Reactive Attachment Disorder

Mary Margaret Gleason

Charles H. Zeanah

Introduction

Bowlby and Ainsworth

Psychiatry has long acknowledged the importance of a child’s caregiving environment for emotional development. Since the mid-twentieth century, the literature has included descriptions of the negative impact of severe emotional deprivation (1). Descriptive studies of young children raised in institutions have described important effects of these caregiving environments on social and emotional development, including descriptions of indiscriminant behavior, which is considered to be part of the clinical syndrome of reactive attachment disorder.

Although disorders of attachment were not described in formal nosologies until the DSM-III (2), attachment theory has been the focus of active investigation for decades. Attachment theory was developed by John Bowlby and refined in collaboration with Mary Ainsworth and others (3,4). Bowlby proposed that infants are born with a biological predisposition to develop an attachment relationship with a small number of caregiving adults from whom the child seeks comfort, nurturance, support, and protection (Table 5.15.3.1).

Developmental Stages of the Attachment Relationship

In the first few 2 months of life, infants preferentially orient to people’s movement, faces, and sounds, although they do not discriminate among people, except in very subtle ways. From ages 2–7 months, children become more socially interactive and do appear to respond differentially to their caregivers, although they continue to engage socially with unfamiliar adults as well. Attachment behavior, characterized by proximity-seeking in times of stress, appears in the second half of the first year of life. The presence of the focused attachment relationship is heralded by the onset of separation protest and stranger anxiety. According to attachment theory, the attachment system works in conjunction with a number of other biologically driven systems, most prominently the exploration system. An equilibrium develops between the attachment and exploration systems. The parent serves as a secure base from which the child can explore the world when the exploration system is more highly activated, and a safe haven to whom s/he can return in times of stress when the attachment behaviors are more prominent.

TABLE 5.15.3.1 DEVELOPMENT OF ATTACHMENT

0–2 months	2–7 months	7–18 months	18–26 months
Bowlby’s Characterization
“Orientation and signals without discrimination”	“Orientation and signals directed towards >1 or more discriminated figures”	“Maintenance of proximity to a discriminated figure”	“Formation of a reciprocal relationship”
Social Interaction Patterns
Physical and social attributes attract adults for social interactions Recognition of maternal face Olfactory/auditory recognition Spontaneous smile	Able to engage adults in reciprocal social interactions Evidence of differential responses to adults	Focused attachment Separation protest Stranger reactions Intersubjectivity evident Social referencing	Develop negotiating abilities with caregivers (“goal-corrected partnership”) Increased interest in peers; moves toward interactive play and exploration
Communication/Methods of Cueing Adults to Needs
Crying, cooing	Eye contact Social smile Responsive cooing, babbling	Intentional communication with gestures and then words	Able to express needs Rapid vocabulary expansion

Interactions of Attachment, Exploration, and Social Systems

In human infants, attachment formation appears to be an example of experience expectant neural development. That is, in species-typical rearing environments, infants are hardwired to form selective attachments to caregiving adults. On the other hand, it appears that environmental and relationship factors play a strong role in the type of attachment relationship that the child develops, reflecting experience dependent neural processes. Ainsworth demonstrated a relationship between early patterns of parental sensitivity, infant responsiveness, and the development of a secure attachment relationship at age 12 months (5,6,7,8).

Different types or patterns of attachment are important because they serve as risk and protective factors for subsequent psychosocial adaptation. Children with insecure attachment patterns are at higher risk for subsequent psychiatric disorders and impairment from emotional and behavioral symptoms than securely attached infants (9,10,11). Although insecure attachment classifications are not necessarily indicative of psychopathology, the extremes of insecurity may reflect clinically relevant disorders of attachment (12).

