Reactive Attachment Disorder (RAD)
Introduction and Clinical Features
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Reactive attachment disorder (RAD) is DSM’s diagnostic term for aberrant social behaviors seen in young children that were believed to derive from being reared in caregiving environments lacking in species-typical nurturance and stimulation, such as in instances of maltreatment or institutional rearing. This entry describes features, characteristics, and treatment considerations for RAD.
Attachment disorders take their name from concepts in attachment theory which have their basis in work by the British psychoanalyst John Bowlby. Attachment theory sought to examine the qualities of behaviors in toddler-age children toward parental figures, highlighting the importance of interpersonal relationships with caregivers to social and emotional development.
Mary Ainsworth would further these concepts in her formation of a research paradigm, the Strange Situation Protocol (SSP), that elicits attachment behaviors in children during the early years. In the SSP, consistent patterns of children’s behavior following a moderately stressful separation from their caregivers were identified over time and interpreted by Ainsworth as reflecting the child’s strategy of seeking comfort from a specific caregiver (Ainsworth, et al., 1978).
Ainsworth’s research identified secure patterns of attachment as compared to insecure patterns of attachment characterized by either indifferent response to the absence and reunification of child with caregiver (avoidant/insecure) or intense levels of distress at separation with persistent difficulty with soothing upon reunification (resistant/insecure).
Longitudinal studies of insecure patterns of attachment were found to place the infant at higher risk for psychiatric disorders as well as increase the chance for functional difficulties within relationships.
According to the DSM-5, RAD is a pattern of absent or aberrant attachment behaviors in infancy or in early childhood, evident after reaching the age at which selective attachment should be made (7–9 months).
Though children with the disorder are thought to possess the capacity to form attachments, because of limited opportunities to form selective attachments, either due to social neglect of the child or frequent changes in caregiving environments (e.g., foster placements), they do not form attachments.
The critical period for attachment typically ranges from 9 months to just before 5 years of age. While lack of selective attachment is the essential criterion for RAD, problems with emotional regulation also exists.
Withdrawn behavior toward caregivers is typical, whereby the child may not seek comfort or respond to comfort when distressed. Limited positive emotions are expressed around caregivers, and children with RAD may express negative emotions in nonthreatening circumstances.
Examples of deprivation sufficient to cause RAD include mistreatment or perhaps institutionalized care where formation of attachment was not possible. If signs of the disorder have been present for more than 12 months, a diagnosis of persistent RAD is given. Severe RAD is noted if all criteria are met and symptoms are present at high levels.
Autism spectrum disorder Opens in new window (ASD [note ASD also stands for Acute Stress Disorder.]) must be ruled out before giving a diagnosis of RAD. Ruling out pervasive developmental disorders or ASD has elicited some controversy.
Zeanah and Gleason (2010) had previously argued that since individuals with intellectual disability (ID) and ASD can develop normal attachment relationships and pathogenic relationships, they can indeed develop RAD in addition to their ASD.
Their argument is supported by more recent data from Giltaij, Sterkenburg, and Schuengel (2015) demonstrating a considerable co-occurrence of the two disorders among individuals with ID. Indeed, 14% (of 102 individuals diagnosed of RAD and ASD. They conclude that, “Important for the ongoing discussion of diagnostic criteria, the findings do not support using PDD as an exclusion criterion for the diagnosis of RAD.” (p. 145).
As with most other disorders of early childhood, RAD is best diagnosed through a combination of interviewing and direct-behavioral observation.
A detailed history of the child’s caregiving experiences is important in order to establish that deficiencies were sufficient to account for the child’s social abnormalities. Therefore, details of the child’s caregiving history, with attention to neglect, changes in primary caregiving relationships, or significant losses of primary caregivers should be determined.
Structural interviews, such as the Disturbances of Attachment Interview (DAI) may be used to inquire about specific signs of the disorder (Smyke, Dumitrescu, & Zeanah, 2002) and often are used to make the diagnosis. Standardized observational procedures that elicit the child’s responses to familiar and unfamiliar caregivers in order to distinguish between the child’s responses to putative attachment figures and to unfamiliar adults have been used in research and also may be useful in clinical settings (Boris et al., 2004; Zeanah et al., 2005).
Interviews and observations should include questioning about the child having one or more adults from whom s/he seeks comfort, reassurance, nurturing, and protection, particularly in times of distress. In addition, failing to use the attachment figure for comfort, as occurs in the emotionally withdrawn/inhibited pattern, and exhibiting overly familiar behaviors with unfamiliar adults, as occurs in the indiscriminate/disinhibited pattern, should be identified.
