Reactive attachment disorder

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Overview
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 characterised 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.

Differential Diagnosis
It should be differentiated from pervasive developmental disorder or mental retardation, both of which conditions can affect attachment. RAD is likely to occur in the context of abusive or impoverished childcare although there can be no diagnosis on this basis alone as many children with such backgrounds do not develop RAD.

RAD should also be differentiated from less than ideal attachment 'styles' or  attachment difficulties which do not amount to the clinical disorder defined as RAD.

RAD was first defined in DSM in 1980. Important modifications have been made but the core remains the same. The definitions in ICD-10 and DSM-IV-TR are similar but not identical and are under constant review in this somewhat controversial area. Leading theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined.

Theoretical 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. Attachment theory is an evolutionary theory whereby the infant or child seeks proximity to a specified attachment figure in situations of alarm or distress, for the purpose of survival. Attachment is not the same as love and/or affection although they often go together. Attachment and attachment behaviors tend to develop between the age of 6 months and 3 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. RAD requires one or both of the attachment behaviors of proximity seeking to a specified attachment figure to be missing. There are a number of attachment 'styles' namely 'secure', 'anxious-ambivalent', 'anxious-avoidant', (all 'organized') and 'disorganized', some of which are more problematical than others, but none constitute a 'disorder' in themselves.

A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders.(AACAP 2005, p1208 ) 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.

Children who are adopted after the age of six months are at risk for attachment problems. Normal attachment develops during the child's first two to three years of life. Problems with the 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.

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 but there is as yet no consensus on this issue. In particular, Zeanah and Boris, building on the earlier work of Leiberman, propose three categories; firstly "disorder of attachment" to indicate a situation in which a young child has no preferred adult caregiver, parallel to Reactive Attachment Disorder as defined in DSM and ICD in its inhibited and disinhibited forms. Secondly "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, may cling to the adult, may be excessively compliant, or may show role reversals in which they care for or punish the adult. Thirdly "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.

Classification
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 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.

Incidence
RAD 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%. 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).

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." 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.

Diagnosis
According to the APSAC Taskforce Report (2006), RAD is one of the least researched and most poorly understood disorders in the DSM. They make the point that there is little systematically gathered epidemiologic information on RAD, its "course" is not well established and it appears difficult to diagnose RAD accurately. Several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, PTSD 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 autistic spectrum disorders, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. Some children simply have very different temperamental dispositions. The Taskforce specifically state "Because of these diagnostic complexities, careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is a must (Hanson & Spratt, 2000; Wilson, 2001)".

In the absence of a standardised diagnosis system, many popular, informal classification systems, outside the DSM and ICD, were created out of clinical and parental experience. These 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 features of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under DSM-IV-TR or ICD-10.

The Randolph Attachment Disorder Questionnaire or "RADQ" is one of the better known checklists and is used by attachment therapists and others, but critics consider it lacks specificity and is unvalidated. 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.

Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation procedure (Mary Ainsworth), the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA", Crittenden 1992), the Observational Record of the Caregiving Environment ("ORCE") and the Attachment Q-sort ("AQ-sort"). More recent research uses the Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah, (1999). 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
There 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). 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. 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. Many of these therapies concentrate on changing the child rather than the caregiver. (Chaffin et al 2006 )

Recent research on deprived populations
A 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. 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.

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.

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.

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.

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. 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. 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.