Reactive attachment disorder (RAD) is the clinical disorder that defines distinctive patterns of aberrant behavior in young children who have been maltreated or raised in environments that limit opportunities to form selective attachments.
ATTACHMENT AND ITS DEVELOPMENT
Attachment may be defined as the organization of behaviors in the young child that are designed to achieve physical proximity to a preferred caregiver at times when the child seeks comfort, support, nurturance, or protection. Typically, preferred attachment appears in the latter part of the first year of life as evidenced by the appearance of separation protest and stranger wariness. Newborns recognize their mother’s smell and sound soon after birth, but they express no preference for a particular person to provide comfort for distress. Between 2 and 7 months of age, infants are motivated to interact socially with a variety of partners, familiar and unfamil- iar. During this time, the infant may be more readily comforted by a familiar caregiver, although he or she is generally able to be soothed by unfamiliar adults as well. However, at around 7 to 9 months, infants begin to exhibit reticence around unfamiliar adults (stranger wariness) and to protest separations from familiar care- givers (separation protest). Once these behaviors have appeared, the infant is said to be attached.
Newborns recognize their mother’s smell and sound soon after birth, but they express no preference for a par- ticular person to provide comfort for distress. Between 2 and 7 months of age, infants are motivated to interact socially with a variety of partners, familiar and unfamil- iar. During this time, the infant may be more readily comforted by a familiar caregiver, although he or she is generally able to be soothed by unfamiliar adults as well. However, at around 7 to 9 months, infants begin to exhibit reticence around unfamiliar adults (stranger wariness) and to protest separations from familiar care- givers (separation protest). Once these behaviors have appeared, the infant is said to be attached.
Infants become attached to caregivers with whom they have had significant amounts of interaction (Boris et al., 1997, 1999). Although no definitive data are available in our culture, this appears to be a relatively small number of adults whom the infant learns through experience that he or she can count on to provide com- fort, support, nurturance, and protection, especially in times of stress. These attachment figures appear to be arranged hierarchically in terms of strength of pref- erence, so that the infant has a most preferred caregiver, a next most preferred caregiver, and so forth (Bowlby, 1982). That infants have limits to their capacities to adapt to large numbers of caregivers seems clear, given that serious attachment disturbances are evident in set- tings in which infants must depend on large numbers of caregivers.
Preferred attachments to caregivers may develop at any time after infants reach a developmental age of 7 to 9 months, provided that the new caregivers have suf- ficient involvement with the child. Thus, young chil- dren adopted out of foster care or institutions readily form attachments to their new caregivers (Chisholm et al., 1995; O’Connor et al., 1999; Tizard and Rees, 1975), although the quality of these subsequent attach- ments is sometimes compromised (Chisholm, 1998; O’Connor and Rutter, 2000). In fact, lack of attachment to a specific attachment figure is exceedingly rare in reasonably responsive caregiving environments; signs of RAD never have been reported in the absence of serious neglect.
By 12 months old, it becomes possible to assess the quality of an infant’s attachment to a discriminated attachment figure. A laboratory paradigm known as the Strange Situation Procedure (Ainsworth et al., 1978) involves a series of interactions between a young child, an attachment figure, and an unfamiliar adult, including separations and reunions. Four patterns of attachment—secure, avoidant, resistant, and disorganized— have described individual differences in the organization of an infant’s attachment behaviors with respect to an attachment figure in this procedure. The Strange Situ- ation Procedure has been conducted in many cultures throughout the world. Although there is variability in distributions within and across different cultures, the same four patterns are evident (van IJzendoorn and Sagi, 1999).
disturbances of attachment become clinical disorders ‘‘when the emotions and be- haviors displayed in attachment relationships are so dis- turbed as to indicate or substantially to increase the risk for persistent distress or disability in the infant’’
the essential feature of RAD is early onset of abnormal social relatedness across con- texts that is distinguishable from pervasive developmen- tal disorders and is the result of ‘‘pathogenic care’’. the behaviors should not be ‘‘accounted for solely by developmental delay’’. In essence, children with RAD have a history of being reared in atypical environments characterized by extreme neglect, and they manifest abnormal social behaviors such as lack of responsiveness, excessive in- hibition, hypervigilance, indiscriminate sociability, or pervasively disorganized attachment behaviors. Implicit in the criteria (although not addressed directly) is the absence of a clearly identifiable preferred attachment figure. These two subtypes are generally referred to as inhibited or emotionally withdrawn and disinhibited or indiscriminate.
