What is reactive attachment disorder (RAD)?

Introduction

Since the 1940s, a substantial body of literature has documented the adverse effects of deprivation and institutionalization on infants and young children. Physical, cognitive, and social developmental delays are often present in such children. In a classic study published in 1945, René Spitz examined a group of children in an orphanage and compared them with children reared in a more attentive foster home setting. His results revealed slowed physical, motor, and intellectual development and high mortality in the orphanage group compared with essentially normal development in the comparison children. Several terms have been used to describe the diverse clinical features of this condition, including failure to thrive, psychosocial dwarfism, maternal deprivation, anaclitic depression, and, most recently, reactive attachment disorder (RAD). This plethora of different terms probably reflects a deeper confusion regarding this syndrome’s symptom picture and etiology.

Description

RAD was first included in the third edition of the
Diagnostic and Statistical Manual of Mental Disorders
(DSM-III), published in 1980. In subsequent editions, the criteria were altered to reflect an emphasis on psychosocial maladjustment rather than on disrupted physical development. The fifth edition, DSM-5 (2013), describes the cardinal feature of RAD as disturbed and developmentally inappropriate social relations produced by persistent neglect or abuse on the part of the child’s caregiver. Prior to the DSM-5, RAD was considered to have two subtypes, inhibited and disinhibited, but in the DSM-5, the disinhibited type was split into a separate disorder, disinhibited social engagement disorder.

Children with RAD are emotionally withdrawn and fail to initiate social relations, particularly with caregivers. They rarely express positive emotions and often do not seek or respond to comfort when distressed. This contrasts with disinhibited social engagement disorder, which is characterized by indiscriminate sociability and a lack of selectivity in seeking out attachment figures. RAD is believed to be the more common of the two, although trustworthy estimates of its prevalence are difficult to come by. Some researchers estimate that RAD occurs in approximately 1 percent of the population, while the DSM states only that it is “very uncommon.”

The onset of RAD occurs before five years of age. Prior to the fourth edition of the DSM, it was required that RAD emerge before six months, but this criterion was altered in response to researchers’ objections that selective attachments are not formed at such an early age. Nevertheless, the current criteria still allow clinicians to diagnose infants with RAD if they see fit.

Associated features of RAD include the physical signs of an impoverished rearing environment, such as developmental delays, feeding disorders, growth delays (that is, failure to thrive), physical abuse, and malnutrition. With the provision of a supportive environment and adequate caretaking for the child, the behavioral difficulties associated with RAD should ostensibly remit.

Other disorders that emerge in childhood can be difficult to distinguish from RAD. Children with RAD may manifest subnormal intellectual functioning comparable to that of children with developmental disabilities, but RAD can be differentiated by the improvement that typically occurs with an enriched environment. Autistic children often exhibit impaired communication and repetitious patterns of movement, but RAD children are much more socially oriented. Although adverse environmental conditions and pathogenic relationships in childhood may increase the risk for later antisocial behavior, no direct etiological links have been established between these behaviors and the characteristics of RAD.

Controversies

Controversies abound concerning the conceptualization, diagnosis, and treatment of RAD. Foremost is the striking paucity of evidence for the validity of this diagnosis. For example, there is little controlled research examining the family history, course, and outcome, biological correlates, or laboratory performance of children with RAD. Such validity research will be essential to justify the continued inclusion of RAD in the diagnostic system.

With respect to the DSM-5 criteria, some researchers, such as Fred Volkmar, object to the stipulation that RAD must be the product of adverse caretaking. This requirement renders it impossible to ascertain the prevalence of RAD among children not subjected to pathogenic care.

Another diagnostic controversy concerns the labeling of RAD as an attachment disorder. Some developmental psychologists suggest that RAD is best conceptualized as a developmental disorder or a maltreatment syndrome. As conceptualized in the developmental literature, the prominent feature of disordered attachment is a disturbance in the child’s use of a primary caregiver as a base of safety and security. From this point of view, evidence of an attachment disorder would require assessment of the child on a number of dimensions not included in the RAD criteria (such as comfort seeking, exploratory behavior, or affectionate responses). Moreover, findings in the child maltreatment literature suggest that although maltreated children often develop insecure or disorganized relational patterns to cope with the erratic care they receive, this is not necessarily synonymous with disordered attachment. Lastly, some developmental researchers note that the organic correlates of the conditions from which RAD derived (such as hospitalism or failure to thrive) have not been causally linked to attachment problems.

A third area of controversy surrounding RAD is the emergence of unvalidated and potentially dangerous attachment therapies, which are sometimes used with disruptive children and adolescents believed to be traumatized by early adverse emotional experiences or adoption. Attachment therapies include rebirthing (a procedure in which several adults simulate the birth process by constricting children in blankets and pillows and pushing them down the makeshift “birth canal”), holding therapy (in which the therapist forcefully restrains the child to achieve “rage reduction” and ostensibly correct aberrations in the “bonding cycle”), and therapeutic parenting (a strict regimen approved by attachment therapists by which parents exert their authority and impose rigid controls on the child). Rebirthing has been linked to several tragic incidents, including the 2000 death in Colorado of Candace Newmaker, a ten-year-old girl who suffocated during the process as her therapists ignored her cries for help. Despite the absence of well-controlled studies in peer-reviewed journals supporting the efficacy of attachment therapies, many proponents of these techniques claim that they are effective and safe. Responsible mental health professionals must take further steps to protect the public from the ever-growing industry of attachment therapies and similar unvalidated treatments.

Bibliography

Brisch, Karl Heinz. Treating Attachment Disorders: From Theory to Therapy. Trans. Kenneth Kronenberg. New York: Guilford, 2004. Print.

Cain, Catherine Swanson. Attachment Disorders: Treatment Strategies for Traumatized Children. Lanham: Aronson, 2006. Print.

Davis, Andrew S. Psychopathology of Childhood and Adolescence: A Neuropsychological Approach. New York: Springer, 2013. Print.

Gleason, Mary Margaret, et al. “Validity of Evidence-Derived Criteria for Reactive Attachment Disorder: Indiscriminately Social/Disinhibited and Emotionally Withdrawn/Inhibited Types.” Journal of the American Academy of Child and Adolescent Psychiatry 50.3 (2011): 216–31. Print.

Mercer, Jean. “’Attachment Therapy’ Using Deliberate Restraint: An Object Lesson on the Identification of Unvalidated Treatments.” Journal of Child and Adolescent Psychiatric Nursing 14.2 (2001): 105–114. Print.

Money, John. The Kaspar Hauser Syndrome of “Psychosocial Dwarfism”: Deficient Statural, Intellectual, and Social Growth Induced by Child Abuse. Amherst: Prometheus, 1992. Print.

Richters, Margot Moser, and Fred R. Volkmar. “Reactive Attachment Disorder of Infancy or Early Childhood.” Journal of American Academy of Child and Adolescent Psychiatry 33.3 (1994): 328–332. Print.

Shreeve, Daniel F. Reactive Attachment Disorder: A Case-Based Approach. New York: Springer, 2012. Print.

Spitz, René. “Hospitalism: An Inquiry into the Genesis of Psychiatric Conditions in Early Childhood.” Psychoanalytic Study of the Child 1 (1945): 53–74. Print.

Volkmar, Fred R. “Reactive Attachment Disorder.” DSM-IV Sourcebook, ed. Thomas A. Widiger, Allen J. Frances, Harold Alan Pincus, Ruth Ross, Michael B. First, and Wendy Davis. Vol. 3. Washington, DC: Amer. Psychological Assoc., 1997. Print.