Reactive attachment disorder

Reactive attachment disorder
Specialty	Psychology

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. 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[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.

SUBTLE AND NOT SO SUBTLE SIGNS OF ATTACHMENT PROBLEMS

Attachment is fundamental to healthy development, normal personality, and the capacity to form healthy and authentic emotional relationships. How can you determine whether your child has attachment issues that require attention? What is normal behavior, and what are the signs of attachment issues? If you’ve adopted an infant, will you see attachment problems develop? These and other related questions are often at the forefront of adoptive parents’ minds. In this article I will help you understand what to look for and how to identify concerns.

Let’s begin with an explanation of attachment. Attachment is the base of emotional health, social relationships, and one's worldview. The ability to trust and form reciprocal relationships affected the emotional health, security, and safety of the child, as well as the child’s development and future inter-personal relationships. The ability to regulate emotions, have a conscience, and experience empathy all require secure attachment. Healthy brain development is built on a secure attachment relationship.

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.

When the first-year-of-life attachment-cycle is undermined 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:

· Multiple disruptions in care giving · Post-partum depression causing an emotionally unavailable mother · Hospitalization of the child causing separation from the parent and/or unrelieved pain. For example, stays in a NICU or repeated hospitalizations during infancy. · Parents who are attachment disordered, leading to neglect, abuse (physical/sexual/verbal), or inappropriate parental responses not leading to a secure/predictable relationship · Genetic factors. · Pervasive developmental disorders · Caregivers whose own needs are not met, leading to overload and lack of awareness of the infants 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.

· Superficially engaging and charming behavior, phoniness · Avoidance of eye contact. · Indiscriminate affection with strangers. · Lack of affection on parental terms. · Destructiveness to self, others, and material things. · Cruelty to animals. · Crazy lying (lying in the face of the obvious) · Poor impulse control. · Learning lags. · Lack of cause/effect thinking. · Lack of conscience. · Abnormal eating patterns. · Poor peer relationships. · Preoccupation with fire and/or gore. · Persistent nonsense questions and chatter indicating a need to control. · Inappropriate clinginess and demandingness. · Abnormal speech patterns. · Inappropriate sexuality.

What are the underlying causes of these 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.

So how does one distinguish the difference between a child who "looks" attached and a child who really is making a healthy, secure attachment? This question becomes important for adoptive families because some adopted children will form an almost immediate dependency bond to their adoptive parents. To mistake this as secure and healthy attachment can lead to many problems down the road. Just because a child calls someone Mom or "Dad," snuggles, cuddles, and says, I love you," does not mean that the child is attached or even attaching. Saying, "I love you", and knowing what that really feels like, can be two different things. Attachment is a process. It takes time. The key to its formation is trust, and trust becomes secure only after repeated testing. Generally attachment develops during the first two to three years of life. The child learns that he or she is loved and can love in return. The parents give love and learn that the child loves them. The child learns to trust that his needs will be met in a consistent and nurturing manner. The child learns that he "belongs" to his family and they to him. It is through these elements that a child learns how to love, and how to accept love.

Older adopted children need time to make adjustments to their new surroundings. They need to become familiar with their caregivers, friends, relatives, neighbors, teachers, and others with whom they will have repeated contact. They need to learn the ins and outs of new household routines and adapt to living in a new physical environment. Some children have cultural or language hurdles to overcome. Until most of these tasks have been accomplished, they may not be able to relax enough to allow the work of attachment to begin. In the meantime, behavioral problems related to insecurity and lack of attachment, as well as to other events in the child's past, may start to surface. Some start to get labels, like "manipulative," "superficial," or "sneaky". On the inside, this child is filled with anxiety, fear, grief, loss, and often a profound sense of being bad, defective, and unlovable. The child has not developed the self-esteem that comes with feeling like a valued, contributing, member of a family. The child cares little about pleasing others since his relationships with them are quite superficial.

