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. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about age 6 months but before about age 3 years, 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 3 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. Thus, no general list of symptoms of attachment disorder can legitimately be presented.
Reactive attachment disorder (also known as "RAD") is the broad term used to describe those disorders of attachment which are classified in ICD-10 94.1 and 94.2, and DSM-IV 313.89. RAD arises from a failure to form normal attachments to primary care giving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about age 6 months but before about age 3 years, frequent change of caregivers, or lack of caregiver responsiveness to child communicative efforts. It is characterized by markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before the age of 5 years. The theoretical base for reactive attachment disorder is attachment theory.
Children who are adopted after the age of six months are at risk for attachment problems.[2] Normal attachment develops during the child's first two to three years of life. Problems with the caregiver-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. However, less than ideal attachment styles are not within the criteria for RAD.
ClassificationICD-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 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.
* 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.
* Implicit lack of identifiable, preferred attachment figure.
There must be a history of 'pathogenic care' defined as disregard of the childs basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discrimination or selective attachment that is presumed to account for the disorder. Unusually therefore part of the diagnosis is 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 way to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent, or contradictory responses, eg the child may respond to caregivers with a mixture of approach, avoidance and resistance to comforting, or may exhibit frozen watchfulness.
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, eg excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures"
There is therefore a lack of 'specificity', 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:
* psychological and physical abuse and injury in addition to neglect. This somewhat controversial, being a commission rather than ommission and because abuse of itself does not lead to attachment disorder.
* associated emotional disturbance.
* poor social interaction with peers.
'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. However, the disinhibited form can endure alonside structured attachment behavior towards the childs permanent caregivers.
Whilst RAD is likely to occur in relation to 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. It is associated with developed, albeit disorganized attachment. 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.
IncidenceRAD is considered to be "very uncommon" under the DSM-IV-TR criteria although there is an estimate of prevalence amongst children freed for adoption within the USA foster care system of 10%.[5] There has been considerable recent research into prevalence amongst children cared for in orphanages, particularly in Romania, where conditions of extreme deprivation were not uncommon.
There are no precise statistics on prevalence. According to the APSAC Taskforce Report (2006), some have suggested that RAD may be quite prevalent because severe child maltreatment, which is known to increase risk for RAD, is prevalent. The Taskforce did not agree with this view as severely abused children may exhibit similar behaviors to RAD behaviors and there are several far more common and demonstrably treatable diagnoses which may better account for these difficulties. Many children experience severe maltreatment but do not develop clinical disorders. The Taskforce states that it should not be assumed that RAD underlies all or even most of the behavioral and emotional problems seen in foster children, adoptive children, or children who are maltreated. Rates of child abuse and/or neglect or problem behaviors should not serve as a benchmark for estimates of RAD. The Taskforce further point out that according to the DSM, RAD is presumed to be a “very uncommon” disorder (APA, 1994).[6]
According to Prior and Glaser (2006), in the absence of available and responsive caregivers it appears that some children are particularly vulnerable to developing attachment disorders. "The prevalence is unclear but is probably quite rare, other than in populations of children being reared in the most extreme, deprived settings such as some orphanages."[4] Many children who have experienced serious maltreatment at the hands of their primary caregiver may have formed a disorganized attachment which manifests itself in difficult behaviors, but they would not fulfil the current criteria for RAD. There is a lack of clarity about the presentation of attachment disorders over the age of 5 years and difficulty in distinguishing between aspects of attachment disorders, disorganized attachment or the sequalae of maltreatment. [4]
TreatmentThere is a variety of effective prevention programs and treatment approaches for attachment disorder based on Attachment theory. All approaches concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver. Approaches with a sound evidential and theoretical base include 'Watch, wait and wonder' (Cohen et al, 1999), manipulation of sensitive responsiveness, (van den Boom 1994 and 1995), modified 'Interaction Guidance' (Benoit et al, 2001), 'Preschool Parent Psychotherapy' (Toth et al, 2002) and Parent-Child psychotherapy (Leiberman et al 2000).[4][1] Other known treatment methods include 'Circle of Security' (Marvin et al, 2002) and 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.
There is considerable controversy over the diagnosis and treatment of attachment disorders including reactive attachment disorder, by attachment therapists, a form of diagnosis and treatment that is largely unvalidated and has developed outside the scientific mainstream.[6]These therapies have little or no evidence base and vary from mild therapeutic work 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 carers. Critics maintain that the link between this kind of therapy and attachment theory is at best tenuous.[4] Many of these therapies concentrate on changing the child rather than the caregiver. (Chaffin et al 2006)
Recent research on deprived populationsA 1998 study showed that children adopted from poorly run Romanian orphanages had a higher frequency of insecure patterns of attachment than control groups, although this difference improved in the follow-up study 3 years later. [11][12] However they continued to show significantly higher levels of indiscriminate friendliness.
