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Understanding Reactive Attachment Disorder
The effects of all forms of child abuse and neglect can result in physical injury, long-term disability, and severe psychological trauma. Reactive attachment disorder (RAD) is one of many possible consequences of such trauma. RAD is a rare condition marked by emotional, behavioral, and psychological dysfunction, found in children who have received extremely negligent care, early abuse, and/or mistreatment and do not form a healthy emotional attachment with their primary caregivers before age five (Prior & Glaser, 2006; Zeanah & Gleason, 2010). Without treatment, RAD may persist for years and have a lasting effect on the child’s emotional and psychological development, and the development and functioning of adult relationships (Zeanah & Gleason, 2010).
This paper will examine the causes of RAD, its foundations in attachment theory, the symptoms, and the prevalence of RAD, and how the condition is diagnosed. It will also address the treatment for RAD, the outlook for those diagnosed with RAD, multicultural considerations, and the prevention of this disorder.
Understanding Attachment Theory
To better understand RAD, it is first necessary to understand attachment; therefore, attachment theory is examined here. In his early works, John Bowlby stated, “attachment is a deep and enduring emotional bond that connects one person to another across time and space; a lasting psychological connectedness between human beings” (Solomon, Duschinsky, Bakkum, & Schuengel, 2017). Attachment is noted in the specific actions of young children, such as looking to remain close to their caregiver when distressed, when vulnerable, or in danger (Bretherton, 1992). Attachment promoting behaviors for caregivers are behaviors involving the delicate and proper response to the child’s physical and emotional requirements (Reebye, 2007). Attachment theory clarifies how the relationship between parent and child emanates and effects the child’s future development (Prior & Glaser, 2006).
The theoretical framework for today’s notion of RAD is found in attachment theory, which originates from work undertaken by Bowlby and others from the 1930s through the 1980s. While working as a psychiatrist in the 1930s Bowlby treated emotionally impaired children (Bretherton, 1992). This work led Bowlby to examine the importance of the child’s relationship with their mother, specifically as pertains to their cognitive, social and emotional development (Solomon et al., 2017). This work shaped Bowlby’s understanding of the connection between early separations from the child’s mother and later adjustment problems (Bretherton, 1992). This led Bowlby to begin to forge his theory of attachment.
In the 1950s Bowlby and his associates noted that children exhibited profound anxiety and distress when separated from their mothers—even when the children were fed by others. These observations were counter to the prevailing behavioral theory of attachment, which posited that attachment happens when an infant is fed by his or her mother (Bretherton, 1992). Instead, Bowlby proposed that attachment should really be viewed within a broader “evolutionary” context in that the caregiver provides care, safety, security, responsiveness, and nourishment for the infant (Solomon et al., 2017). Infants have an innate need to be near their caregiver, particularly when under duress and thus, healthy attachment, according to Bowlby, increases the child’s probability of surviving and flourishing (Reebye, 2007). This evolutionary theory of attachment holds that infants are born programmed biologically to build lasting connections with others as a means of survival and that birth until five years of age is the crucial time frame for solidifying an attachment (Zeanah & Gleason, 2010). If an attachment fails to occur during this time frame the child may experience permanent psychological and developmental repercussions (Solomon et al., 2017).
These attachment behaviors appear to be pervasive and universal across all cultures (Brown, Hawkins-Rodgers, & Kapadia, 2008). There are two primary cultural types, individualist and collectivist. Those in individualist cultures (e.g., the United States, most European countries, and other Western cultures) tend to value the independence of the individual, wherein each person works more or less separately on his or her goals. In collectivist cultures (e.g., Japan, Israel, and other Eastern cultures) tend to value cooperation over individualism, wherein each person in the unit works together to achieve family or community goals (Brown et al., 2008). Research on attachment across cultures has focused on the types of attachment seen in each, to determine if attachment behaviors are universal across cultures or vary considerably between individualist and collectivist cultures. The literature shows that although the specific expression of care and love may vary in some circumstantial ways, there are innate characteristics that appear to be universal as relates to infant/child-caregiver attachment and interaction (Keller, 2018).
Causes of Reactive Attachment Disorder
As noted previously, attachment forms when a caregiver consistently cares for, protects, and meets the needs of the child. This is how a young child learns to trust others, develop awareness of others’ sentiments and requirements, manage his or her feelings, cultivate positive relationships with others, and a develop a healthy self-image (Alink, Cicchetti, Kim, & Rogosch, 2009). The absence of healthy attachment during the early years of life can negatively impact the child’s future development and emotional growth (Zeanah & Gleason, 2010). To date, there is no evidence of genetic etiology for RAD (Zeanah & Gleason, 2015).
