Reactive Attachment Disorder

Reactive Attachment Disorder and its Representation in

Eastern European Children in Institutional Care

Reactive attachment disorder (RAD) refers to an unrelenting and severe disturbance in a child's ability to interact and relate to others across social situations (Hanson & Spratt, 2000). The onset of RAD typically occurs before the age of five, and begins in a child's earliest relationships with caregivers. It is to be differentiated from autism and pervasive developmental disorders by its distinctively social origins and the child's relatively normal cognitive functioning (Zeanah & Emde, 1985).

The prevalence of reactive attachment disorder is unclear. Attachment disorders are commonly misconstrued and under-diagnosed. The symptoms begin early and they often become pervasive throughout life; the disorder may bear a resemblance to many others by the time they are recognized (Sheperis, Renfro-Michel & Doggett, 2003). Although a significant amount of research has been reported on attachment between parents and infants, only a minority of researchers have investigated the disorder that results when the attachment process is disturbed.

Inter-country adoption is a progressively more common manner of family formation, with an annual rate of approximately 2000 adoptions in Canada over the past decade (Citizenship and Immigration Canada, 2003). Research suggests that the majority of these children do very well in their new homes. For example, a Quebec study (Tessier, Larose, Moss, et al, 2005) which surveyed children adopted between 1985 and 2002 found that, although there is a great variability of outcome among inter-country adopted children, as a whole these children show rates of attachment security and social adaptation that is comparable to the general population of the province. Nevertheless, it must be recognized that some children adopted from foreign countries arrive in their new families with special needs.

Using recent research, this paper will provide an overview of reactive attachment disorder, its symptoms, characteristics and causal factors and a look into the susceptibility of institutionalized infants and children. It will conclude with a discussion of the current evaluation and treatment implements.

Theories of Attachment

John Bowlby developed the theory of attachment that underscored the significance of the relationship between a mother and her infant. His theory has since been confirmed and it is now realized that this bond influences a child’s ability to develop quality relationships throughout life (Maroney, 2001). Bowlby's theory of attachment was established upon evolutionary thinking. Infants are vulnerable and incapable of fending for themselves. Thus, the attachment process is designed to ensure the survival of the infant and, in turn, the species (Haugaard & Hazan, 2004). Given that an infant is well loved and its biological needs are reliably met, the child will learn to trust and feel secure with his caregiver, and a healthy attachment will be made (Wilson, 2001). This attachment will persistently influence one's interpersonal relationships throughout life.

In 1978, Ainsworth and her colleagues expanded on Bowlby's work with the idea that the primary caregiver acts as a secure base for exploration. They established the theory of “caregiver sensitivity to infant signals and the role of this sensitivity in the development of attachment patterns”(Wilson, 2001, p.38). Using what is referred to as “the strange situation”, they developed a method for assessing the quality of attachment. This laboratory procedure characterizes the attachment patterns corresponding to the infant’s reactions to reunion with the caregiver. Infants fall into three distinct attachment patterns: secure, insecure-resistant and insecure-avoidant (Wilson, 2001). The amalgamation of Bowlby’s attachment theory and the findings of the strange situation opened the door for research into infants and adolescents who present attachment problems. Securely attached infants demonstrate little avoidance or resistance to contact with the caregiver and draw on the caregiver as a secure base for exploration. Insecure-avoidant infants demonstrate avoidance of contact with the caregiver and often show little preference for the caregiver over a stranger. Insecure-resistant infants demonstrate resistance to contact with the caregiver and frequently show greater hostility and ambivalence than infants in the other two groups (Wilson, 2001).

Reactive Attachment Disorder

In the late 1970s and early 1980s, clinicians and researchers began to recognize that children who encountered abuse, neglect, or recurrent disruptions in primary caregivers often display varying degrees of cognitive, physical and social-emotional problems (Richters & Volkmar, 1994). After numerous modifications, the existing diagnosis of reactive attachment disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) characterizes RAD as “markedly disturbed and developmentally inappropriate social relatedness in most contexts” (Zeanah, 2000, p.1). The DSM-IV requires that the behaviour not be solely due to developmental delay or pervasive development disorders. A child diagnosed with RAD must have a history of pathogenic care, meaning experiences of parental/caregiver abuse and neglect or lack of a consistent caregiver (O'Connor T, Bredenkamp D, Rutter M, et al, 1999; Zeanah & Fox, 2004)