A later study looked at chidren adopted in the UK who had suffered early severe deprivation in Romania, some 'early placed' and some 'late placed'. The 'late-placed' children showed a far higher incidence of atypical insecure patterns such as displaying both strong avoidant and strong dependent attachment behavior patterns. [13]
A 2002 study of children in residential nurseries in Bucharest, using the DAI, challenged the current DSM and ICD conceptualisations of disordered attachment and showed that inhibited and disinhibited disorders could co-exist in the same child. It also showed higher incidence of RAD in the standard care group in the institution than in the 'pilot group' receiving more consistent care, or in the non-institutionalised group. [14]
A 2005 study comparing institutionalised and community children in Bucharest, using the DAI, again showed significantly higher levels of both forms of RAD in the institutionalised children, regardless of how long they had been there. Further, only 22% of the institutionalised children had organised attachments as opposed to 78% of the community children, and all the children in the community group showed clear attachment patterns as opposed to only 3% in the institutionalised group. It would appear that children in institutions like these are unable to form selective attachments to their caregivers. The study also concluded the signs of RAD related to how fully developed and expressed attachment behaviors are rather than the organisation of a particular pattern.[15]
There are two important studies relating to high risk and maltreated children in the USA. The first, in 2004, compared ill-treated children in foster care, children in a homeless shelter with their mothers and low income children in the Head Start programme. The children were assessed using DSM and ICD and Zeanah and Boris' alternative proposed criteria. The study reports that children from the maltreatment sample were significantly more more likely to meet criteria for one or more attachment disorders than children from the other groups, however this was mainly disrupted attachment disorder rather than DSM or ICD classified disorder. Under DSM and ICD classifications there was little difference between the foster care and homeless shelter groups.[16]
The second study, also in 2004, was for the purposes of ascertaining prevalence of RAD, whether RAD could be reliably identified in maltreated rather than neglected toddlers and whether the two types of RAD were independent. The DAI and DSM and ICD were used. 35% were identified as having ICD RAD and 22% as having ICD DAD. 38% fulfilled the DSM criteria for RAD. [17]The 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 did in fact have a preferred attachment figure.[4] This study also showed that mothers with a history of psychiatric problems were more likely to have children exhibiting signs of inhibited/emotionally withdrawn RAD but mothers with a history of psychiatric problems and substance misuse had children more likely to exhibit signs of disinhibited/indiscriminate RAD. [17]
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References 1. ^ a b Practice Parameter for the Assessment and Treatment of Children and Adolescents with Reactive Attachment Disorder of Infancy and Early Childhood. AACAP 2005
2. ^ Brodzinsky, D., Schechter, M., & Henig, R.,(Eds.) (1992) On Being Adopted, Doubleday, NY.
3. ^ O'Connor TG; Zeanah CH (Sep 2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment & Human Development 5 (3): 223-244. DOI:10.1080/14616730310001593974. ISSN 1461-6734.
4. ^ a b c d e f g Prior V., Glaser D., book "Understanding Attachment and Attachment Disorders. Theory, Evidence and Practice. 2006. Child and Adolescent Mental health series, RCPRTU, Jessica Kingsley Publishers.
5. ^ 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.
6. ^ a b c Chaffin M; et al. (Feb 2006). Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems. Child Maltreatment 11 (1): 76-89. DOI:10.1177/1077559505283699. ISSN 1552-6119.
7. ^ Randolph, Elizabeth Marie. (1996) Randolph Attachment Disorder Questionnaire:Institute for Attachment, Evergreen CO.
8. ^ "The findings showed that children in foster care have reported symptoms within the range typical of children not involved in foster care. The conclusion is that the RADQ has limited usefulness due to its lack of specificity with implications for treatment of children in foster care".Cappelletty, G., Brown, M., Shumate, S. "Correlates of the Randolph Attachment Disorder Questionnaire (RADQ) in a Sample of Children in Foster Placement". Child and Adolescent Social Work Journal, Volume 22, Number 1, February 2005 , pp. 71-84(14)
9. ^ Smyke,A. and Zeanah,C. (1999)'Disturbaces of Attachment Interview'. Available on the Journal of the American Academy of Child and Adolescent Psychiatry website at www.jaacap.com
10. ^
11. ^ Chisholm K. Carter M., Ames E.,and Morison S.,(1995) 'Attachment Security and indiscriminately friendly behavior in children adopted from Romanian orphanages.' Development and psychopathology 7, 283-294
12. ^ Chisholm K., (1998) 'A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian orphanages.'
13. ^ O'Connor T., Marvin R., Rutter M., Olrick J., BritnerP. and the English and Romanian Adoptees Study Team (2003b) 'Child-parent attachment following early institutional deprivation.' Development and Psychopathology 15, 19-38.
14. ^ Smyke,A., Dumitrescu,A. and Zeanah,C (2002) 'Attachment disturbances in young children.: The continuum of caretaking casualty.' Journal of the American Academy of Child and Adolescent Psychiatry 41, 972-982.
15. ^ Zeanah,C., Smyke,A., Koga,S,. and Carlson,E. (2005) 'Attachments in institutionalised and Community Children in Romania' Child Development 76, 1015-1028.
16. ^ Boris,N., Hinshaw-Fuselier,S., Smyke,A., Scheeringa,M., Heller,S., and Zeanah,C. (2004) 'Comparing criteria for attachment disorders: establishing reliability and validity in high risk samples.' Journal of the American Acxademy of Child and Adolescent psychiatry 43, 568-577
17. ^ a b Reactive Attachment Disorder in Maltreated Toddlers", "Zeanah,C,. Scheeringa,M,. Boris,N,. Heller,S,. Smyke,A,. and Trapani,J. (2004) Child Abuse & Neglect: The International Journal", 2004-28-8. Retrieved on April 25, 2007.
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Video Tutorial: Parenting RAD ChildrenYou have adopted a girl who is 9 years old from the Foster Care system. You know that she has lived in 10 different homes with 10 different sets of caregivers in her lifetime, and she has witnessed domestic violence, as well as been abused and neglected. You are busy preparing dinner for your family. Click begin [below] to see a video of a situation. After you watch the situation, you must choose a response. Your goal is to respond in a way that helps build a healthy attachment, while keeping parent and child anger levels down. There are three meters to measure your progress, parent anger, child anger, attachment. Try to keep the anger meters low, and the attachment meter high. When you've finished the activity, return to the Parenting Activities page to try again. Good luck!
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BEGIN [Online Parent Support RAD Site]
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Parenting RAD Children