RAD can develop when healthy attachment does not take place or is disrupted due to delinquent care and neglect (Pritchett, Pritchett, Marshall, Davidson, & Minnis, 2013; Zeanah & Gleason, 2015). When the child’s primary caregiver is regularly distracted, aloof, unreliable, overly punitive, or excessively distraught and not consistently dependable, children become easily upset and fail to learn to rely upon and cofunction with others when in need (Alink et al., 2009). These children learn not to expect consistent care and comfort from caregivers (Lehmann, Monette, Egger, Breivik, Young, Davidson, & Minnis, 2018). Examples of the causes of RAD are as follows: continued inattention to the child’s emotional needs for soothing, stimulation, and care; consistent inattention to the child’s basic physical needs; recurrent changes in caregivers preventing the formation of solid attachments (e.g., repeated changes to foster care placement) (Lehmann, Breivik, Heiervang, Havik, & Havik, 2015). Other causes of RAD include emotional, physical, and sexual abuse, harsh corporal punishment, repeated exposure to domestic violence, parental verbal abuse, ethnic cleansing, exposure to war, and other atrocities (Fujisawa, Shimada, Takiguchi, Mizushima, Kosaka, Teicher, & Tomoda, 2018).
The occurrence of RAD is increased in infants and young children who are institutionalized (e.g., orphans), whose mothers experience postpartum depression, children in foster care who are moved frequently, those who are separated from their primary caregiver for a long period of time, or who have unskilled or negligent caregivers (Woolgar & Baldock, 2015). The great majority of children at risk are eventually able to form normal healthy, secure relationships notwithstanding early adversity, but some cannot (Shimada, Takiguchi, Mizushima, Fujisawa, Saito, Kosaka, Okazawa, Tomoda, 2015)
Symptoms of Reactive Attachment Disorder
As Bowlby noted in his attachment theory, maladaptive attachment can affect every aspect of a child’s life and development (Bretherton, 1992). Because RAD is a disorder that impairs one’s social behavior, compared to those who do not have this disorder, those with RAD will display increased maladaptive behavioral and psychosocial problems (Pritchett et al., 2013).
Signs of RAD in infants and toddlers include an inhibited, withdrawn or detached demeanor, display of a mixture of approach and avoidance with others, an apparent inability to smile and show signs of joy, and a failure to respond in social interaction (Lehmann et al., 2015). These children may seem sad, afraid, annoyed, irritable, and lethargic, and may be unresponsive or resistant to comforting. They may be withdrawn emotionally, have trouble regulating their emotions, and be cautious of others as they lack trust (Alink et al., 2009). Children with RAD will attempt to comfort themselves rather than allowing others to comfort and nurture them. When under duress, they are apt to quiet themselves without the intervention of a caregiver (Woolgar & Baldock, 2015).
Older youth with RAD may have trouble showing affection and be uncomfortable with touch, lack interest in playing, interacting with other children or engaging at all in any type of social interaction (Lehmann et al., 2018). These children may display symptoms of other disorders, show signs of problem behaviors, display anger, lack control, display signs of severe anxiety, engage in unsafe behaviors, appear to have low self-esteem, and may even show signs of sociopathy—including failure to show remorse for inappropriate behavior (Zeanah & Gleason, 2010). RAD children may also experience several developmental delays, including language and physical delays, and score lower than normal on IQ tests. As RAD children age, they may be reluctant to receive assistance from others and failure to show caution with strangers. They are typically impulsive, hyperactive, and have trouble dealing effectively with transitions (Lehmann et al., 2015; Lehmann et al., 2018). They may have an inability to delay gratification and display ineffective problem-solving skills. Other symptoms that may be displayed include a propensity for lying, hoarding, stealing, hypersexuality, vandalism, arson, increased aggression, animal cruelty, and homicidal and suicidal ideation (Lehmann et al., 2018).
The types of early trauma that lead to RAD result in problems may extend from childhood through adolescence and into adulthood placing them at risk for additional exposure to trauma and long-term impairment (e.g., psychiatric and addictive disorders; chronic physical illness; legal, vocational, and family problems) (Lehmann et al., 2015; Lehmann et al., 2018). The symptoms of RAD can mimic other disorders, therefore it is critical to have the child assessed by a mental health professional to ascertain the correct diagnosis and treatment plan.
Diagnosing Reactive Attachment Disorder
As with adults, mental health conditions in youth are diagnosed based on symptoms that point to a particular disorder. The Diagnostic and Statistical Manual of Mental Disorders (DSM) published by the American Psychological Association (APA) is used to diagnose mental health disorders.