The clinical examination provides an opportunity to observe and elicit attachment behaviors. The child’s reaction on first meeting the interviewer (a stranger) can provide information about how a child references and/or seeks comfort from a caregiver in the context of a new person and setting.
In addition, asking a parent to leave the room for a brief separation from the child can activate the child’s attachment system and provide valuable information about how a child uses a parent upon reunion. Multiple observations and agreement between historical information and directly observed behaviors increase confidence in the diagnostic findings.
Historically, standardized observations of attachment behaviors were used to classify attachment but rarely to diagnose RAD. However, more recently, a clinical assessment of attachment involving a stranger, separations and reunions, and the introduction of a robot as a mildly distressing stimulus also has been used reliably to diagnosis attachment disorders in a clinical context (Boris et al., 2004). The use of standardized procedures provides the clinician the opportunity to observe children’s patterns of attachment behaviors in a consistent manner, reducing the influence of other variables.
Severe neglect that comes from early psychosocial deprivation leads to delays in cognition and language (Nelson et al., 2007), since child may not have received adequate verbal stimulation or interaction during critical developmental periods.
Growth parameters including height, weight, and head circumference can be diminished (Rutter, 1998), likely secondary to nutritional compromise. Though it is often immediately treatable, lingering effects can manifest in children’s continued problems with food hoarding behavior, despite ample food availability (Parker & Forrest, 1993).
One study of subjects raised in Romanian orphanages found an association between RAD and signs of depression (Gleason et al., 2011a), which may reflect the fact that both diagnoses can present with reduced positive affect.
While the conditions that contribute to the development of RAD are present very early in a child’s life, the diagnosis is not distinguishable until 9 months, when children are expected to form attachments to caregivers. Among children experiencing severe neglect, the behavioral features of RAD have been documented to persist to 12 years of age (Humphreys et al., 2017).
Although elevated signs of RAD have been detected in children with histories of post-institutional rearing, it is unclear if any of these children reach the diagnostic threshold. Functional impairment in interpersonal relationships for children with RAD is well documented (Hodges & Tizard, 1989), manifested by decreased social competence appropriate for developmental age.
Autism spectrum disorder (ASD) Opens in new window shares several of the behavioral features seen in RAD. A child with ASD can manifest the same lack of positive affect and social reciprocity, as well as the developmental delays typically seen in RAD. Stereotypic rocking movements can be characteristic of either ASD or RAD (Smyke et al., 2002).
A history of neglect required for the diagnosis of RAD would be the classic way to differentiate the two. Also, RAD lacks the repetitive rituals and restrictive interests that are typical of ASD. Individuals with ASD typically have developmental histories notable for stereotyped speech such as echolalia Opens in new window, persistent pronoun reversal, or scripted speech and frequently demonstrate ongoing problems with goal-oriented communication.
In RAD, communication skills are comparable to the individual’s developmental level. While a lack of attachment behaviors define RAD, a majority of studies of participants with ASD demonstrate attachment behaviors toward preferred caregivers, especially among subjects with higher cognitive capacity (Rutgers, Bakermans-Kranenburg, Ijzendoorn, & Berckelaer-Onnes, 2004).
While children with RAD typically have co-occurring language and cognitive delays, it must be distinguished from intellectual disabilities (ID). Children with ID are not expected to manifest limited positive affect or reduced emotional responsiveness typically seen in RAD. Moreover, children with ID with a developmental age of at least 9 months are expected to exhibit selective attachment to caregivers.
Distinguishing RAD from depression Opens in new window and posttraumatic stress disorder Opens in new window among traumatized or neglected individuals can be difficult as each may present with blunted affect, social withdrawal, or emotional indifference.
Seeking comfort when distressed will distinguish depressed and traumatized individuals from those with RAD as will the presence of overt intrusion symptoms (flashbacks, nightmares), increase in arousal or reactivity, or avoidance of reminders of trauma Opens in new window.
Etiology and Pathophysiology
- Social/Environmental Factors
RAD shares a unique characteristic with other diagnoses within the trauma-and stressor-related disorders category within the DSM-5—the role of social and environmental factors in the etiology of the disorder.
