Reactive attachment disorder

Reactive Attachment Disorder (sometimes called "RAD") (DSM-IV 313.89, ICD-10 F94.1/2) is a psychophysiologic condition [1] with markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age five years and is associated with grossly pathological care. This pathological caregiving behaviour may consist of any form of neglect, abuse, mistreatment and abandonment.

In Mental Retardation attachments to caregivers are consistent with the level of development. In Pervasive Developmental Disorders attachments to caregivers either fail to develop or are highly deviant, but this usually occurs in a context of reasonably supportive care.

Due to maltreatment by caregivers, RAD sufferers have difficulty forming healthy relationships with their caregivers, peers and families.

RAD can reportedly be diagnosed as early as the first month of life, but critics have charged such diagnoses are often inaccurate.

Some estimate that 10%[2] to 80%[3] of children and adolescents in adoptive families, and an unknown number of children who remain in their family of origin, suffer from RAD. (note some critics have questioned the accuracy of these percentages) There generally tend to be the same causes regardless of family setting.

A crucial defining characteristic of Reactive Attachment Disorder--explicit in DSM and ICD--is that there be pathogenic caregiving. This can be very difficult to prove, but it makes lasting effects on the children concerned.

Critics charge that actual RAD is rather rare, and that diagnoses are often incorrect, too broadly applied and are made by unqualified persons. Some critics have further charged that RAD is a fad diagnosis for any number of unrelated behaviors that parents disapprove of in their children. In actuality RAD has varying degrees unique to each child, therefore it is often misdiagnosised or left untreated but still most professionals agree it is uncommon.

Critics also charge that some treatments for RAD--especially so-called "holding therapy"--"routinely use restraint and physical and psychological abuse to seek their desired results."

Contents

Classification

The DSM-IV specifically includes two forms of clinical presentation:

"Inhibited" (Criterion A1)

And "disinhibited" (Criterion A2)

These are roughly equivalent to the ICD-10, in which 94.1 represents the "inhibited" form of the disorder, and 94.2 represents the "disinhibited" form.

When either classification system is used, the inhibited form tends to have more withdrawal behaviours towards a caregiver[4], and the disinhibited more externalising behaviours[5].

Many popular, informal classification systems, outside the DSM and ICD, have been created out of clinical and parental experience. Some critics have charged these informal classification systems are inaccurate, too broadly defined or applied by unqualified persons.

One popular classification system is the Randolph Attachment Disorder Questionnaire[6]. The checklist includes 93 discrete behaviours, many of which overlap with other disorders, like Conduct Disorder and Oppositional Defiant Disorder.

Framework

The theoretical framework for Reactive Attachment Disorder is based on work by Bowlby, Ainsworth and Spitz, from the 1940s to the 1980s. Some critics charge later therapists have misused or misrepresented Ainsworth's or Bowlby's work.

In contrast, the popular framework tends to be more eclectic, using many sources from birth/prenatal psychology[7], the human potential movement[8] (where issues of coercion and consent in treatment are especially relevant) to transactional analysis and ethology.

The development of diagnostic criteria was further operationalised by Zeanah and O’Connor throughout the 1980s and 1990s[9], and through greater awareness garnered from the adoption of institutionalised children from Romania, Russia and China, and also foster care in America and other nations.

Psychiatrist Michael Rutter has done an outcome study, the largest of its kind, called the Romanian Adoption Project. Victor Groza has done another outcome study, and as of 2004 there are many in process[10].

Diagnosis

In mainstream medical practice, Reactive Attachment Disorder is most often diagnosed by social workers or psychologists. Psychiatrists may be called in when there is medication involved.

It is important to note that there are various "attachment styles" that are not pathological, and attachment issues that may run anywhere across the continuum. "Reactive Attachment Disorder" has been traditionally used to describe a "severe disturbance in the attachment between caregiver and child that is of long standing and applicable/observable in all contexts in which the child interacts."

Some of the "attachment styles" are named: "avoidant," "aggressive," "ambivalent" and "disorganised/mixed". There is often a blending of several "attachment styles" in an individual.