RAD was first introduced in the DSM-III in 1980. It was revised in the DSM III-Revised and has remained substantially the same since (Zeanah & Gleason, 2010). This makes RAD a relatively new diagnosis in spite over fifty years of research on the importance of human relationships in child development (Shimada et al., 2015; Zeanah & Gleason, 2015). Since its first appearance in DSM-III, RAD stands apart from other diagnoses. This is due to the fact that RAD remains the only diagnosis designated specifically for infants (of at least nine months) and that the diagnosis necessarily includes a specific cause (Woolgar & Baldock, 2015). The DSM-5 (APA, 2013) classifies RAD as one of the Trauma and Stressor-Related Diagnoses and gives the following criteria for RAD:
- Criterion A: A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: 1) the child rarely or minimally seeks comfort when distressed, and 2) the child rarely or minimally responds to comfort when distressed.
- Criterion B: A persistent social or emotional disturbance characterized by at least two of the following: 1) minimal social and emotional responsiveness to others, 2) limited positive affect, and 3) episodes of unexplained irritability, sadness, or fearfulness that are evident even during non-threatening interactions with adult caregivers.
- Criterion C: The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following: 1) social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults, 2) repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care), and 3) rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).
During their first five years, children should visit their pediatrician regularly. If the child is displaying maladaptive signs and symptoms the physician would first complete a thorough medical history and physical exam, which should include a thorough examination of developmental milestones (Zeanah & Gleason, 2015). There are no laboratory protocols to diagnose RAD per se, but if there are concerns that an illness might be causing the symptoms the physician may order neuroimaging studies or blood tests. If the tests fail to identify a physical cause for the symptoms, the physician should refer the child to a mental health professional, preferably one trained to diagnose and treat disorders in youth (Woolgar & Baldock, 2015).
As of now, there is no precise, valid instrument for diagnosing RAD. Diagnosis must be made using diagnostic interviews, reports, and documentation of developmental history, and behavioral observation of the child’s symptoms, attitude and behavior (Woolgar & Baldock, 2015). Both medical and mental health investigations of children displaying RAD symptoms must perform a differential diagnosis to first rule out other physical and mental health disorders that may account for maladaptive symptoms (Woolgar & Baldock, 2015). For example, the diagnosis of numerous other disorders (social phobia, autism, etc.) should be ruled out before a diagnosis of RAD is arrived upon. This is because other disorders can present with similar symptoms.
It should be noted that the application of the DSM-5 RAD criteria and attachment-related signs and symptoms used in diagnosis must be used cautiously when applied to children aged five through adolescence—as attachment behaviors displayed at these older ages can be dramatically different than behaviors displayed in younger children (Lehmann et al., 2018). Furthermore, no matter what age the child presents for diagnosis, the identification of criteria for RAD relies upon the history of the child’s attachment behavior and symptoms prior to five years of age (Zeanah & Gleason, 2010).
Treatment of Reactive Attachment Disorder
There is no definitive cure for RAD, however, the treatment of young children diagnosed with RAD has two primary goals. First and foremost, the treatment plan should ensure that the child is in a safe and nurturing atmosphere (Zeanah & Gleason, 2015). Secondly, treatment should aim at helping the child develop and maintain wholesome, appropriate relationships with caregivers (Woolgar & Baldock, 2015). Consistently caring, responsive, and capable caregivers are at the heart of treatment for children diagnosed with RAD (Zeanah & Gleason, 2015). It is not necessary for children to be removed from formerly abusive or neglectful parents or caregivers, assuming that the caregivers are proven to be sufficiently rehabilitated such that they can be consistently loving and competent caregivers for the child (Alink et al., 2009). Clinical treatment typically involves the child and his or her caregivers and often is comprised of counseling for the child and family unit, parenting education and training, and special education services (Zeanah & Gleason, 2015). Counseling is used to improve the caregiver’s relationship with and behavior toward the child. Parenting training is meant to educate the caregivers by teaching skills to help improve the caregiver-child relationship, develop attachment between them, manage behavioral symptoms of RAD, and develop an understanding of what is necessary for the child to trust others and form healthy relationships (Zeanah & Gleason, 2015). Treatment for the child might include play therapy, which often includes the caregiver and family, allowing all to explore their thoughts, fears, and needs in the safe context of play. Those involved need not be biologically related to the child (Alink et al., 2009). It should be noted that there is no evidence that using controversial “holding therapy” or “rebirthing” techniques are effective (Holmes & Farnfield, 2014).
