Reactive attachment disorder
Classification and external resources
Children need sensitive and responsive caregivers to develop secure attachments. RAD arises from a failure to form normal attachments to primary caregivers in early childhood.
ICD-10	F94.1, F94.2
ICD-9	313.89
eMedicine	ped/2646
MeSH	D019962

Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children.^[1][2] RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. 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—or can present itself as indiscriminate sociability, such as excessive familiarity with relative strangers—known as the "disinhibited form". The term is used in both the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10)^[3] and in the DSM-IV-TR, the revised fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).^[4] In ICD-10, the inhibited form is called RAD, and the disinhibited form is called "disinhibited attachment disorder", or "DAD". In the DSM, both forms are called RAD; for ease of reference, this article will follow that convention and refer to both forms as reactive attachment 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 change of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts. Not all, or even a majority of such experiences, result in the disorder.^[5] It is differentiated from pervasive developmental disorder or developmental delay and from possibly comorbid conditions such as mental retardation, all of which can affect attachment behavior. The criteria for a diagnosis of a 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 which 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.^[6][7] 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, mechanism 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.^[8]

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.^[9] Most such strategies are in the process of being evaluated. Mainstream practitioners and theorists have presented significant criticism of the diagnosis and treatment of alleged reactive attachment disorder or attachment disorder within the complementary and alternative medicine field commonly known as attachment therapy. Attachment therapy has an unconventional theoretical base and uses diagnostic criteria or symptom lists unrelated to 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 coercive and considered to be antithetical to attachment theory.^[10]

Signs and symptoms[link]

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.^[11]

The core feature is severely inappropriate social relating by affected children. This can manifest itself in two ways:

1. Indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers (older children and adolescents may also aim attempts at peers)
2. Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed^[12]

While RAD is likely to occur in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect.^[13]

Assessment tools[link]

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),^[14][15][16] the separation and reunion procedure and the Preschool Assessment of Attachment,^[17] the Observational Record of the Caregiving Environment,^[18] the Attachment Q-sort^[19] 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.^[20]

More recent research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah (1999).^[21] 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[link]

Although increasing numbers of childhood mental health problems are being attributed to genetic defects,^[22] 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.^[23] 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.^[24] In the absence of available and responsive caregivers it appears that some children are particularly vulnerable to developing attachment disorders.^[25]

There is as yet no explanation for why similar abnormal parenting may produce the two distinct forms of the disorder, inhibited and disinhibited. 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 vary widely.^[26]

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.^[27]

Diagnosis[link]

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.^[12] 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.^[7]

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.^[28] Their practice parameter states that the assessment of reactive attachment disorder 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. 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.^[6] In the US, initial evaluations may be conducted by psychologists, psychiatrists, specialist Licensed Clinical Social Workers or psychiatric nurses.^[29]

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.^[30]

According to the AACAP Practice Parameter (2005) the question of whether attachment disorders can reliably be diagnosed in older children and adults has not been resolved. Attachment behaviors used for the diagnosis of RAD change markedly with development and defining analogous behaviors in older children is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence.^[6] Assessments of RAD past school age may not be possible at all as by this time children have developed along individual lines to such an extent that early attachment experiences are only one factor among many that determine emotion and behavior.^[31]

Criteria[link]

ICD-10 describes reactive attachment disorder of childhood, known as RAD, and disinhibited attachment disorder, less well known as DAD. DSM-IV-TR also describes reactive attachment disorder of infancy or early childhood divided into two subtypes, inhibited type and disinhibited type, both known as RAD. The two classifications are similar and both include:

• markedly disturbed and developmentally inappropriate social relatedness in most contexts (e.g., the child is avoidant or unresponsive to care when offered by caregivers or is indiscriminately affectionate with strangers);^[32]
• the disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder;
• onset before five years of age (there is no age specified before five years of age at which RAD cannot be diagnosed);^[32]
• a history of significant neglect;
• an implicit lack of identifiable, preferred attachment figure.

ICD-10 states in relation to the inhibited form only that the syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. DSM states in relation to both forms there must be a history of "pathogenic care" defined as persistent disregard of the child's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to account for the disorder. For this reason, part of the diagnosis is the child's history of care rather than observation of symptoms.

In DSM-IV-TR the inhibited form is described as persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting or may exhibit "frozen watchfulness", hypervigilance while keeping an impassive and still demeanour).^[4] Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain "proximity", an essential element of attachment behavior. The disinhibited form shows diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures).^[4] There is therefore a lack of "specificity" of attachment figure, the second basic element of attachment behavior.

The ICD-10 descriptions are comparable save that ICD-10 includes in its description several elements not included in DSM-IV-TR as follows:

• abuse, (psychological or physical), in addition to neglect;
• associated emotional disturbance;
• poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases (inhibited form only);
• evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness in interactions with appropriately responsive, non-deviant adults (disinhibited form only).

The first of these is somewhat controversial, being a commission rather than omission and because abuse of itself does not lead to attachment disorder.