When are problems first apparent? Children who have experienced physical or sexual abuse, physical or psychological neglect, or orphanage life will begin to show difficulties as young as six-months of age. For example, the signs of difficulties for an infant include the following:

Ø Weak crying response or rageful and/or constant whining; inability to be comforted Ø Tactile defensiveness Ø Poor clinging and extreme resistance to cuddling: seems stiff as a board Ø Poor sucking response Ø Poor eye contact, lack of tracking Ø No reciprocal smile response Ø Indifference to others Ø Failure to respond with recognition to parents. Ø Delayed physical motor skill development milestones (creeping, crawling, sitting, etc.,) Ø Flaccid

WHAT ARE THE SUBTLE SIGNS OF ATTACHMENT PROBLEMS? Gail tells her seven-year-old daughter, Sally, to pick up the napkin Sally has dropped. As Sally crosses her arms a sad and angry pout darkens her face. Gail says, “Sally, I told you to pick up the napkin and throw it away.” Sally stomps over to the napkin, picks it up, and throws it away. Crying and whining, Sally stands with her back to Gail. Sally, angry and unhappy, is exhibiting one of the subtle signs of attachment sensitivity that nearly all children adopted after six-months demonstrate. Attachment is an interpersonal, interactive process that results in a child feeling safe, secure, and able to develop healthy, emotionally meaningful relationships. The process requires a sensitive, responsive parent who is capable of emotional engagement and participation in contingent collaborative communication (responsive communication) at nonverbal and verbal levels. The parent’s ability to respond to the child’s emotional state is what will prevent attachment sensitivities from becoming problems of a more severe nature.

What are the subtle signs of attachment issues? 1. Sensitivity to rejection and to disruptions in the normally attuned connection between mother and child. 2. Avoiding comfort when the child’s feelings are hurt, although the child will turn to the parent for comfort when physically hurt. 3. Difficulty discussing angry feelings or hurt feelings. 4. Over valuing looks, appearances, and clothes. 5. Sleep disturbances. Not wanting to sleep alone. 6. Precocious independence. A level of independence that is more frequently seen in slightly older children. 7. Reticence and anxiety about changes. 8. Picking a scabs and sores. 9. Secretiveness 10. Difficulty tolerating correction or criticism.

Internationally adopted children experience at least two significant changes during the first few months of life that can have a profound impact on later development and security. Birth mother to orphanage or foster care and then orphanage to adoptive home are two transitions. We know from extensive research that prenatal, post-natal, and subsequent experiences create lasting impressions on a child. During the first few minutes, days, and weeks of life, the infant clearly recognizes the birth mother’s voice, smell, and taste. Changes in caregivers are disruptive. The new caregivers look different, smell different, sound different, taste different. In the orphanage there are often many care givers but no one special caregiver. Adoption brings with it a whole new, strange, and initially frightening world. These moves and disruptions have profound effects on a child’s emotional, interpersonal, cognitive, and behavioral development. The longer a child is in alternate care, the more these subtle signs become pervasive.

There are effective ways for a parent to help his or her child. Parents and the right parenting are vital to preventing subtle signs from becoming anything more than sensitivities. Parenting consistently with clear and firm limits is essential. Discipline should be enforced with an attitude of sensitive and responsive empathy, acceptance, curiosity, love, and playfulness. This provides the most healing and protective way to correct a child.

As Sally walks away to pout, Gail comes up behind her, scoops her up, and begins rocking her gently while crooning in Sally’s ear. Gail sings songs and tells Sally she loves her and understands Sally is angry at being told what to do. Gail expresses sadness that Sally is so unhappy. At first Sally resists a bit, but she soon calms down and listens as Gail tells her how much she loves Sally. Sally is sensitive to feelings of rejection and abandonment that are evoked by her mother’s displeasure, so Gail brings Sally closer to reassure Sally nonverbally. It is by experience that the subtle signs are addressed and managed. Nonverbal experience is much more powerful than verbal experience since most of the subtle signs have their origin in nonverbal experience and nonverbal memory. Finally, Sally eventually did what she was asked to do and praised for doing what was expected. In this manner, Sally experiences acceptance of who she is while becoming socialized.