The DSM-IV distinguishes between two forms of reactive attachment disorder. The inhibited type is characterized by a failure to suitably initiate and respond to social interactions. These children may have a propensity toward avoidance behaviours (Wilson, 2001). Zeanah, Smyke, & Dumitrescu, (2002) describe children with the inhibited type as lacking the propensity to initiate or respond suitably during social interactions. They may be hypervigilant or highly ambivalent. The disinhibited type is more closely associated with social promiscuity. The child may be excessively social in inappropriate circumstances (Wilson, 2001). A child who is diagnosed with this subtype lacks any preferences when choosing those from whom to seek comfort, support and nurturance. This results in an atypical overfriendliness with relatively unfamiliar adults and has been labelled “indiscriminate sociability” (Zeanah, 2000, p. 1).

Symptoms and Characteristics

The symptoms associated with reactive attachment disorder may confuse many mental health counsellors (Lieberman & Zeanah, 1995). Sheperis, Renfro-Michel, et al. (2003) explain that symptoms seem very similar to other childhood disorders and therefore RAD may go undiagnosed. Infants who exhibit a weak crying response, perceptible defensiveness or a failure to thrive may indicate cause for alarm (Solomon & George, 1999). However, many symptoms may not be discernible until the child begins school (Hayes, 1997). These symptoms include low self-esteem, lack of self-control, antisocial attitudes, and aggression. Teachers and other adults may also notice an inability to ...

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Symptoms and Characteristics

Children with RAD often project a self-reliant and charismatic image while concealing inner feelings of insecurity and self-loathing. Infantile fear, hurt and anger are expressed in disconcerting behaviours that serve to keep caregivers at a distance and perpetuate the child's belief that (s)he is unlovable. These children experience difficulties giving and receiving affection on their parents' terms, are excessively demanding and clingy, and may irritate caregivers with endless chatter. They endeavour to control attention in negative ways (Lyons-Ruth & Jacobvitz, 1999). Additional behaviours may include: poor eye contact, abnormal eating patterns, poor impulse control, poor conscience maturity, chronic lying, stealing, and destructiveness to self and others. These children are often cunningly manipulative and view themselves as perpetual victims. As adolescents, children with RAD, who have not received treatment, may have distorted body images, aggressive behaviours, and sexual promiscuity. Finally, they may lack remorse for their own behaviours and may not demonstrate a concern for right and wrong (Sheperis, Renfro-Michel et al., 2003).

Causal Factors in Institutionalized Children

Children's early development depends largely on the health and emotional well being of their caregiver. Many orphans in Eastern European orphanages have been subjected to distressing and damaging environmental influences that can create severe and enduring social, emotional and regulatory damage. The ratio of caregiver to child can be as extreme as 1:50 (Federici, 1998). Infants and children residing in these institutions often suffer appalling living conditions, lack of medical care, inadequate food and shelter, occurrences of physical and sexual abuse, absence of cognitive stimulation, cruelty from institution staff and poor and detached care given by insufficient staffing (Federici, 1998).

Many children who are institutionalized are there because they have been discarded, neglected, or suffer from significant medical problems (Judge, 2000). These children have come from unloving homes where they have received poor nutrition and care. Inadequate attachment with parental or family members can impede the developmental process. The ratio of staff to children in Eastern European orphanages consequently results in a severe deficit of sensitive care that is essential for normal development and growth (Federici, 1998).

Institutionalized children appear to have a significantly elevated risk for serious disturbances of attachment (Zeanah, 2000). They have often undergone changes in caregiver at critical times relative to the formation of a secure attachment orientation. When they are searching for a discriminate attachment figure from which to venture out to unfamiliar adults, they often do not have that secure base established. They may develop an attachment orientation apparent by indiscriminate or diffuse attachments. They may endeavour to find comfort, support and nurturance in a peculiar manner with unfamiliar adults. Adoptive parents often perceive this orientation as very superficial.

The length and severity of early deprivation appears to add to the increased risk (O'Conner, Rutter, et al, 2002). Children placed with an adoptive family early seem to experience fewer difficulties than children placed as a later age (O'Conner & Rutter, 2002). Statistical correlations from the British Columbia Romanian Orphan Study (Ames, 1997) showed that the amount of time spent in an orphanage was the most predictive factor for later difficulties. In a study from the United Kingdom, 165 children adopted from Romania, were compared with 52 children adopted within the UK (O'Conner & Rutter, 2002). There was a significant association between length of deprivation and severity of attachment disorder. Although many adopted children do not exhibit severe problem behaviour, many continue to exhibit indiscriminate sociability long after they become attached to their adoptive parents.