The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is more enduring.^[33] ICD-10 states the disinhibited form "tends to persist despite marked changes in environmental circumstances". Disinhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same child.^[34] The question of whether there are two subtypes has been raised. The World Health Organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate subdivision.^[3] One reviewer has commented on the difficulty of clarifying the core characteristics of and differences between atypical attachment styles and ways of categorizing more severe disorders of attachment.^[35]

As of 2010, the American Psychiatric Association has proposed to redefine RAD into two distinct disorders in the DSM-V.^[36] Corresponding with the inhibited type, one disorder will be reclassified as Reactive Attachment Disorder of Infancy and Early Childhood.^[32]

In regards to pathogenic care, or the type of care in which these behaviors are present, a new criterion for Disinhibited Social Engagement Disorder now includes chronically harsh punishment or other types of severely inept caregiving. Relating to pathogenic care for both proposed disorders, a new criterion is rearing in atypical environments such as institutions with high child/caregiver ratios that cut down on opportunities to form attachments with a caregiver.^[36]

Differential diagnosis[link]

The diagnostic complexities of RAD mean that careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential.^[37][38][39] Several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, post traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with RAD, leading to over and under diagnosis. RAD can also be confused with neuropsychiatric disorders such as autism spectrum disorders, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. Infants with this disorder can be distinguished from those with organic illness by their rapid physical improvement after hospitalization.^[11] Children with an autistic disorder are likely to be of normal size and weight and often exhibit a degree of mental retardation. They are unlikely to improve upon being removed from the home.^{[11][37][38][39]}

Alternative diagnosis[link]

In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the DSM and ICD, were created out of clinical and parental experience within the field known as attachment therapy. These lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common elements of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either DSM-IV-TR or ICD-10.^[40] Many children are being diagnosed with RAD because of behavioral problems that are outside the criteria.^[37] There is an emphasis within attachment therapy on aggressive behavior as a symptom of what they describe as attachment disorder whereas mainstream theorists view these behaviors as comorbid, externalizing behaviors requiring appropriate assessment and treatment rather than attachment disorders. However, knowledge of attachment relationships can contribute to the etiology, maintenance and treatment of externalizing disorders.^[41]

The Randolph Attachment Disorder Questionnaire or RADQ is one of the better known of these checklists and is used by attachment therapists and others.^[42] The checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment difficulties. Critics assert that it is unvalidated^[43] and lacks specificity.^[44]

Treatment[link]

Assessing the child's safety is an essential first step that determines whether future intervention can take place in the family unit or whether the child should be removed to a safe situation. Interventions may include psychosocial support services for the family unit (including financial or domestic aid, housing and social work support), psychotherapeutic interventions (including treating parents for mental illness, family therapy, individual therapy), education (including training in basic parenting skills and child development), and monitoring of the child's safety within the family environment^[11]

In 2005 the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W. Boris and C.H. Zeanah) based on its published parameters for the diagnosis and treatment of RAD.^[6] Recommendations in the guidelines include the following:

1. "The most important intervention for young children diagnosed with reactive attachment disorder 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."
2. "Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child, assessing the caregiver's attitudes toward and perceptions about the child is important for treatment selection."
3. "Children with reactive attachment disorder 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."
4. "Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive (additional) treatments."

Mainstream prevention programs and treatment approaches for attachment difficulties or disorders for infants and younger children 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.^[6][45][46] These approaches are mostly in the process of being evaluated. The programs invariably include a detailed assessment of the attachment status or caregiving responses of the adult caregiver as attachment is a two-way process involving attachment behavior and caregiver response. Some of these treatment or prevention programs are specifically aimed at foster carers rather than parents, as the attachment behaviors of infants or children with attachment difficulties often do not elicit appropriate caregiver responses.^[47] Approaches include "Dyadic Developmental Psychotherapy,"^[48][49][50] "Watch, wait and wonder,"^[51] manipulation of sensitive responsiveness,^[52][53] modified "Interaction Guidance",^[54] "Clinician-Assisted Videofeedback Exposure Sessions (CAVES)",^[55] "Preschool Parent Psychotherapy",^[56] "Circle of Security",^[57][58] "Attachment and Biobehavioral Catch-up" (ABC),^[59] the New Orleans Intervention,^[60][61][62] and parent–child psychotherapy.^[63] Other treatment methods include Developmental, Individual-difference, and Relationship-based therapy (DIR, also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders.^[64]

The relevance of these approaches to intervention with fostered and adopted children with RAD or older children with significant histories of maltreatment is unclear.^[65]

Alternative treatment[link]

Outside the mainstream programs is a form of treatment generally known as attachment therapy, a subset of techniques (and accompanying diagnosis) for supposed attachment disorders including RAD. In general, these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers. The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasize obedience and parental control.^[66] There is considerable criticism of this form of treatment and diagnosis as it is largely unvalidated and has developed outside the scientific mainstream.^[67] There is little or no evidence base and techniques vary from non-coercive therapeutic work to more extreme forms of physical, confrontational and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model. These forms of the therapy may well involve physical restraint, the deliberate provocation of rage and anger in the child by physical and verbal means including deep tissue massage, aversive tickling, enforced eye contact and verbal confrontation, and being pushed to revisit earlier trauma.^[68][69] Critics maintain that these therapies are not within the attachment paradigm, are potentially abusive,^[70] and are antithetical to attachment theory.^[10] The APSAC Taskforce Report of 2006 notes that many of these therapies concentrate on changing the child rather than the caregiver.^[71] Children may be described as "RADs", "Radkids" or "Radishes" and dire predictions may be made as to their supposedly violent futures if they are not treated with attachment therapy.^[66] The Mayo Clinic, a well known U.S. non-profit medical practice and medical research group, cautions against consulting with mental health providers who promote these types of methods and offer evidence to support their techniques; to date, this evidence base is not published within reputable medical or mental health journals.^[72]

Prognosis[link]

The AACAP guidelines state that children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others.^[6] However, the course of RAD is not well studied and there have been few efforts to examine symptom patterns over time. The few existing longitudinal studies (dealing with developmental change with age over a period of time) involve only children from poorly run Eastern European institutions.^[6]

