Reactive attachment disorder
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Reactive Attachment Disorder (RAD) is a condition where children fail to form normal attachments to caregivers. There are two subtypes - inhibited and disinhibited. It results from pathogenic or severely neglectful care before age 5. Diagnosis involves disturbed social relationships and lack of appropriate response to caregivers. Treatment aims to enhance security, stability and caregiver sensitivity through parenting skills training, play therapy, and establishing consistent routines and discipline. The goal is to help the child form a secure attachment to promote healthy development.
Reactive attachment disorder
- 1. Reactive Attachment Disorder Diagnosis and Treatment Brooke Schauder, MS Erie Psychology Consortium
- 2. DSM IV Definition: A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5, as evidenced by either 1 or 2: 1. Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as inhibited, or highly ambivalent and contradictory responses.
- 3. 2. diffuse attachments as manifested by indiscriminate sociability. Not accounted for by MR or a PDD. Pathogenic care as: Disregard for basic emotional needs or comfort, stimulation, and affection. Disregard for basic physical needs. Repeated changes of primary caregiver preventing formulation of stable attachment (i.e., foster care changes).
- 4. Types Inhibited Type : Child does not initiate and respond to social interactions appropriately. Disorder of nonattachment related to loss of primary caregiver. Disinhibited Type : Diffuse attachments and indiscriminating sociability. Disorder of repeated loss of attachment figures. (more common type)
- 5. Associated Features (RED FLAGS) Grossly Pathological Care Foster Care Changes Prolonged Hospitalization of Caregiver or Child (Postpartum Depression) Developmental Delays Feeding Disorder Pica Rumination Disorder Malnutrition in lab findings
- 6. More RED FLAGS Isolated parents Depressed/SMI parents Parents who lack financial resources and social support. Suicidal behavior in young children / severe aggression Cruelty to animals in young children.
- 7. Differential Diagnoses Mental Retardation ( MR children can have normal attachments ) Autism and other Pervasive Developmental Disorder ( communication problems with PDD as well as behavioral stereotypes) Social Phobia ( inhibition is not present among family members) ADHD ( disinhibited type of RAD is socially impulsive/inappropriate only ) ODD/Conduct ( Evidence of pathologic care responsible for behavior in RAD )
- 8. Things to be Aware of in Clinical Interview Many RAD children have capability to “fake good” for short period of time. Symptoms usually displayed more intensely with mother than father. Parent’s will be uncertain of how to respond to “Does your child love you?”
- 9. Things to be Aware of in Clinical Interview Caregivers will report anger management issues – temper tantrums. Parents will report that child is a “control freak” or extremely strong willed. Often symptoms occur by age 2 (ask about child’s history of attachment).
- 10. Additional Subtypes of RAD Ambivalent: angry, oppositional, violent Anxious: clingy, anxious, separation anxiety. Avoidant: compliant, agreeable, superficially engaging, but lacks depth to emotion. Disorganized Subtype: Bizarre symptoms.
- 11. Treatment No scientifically established treatments exist for RAD. Strategy is to teach caregiver: About the disorder About activities that promote normal child development How to play with the child How to manage child’s aggressive and problematic behavior How to communicate with the child
- 12. Therapy Goals Enhance child’s sense of security , or sense of psychological safety . Establish sense of stability or permanence of attachment figure. Enhance the sensitivity or emotional availability from the caregiver.
- 13. Objective Treatment Goals Increased Eye Contact Increased effort to seek out caregiver when in need. Increased vocalization to parent. Increased affection from both parent and child. Increased amount of reciprocal responses. Increased independent actions, not stemming from passive aggression or anger.
- 14. Play Therapy Art therapy: Draw the “family doing something”. Doll Play – dollhouse Completing a story. RAD symptoms: family separate or child alone, chaotic themes, disorganization, fear, violence, punishment.
- 15. What to focus on in therapy Child’s lack of empathy - model empathy for child and parent. Many are preoccupied with violent play, blood, etc. – model non-violent, appropriate social play and social stories. Many do not appear to show regret for harm – model sincerity in apology and encourage discussion of “conscience” in older children.