Institutionalized children or those in foster care experiencing isolation, limited stimulation, poor child/caregiver ratios, or neglect can develop attachment disorders (Bos et al., 2011). The severity of the adversity in a rearing environment is relevant. When two groups of institutionalized children were compared, the group with more consistent caregivers on the unit demonstrated fewer signs of attachment disorders (Smyke et al., 2002).
A separate study found that a measure of “quality of caregiving” (meant to gauge the sensitivity/responsiveness of caregivers) was associated with signs of RAD in children who had grown up in institutions (Zeanah et al., 2005).
Children removed early from institutionalized care may have better outcomes than those removed later. For example, Smyke et al. (2010) showed infants removed from institutionalized care before 24 months of age developed more secure and more organized attachments at age 42 months than those removed after 24 months.
Despite these findings, age of removal has less of an impact on the course of RAD than that of DSED. One study of institutionalized children found all subjects went on to have resolution of signs of RAD independent of age of adoption (Smyke et al., 2012).
- Genetic Factors
Limited data are available concerning any genetic risk factors for RAD. In one study, Minnis et al. (2017) compared behaviors indicative of attachment disorder, such as inhibition and disinhibition, in monozygotic and dizygotic twins. Correlations of these behaviors between monozygotic twins were higher than those between dizygotic twins, supporting the idea of strong genetic influences. Additional research points to a genetic susceptibility for disorganized attachment in individuals with a particular dopamine D4 receptor (DRD4) polymorphism (Bakermans-Kranenburg & Van Ijzendoorn, 2007). Still, this susceptibility only leads to an increased risk of disorganized attachment when combined with environmental factors.
- Neurobiological Factors
Increasingly, research has demonstrated neurobiological effects of deprivation among institutionalized subjects. Magnetic resonance imaging (MRI) studies of institutionalized children have shown reductions in white matter connectivity in areas of the brain, including both the amygdala and prefrontal cortex, which are areas of higher cognition and emotion (Govindan, Behen, Helder, Makki, & Chugani, 2010).
Other neurobiological differences demonstrated include reductions in grey and white matter volumes (Sheridan et al., 2012) and aberrant electrical activity (Marshall, Fox, & BEIP Core Group, 2004) that may normalize over time with subsequent adoption (Vanderwert et al., 2010).
These children also show lower overall levels of vasopressin, as well as lower levels of oxytocin after interactions with caregivers (Bos et al., 2011). These hormones are believed to contribute to prosocial behaviors. Providing more evidence for hormone disruptions, children adopted from institutionalized care show higher levels of cortisol when interacting with their new caregiver than with unfamiliar adults (Bos et al., 2011). While this line of evidence has not been studied directly in children with RAD, the available evidence from institutionalized children may point to new directions in research for other factors that play a role in attachment disorders.
- Psychological Factors
While a diagnosis of RAD implies that a child endured adverse environmental conditions in early childhood, it is interesting that, even in this population, very few exposed children develop the disorder. One area of interest has been interactions between temperament, environmental factors, and caregiver behaviors.
Temperament and attachment patterns have long been thought to be related to each other; for example, an infant’s reaction to behaviors, thus influencing attachment (Zeanah et al., 2004). Additionally, the synergistic effects of negative temperaments when combined with adverse environmental situations may put a child at a higher risk of developing the disorder.
Adverse effects also tend to negatively influence temperament, thus meaning that not only may a child with an irritable and negative affect temperament placed into foster care be prone to developing RAD but also these circumstances may worsen his temperament, increasing the likelihood of development of the disorder (Zeanah et al., 2004).
Treatment for RAD and DSED
The key intervention for these conditions is ensuring a caregiving environment that is sensitive, responsive, and likely to build a sense of security in the child (Boris, Zeanah, & Zeanah, C. H., & Work Group on Quality Issues, 2005).
Currently there are no pharmacologic interventions for attachment disorders unless clinicians identify a separate comorbid condition such as ADHD Opens in new window. Among studies with subjects raised in institutions, the primary intervention is adoption into stable, safe, and emotionally available families.
Studies of the quality of such adoptive families (as measured by the sensitivity and responsiveness of caregivers) have linked such measures to improvement in RAD but less robustly to DSED Opens in new window (Smyke et al., 2012). Such a finding may suggest a threshold effect of caregiving quality, wherein further enhancement does not further reduce signs of DSED.
Therapeutic interventions that may hasten remission of signs of attachment disorders or treat refractory cases have been examined, but guidelines and effectiveness data is limited. Psychoeducation of caregivers is, after ensuring safety of children, the first crucial step in helping families understand the context and proposed meaning behind disordered attachment behaviors.