Findings from the studies of children from Eastern European orphanages indicate that persistence of the inhibited pattern of RAD is rare in children adopted out of institutions into normative care-giving environments. However, there is a close association between duration of deprivation and severity of attachment disorder behaviors.^[73] The quality of attachments that these children form with subsequent care-givers may be compromised, but they probably no longer meet criteria for inhibited RAD.^[74] The same group of studies suggests that a minority of adopted, institutionalized children exhibit persistent indiscriminate sociability even after more normative caregiving environments are provided.^[27] Indiscriminate sociability may persist for years, even among children who subsequently exhibit preferred attachment to their new caregivers. Some exhibit hyperactivity and attention problems as well as difficulties in peer relationships.^[75] In the only longitudinal study that has followed children with indiscriminate behavior into adolescence, these children were significantly more likely to exhibit poor peer relationships.^[76]

Studies of children who were reared in institutions have suggested that they are inattentive and overactive, no matter what quality of care they received. In one investigation, some institution-reared boys were reported to be inattentive, overactive, and markedly unselective in their social relationships, while girls, foster-reared children, and some institution-reared children were not. It is not yet clear whether these behaviors should be considered as part of disordered attachment.^[77]

There is one case study on maltreated twins published in 1999 with a follow-up in 2006. This study assessed the twins between the ages of 19 and 36 months, during which time they suffered multiple moves and placements.^[78] The paper explores the similarities, differences and comorbidity of RAD, disorganized attachment and post traumatic stress disorder. The girl showed signs of the inhibited form of RAD while the boy showed signs of the indiscriminate form. It was noted that the diagnosis of RAD ameliorated with better care but symptoms of post traumatic stress disorder and signs of disorganized attachment came and went as the infants progressed through multiple placement changes. At age three, some lasting relationship disturbance was evident.

In the follow-up case study when the twins were aged three and eight years, the lack of longitudinal research on maltreated as opposed to institutionalized children was again highlighted. The girl's symptoms of disorganized attachment had developed into controlling behaviors—a well-documented outcome. The boy still exhibited self-endangering behaviors, not within RAD criteria but possibly within "secure base distortion", (where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment). At age eight the children were assessed with a variety of measures including those designed to access representational systems, or the child's "internal working models". The twins' symptoms were indicative of different trajectories. The girl showed externalizing symptoms (particularly deceit), contradictory reports of current functioning, chaotic personal narratives, struggles with friendships, and emotional disengagement with her caregiver, resulting in a clinical picture described as "quite concerning". The boy still evidenced self-endangering behaviors as well as avoidance in relationships and emotional expression, separation anxiety and impulsivity and attention difficulties. It was apparent that life stressors had impacted each child differently. The narrative measures used were considered helpful in tracking how early attachment disruption is associated with later expectations about relationships.^[27]

One paper using questionnaires found that children aged three to six, diagnosed with RAD, scored lower on empathy but higher on self-monitoring (regulating your behavior to "look good"). These differences were especially pronounced based on ratings by parents, and suggested that children with RAD may systematically report their personality traits in overly positive ways. Their scores also indicated considerably more behavioral problems than scores of the control children.^[79]

Epidemiology[link]

Epidemiological data are limited, but reactive attachment disorder appears to be very uncommon.^[1] The prevalence of RAD is unclear but it is probably quite rare, other than in populations of children being reared in the most extreme, deprived settings such as some orphanages.^[25] There is little systematically gathered epidemiologic information on RAD.^[37] A cohort study of 211 Copenhagen children to the age of 18 months found a prevalence of 0.9%.^[80]

Attachment disorders tend to occur in a definable set of contexts such as within some types of institutions, in the presence of repeated changes of primary caregiver or of extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, but not all children raised in these conditions develop an attachment disorder.^[81] Studies undertaken on children from Eastern European orphanages from the mid-1990s showed significantly higher levels of both forms of RAD and of insecure patterns of attachment in the institutionalized children, regardless of how long they had been there.^[82][83][84] It would appear that children in institutions like these are unable to form selective attachments to their caregivers. The difference between the institutionalized children and the control group had lessened in the follow-up study three years later, although the institutionalized children continued to show significantly higher levels of indiscriminate friendliness.^[82][85] However, even among children raised in the most deprived institutional conditions the majority did not show symptoms of this disorder.^[73]

A 2002 study of children in residential nurseries in Bucharest, in which the DAI was used, challenged the current DSM and ICD conceptualizations of disordered attachment and showed that inhibited and disinhibited disorders could coexist in the same child.^[83]

There are two studies on the incidence of RAD relating to high risk and maltreated children in the U.S. Both used ICD, DSM and the DAI. The first, in 2004, reported that children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups, however this was mainly the proposed new classification of disrupted attachment disorder rather than the DSM or ICD classified RAD or DAD.^[86] The second study, also in 2004, attempted to ascertain the prevalence of RAD and whether it could be reliably identified in maltreated rather than neglected toddlers. Of the 94 maltreated toddlers in foster care, 35% were identified as having ICD RAD and 22% as having ICD DAD, and 38% fulfilled the DSM criteria for RAD.^[34] This study found that RAD could be reliably identified and also that the inhibited and disinhibited forms were not independent. However, there are some methodological concerns with this study. A number of the children identified as fulfilling the criteria for RAD did in fact have a preferred attachment figure.^[87]

It has been suggested by some within the field of attachment therapy that RAD may be quite prevalent because severe child maltreatment, which is known to increase risk for RAD, is prevalent and because children who are severely abused may exhibit behaviors similar to RAD behaviors.^[39] The APSAC Taskforce consider this inference to be flawed and questionable.^[39] Severely abused children may exhibit similar behaviors to RAD behaviors but there are several far more common and demonstrably treatable diagnoses which may better account for these difficulties.^[88] Further, many children experience severe maltreatment and do not develop clinical disorders.^[88] Resilience is a common and normal human characteristic.^[89] RAD does not underlie all or even most of the behavioral and emotional problems seen in foster children, adoptive children, or children who are maltreated and rates of child abuse and/or neglect or problem behaviors are not a benchmark for estimates of RAD.^[39]