The Quebec study (Tessier et al, 2005) found that the younger the child at the time of adoption, the more securely attached the child became to the adoptive parents. They also found that boys tended to be somewhat less securely attached than girls at the same age. Children who were under the age of six at the time of the study had similar levels of attachment as children of the same age who were born in Quebec. The B.C. Romanian Orphan Study found that the children who had resided in Romanian orphanages for long periods exhibited less secure patterns of attachment than the children who had been adopted from Romania shortly after birth, but that over time even the institutionalized children became more attached (not necessarily securely attached) to their adoptive parents. The children who continued to have attachment problems three or four years after adoption were those who also had other developmental problems (such as low IQ). One conclusion from this study was that the likelihood of attachment difficulties increases when there is a combination of several risk factors.

Assessment and Identification

Reactive attachment disorder affects more than just the individual child. Adoptive family members of children with the disorder may find themselves unable to deal with the problem behaviours. Schools face the dilemma of how to educate these children. Children with reactive attachment disorder tend to act out, torment, frighten, and injure other children (Hall & Geher, 2003), they may also have trouble functioning both in general and special education classrooms. There is a tendency for these children to gravitate towards other antisocial children, establishing hazardous associations (Hall & Geher, 2003).

Early recognition of the disorder is imperative because of the severity of the impact on families, schools and society. However, currently there is no comprehensive procedure to assess a child for RAD, but instead a series of semi-structured interviews, universal assessment scales, attachment-specific scales, and behavioural observations (Sheperis, Doggett, et al., 2003) have been proposed to aid in identifying the disorder.

Two scales directly related to attachment have been developed in recent years. The Reactive Attachment Disorder Questionnaire was introduced in Europe and may present generalization problems in North America. However, the Randolph Attachment Disorder Questionnaire (RADQ) has shown promise in identifying children with attachment problems from those with other troublesome behaviour disorders (Sheperis, Doggett, et al., 2003, p. X). However, this diagnostic scale has not been independently evaluated and does not assess sub-types of insecure attachment patterns. (Sheperis, Doggett, et al., 2003).

Another important component of the diagnosis of reactive attachment disorder comes in the form of direct behavioural observations. These observations are consistent with that of a functional behavioural assessment, which serves as a useful tool in determining the purpose behind specific behaviours. It is important to use corresponding observations of familial interactions to differentiate between task avoidance from social avoidance. This can be vital in distinguishing reactive attachment disorder from other behavioural disorders in children (Sheperis, Doggett, et al., 2003).

Treatment and Outcomes

Intensive interventions can be successful even for severe cases of attachment disorder. For example, the Cascade Centre for Family Growth had a success rate of over 75 percent in treating severe Reactive Attachment Disorder (Reber, 1999). A significant factor for success in treating attachment disorders is the age of the child. When a child is diagnosed and receives therapy before the age of seven, the chances of success are considered high; after age seven, the chances of success are only half as good; after puberty the chances of success diminish greatly (Reber, 1999).

When identification of RAD is made at an early age, direct work with caregivers can be initiated to promote attachment-related parenting skills and a nurturing, safe environment. Once a child has begun school and social behaviours become more of an issue, intervention becomes more necessary and controversial. Reactive attachment disorder and its presence in school-aged children can be an indication of future pathological disturbances and therefore the treatment is of critical importance (Wilson, 2001). Yet, children with reactive attachment disorder can be resistant to conventional therapies. The obstacles to therapy are the child’s perceived lack of ability to profit from the therapy, a negligible desire for change, little or no consideration for authority and inadequate impulse control (Wilson, 2001).

A controversial therapy sometimes used in treatment is called holding therapy. This holding therapy may also be called rebirthing or rage-reduction therapy. The goal is to recreate the bonding cycle that an infant experiences. Components of this therapy include: “prolonged restraint, prolonged noxious stimulation, and interference with bodily functions such as vision and breathing” (Robinson, 2002, p. 12). A therapist restrains the child’s arms and feet while forcing the child to maintain eye contact. The therapist then encourages the child to experience inner rage from past experiences by using antagonistic dialogue. There is purportedly encouraging feedback through the entire session and the purpose is to liberate the inner rage to allow for the formation of a healthy attachment (Myeroff, Mertlich & Gross, 1999).

