Reactive Attachment Disorder and Attachment Therapy University of New York in Prague Reactive Attachment Disorder and Attachment Therapy Introduction There has been growing attention on attachment theory and its impacts on later behavioral outcomes. Several research have found an association between attachment insecurity and personality disorders due to inconsistent and unstable sense of self; and association between insecure attachment and physical illness due to susceptibility to stress.
Although it has various implications on sense of integrated personality and psychological well-being, the only pathology that is officially related to attachment is Reactive Attachment Disorder (RAD) of infancy or early childhood which is counted as very rare disorder in Diagnostic Statistical Manuel. There has been a wide range of debates on RAD with regard to its difficulties in diagnosing, validity of its subtypes, its susceptibility of being confused with other disorders, its relation with attachment theory and its treatment methods.
In my opinion, RAD has not given much attention and has not been studied much due to these complications. In this paper, my attempt is to discuss these issues about RAD and its treatment models by providing with some empirical findings. Reactive Attachment Disorder can historically be traced on the studies with institutionalized children who were deprived from secure attachment and who had multiple caregivers. In very young institutionalized children who experienced social deprivation, Tizard and Rees (1975) identified two types of disorders.
The first one was socially indiscriminate/ disinhibited type, in which children displayed nonselective preferences of using adults as seeking comfort and tendency to go with the strangers who offered them comfort. In the second type, children were relatively socially withdrawn/ inhibited, who showed limited social responsiveness, little positive affect and failure to seek comfort when needed. Later, these behavioral patterns with the requirement of signs result from pathogenic care were described as reactive attachment disorder. Zeanah& Gleason, 2010) Attachment Theory suggests that infants are evolutionarily primed to form close, enduring, dependent bond on a primary caregiver. The fulfillment of their physiological needs require close physical contact (Carlson, Sampson& Sroufe, 2003). In Diagnostic Statistical Manuel, the only pathology that is officially related to attachment is Reactive Attachment Disorder (RAD) of infancy or early childhood.
The diagnostic criteria for RAD include: disturbed and developmentally inappropriate social relatedness prior to age five, pathogenic care such as persistent disregard of the child’s basic emotional and physical needs and repeated changes of primary caregiver that prevents development of stable attachment, and these disturbances are not better accounted for pervasive developmental disorders or developmental delay (DSM-IV-TR, 2007).
Two types of RAD behaviors have been classified: Inhibited type refers to emotionally withdrawn children who show limited social responsiveness, ambivalent or contradictory responses, little positive affect and a failure to seek comfort when they feel distressed. These behavior patterns are believed to be related with experiences with caregivers who do not provide emotional support and comfort when needed. Secondly, disinhibited type refers to children who have diffuse attachment and who show accessive and inappropriate familiarity with strangers.
These behaviors are resulting from experiences with caregivers who are not very responsive but can provide some affection. (Haugaard and Hazan, 2004) Some studies demonstrated that children with RAD might display inhibited behavioral patterns, disinhibited behavioral patterns and both inhibited and disinhibited behavioral patterns (Smyke, Dumitrescu ; Zeanah, 2002). However there is a disagreement in subclassification of RAD. Some other studies based on the follow-up studies of children placed in adoptive homes showed that inhibited types were nonexistent whereas disinhibited types were much higher (Chisholm, 1998).
These findings have raised the question that inhibited and disinhibited types might have different clinical entities. Mary Margaret Gleason and her collegues (2011) examined inconsistent findings and validity of the two types of RAD. The construct validity of two types of RAD was examined by comparing the caregiving quality, a putative risk factor for each type of RAD, and attachment security. In existing literature, attachment security is found as inconsistently linked to indiscriminately social/disinhibited RAD and more consistently linked with emotionally withdrawn/inhibited RAD.
They predicted that each type of RAD would show stability over time. The results supported the validity of these two types. Signs of inhibited RAD were distinct from the disinhibited type; and they were associated with poor caregiving quality (Gleason, Fox, Drury, Smyke, Egger, Nelson, Gregas ; Zeanah, 2011). There has been an implicit assumption that RAD is caused by attachment deficit; however, this assumption may have blocked the research. There are some difficulties in diagnosing RAD due to complications of assessing attachment. The assessment may be derived from the observations of relationship between child and caregiver.
