Reactive Attachment Disorder

Causes

Diagnosis

Treatment

Basic Trust vs. Mistrust (Erikson)

Infants are totally helpless and dependent on parents/caregivers.

If needs are met consistently, the child learns to trust others, and the foundation for a secure attachment is laid.

If needs are not met consistently, the child becomes fearful and learns not to rely on others.

The Attachment Cycle: First Year

The Attachment Cycle: 2nd Year

The 2nd year attachment cycle cannot be started until the first year secure attachment cycle has been met.

Children with insecure attachment do not progress to this 2nd year cycle.

www.attachmentdisorder.net.

Unhealthy Attachment & the Brain

Dr. Allan N. Schore’s 2001 article detailing the effects of traumatic attachment on the development of the right hemisphere changed the way RAD is conceptualized and treated.

Traumatic attachment results in periods of “hyperarousal and dissociation,” which interferes with the developing autonomic nervous system & limbic system of the right brain.

The structural changes in the brain lead to ineffective stress coping mechanisms in the child.

What results is PTSD symptomatology.

Early intervention with neurofeedback programs is crucial to altering the process.

RAD as a diagnosis

First talked about in 1980 as part of DSM- III Considered a controversial diagnosis at the time Some disagreement as to whether it is separate

from Ainsworth’s disorganized attachment or basically the same thing.

Current thinking is that it is a subcategory of disorganized attachment

Disorganized attachment is also considered a risk factor for RAD.

Changes from DSM IV to DSM 5

DSM-IV listed RAD as having two subtypes: --Emotionally withdrawn/inhibited --Indiscriminately social/disinhibited

DSM 5 turned the two subtypes into separate disorders: --Reactive Attachment Disorder (RAD) --Disinhibited Social Engagement Disorder (DSED)

Category placement of RAD/DSED

DSM 5 places both disorders in the general category of trauma & stress-related disorders.

Included in this group (besides RAD and DSED) are PTSD Adjustment disorders Acute stress disorder

RAD vs. DSED

Same etiological pathway for both RAD has dampened positive affect (depressive symptoms) and is

more internalized; equivalent to a lack of or improperly formed attachment to caregivers.

DSED resembles ADHD more closely. Marked by externalized behavior and disinhibition.

Social neglect during childhood is a diagnostic requirement for both conditions, but a child with DSED may have secure attachments.

Diagnoses differ in correlates, causes, and responses to intervention and are therefore considered separate disorders in DSM 5.

DSM 5 criteria for RAD

A. Consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: --Rarely/minimally seeks out comfort when distressed --Rarely/minimally responds to comfort when distressed

B. A persistent social & emotional disturbance characterized by at least 2 of the following:

--Minimal social & emotional responsiveness to others

--Limited positive affect

--Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with caregivers

DSM Criteria (cont.)

C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least 1 of the following:

1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection by caregiving adults.

2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).

3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).

DSM criteria (cont.)

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).

E. The criteria are not met for autism spectrum disorder. F. The disturbance is evident before age 5. G. The child has a developmental age of at least 9

months.

Specifications

Specify if: Persistent: The disorder has been present

for more than 12 months. Specify current severity:

RAD is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

Key Diagnostic Features

Absent or extremely underdeveloped attachments between the child and caregiving adults.

No comfort-seeking behavior or responses to comfort when child is distressed.

Diminished or absent positive emotions when interacting with caregivers

Evidence that emotional regulation is compromised; negative emotions of fear, sadness, and irritability that are not easily explained.

Older vs. Young Children

It is unclear whether older children show the same symptoms as younger children do or if the disorder even presents in older children.

Diagnosis should be made with caution in children older than age 5.

Signs and Symptoms of RAD

In Infants Withdrawn, sad, listless

appearance Failure to smile Failure to follow others with

eyes No interest in interactive

games (peek-a-boo) or toys Won’t hold out arms to be

picked up Self-soothing behavior Calm when left alone

In Toddlers & Children Withdrawing from others Aggressive behavior Avoiding or dismissing comfort Watching others closely but

not getting involved Obvious & consistent

awkwardness or discomfort Failing to ask for assistance Masking feelings of anger or

distress

Treatment of RAD

No standard treatment Individual and family

counseling is typical. Behavior therapy is

sometimes used. No pharmacological

treatment exists. Neurofeedback is a

promising new research & treatment area.

Three Crucial Ingredients by Caregivers: Security Stability Sensitivity

Beware of “Attachment Therapy”

Based on the idea that the child must release pent-up rage in order to become emotionally healthy

“Rebirthing”—has been linked to several deaths Holding therapy “Strong sitting” Forced eye contact Craniosacral therapy Some attachment therapists are quick to diagnose RAD based on

vague symptoms; they do not follow the DSM’s diagnostic criteria and charge thousands of dollars for their “therapy.”

http://www.youtube.com/watch?v=tNoIIwO3uIk

BethThomas—original RAD kid (1989)

http://www.youtube.com/watch?v=g2-Re_Fl_L4 HBO documentary Child of Rage.