Reactive attachment disorder

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Reactive Attachment Disorder
Classification & external resources
ICD-10 F94.1/2
ICD-9 313.89

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 five years of age 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.

A study by the National Adoption Center found that 52% of adoptable children (meaning those children in U.S. foster care freed for adoption) had symptoms of RAD. Other estimates range from 10 to 80%. [1][2]

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.

Contents

[edit] 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.

Children who are adopted after the age of six months are at risk for attachment problems.[3] 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 Bowlby.

When the first-year-of-life attachment-cycle is undermined (Basic Trust vs. Mistrust, in Erik Erikson's framework) 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. [4] [5] In direct consequence, 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. [6]

[edit] Framework

The theoretical framework for Reactive Attachment Disorder is Attachment theory based on work by Bowlby, Ainsworth and Spitz, from the 1940s to the 1980s.

The development of diagnostic criteria was further operationalised by Zeanah and O’Connor throughout the 1980s and 1990s9, 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)

A defining characteristic of Reactive Attachment Disorder is early chronic maltreatment. Maltreatment means child abuse, physical abuse, neglect, sexual abuse, and is closely associated with Complex post-traumatic stress disorder. Another defining trait of Reactive Attachment Disorder is Emotional dysregulation.

[edit] 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.

There are various "attachment styles" that are not pathological, and attachment issues that may be found anywhere within 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" of the self. This working model is shaped by the child's attachment to mother and father. [7] Many parents of RAD children report that they do not understand what their child is thinking or feeling. This may be due to inconsistent signals from the child, or to the inability of parents to interpret signals (due, for example, to the parents own experience with childhood abuse), or both. As with all disorders, the focus of the diagnosis of RAD is on the cause of the observed attachment style, not on specific symptoms or surface behaviors.

[edit] Intervention

Evidence based approaches do exist for the effective treatment of Reactive Attachment Disorder. Two important studies found that "usual treatments" for RAD are ineffective, while the intervention under investigation, Dyadic Developmental Psychotherapy (10) (11), was effective [8]. (see "Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy", Child and Adolescent Social Work Journal. 23(2), April 2006). There is a significant body of literature on the assessment and treatment of Post Traumatic Stress Disorder and Complex Post Traumatic Stress Disorder which apply to the treatment of this condition.

[edit] Dyadic Developmental Psychotherapy

Dyadic Developmental Psychotherapy[9] [10] is an effective and evidence-based treatment developed by Daniel Hughes, Ph.D., (Hughes, 2005, Hughes, 2004, Hughes, 2003; Hughes, 1997)(13-15). Its basic principals are described by Hughes (2003) and summarized as follows:

1. A focus on both the caregivers and therapists own attachment strategies. Previous research (Dozier, 2001,(16) Tyrell 1999 (17)) has shown the importance of the caregivers and therapists state of mind for the success of interventions.

2. Therapist and caregiver are attuned to the child’s subjective experience and reflect this back to the child. In the process of maintaining an intersubjective attuned connection with the child, the therapist and caregiver help the child regulate affect and construct a coherent autobiographical narrative.

3. Sharing of subjective experiences.

4. Use of PACE and PLACE are essential to healing.

5. Directly address the inevitable misattunements and conflicts that arise in interpersonal relationships.

6. Caregivers use attachment-facilitating interventions.

7. Use of a variety of interventions, including cognitive-behavioral strategies.

PACE refers to the therapist setting a healing pace by being playful, accepting, curious, and empathic. PLACE refers to the parent creating a healing environment by being playful, loving accepting, curious, and empathic. These ideas are described more fully below.

Dyadic Developmental Psychotherapy interventions flow from several theoretical and empirical lines (Becker-Weidman & Shell, 2005). Attachment theory (Bowlby, 1980, Bowlby, 1988) provides the theoretical foundation for Dyadic Developmental Psychotherapy.

This treatment has been found to produce meaurable and sustained improvement in children diagnosed with Reactive Attachment Disorder (Becker-Weidman, 2005)(12). In that study it was found that other forms of treatment, such as individual therapy or play therapy did not produce any improvement; thus indicating that Dyadic Developmental Psychotherapy is effective while other forms of treatment are not effective for this disorder.