To date, there are no known pharmaceutical treatments for RAD, although physicians may prescribe medications as a supplement to therapeutic treatment to help curb severe behavioral issues such as depression, sleeping disturbances, anger, etc. (Zeanah & Gleason, 2015).
The treatment for RAD centers on improving the child’s healthy attachment relationships, decreasing unhealthy and unsafe attachment behaviors, enhancing appropriate relationships within the family unit, and augmenting the child’s social behaviors and support mechanisms. The goal of intervention is to enable the child to develop trust in positive relationships, which enhances their capacity to grow up to enjoy healthy relationships with others outside the family unit and to take part in the adult social community. In most cases, in time, RAD symptoms are greatly reduced or eliminated entirely when children are cared for by capable caregivers in a loving environment and treated with appropriate therapies (Zeanah & Gleason, 2015).
Prevention of Reactive Attachment Disorder
The likelihood of the development of RAD is reduced when caregivers are appropriately responsive to the child’s emotional and physical needs (Woolgar & Baldock, 2015). Caregivers are advised to become as knowledgable as is possible about the stages and signs of child growth and development by reading, talking with other parents, seeking counseling, talking with a physician or pediatrician, and/or attending parenting classes. Recognizing the early symptoms of attachment problems and engaging prompt intervention is crucial to preventing RAD (Lehmann et al., 2015).
Prevalence of Reactive Attachment Disorder
Unfortunately, many families affected by RAD are unaware there is a problem and so do not seek help; therefore, it is impossible to know exactly how many children are affected by RAD (Lehmann et al., 2018). The literature reflects, however, that it is generally thought that RAD is not common (Lehmann et al., 2018; Zeanah & Gleason, 2010). It is believed that when the child-caregiver relationship is the cause of early trauma, attachment is nearly always compromised in some way; 80% of mistreated youth develop some form of insecure attachment behaviors (Woolgar & Baldock, 2015). That said, however, a majority of young children who have experienced neglectful or abusive early care or who have been shifted among multiple caretakers early in do not develop the disorder (Lehmann et al., 2018). Additional research is needed to understand why some children develop an attachment disorder and others do not (Alink et al., 2009). Some literature suggests that there may be a link between the length of the maltreatment and how severe the symptoms of RAD (Alink et al., 2009; Fujisawa et al., 2018). Further, it appears that males are more likely than females to be diagnosed with RAD, but because there is a paucity of literature and how uncommon the disorder is, those researching RAD have had a difficult time determining the true prevalence of RAD (Zeanah & Gleason, 2010).
Prognosis for Children with Reactive Attachment Disorder
The long-term outlook for children diagnosed with RAD is favorable assuming the child and family unit receive prompt and effective treatment (Pritchett et al., 2013). Longitudinal studies must be conducted to be more certain, but experts believe that RAD may lead to other physical, psychological, social, behavioral, emotional and moral development issues later in life if RAD goes untreated (Lehmann et al., 2015). These issues can include depression, aggressive and/or disruptive behavior, extreme controlling behavior, self-harm, learning difficulties, behavior problems in school, inability to form meaningful relationships, low self-esteem, developmental delays, delays in physical growth, eating disorders, anger management problems, anxiety, and substance abuse (Lehmann et al., 2015; Pritchett et al., 2013; Zeanah & Gleason, 2010; Zeanah & Gleason, 2015). With prompt and effective treatment, it is possible for children with RAD to learn to form meaningful attachments, trust others, and lead healthy and productive lives (Zeanah & Gleason, 2015).
RAD has been the subject of systemic research for fifty years, more in the last fifteen years than the thirty-five before (Zeanah & Gleason, 2015). The literature provides a rich body of work that substantiates the importance of early attachment relationships to human development, and the disturbances that are associated with the lack of healthy attachment in childhood leading to RAD and other disorders. The medical and mental health communities can play a vital role in recognizing RAD in young children and ensuring that children with this disorder and their caregivers receive prompt assessment and treatment. Researchers have learned a great deal about attachment and the causes, symptoms, diagnosis, treatment, and prevention of RAD. Less is known about the prevalence of RAD, the long-term prognosis for those diagnosed with RAD, and the effectiveness of known interventions. Longitudinal studies are needed with older youth and adults who had been diagnosed with RAD as children, including the development of peer relationships and interpersonal competence (Zeanah & Gleason, 2015). Also needed is a better understanding of why some children who have experienced maltreatment develop RAD and others do not, as well as a continued search for additional interventions and assessment tools (Alink et al., 2009; Zeanah & Gleason, 2015).
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