Such education may help caregivers who feel hurt or rejected by the absence or indiscriminant display of affection. Furthermore, this education can help guide caregivers in how to respond to their child. For instance, many clinicians advise that a child with RAD or DSED Opens in new window may need an overemphasized emotional response from parents in order to sufficiently establish new attachments and make the connection clear to the child (Lieberman, 2003).
Restricting the child’s contacts to family only, especially in the early months of placement, is often recommended for DSED Opens in new window, although no studies have evaluated this approach. Such restriction is thought to help the children learn to focus comfort and affection seeking to attachment figures.
Including the caregiver in therapy is important for treatment success. A study by Dozier, Stovall, Albud, and Bates (2001) found that maltreated children placed in foster care were more likely to develop secure attachments if their foster mothers were themselves securely attached.
Manualized guidelines for treatments for working with families to foster caregiver sensitivity and emotional availability have been explored with promising results (Bernard et al., 2012) and should especially be considered in treatment refractory cases (Zeanah, Berlin, & Boris, 2011).
Moreover, interventions that address the history of caregivers’ own attachment styles and relationships may play a preventative role for infants at risk for developing attachment disorders (Cicchetti, Rogosch, & Toth, 2006). Infant-parent psychotherapy and child-parent psychotherapy can be used for the treatment of attachment disorders with modifications geared specifically for families dealing with these disorders.
Working individually with the caregivers or, when appropriate, children on specific strategies to manage maladaptive behaviors can also be helpful in strengthening the child’s attachment (Boris et al., 2005).
Interaction guidance therapy is a way to incorporate working with both child and caregiver and involves shaping positive behaviors through suggestion and positive reinforcement during interactions between the child and caregiver.
Basic behavioral or cognitive behavioral therapy (CBT) Opens in new window may also be helpful in DSED Opens in new window to assist the child or teenager in learning socially appropriate behaviors. Research has implicated social cognitive abnormalities in this disorder, which may be particularly well addressed with CBT.
The presence of co-occurring RAD or DSED Opens in new window can reduce the effectiveness of trauma-focused therapies. A randomized controlled trial titled, “It’ My Turn Now” targeted internalizing and externalizing disordered youth exposed to interpersonal violence within a Dutch sample.
Results indicated that RAD and DSED negatively impacted recovery from trauma, such that treatment outcomes for both internalizing and externalizing disorders were slowed in individuals with RAD or DSED compared to individuals without the comorbidities.
The authors hypothesized that youth with attachment disturbance lacked appropriate social engagement necessary to fully benefit from the therapy process, thereby reducing the therapy’s potency (Overbeek, de Schipper, Lamers-Winkelman, & Schuengel, 2014).
A study by Dozier, Peloso, Lewis, Laurenceau, and Levine (2008) examined the Attachment and Biobehavioral Catch-up Opens in new window manualized intervention for children in foster care.
To measure the efficacy of the program, cortisol levels were measured for the interventional group of foster children, a control group of foster children with no intervention program, and a control group of children never in foster care and not receiving any intervention.
The intervention program combined the teaching of self-regulatory capabilities and focused on teaching parents how to be responsive to their child’s emotions, along with attachment security.
Cortisol levels of those children participating in the intervention were lower after the Strange Situation Test Opens in new window compared to the foster care control group. Even more surprising, cortisol levels from the control group that had never been in foster care did not statistically differ from those children in foster care receiving the intervention. Research such as this provides important insight into ways of treating children with attachment disorders.
A small number of individuals from neglectful or abusive environets during critical developmental periods go on to display a variety of problematic behaviors as a result of their experiences.
During these times of neglect and abuse, and sometimes even months and years afterward, they have difficulty regulating and managing their social relationships.
Descriptions in the DSM-5 provide further refinement for many years—though the etiology may be similar, there are important distinctions between children who go on to develop RAD and those developing the new diagnosis of DSED.
Despite the newer nosology, little is known about what constitutes efficacious care for these vulnerable children, opening up opportunities for valuable contributions to the treatment literature. until recently efficacy studies show the best form of therapy, practitioners are often left to rely on pragmatically designed symptom-focused treatment.
- Adapted from: Trauma- and Stressor-Related Disorders, edited by Frederick J. Stoddard, David M. Benedek, Mohammed R. Milad, Robert J. Ursano. References as cited include:
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