- 16. Bowlby’s stages of Attachment 1. 0-8 weeks: infant’s communication of need for proximity and physical contact through vocal and behavioral cues. Therapy may consist of learning to give affection, eye contact, and rewarding appropriate verbalizations for both the parent and child.
- 17. Bowlby’s stages 2. 8-12 weeks: child establishes indicators of caregiver preference through behavioral cues such as reaching and scooting. In therapy, encourage a disinhibited child for appropriately distinguishing between parents, non-parent friends, and strangers.
- 18. Bowlby’s stages 3. 12 weeks – 2 years: Child begins to anticipate caregiver actions and adjusts behavior accordingly. Therapy focuses on encouraging appropriate responses and interactions from both parent and child. Stress is on consistency in responses.
- 19. Bowlby’s stages 4. 2 years – childhood: Independence is introduced and the concept of Reciprocity in responses is the focus. Enabling the child to gain independence, but being available when necessary is key at this phase.
- 20. Parenting Skills Discipline is vital to give child sense of safety and security: Encourage parent to express anger or discipline consistently, but quickly and effectively. Consequence should be as “natural” as possible, in terms of relationship with misbehavior. (ie., If child refuses to eat, remove him from the table, if he yells, send to private area, etc.)
- 21. Parenting Skills (Continued) In the beginning of forming new attachment, close proximity between caregiver and child may be necessary. An older child (age 7) may need constant monitoring that would seem appropriate for a 3-year old. This may be necessary for the child to rely on parents to shape behavior and learn trust.
- 22. Recommended RAD Articles Sheperis, C.J., Renfro-Michel, E.L., Doggett, R.A. (2003). In-Home treatment of reactive attachment disorder in a therapeutic foster care setting: A case example. Journal of Mental Health Counseling , 25(1), 7-8. Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development , 6(3), 263-278. Wilson, S.L. (2001). Attachment disorders: review and current status. Journal of Psychology, 135(1), 37-51.
Editor's Notes
- #5: According to DSM
- #6: On the left are the situational factors that should be a red flag to alert you to the possibility of RAD presentation -most often you will see the first factor as the causal one – pathologic care, as severe and chronic neglect or abuse, but sometimes RAD can occur after hospitalized (of caregiver or child) during the critical attachment periods in the first years of life -it can also occur because of a severe postpartum depression – resulting in nonattachment during the first months or year of life. Even though after that point the mother’s depression may remit, there is an important window of time that the primary attachment occurs and if this isn’t met during that period, it can severely disrupt the bond that the infant develops. -on the right are comorbid symptoms – not differential diagnoses necessarily, but problems that commonly co-occur with RAD
- #7: Obviously some of these signs are also signs of other disorders and commonly results of child abuse, but still when one of these comes up, you should automatically think RAD as a rule-out diagnosis.
- #11: These subtypes are not defined in the DSM, but are fairly accepted classifications among literature
- #12: There is not yet a strict “best practices” method for treating RAD. In the past, something called “holding therapy,” in which they would physically restrain the child and provoke him to anger and then soothe the child – sound somewhat similar to how to establish learned helplessness and is rarely used. Little, if any support for it’s effectiveness and may be harmful. Right now, the agreed upon method basically entails training the parent on how to interact with the child to re-establish the bond. Perhaps more than in some other disorders of childhood, the parent has to be VERY involved in this therapy, as it is based primarily on interaction between the child and parent. If the parent is not yet ready emotionally to undergo this type of interaction or if she/he is at all distant, aloof, avoidant, etc. the therapy will be inappropriate and maybe even disruptive to the child.
- #13: Three S’s are really the goals of therapy:
- #15: Play therapy can be a good intervention and also an excellent way to monitor symptoms and progress. Telling the child to draw a picture of a “family doing something” is used commonly to assess the child’s opinions or emotions – this is a projective measure – of feelings toward family. Make sure you only state that instruction “draw your family doing something” and don’t use the word “together” and then see what the child comes up with. There is not an empirically validated method for scoring these, but fortunately in one study, non-professionals were quite accurate at deciding whether a drawing was done by a child with a disorganized caregiver attachment.
- #17: It’s good to keep these stages of attachment in mind when doing therapy. The child may have moved appropriately through some stages, but not others. Or, if the disruption in attachment was early, you may need to progress through each level with the parent and child.