Reactive Attachment Disorder affects the "basic working model." Many parents report that they do not understand what their child is thinking or feeling at any given time. Some diagnosticians of RAD argue these sensations are due to the child giving inconsistent, "low-level" or mixed signals.

In practice, the popular (though not the scientific, due to concerns about psychological ethics and how these affect the best interests of the client) approach tends to use "paradoxical interventions" where maladaptive behaviour is coaxed or provoked so that the caregiver can have control over the behaviour. Critics cite this "intervention" as a consequentialist view of behaviour, and would prefer to use other treatment methods. Further, some critics charge such "interventions" are abusive.

Many caregivers and therapists, say, however, that "traditional therapies" do not always work on those who have Reactive Attachment Disorder.

Controversy

Critcs charge that some treatments for RAD are abusive and improper.

The so-called "intensive" was pioneered at the Institute for Attachment and Child Development (in the 1970s the Youth Behaviour Programme, and until 2002 The Attachment Centre), Evergreen, Colorado. The intensive involves ten days or more of specialised therapy for the caregivers and the child. In an "intensive", the child is held in ways that may depend on the therapists. Some therapists wrap the child in blankets in an effort at "rebirthing"

The holding, "rebirthing" and related actions are intended to bring up memories of ill-treatment and serve as a "corrective emotional experience". In many centres the cost is $7,000 or more.

Eight children have died from "intensives." Perhaps the best-known was 10-year-old Candace Newmaker who died April 18, 2000. Her therapists were prosecuted, and one sentenced to 16 years in prison .

Such "holding therapy" has been forbidden by a few US states[11]. One critic of "holding therapy," William N. Friedrich of the Mayo Clinic has written "The fact that two children have died in two years demands an immediate and powerful statement: 'Holding therapy' and its permutations are not therapeutic, can be thought of only as punishing, and must never be used."

Many attachment therapists have since lost their licenses to practice or have been sanctioned for their treatments.

Some critics charge neither parents nor "treated" children are allowed to give informed consent to such treatments.

References

[1]: Alston, John. (2000) Characteristics of Attention Deficit Disorder, Bipolar I Disorder and Reactive Attachment Disorder.
[2]: Alston, John. (2000) op cit.
[3]: Support for the lower estimate given here: Boris N. W, Zeanah C. et al (1998) Attachment Disorders in Infancy and Early Childhood: A Preliminary Investigation of Diagnostic Criteria. American Journal of Psychiatry February 1998. (The actual figure for their preliminary report was 42%).
[4]: Support for the higher estimate given here: Cicchetti D, Cummings EM, Greenberg MT, & Marvin RS: An organizational perspective on attachment beyond infancy. In: Attachment in the Preschool Years. Ed. Greenberg MT, Cicchetti D, & Cummings EM, Chicago: University of Chicago Press, 1990. (Cited: Becker-Weidman [2003], Dyadic Developmental Psychotherapy: An Effective Treatment for Children with Trauma-Attachment Disorders)
[5]: Ames, Elinor Recommendations from the Final Report: The Development of Romanian Orphanage Children Adopted to Canada (1997) cited in Hanlon L, Tepper T and Sanstrom S (eds) International Adoption-Challenges and Opportunities (1999)
[6]: Ames, Elinor op cit.
[7]: Randolph, Elizabeth Marie. (1996) Randolph Attachment Disorder Questionnaire:Institute for Attachment, Evergreen CO.
For criticisms of this device see: Mercer, Jean (2001, 2002).
[8]: Mercer, Jean (2003). Violent therapies: the rationale behind a potentially harmful child psychotherapy. Scientific Review of Mental Health Practice:Spring/Summer 2004
[9]: See especially Speltz (2002) Description, History, and Critique of Corrective Attachment Therapy. The APSAC Advisor 14(3), 4-8
[10]: The given reference is not to demean the good work of subcommittees from the DSM-III onwards; nor their counterparts in ICD or the many others who have done clinical and research work. O’Connor and Zeanah (2003) Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244:Taylor and Francis
[11]: As of 2004, these US states have forbidden attachment therapy: Massachusetts, New York (State), New Jersey, Pennsylvania, Texas and Utah, as indicated by action by the respective mental health authorities, including resolutions.