There are few data on comorbid conditions, but there are some conditions that arise in the same circumstances in which RAD arises, such as institutionalization or maltreatment. These are principally developmental delays and language disorders associated with neglect.^[6] Conduct disorders, oppositional defiant disorder, anxiety disorders, post-traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with RAD.^[39][78] Attachment disorder behaviors amongst institutionalized children are correlated with attentional and conduct problems and cognitive levels but nonetheless appear to index a distinct set of symptoms and behaviors.^[73]

History[link]

Reactive attachment disorder first made its appearance in standard nosologies of psychological disorders in DSM-III, 1980, following an accumulation of evidence on institutionalized children. The criteria included a requirement of onset before the age of 8 months and was equated with failure to thrive. Both these features were dropped in DSM-III-R, 1987. Instead, onset was changed to being within the first 5 years of life and the disorder itself was divided into two subcategories, inhibited and disinhibited. These changes resulted from further research on maltreated and institutionalized children and remain in the current version, DSM-IV, 1994, and its 2000 text revision, DSM-IV-TR, as well as in ICD-10, 1992. Both nosologies focus on young children who are not merely at increased risk for subsequent disorders but are already exhibiting clinical disturbance.^[90]

The broad theoretical framework for current versions of RAD is attachment theory, based on work conducted from the 1940s to the 1980s by John Bowlby, Mary Ainsworth and René Spitz. Attachment theory is a framework that employs psychological, ethological and evolutionary concepts to explain social behaviors typical of young children. Attachment theory focuses on the tendency of infants or children to seek proximity to a particular attachment figure (familiar caregiver), in situations of alarm or distress, behavior which appears to have survival value.^[91] This is known as a discriminatory or selective attachment. Subsequently, the child begins to use the caregiver as a base of security from which to explore the environment, returning periodically to the familiar person. Attachment is not the same as love and/or affection although they are often associated. Attachment and attachment behaviors tend to develop between the ages of six months and three years. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time.^[92] Caregiver responses lead to the development of patterns of attachment, that in turn lead to internal working models which will guide the individual's feelings, thoughts, and expectations in later relationships.^[93][94] For a diagnosis of reactive attachment disorder, the child's history and atypical social behavior must suggest the absence of formation of a discriminatory or selective attachment.

The pathological absence of a discriminatory or selective attachment needs to be differentiated from the existence of attachments with either typical or somewhat atypical behavior patterns, known as styles or patterns. There are four attachment styles ascertained and used within developmental attachment research. These are known as secure, anxious-ambivalent, anxious-avoidant, (all organized)^[14] and disorganized.^[15][16] The latter three are characterised as insecure. These are assessed using the Strange Situation Procedure, designed to assess the quality of attachments rather than whether an attachment exists at all.^[6]

A securely attached toddler will explore freely while the caregiver is present, engage with strangers, be visibly upset when the caregiver departs, and happy to see the caregiver return. The anxious-ambivalent toddler is anxious of exploration, extremely distressed when the caregiver departs but ambivalent when the caregiver returns. The anxious-avoidant toddler will not explore much, avoid or ignore the parent—showing little emotion when the parent departs or returns—and treat strangers much the same as caregivers with little emotional range shown. The disorganized/disoriented toddler shows a lack of a coherent style or pattern for coping. Evidence suggests this occurs when the caregiving figure is also an object of fear, thus putting the child in an irresolvable situation regarding approach and avoidance. On reunion with the caregiver, these children can look dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors implying fear of the person who is being sought. It is thought to represent a breakdown of an inchoate attachment strategy and it appears to affect the capacity to regulate emotions.^[95]

Although there are a wide range of attachment difficulties within the styles which may result in emotional disturbance and increase the risk of later psychopathologies, particularly the disorganized style, none of the styles constitute a disorder in themselves and none equate to criteria for RAD as such.^[96] A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders.^[6] Reactive attachment disorder denotes a lack of typical attachment behaviors rather than an attachment style, however problematic that style may be, in that there is an unusual lack of discrimination between familiar and unfamiliar people in both forms of the disorder. Such discrimination does exist as a feature of the social behavior of children with atypical attachment styles. Both DSM-IV and ICD-10 depict the disorder in terms of socially aberrant behavior in general rather than focusing more specifically on attachment behaviors as such. DSM-IV emphasizes a failure to initiate or respond to social interactions across a range of relationships and ICD-10 similarly focuses on contradictory or ambivalent social responses that extend across social situations.^[90] The relationship between patterns of attachment in the Strange Situation and RAD is not yet clear.^[97]

There is a lack of consensus about the precise meaning of the term "attachment disorder".^[98] The term is frequently used both as an alternative to reactive attachment disorder and in discussions about different proposed classifications for disorders of attachment beyond the limitations of the ICD and DSM classifications.^[90] It is also used within the field of attachment therapy, as is the term reactive attachment disorder, to describe a range of problematic behaviors not within the ICD or DSM criteria or not related directly to attachment styles or difficulties at all.^[99]

Research[link]

Research from the late 1990s indicated there were disorders of attachment not captured by DSM or ICD and showed that RAD could be diagnosed reliably without evidence of pathogenic care, thus illustrating some of the conceptual difficulties with the rigid structure of the current definition of RAD.^[100] Research published in 2004 showed that the disinhibited form can endure alongside structured attachment behavior (of any style) towards the child's permanent caregivers.^[34]

