Reactive Attachment Disorder

Diagnosis and Treatment

Brooke Schauder, MS

Erie Psychology Consortium

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.

2. diffuse attachments as manifested by indiscriminate sociability.

B. Not accounted for by MR or a PDD.

C. Pathogenic care as:A. Disregard for basic emotional needs or

comfort, stimulation, and affection.

B. Disregard for basic physical needs.

C. Repeated changes of primary caregiver preventing formulation of stable attachment (i.e., foster care changes).

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)

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

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.

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)

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?”

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).

Additional Subtypes of RAD

Ambivalent: angry, oppositional, violentAnxious: clingy, anxious, separation anxiety.Avoidant: compliant, agreeable, superficially engaging, but lacks depth to emotion. Disorganized Subtype: Bizarre symptoms.

Treatment

No scientifically established treatments exist for RAD.

Strategy is to teach caregiver:About the disorderAbout activities that promote normal child developmentHow to play with the childHow to manage child’s aggressive and problematic behaviorHow to communicate with the child

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.

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.

Play Therapy

Art therapy: Draw the “family doing something”.Doll Play – dollhouseCompleting a story.

RAD symptoms: family separate or child alone, chaotic themes, disorganization, fear, violence, punishment.

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.

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.

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.

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.

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.

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.)

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.

Recommended RAD ArticlesSheperis, 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.