Emotionally Withdrawn/Inhibited
The emotionally withdrawn/inhibited pattern is characterized by emotionally constricted and socially withdrawn behavior during interactions with others. In times of distress when young children ordinarily seek comfort from a discriminated attachment figure and re- spond to the comfort that is offered, children with the inhibited type of RAD exhibit aberrant responses. They do not consistently seek comfort from others and may even be fearful of seeking comfort despite observable distress. When comfort is offered by a caregiver, these children may fail to respond or may actively resist that comfort. These responses are not isolated or rare but rather are characteristic patterns over time. This pattern of RAD has been identified in children with histories of maltreatment (Boris et al., 1998, 2004; Zeanah et al., in press) and in children who are being reared in in- stitutions. Children with the inhibited subtype of RAD also may exhibit a variety of difficulties with regulation of emotions. Absence of expected positive affect, sudden outbursts of crying, persistent irritability, or anger/ag- gression in response to attempts at comforting have been described in the literature (Boris and Zeanah, 2005; Hinshaw-Fusilier et al., 1999; Zeanah et al., 1993, 2000). Although ‘‘hypervigilant or highly ambiv- alent responses’’ are required by DSM-IV-TR for a diag- nosis of RAD.
Indiscriminate/Uninhibited
The disinhibited type of RAD is characterized by children who, beginning before age 5, may approach unfamiliar adults without any reticence, seek or accept comfort from unfamiliar adults, protest separation from total strangers, or wander away from their caregiver without checking back. They fail to turn selectively to discriminated attachment figures, seemingly willing to seek and accept comfort from almost anyone, includ- ing strangers. They are sometimes considered attention seeking, shallow, and superficial interpersonally.
The disinhibited type of RAD has been described both in children who have been maltreated and in chil- dren who have been institutionalized. In fact, indiscrim- inate behavior is one of the most persistent signs of social abnormalities in young children adopted out of institutions.
DD:
mental retardation because of the known association between social neglect and develop- mental delays. However, developmental delays are often reversible, much like the signs of RAD, once a more normative caregiving environment is provided. Devel- opmental delays in institutionalized children are com- mon (Johnson, 2000), but these children have been documented to make steady gains after adoption.
Similarly, language disorders are associated with ne- glect and language delays have been documented in in- stitutionalized children.
DSM-IV criteria for RAD explicitly exclude children with pervasive developmental disorders (PDDs) from receiving a diagnosis of RAD. Both PDDs and RAD may share abnormalities in social and emotional reci- procity and difficulties in emotion regulation. Still, the social abnormalities of PDDs are believed to be dis- tinguishable from those of RAD. Persistently restricted, repetitive, and stereotyped patterns of behaviors, inter- ests, and activities ought to be more characteristic of PDD than of RAD. The child with RAD also ought to have more reversible social abnormalities when the child is in a more favorable environment, although this may be difficult to discern in a cross-sectional evalua- tion.
The Assessment of RAD Requires Evidence Directly Obtained from Serial Observations of the Child Interacting with his or her Primary Caregivers and History (as available) of the Child’s Patterns of Attachment Behavior with These Caregivers. Observations of the Child’s Behavior with Unfamiliar Adults are also Necessary for Diagnosis. Given the Association Between a Diagnosis of RAD and a History of Maltreatment, the Clinician Should also Gather a Comprehensive History of the Child’s Early Caregiving Environment, Including from Collateral Sources (e.g., Pediatricians, Teachers, or Caseworkers Familiar with the Child) [MS]. After Assessment, any Suspicion of Previously Unreported or Current Maltreatment Requires Reporting to the Appropriate Law Enforcement and Protective Services Authorities [MS]. Maltreated Children are at High Risk of Developmental Delays, Speech and Language Deficits or Disorders, and Untreated Medical Conditions. Referral for Developmental, Speech, and Medical Screening may be Indicated [CG]. The Most Important Intervention for Young Children Diagnosed with RAD 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]. Although the Diagnosis of RAD 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].