Some authors have proposed a broader continuum of definitions of attachment disorders ranging from RAD through various attachment difficulties to the more problematic attachment styles. There is as yet no consensus, on this issue but a new set of practice parameters containing three categories of attachment disorder has been proposed by C.H. Zeanah and N. Boris. The first of these is disorder of attachment, in which a young child has no preferred adult caregiver. The proposed category of disordered attachment is parallel to RAD in its inhibited and disinhibited forms, as defined in DSM and ICD. The second category is secure base distortion, where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, cling to the adult, be excessively compliant, or show role reversals in which they care for or punish the adult. The third type is disrupted attachment. Disrupted attachment is not covered under ICD-10 and DSM criteria, and results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed.^[101] This form of categorisation may demonstrate more clinical accuracy overall than the current DSM-IV-TR classification, but further research is required.^[8][102] The practice parameters would also provide the framework for a diagnostic protocol. Most recently, Daniel Schechter and Erica Willheim have shown a relationship between some maternal violence-related posttraumatic stress disorder and secure base distortion (see above) which is characterized by child recklessness, separation anxiety, hypervigilance, and role-reversal.^[103]

Some research indicates there may be a significant overlap between behaviors of the inhibited form of RAD or DAD and aspects of disorganized attachment where there is an identified attachment figure.^[95]

An ongoing question is whether RAD should be thought of as a disorder of the child's personality or a distortion of the relationship between the child and a specific other person. It has been noted that as attachment disorders are by their very nature relational disorders, they do not fit comfortably into noslogies that characterize the disorder as centered on the person.^[104] Work by C.H. Zeanah^[34] indicates that atypical attachment-related behaviors may occur with one caregiver but not with another. This is similar to the situation reported for attachment styles, in which a particular parent's frightened expression has been considered as possibly responsible for disorganized/disoriented reunion behavior during the Strange Situation Procedure.^[105]

The draft of the proposed DSM-V suggests dividing RAD into two disorders, Reactive Attachment Disorder for the current inhibited form of RAD, and Disinhibited Social Engagement Disorder for what is currently the disinhibited form of RAD, with some alterations in the proposed DSM definition.^[106]

See also[link]

Notes[link]

References[link]

• American Psychiatric Association (1994). DSM-IV-TR: Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Text Revision Washington, DC: American Psychiatric Association. ISBN 0-89042-025-4
• Bowlby J [1969] (1997). Attachment and Loss: Attachment Vol 1 (Attachment and Loss). Pimlico; New Ed edition ISBN 0-7126-7471-3
• Bowlby J (1973). Attachment and Loss: Separation — Anxiety and Anger v. 2 (International Psycho-Analysis Library). London: Hogarth Press. ISBN 0-7012-0301-3
• Bowlby J (1980). Attachment and Loss: Loss — Sadness and Depression v. 3 (International Psycho-Analysis Library). London: Hogarth Press. ISBN 0-7012-0350-1
• Chaffin M, Hanson R, Saunders BE, et al. (2006). "Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems". Child Maltreat 11 (1): 76–89. DOI:10.1177/1077559505283699. PMID 16382093. 
• Mercer J (2006). Understanding Attachment: Parenting, child care and emotional development. Westport, CT: Praeger. ISBN 0-275-98217-3
• Prior V, Glaser D (2006). Understanding Attachment and Attachment Disorders. Theory, Evidence and Practice. Child and Adolescent Mental Health series, RCPRTU, Jessica Kingsley Publishers. ISBN 978-1-84310-245-8 (pbk)

v t e Attachment theory Theory Affectional bond Attachment in adults Attachment in children Attachment disorder Attachment measures Attachment parenting Attachment theory Human bonding Maternal deprivation Object relations theory Reactive attachment disorder Notable theorists Mary Ainsworth John Bowlby Erik Erikson Sigmund Freud Harry Harlow Jerome Kagan Melanie Klein Konrad Lorenz Mary Main Nikolaas Tinbergen Rene Spitz Controversy Attachment therapy Candace Newmaker Clinical applications Attachment-based therapy (children) Attachment-based psychotherapy

Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood, resulting in problematic social expectations and behaviors. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about six months of age but before about three years of age, frequent change of caregivers or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts. A problematic history of social relationships occurring after about age three may be distressing to a child, but does not result in attachment disorder.

The term attachment disorder is most often used to describe emotional and behavioral problems of young children, but is sometimes applied to school-age children or even to adults. The specific difficulties implied depend on the age of the individual being assessed, and a child's attachment-related behaviors may be very different with one familiar adult than with another, suggesting that the disorder is within the relationship and interactions of the two people rather than an aspect of one or the other personality.^[1] No list of symptoms can legitimately be presented but generally the term attachment disorder refers to the absence or distortion of age appropriate social behaviors with adults. For example, in a toddler, attachment-disordered behavior could include a failure to stay near familiar adults in a strange environment or to be comforted by contact with a familiar person, whereas in a six-year-old attachment-disordered behavior might involve excessive friendliness and inappropriate approaches to strangers.

There are currently two main areas of theory and practice relating to the definition and diagnosis of attachment disorder, and considerable discussion about a broader definition altogether. The first main area is based on scientific enquiry, is found in academic journals and books and pays close attention to attachment theory. It is described in ICD-10 as reactive attachment disorder, or "RAD" for the inhibited form, and disinhibited attachment disorder, or "DAD" for the disinhibited form. In DSM-IV-TR both comparable inhibited and disinhibited types are called reactive attachment disorder or "RAD".^[2]

The second area is controversial and considered pseudoscientific.^[3] It is found in clinical practice, on websites and in books and publications, but has little or no evidence base. It makes controversial claims relating to a basis in attachment theory.^[4] The use of these controversial diagnoses of attachment disorder is linked to the use of pseudoscientific attachment therapies to treat them.^[2][3]

Some authors have suggested that attachment, as an aspect of emotional development, is better assessed along a spectrum than considered to fall into two non-overlapping categories. This spectrum would have at one end the characteristics called secure attachment; midway along the range of disturbance would be insecure or other undesirable attachment styles; at the other extreme would be non-attachment.^[5] Agreement has not yet been reached with respect to diagnostic criteria.^[6]

Finally, the term is also sometimes used to cover difficulties arising in relation to various attachment styles which may not be disorders in the clinical sense.