It also may focus on the behavioral outcomes of children (Lyons T. Hardy, 2007). Minnis et. al. (2006) proposed that RAD is construed in intersubjectivity. RAD has raised various questions since there is not a single explanation of the behaviors of children that are afflicted of the disorder. In the DSM-IV classification, diagnostic requirement of grossly pathogenic care does not explain the aspects of social, emotional and physical maltreatment. Children who experienced grossly pathogenic care may display aggressiveness, indiscriminate friendliness, social withdrawal and poor emotional regulation.
However, these behaviors can also be observed in some other disorders such as Conduct disorder, ADHD and autism. Therefore, presuming attachment as a core etiology may be misleading. They offer, instead, intersubjectivity- the infants’ brain development is supported by the responses of parents or caregivers. Since this process is always active, an infant will always be affected by other person’s actions and the other person’s rejection will have a negative impact on the infant. Although there are some overlaps between intersubjectivity and attachment, intersubjectivity processes are active in all interaction including low affect.
Children who have never experienced intersubjectivity will not have the capacity of removing early false relationship and they may be condemned to seek it throughout their life (Minnis,Marwick, Arthur & McLaughlin, 2006). Through the active process of intersubjectivity, caregiver’s neglect in the early ages will have a negative effect on the infant. Similar to this claim, Corbin (2007) states that pathological caregiving characteristic of RAD does its harm through the ruptures and developmental difficulties in the early ages (Minnis et al. , 2006).
Liggan and Kay (1999) found that early pre-symbolic memory is an enduring implicit memory that depends on “whose existence is inferred from observable influence on emotional behaviors related to early attachment experiences”. Implicit memory is an unconscious memory that has the potential to influence the storage of long-term memory. These findings have implication on RAD since early experiences would form prototypes, schemes that affect interpretation of subsequent experiences. Therefore the information stored is not available in conscious reflection and thought.
This may explain the insufficient researches on the effectiveness of some treatment strategies with children with RAD. Nevertheless, some studies showed that attachment therapy and clinical intervention have led to significant improvement on children with RAD. Even though there are some different perspectives on etiology of RAD and presentation of the symptoms, it is largely influenced by early emotional and social deficiencies. Treatment of RAD focuses on enhancing current attachment relationship, creating new attachment relationships and reducing problematic symptoms.
Barth et al. (2005) examined the rationale of the development of attachment-based therapies in the treatment of RAD. The findings supported that early anxious attachment is not a direct cause of psychopathology but it is an initiator of pathways associated with later pathology (Sroufe et al. , 1999). Some therapists point out that early frustration of being rejected and helplessness lead pessimistic view of the world and sociopaths such as serial killers may have attachment disorders (Thomas 1997).
Although some studies found that most of the adopted children do not have insecure attachment (Singer et al. 1985; Juffer;Rosenboom, 1997), Barth et. al. argue that these studies are characteristically short-term and mostly based on children in non-adoptive families. RAD is considered as very uncommon disorder by American Psychiatric Association 2000,p. 129), however, it is thought that there may be one million children, half of all adopted children, diagnosed with RAD in USA. (Werner-Wilson; Davenport, 2003). Millward et al. (2006) examined 100 children in foster care in Scotland.
They predicted that there would be higher symptom scores for RAD in children in care compared with general population controls and that high symptom scores for RAD would be associated with other psychiatric disorders. Parents and carers took RAD Scale. As they predicted, children living in care had higher rates of mental health problems including RAD. They were more likely to have anxiety, depression, conduct disorder and hyperactivity (Millward, Kennedy, Towlson ; Minnis, 2006). Attachment based therapies regard the child as a focus of clinical intervention.
In this perspective, the purpose of the treatment of RAD is helping the children to release anger resulting from their early negative experiences and teaching the child that new parents can be trusted as caregivers. Wimmer et al. (2009) investigated the effectiveness of attachment therapy in treating adopted children diagnosed with RAD. Adopted parents often face with the lack of affection of their adopted children. They feel that they are unable to contact with the child to establish reciprocal emotional relationship. Attachment therapy aims to provide some improvement in their relationship with their child.
Based on the presumption that adopted children may have insecure attachment due to early experiences of deprivation, attachment theory has been developed to improve child’s trust in the adoptive parents. Moreover development in child’s social and emotional functioning and teaching effective parenting techniques are promises of attachment therapy (Wimmer, Vonk ; Bordnick, 2009). In order to investigate the effectiveness of attachment therapy, they gathered data from 24 children who were adopted and who had been treated with attachment therapy for three years.