There are numerous critics of holding therapy (Chaffin, Hanson, Saunders, et al., 2006; Kennedy, Mercer, Mohr, et al, 2002; Wilson, 2001). It has been compared to brainwashing and has been called malicious, unprincipled and dangerous. Many claim the benefits are founded on fear. Even so, the practice continues at many private attachment centres (Robinson, 2002). There is limited research on the effectiveness and it has not been empirically authenticated. While in some studies children have shown a decrease in aggression and misbehaviour after treatment, no long-term studies have been conducted (Wilson, 2001).

Interventions should be assessed to establish their suitability in the treatment of RAD. The most important element of any intervention should be to provide a care-giving relationship. This factor should come from an emotionally available, receptive and responsive, parental figure to which attachment can develop (Robinson, 2002).

Another form of attachment therapy has three components (Chaffin, Hanson, Saunders, et al., 2006). The first is instructive, designed to help parents understand children with RAD. The teaching of consequential parenting skills comprises the second component. Consequential parenting assists in heightening the child's motivation for treatment by allowing them to face the pain of their condition rather than displacing it on the parents. The third component is comprised of rigorous emotional work with the child. This part constitutes a significant portion of the treatment.

The fundamental purpose of attachment therapy is to help the child resolve an ineffectual attachment and develop a healthy attachment (Levy, T.M. and Orlans, M. (2000). The objective is to help the child bond to the parents and come to accept the disappointment and resentment with his/her first attachment figure(s), while resolving trust and intimacy issues. (Diamond, Reis, Diamond, et al, 2002). The child is assisted in accessing genuine and intense emotions associated with the events and people who created those feelings. The curative experience is designed to allow the child to recognize and recall these emotions and identify the events and the people involved. This experience then presents an opportunity for resolution of past pathological emotions while establishing powerful new attachments with parents.

The futures for children with reactive attachment disorder are diverse. Many adolescents with RAD communicate a desire for things they cannot affectively or cognitively manage such as strong friendships and intimacy (Sheperis, Renfro-Michel, et al., 2003; Voss, 1999). Even when children develop positive attachment relationships with their adoptive caregivers indiscriminate sociability often continues and this often foretells of consequent difficulties in peer relationships later in life (Zeanah, 2000). As these children get older they develop diverse attachment styles in an effort to cope (Richters & Volkmar, 1994) with their incoherent understanding of attachment and intimacy. Wilson (2001) examines numerous studies that associate attachment problems in infancy with later psychiatric diagnoses. Wilson also refers to a study conducted by Rosenstein and Horowitz in 1996 that discovered that 97 percent of a group of 60 adolescents admitted to a psychiatric hospital reported feelings related to insecure attachment.

Conclusion

For institutionalized children awaiting adoption, tremendous caution should be used when administering care. Smyke et al. (2002) reported that when children in Eastern European orphanages had contact restricted to only a few caretakers, they were better able to establish a preference for a single caretaker. These children then profited emotionally from attaching to that favoured caregiver. When primary prevention has not occurred in the institution, treatment should begin as soon as symptoms are noticed and takes the form of early intervention. Parents should receive candid instruction in care-taking responsibilities as well as education in understanding their child’s needs.

Reactive attachment disorder is a bewildering, taxing problem facing children and families. Lack of sufficient research on reactive attachment disorder is an obstacle to forming the

well-defined characterization of the disorder that is needed for consistency and validity in its diagnosis. What has long been established is that when caring and patient adults encourage traumatized children to express their emotions, they will gradually open up to new emotional experiences (Eagle, 1994, cited in Hayes, 1997). With successful intervention, there is a considerable likelihood that these children will learn to resolve persistent emotional numbness and defensiveness. At this time, attention may be best served in educating adoptive parents in the recognition of symptoms of RAD as well as in effective nurturing and attentive parenting methods. Further research into assessment and diagnostic tools is needed to allow for earlier recognition of RAD in clinical and counselling settings. Studies need also be conducted in assessing current and possible therapies for children suffering from reactive attachment disorder to determine which possibilities offer the best outcomes in the development of positive attachments between child and caregiver.

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Reactive Attachment Disorder

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