[edit] Attachment and attachment disorder

Attachment theory is primarily an evolutionary and ethological theory. In relation to infants, it primarily consists of proximity seeking to an attachment figure in the face of threat, for the purpose of survival.^[7] Although an attachment is a "tie" it is not synonymous with love and affection although they often go together and a healthy attachment is considered to be an important foundation of all subsequent relationships. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time. Parental responses lead to the development of patterns of attachment which in turn lead to 'internal working models' which will guide the individual's feelings, thoughts and expectations in later relationships.^[8]

In the clinical sense, a disorder is a condition requiring treatment as opposed to risk factors for subsequent disorders.^[9] There is a lack of consensus about the precise meaning of the term 'attachment disorder' although there is general agreement that such disorders only arise following early adverse caregiving experiences. Reactive attachment disorder indicates the absence of either or both the main aspects of proximity seeking to an identified attachment figure. This can occur either in institutions, or with repeated changes of caregiver, or from extremely neglectful primary caregivers who show persistent disregard for the child's basic attachment needs after the age of 6 months. Current official classifications of RAD under DSM-IV-TR and ICD-10 are largely based on this understanding of the nature of attachment.

The words attachment style or pattern refer to the various types of attachment arising from early care experiences, called secure, anxious-ambivalent, anxious-avoidant, (all organized), and disorganized. Some of these styles are more problematic than others, and, although they are not disorders in the clinical sense, are sometimes discussed under the term 'attachment disorder'.

Discussion of the disorganized attachment style sometimes includes this style under the rubric of attachment disorders because disorganized attachment is seen as the beginning of a developmental trajectory that will take the individual ever further from the normal range, culminating in actual disorders of thought, behavior, or mood.^[10] Early intervention for disorganized attachment, or other problematic styles, is directed toward changing the trajectory of development to provide a better outcome later in the person's life.

Zeanah and colleagues proposed an alternative set of criteria (see below) of three categories of attachment disorder, namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". These classifications consider that a disorder is a variation that requires treatment rather than an individual difference within the normal range.^[11]

Classification[link]

ICD-10 describes Reactive Attachment Disorder of Childhood, known as RAD, and Disinhibited Disorder of Childhood, less well known as DAD. DSM-IV-TR also describes Reactive Attachment Disorder of Infancy or Early Childhood. It divides this into two subtypes, Inhibited Type and Disinhibited Type, both known as RAD. The two classifications are similar and both include:

• markedly disturbed and developmentally inappropriate social relatedness in most contexts,
• the disturbance is not accounted for solely by developmental delay and does not meet the criteria for Pervasive Developmental Disorder,
• onset before 5 years of age,
• requires a history of significant neglect, and
• implicit lack of identifiable, preferred attachment figure.

ICD-10 includes in its diagnosis psychological and physical abuse and injury in addition to neglect. This is somewhat controversial, being a commission rather than omission and because abuse in and of itself does not lead to attachment disorder.

The inhibited form is described as "a failure to initiate or respond...to most social interactions, as manifest by excessively inhibited responses" and such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain 'proximity', an essential element of attachment behavior. The disinhibited form shows "indiscriminate sociability...excessive familiarity with relative strangers" (DSM-IV-TR) and therefore a lack of 'specificity', the second basic element of attachment behavior. The ICD-10 descriptions are comparable. 'Disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in the same child. The inhibited form has a greater tendency to ameliorate with an appropriate caregiver whilst the disinhibited form is more enduring.^[12]

While RAD is likely to occur following neglectful and abusive childcare, there should be no automatic diagnosis on this basis alone as children can form stable attachments and social relationships despite marked abuse and neglect. Abuse can occur alongside the required factors but on its own does not explain attachment disorder. Experiences of abuse are associated with the development of disorganised attachment, in which the child prefers a familiar caregiver, but responds to that person in an unpredictable and somewhat bizarre way. Within official classifications, attachment disorganization is a risk factor but not in itself an attachment disorder. Further although attachment disorders tend to occur in the context of some institutions, repeated changes of primary caregiver or extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, not all children raised in these conditions develop an attachment disorder.^[13]

Boris and Zeanah's typology[link]

Many leading attachment theorists, such as Zeanah and Leiberman, have recognized the limitations of the DSM-IV-TR and ICD-10 criteria and proposed broader diagnostic criteria. There is as yet no official consensus on these criteria. The APSAC Taskforce recognised in its recommendations that "attachment problems extending beyond RAD, are a real and appropriate concern for professionals working with children", and set out recommendations for assessment.^[14]

Boris and Zeanah (1999),^[15] have offered an approach to attachment disorders that considers cases where children have had no opportunity to form an attachment, those where there is a distorted relationship, and those where an existing attachment has been abruptly disrupted. This would significantly extend the definition beyond the ICD-10 and DSM-IV-TR definitions because those definitions are limited to situations where the child has no attachment or no attachment to a specified attachment figure.

Boris and Zeanah use the term "disorder of attachment" to indicate a situation in which a young child has no preferred adult caregiver. Such children may be indiscriminately sociable and approach all adults, whether familiar or not; alternatively, they may be emotionally withdrawn and fail to seek comfort from anyone. This type of attachment problem is parallel to Reactive Attachment Disorder as defined in DSM and ICD in its inhibited and disinhibited forms as described above.