These sensitivities do not constitute a mental illness or Reactive Attachment Disorder. They are subtle signs of attachment sensitivities. So, what can you do?

First, the most important thing you can do is maintain an attuned emotionally close and positive relationship with your child even when your child is being nasty or pushing your buttons…it is at those times that the child most needs to feel loved and loveable, even if the behavior is unacceptable. First, create a connection with your child and then discipline.

Second, bringing the child in close is better than allowing the child to be alone or isolate him or her self.

Third, talk for the child. Put words to what the child is feeling. This allows the child to feel understood by you, maintains a connection, and helps assuage the fear of rejection and abandonment. It also helps the child become self-aware, models verbal behavior, and facilitates a sense of emotional attunement between parent and child.

Fourth, don’t make food a battle. A child who steals food or hoards food usually has sound emotional reasons for this. Providing the child with food so that your child experiences you as provider is often the solution. Put a bowl of fruit in the child’s room. (Be sure to keep if filled. It does not good if you provide and then leave an empty bowl!) In some instances, I’ve recommended that the parents provide the child with a fanny pack and keep it stocked with snacks. This usually quickly ends hoarding and stealing of food.

Fifth, for the child who is overly independent, doing for the child and not encouraging precocious independence is helpful. So, making a game of brushing your six-year old’s teeth, dressing your seven-year-old, or playing at feeding a nine-year-old, are all ways to demonstrate that you will care for the child. Keeping it playful and light, allows the child to experience what the child needs and helps eliminate hurtful battles.

Sixth, Time-In rather than Time-out. When your child is becoming dysregulated, they need you to regulate their emotions. You do that by reflecting the child’s emotions back to the child; putting into words what you think the child may be feeling. In this manner you demonstrate that you can accept what the child is feeling, that feelings can be tolerated and discussed; even if the behavior will be disciplined at a later time. Remember; first connect with you child, then discipline.

Seventh, reduce shame. Avoid shaming parenting methods and interactions that might be harsh or punitive. If the child is already experiencing too much shame, increasing that will only be destructive to the child and your relationship with your child. You set the emotional tone for the relationship, so keeping things positive is important. So, as an example, your seven year old has just screamed at you, “I hate you,” because you said it’s time to go to bed. I’d start by reflecting the child’s feelings back to the child as you walk the child to bed with your arm around the child, “Boy, you are really mad that you have to go to bed now.” “You sure don’t want to go to bed now. I wonder what you think is making me send you to bed now? … Maybe you just think I’m being mean?” Through this sort of dialogue you are demonstrating your acceptance of the child’s feelings and your interest in the child’s thinking and feeling…you are showing the child how to reflect on one’s inner life. The model I suggest for parents is to create a healing PLACE (being Playful, Loving, Accepting, Curious, and Empathic. You can read about this in Creating Capacity for Attachment, edited by Arthur Becker-Weidman, Ph.D., & Deborah Shell, MA, Wood ‘N’ Barnes, OK).

In conclusion, these subtle signs are important reminders that our children have ongoing sensitivities that as parents we must address. Responsive and sensitive communication is essential. Attachment is a function of reciprocal communication; attachment does not reside in the child alone. It is very important for the parent to manage and facilitate this attuned connection within a framework of clear limits and boundaries, natural consequences, and firm loving discipline.

References: Creating Capacity for Attachment, edited by Arthur Becker-Weidman, Ph.D., & Deborah Shell, MA, Wood ‘N’ Barnes, OK

Retrieved from "http://en.wikipedia.org/wiki/Talk:Attachment_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[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[9], 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, was effective[12]. (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[12], 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

[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 [2003], 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.
[9]: See especially Speltz (2002) Description, History, and Critique of Corrective Attachment Therapy. The APSAC Advisor 14(3), 4-8
[10]: 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
[12]: “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. [11]: 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.

External links

• "Qualifications to be a registered clinician and position statement prohibiting the use of coercive interventions"
• "Center For Family Development."
• "RadKid.Org Support & Information"