocol: Disturbances and Disorders of Attachment (PDF), Arizona Department of Health Services, 2 October 2006. Retrieved on 23 February 2008.
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 child's individual and family history.Attachment Disorders, their Assessment and Intervention/Treatment (PDF). British Association for Adoption and Fostering, Position Statement 4, 2006. Retrieved on 23 February 2008