Boris and Zeanah also describe a condition they term "secure base distortion". In this situation, the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, may cling to the adult, may be excessively compliant, or may show role reversals in which they care for or punish the adult.

The third type of disorder discussed by Boris and Zeanah is termed "disrupted attachment". This type of problem, which is not covered under other approaches to disordered attachment, results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed. The young child's reaction to such a loss is parallel to the grief reaction of an older person, with progressive changes from protest (crying and searching) to despair, sadness, and withdrawal from communication or play, and finally detachment from the original relationship and recovery of social and play activities.

Most recently, Daniel Schechter and Erica Willheim have shown a relationship between maternal violence-related posttraumatic stress disorder and secure base distortion (see above) which is characterized by child recklessness, separation anxiety, hypervigilance, and role-reversal.^[16]

Problems of attachment style[link]

The majority of 12-month-old children can tolerate brief separations from familiar caregivers and are quickly comforted when the caregivers return. These children also use familiar people as a "secure base" and return to them periodically when exploring a new situation. Such children are said to have a secure attachment style, and characteristically continue to develop well both cognitively and emotionally.

Smaller numbers of children show less positive development at age 12 months. Their less desirable attachment styles may be predictors of poor later social development. Although these children's behavior at 12 months is not a serious problem, they appear to be on developmental trajectories that will end in poor social skills and relationships. Because attachment styles may serve as predictors of later development, it may be appropriate to think of certain attachment styles as part of the range of attachment disorders.

Insecure attachment styles in toddlers involve unusual reunions after separation from a familiar person. The children may snub the returning caregiver, or may go to the person but then resist being picked up. These children are more likely to have later social problems with peers and teachers, but some of them spontaneously develop better ways of interacting with other people.

A small group of toddlers show a distressing way of reuniting after a separation. Called a disorganized/disoriented style, this reunion pattern can involve looking dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors that seem to imply fearfulness of the person who is being sought.^[17] Disorganized attachment has been considered a major risk factor for child psychopathology, as it appears to interfere with regulation or tolerance of negative emotions and may thus foster aggressive behavior.^[18] Disorganized patterns of attachment have the strongest links to concurrent and subsequent psychopathology, and considerable research has demonstrated both within-the-child and environmental correlates of disorganized attachment.^[19]

Diagnosis[link]

Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation procedure (Mary Ainsworth),^[20][21][22] the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA"),^[23] the Observational Record of the Caregiving Environment ("ORCE")^[24] and the Attachment Q-sort ("AQ-sort").^[25] More recent research also uses the Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah, (1999).^[26] This 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.

Treatment[link]

There are a variety of mainstream prevention programs and treatment approaches for attachment disorder, attachment problems and moods or behaviors considered to be potential problems within the context of attachment theory. All such approaches for infants and younger children concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver.^[27][28][29] Such approaches include 'Watch, wait and wonder,'^[30] manipulation of sensitive responsiveness,^[31][32] modified 'Interaction Guidance,'.^[33] 'Preschool Parent Psychotherapy,'.^[34] 'Dyadic Developmental Psychotherapy' ^[35],^[36], ^[37] 'Circle of Security',^[38][39] Attachment and Biobehavioral Catch-up (ABC),^[40] the New Orleans Intervention,^[41][42][43] and Parent-Child psychotherapy.^[44] Other known treatment methods include Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders^[45] Some of these approaches, such as that suggested by Dozier, consider the attachment status of the adult caregiver to play an important role in the development of the emotional connection between adult and child. This includes foster parents, as children with poor attachment experiences often do not elicit appropriate caregiver responses from their attachment behaviors despite 'normative' care.^[40]

Treatment for reactive attachment disorder for children usually involves a mix of therapy, counseling, and parenting education. These must be designed to make sure the child has a safe environment to live in and to develop positive interactions with caregivers and improves their relationships with their peers.

Medication can be used as a way to treat similar conditions, like depression, anxiety, or hyperactivity; however, there is no quick fix for treating reactive attachment disorder. A pediatrician may recommend a treatment plan. For example, a mix of family therapy, individual psychological counseling, play therapy, special education services and parenting skills classes. .^[46]

Possible mechanisms[link]

One study has reported a connection between a specific genetic marker and disorganized attachment (not RAD) associated with problems of parenting.^[47] Another author has compared atypical social behavior in genetic conditions such as Williams syndrome with behaviors symptomatic of RAD.^[48]

Typical attachment development begins with unlearned infant reactions to social signals from caregivers. The ability to send and receive social communications through facial expressions, gestures and voice develops with social experience by seven to nine months. This makes it possible for an infant to interpret messages of calm or alarm from face or voice. At about eight months, infants typically begin to respond with fear to unfamiliar or startling situations, and to look to the faces of familiar caregivers for information that either justifies or soothes their fear. This developmental combination of social skills and the emergence of fear reactions results in attachment behavior such as proximity-seeking, if a familiar, sensitive, responsive, and cooperative adult is available. Further developments in attachment, such as negotiation of separation in the toddler and preschool period, depend on factors such as the caregiver's interaction style and ability to understand the child's emotional communications.^[49]

With insensitive or unresponsive caregivers, or frequent changes, an infant may have few experiences that encourage proximity seeking to a familiar person. An infant who experiences fear but who cannot find comforting information in an adult's face and voice may develop atypical ways of coping with fearfulness such as the maintenance of distance from adults, or the seeking of proximity to all adults. These symptoms accord with the DSM criteria for reactive attachment disorder.^[50] Either of these behavior patterns may create a developmental trajectory leading ever farther from typical attachment processes such as the development of an internal working model of social relationships that facilitates both the giving and the receiving of care from others.^[51][52]