Children with RAD 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]. There are three basic psycho- therapeutic modalities to help children with RAD and their caregivers attune to each other and interact more positively: working through the caregiver, working with the caregiver–child dyad (and/or family) together, and/or working with the child alone.
First, the clinician can work through the caregiver by helping him/her learn how to establish positive interac- tions with a hard-to-reach child, by helping the care- giver manage the child’s behavior, or by working intensively to address the caregiver’s own feelings of anxiety, frustration, or anger when needed. When a care- giver is not extremely stressed and the clinician has es- tablished through observation and interview that the caregiver is emotionally available and readily able to re- flect on the child’s feelings, it may be possible to train the caregiver as a cotherapist and work to strengthen the child’s attachment with the caregiver by encouraging sensitive responsiveness (Hart and Thomas, 2000). The advantage of solely working through the caregivers is that the therapist can avoid being the focus of the child’s attachment behavior, while giving the caregivers the message that they are capable of managing the child themselves (Hart and Thomas, 2000). In some cases, however, caregivers may be so overwhelmed and angry that coaching proves ineffective. When caregiver stress is high, working through the caregiver may be difficult un- til the caregiver’s own symptoms are addressed. It is not often possible for highly stressed caregivers who have negative perceptions of their children to maintain sen- sitive responsiveness until their own stress is relieved. Sometimes caregivers need individual treatment, though often the clinician will choose also to work with the primary caregiver–child dyad.
Dyadic work, therapy with the child and primary caregiver together, is the second basic modality for work- ing to address symptoms of RAD (Lieberman and Zeanah, 1999). There are at least two established models of effective dyadic interactive therapy, infant–parent psychotherapy (Lieberman et al., 2000) and interaction guidance (McDonough, 2000). Although neither has been examined formally in children with attachment disorders, each has been evaluated in children with dis- turbed attachment relationships (Cramer et al., 1990; Lieberman et al., 1991). Infant–parent psychotherapy focuses primarily on the caregiver and child’s experi- ence of one another and on altering patterns of emo- tional communication in the dyad. The therapist helps the caregiver appreciate the emotional experience of the child and its connection to the emotional experi- ence of the caregiver. Interaction guidance focuses on behavioral interaction and uses videotaping to allow the clinician to review with the caregiver specific pat- terns of interaction while shaping (mostly through sug- gestion and positive reinforcement) the caregiver’s responses. In both approaches, the behaviors listed in Table 1 are useful focal points for intervention.
A basic tenet in dyadic therapy is to focus on parent- ing strengths as reflected in observed moments of clear caregiver–child engagement. Once trust is built through positive reinforcement of the caregiver, the therapist can point out and process moments of frustration and disengagement to begin to reshape the interac- tions. Because it is frequently difficult for parents to self-reflect in the moment, reflective function can be enhanced by reviewing videotaped sessions.
Although dyadic therapy often is indicated for attach- ment disturbances and disorders, subsequently it may be necessary to widen the intervention to use a family- based treatment. This is often a second stage of treat- ment in which the gains made in dyadic therapy are reinforced by involving other family members.
The third modality for intervention is individual therapy with the child. Although RAD is presumed to be a within-the-child disorder, attachment theory would suggest that children with RAD are best treated with modalities that shape their social processing and interactive behavior beginning with their pri- mary caregiving relationships. Especially with youn- ger children, dyadic intervention is therefore a preferred intervention strategy. Individual therapy, in which the therapist forms a trusting relationship with the patient, should be considered adjunctive to re- duce behaviors in the child that may interfere with dyadic therapy. Of course, individual therapy, to be successful, requires active collaboration with the caregiver.
Children Who Meet Criteria for RAD and Who Display Aggressive and Oppositional Behavior Require Adjunctive Treatments [CG]: ODD, CD. No trials so far.