[edit] References

  1. ^ 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.
  2. ^ Cicchetti D., Cummings E.M., Greenberg M.T., & Marvin R.S.: An organizational perspective on attachment beyond infancy. In: Attachment in the Preschool Years. Ed. Greenberg M.T., Cicchetti D., & Cummings E.M., Chicago: University of Chicago Press, 1990.
  3. ^ Brodzinsky, D., Schechter, M., & Henig, R.,(Eds.) (1992) On Being Adopted, Doubleday, NY.
  4. ^ Erikson, E., (1968), Identity, Youth and Crisis, NY: Norton
  5. ^ Becker-Weidman, A., & Shell, D., (Eds.)(2005), Creating Capacity For Attachment, Wood 'N' Barnes, Oklahoma City, OK.
  6. ^ Cassidy, J., & Shaver, P., (Eds.), Handbook of Attachment: Theory, Research, and Clinical Applications, NY: Guilford
  7. ^ Verschueren, K, Marcoen A, Schoefs V (1996) "The internal working model of the self, attachment, and competence in five-year-olds", Child Development, vol 67, No. 5, pp.2493-2511.
  8. ^ Becker-Weidman, A., (2006c) “Treatment For Children with Reactive Attachment Disorder: Dyadic Developmental Psychotherapy,” Child and Adolescent Mental Health Published article online: 21-Nov-2006 doi: 10.1111/j.1475-3588.2006.00428.x.
  9. ^ Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity For Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9
  10. ^ Becker-Weidman, A., (2006). Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy, Child and Adolescent Social Work Journal. Vol. 23 #2, April 2006.
  1. Alston, John. (2000) Characteristics of Attention Deficit Disorder, Bipolar I Disorder and Reactive Attachment Disorder.
  2. Alston, John. (2000) op cit.
  3. 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).
  4. Ames, Elinor op cit.
  5. Randolph, Elizabeth Marie. (1996) Randolph Attachment Disorder Questionnaire:Institute for Attachment, Evergreen CO.
  6. Speltz (2002) Description, History, and Critique of Corrective Attachment Therapy. The APSAC Advisor 14(3), 4-8.
  7. O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244:Taylor and Francis.
  8. "Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy" Child and Adolescent Social Work Journal. 12(6), December 2005.
  9. Creating Capacity For Attachment, (Eds.) Arthur Becker-Weidman, Ph.D., & Deborah Shell, MA, Wood 'N' Barnes, OK: 2005.
  10. As of 2004, these US states have forbidden rebirthing or 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.
  11. Hughes, D. (1997). Facilitating developmental attachment. NJ: Jason Aronson.
  12. Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 3, 263–278.
  13. Hughes, D. (2003). Psychological intervention for the spectrum of attachment disorders and intrafamilial trauma. Attachment & Human Development, 5, 271–279.Hughes, D., "The Development of Dyadic Developmental Psychotherapy", In Becker-Weidman, A., & Shell, D., (Eds.), Creating Capacity for Attachment. OK: Wood ‘N’ Barnes, 2005, pp vii – xvii.
  14. Dozier, M. Stovall, K.C., Albus, K.E., & Bates, B. (2001) Attachment for Infants in Foster Care: The Role of Caregiver State of Mind. Child Development, 70, 1467-1477.
  15. Tyrell, C., Dozier, M., Teague, G.B. & Fallot, R. (1999). Effective treatment relationships or persons with serious psychiatric disorders: the importance of attachment states of mind. Journal of Consulting and Clinical Psychology, 67, 725-733.
  16. Cicchetti, D., & Toth, S., (Eds). (1995) Child Abuse, Child Development, and Social Policy. Ablex Pub., Norwood, NJ.
  17. See the Journal, 'Attachment and Human Behavior,' which is peer-reviewed.
  18. See the Journal, 'Child & Adolescent Social Work,' which is peer-reviewed.
  19. See the Journal, 'Infant Mental Health,' which is peer-reviewed.
  20. American Professional Society on the Abuse of Children, Task Force Report on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems


[edit] See also

Attachment theory

Attachment in children | Attachment in adults | Attachment measures | Attachment disorder | Reactive attachment disorder | Dyadic Developmental Psychotherapy | Theraplay | Object relations theory | Affectional bond | Human bonding

Notable Theorists: Mary Ainsworth | John Bowlby | Erik Erikson | Sigmund Freud | Jerome Kagan | Melanie Klein

[edit] External links

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