Atypical development of fearfulness, with a constitutional tendency either to excessive or inadequate fear reactions, might be necessary before an infant is vulnerable to the effects of poor attachment experiences.^[53]

Alternatively, the two variations of RAD may develop from the same inability to develop "stranger-wariness" due to inadequate care. Appropriate fear responses may only be able to develop after an infant has first begun to form a selective attachment. An infant who is not in a position do this cannot afford not to show interest in any person as they may be potential attachment figures. Faced with a swift succession of carers the child may have no opportunity to form a selective attachment until the possible biological-determined sensitive period for developing stranger-wariness has passed. It is thought this process may lead to the disinhibited form.^[54]

In the inhibited form infants behave as if their attachment system has been "switched off". However the innate capacity for attachment behavior cannot be lost. This may explain why children diagnosed with the inhibited form of RAD from institutions almost invariably go on to show formation of attachment behavior to good carers. However children who suffer the inhibited form as a consequence of neglect and frequent changes of caregiver continue to show the inhibited form for far longer when placed in families.^[54]

Additionally, the development of Theory of Mind may play a role in emotional development. Theory of Mind is the ability to know that the experience of knowledge and intention lies behind human actions such as facial expressions. Although it is reported that very young infants respond differently to humans and objects, Theory of Mind develops relatively gradually and possibly results from predictable interactions with adults. However, some ability of this kind must be in place before mutual communication through gaze or other gesture can occur, as it does by seven to nine months. Some neurodevelopmental disorders, such as autism, have been attributed to the absence of the mental functions that underlie Theory of Mind. It is possible that the congenital absence of this ability, or the lack of experiences with caregivers who communicate in a predictable fashion, could underlie the development of reactive attachment disorder.^[55][56]

Pseudoscientific diagnoses and treatment[link]

In the absence of officially recognized diagnostic criteria, and beyond the ambit of the discourse on a broader set of criteria discussed above, the term attachment disorder has been increasingly used by some clinicians to refer to a broader set of children whose behavior may be affected by lack of a primary attachment figure, a seriously unhealthy attachment relationship with a primary caregiver, or a disrupted attachment relationship.^[57] Although there are no studies examining diagnostic accuracy, concern is expressed as to the potential for over-diagnosis based on broad checklists and 'snapshots'.^[58] This form of therapy, including diagnosis and accompanying parenting techniques, is scientifically unvalidated and is not considered to be part of mainstream psychology or, despite its name, to be based on attachment theory, with which it is considered incompatible.^[59][60] It has been described as potentially abusive and a pseudoscientific intervention, that has resulted in tragic outcomes for children.^[3]

A common feature of this form of diagnosis within attachment therapy is the use of extensive lists of "symptoms" which include many behaviours that are likely to be a consequence of neglect or abuse, but are not related to attachment, or not related to any clinical disorder at all. Such lists have been described as "wildly inclusive".^[61] The APSAC Taskforce (2006) gives examples of such lists ranging across multiple domains from some elements within the DSM-IV criteria to entirely non-specific behavior such as developmental lags, destructive behaviors, refusal to make eye contact, cruelty to animals and siblings, lack of cause and effect thinking, preoccupation with fire, blood and gore, poor peer relationships, stealing, lying, lack of a conscience, persistent nonsense questions or incessant chatter, poor impulse control, abnormal speech patterns, fighting for control over everything, and hoarding or gorging on food. Some checklists suggest that among infants, “prefers dad to mom” or “wants to hold the bottle as soon as possible” are indicative of attachment problems. The APSAC Taskforce expresses concern that high rates of false positive diagnoses are virtually certain and that posting these types of lists on web sites that also serve as marketing tools may lead many parents or others to conclude inaccurately that their children have attachment disorders."^[62]

There is also a considerable variety of treatments for alleged attachment disorders diagnosed on the controversial alternative basis outlined above, popularly known as attachment therapy. These therapies have little or no evidence base and vary from talking or play therapies to more extreme forms of physical and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model. In general these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers. Critics maintain these therapies are not based on an accepted version of attachment theory.^[63] The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasise obedience and parental control.^[64] These therapies concentrate on changing the child rather than the caregiver.^[65] An estimated six children have died as a consequence of the more coercive forms of such treatments and the application of the accompanying parenting techniques.^[66][67][68]

Two of the most well-known cases are those of Candace Newmaker in 2001 and the Gravelles in 2003 through 2005. Following the associated publicity, some advocates of attachment therapy began to alter views and practices to be less potentially dangerous to children. This change may have been hastened by the publication of a Task Force Report on the subject in January 2006, commissioned by the American Professional Society on the Abuse of Children (APSAC) which was largely critical of attachment therapy, although these practices continue.^[69] In April 2007, ATTACh, an organisation originally set up by attachment therapists, formally adopted a White Paper stating its unequivocal opposition to the use of coercive practices in therapy and parenting.^[70]

See also[link]

• Emotional dysregulation
• John Bowlby

Notes[link]

References[link]

Further reading[link]

• Holmes, J (2001). The Search for the Secure Base. Philadelphia: Brunner-Routledge. ISBN 1-58391-152-9
• Cassidy, J; Shaver, P (eds.) (1999). Handbook of Attachment: Theory, Research, and Clinical Applications. New York: Guilford Press. ISBN 1-57230-087-6.
• Zeanah, CH (ed.) (1993). Handbook of Infant Mental Health. New York: Guilford Press. ISBN 1-59385-171-5
• Bowlby, J (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. London: Routledge; New York: Basic Books. ISBN 0-415-00640-6.