Definitions

While the core features of reactive attachment disorder (RAD) are fairly consistent across diagnostic nosologies, each nosology uses a slightly different focus, as described in Table 5.15.3.2. For the first time in the DSM-III-R, the two subtypes of “inhibited” and “disinhibited” reactive attachment disorder were introduced; these subtypes remain in all extant nosologies. The DSM-IV criteria highlight problems of social relatedness in RAD, and require that a child demonstrate these aberrant patterns across settings. The DSM-IV also requires that there be a known history of “grossly pathogenic care (13)”.

More recently, the American Academy of Child and Adolescent Psychiatry convened an expert task force to develop empirically based research diagnostic criteria for the preschool age group using DSM-IV criteria and existing clinical and research data. These Research Diagnostic Criteria— Preschool Age (RDC-PA) explicitly link the diagnosis to disordered attachment behaviors and to a child’s lack of use, or misuse, of the primary attachment figure, unlike the DSM, which describes aberrant social behavior patterns (14). The use of these criteria may help to standardize the way in which RAD is studied and described in the literature.

The ICD-10, used primarily in Europe, classifies reactive attachment symptoms into two separate disorders, both with an emphasis on social relatedness. The first, which corresponds to the inhibited form of RAD, is called simply “reactive attachment disorder of childhood” and describes children with inhibited emotional responsiveness and contradictory social responses. In the ICD-10 nosology, “disinhibited attachment disorder of childhood” describes children with diffuse attachments and indiscriminate behaviors (15).

Phenomenology of RAD

While the categorization of RAD differs across diagnostic nosologies, and continues to evolve, there are certain common features that are generally agreed upon. The major nosologies, as well as historical descriptions of RAD (16), consistently describe two categories of attachment disorder behaviors: the inhibited and the disinhibited or indiscriminate types. It remains unclear how these two distinct subtypes relate to one another (17).

Emotionally Withdrawn/Inhibited Reactive Attachment Disorder

In the inhibited form of RAD, children show restriction of affect and behavior in situations that would normally activate the attachment system. In a healthy attachment behavioral
system, stressors activate the attachment system and a child seeks comfort from his or her attachment figure, but children with inhibited RAD tend neither to seek comfort from nor to respond to comfort offered by their caregiver. These children also may show contradictory behavioral response patterns, such as approaching and then avoiding a parent during a reunion (2,18). Children with the inhibited form of RAD tend to demonstrate a constricted range of affect and limited social reciprocity in social situations (19,20). In addition, emotional dysregulation has been described in clinical populations of children with RAD (15,19,21). Although emotional dysregulation may be an important clinical finding in children with histories of maltreatment, concerns have been raised about including it in the diagnostic criteria, as it lacks diagnostic specificity, particularly in the preschool age range (22). The inhibited form of RAD has been described primarily in maltreated or institutionalized children (20,23).

TABLE 5.15.3.2 COMPARATIVE NOSOLOGY OF REACTIVE ATTACHMENT DISORDER

DSM-IV	DSM-IV RDC: PA	ICD-10	DC: Zero to three
Core Criteria
“Markedly disturbed and developmentally inappropriate social relatedness in most contexts” (p.118)	“A pattern of markedly disturbed and developmentally inappropriate attachment behaviors in which the child rarely or minimally turns preferentially to a discriminated attachment figure for comfort, support, protection, and nurturance” (p.11)	“Persistent abnormalities in the child’s pattern of social relationships” (p. 219) and “particular pattern of… diffuse attachments” from infancy through middle childhood (pp. 220–221)	“A child with RAD will usually fail to initiate social interactions or will manifest ambivalent or contradictory social responses… A child may also show developmentally inappropriate social relatedness by social indiscriminance” (p. 30)
Age of Symptom Development
<5 yo	<5 yo	<5 yo	Not specified
Maltreatment Criteria?
“Grossly pathogenic care”	No requirement	Suggests caution if no known history of abuse or neglect	“Evidence of deprivation or maltreatment” (pp. 29–30)
Subtypes of Disorder
Inhibited, disinhibited	Inhibited, disinhibited/indiscriminate, mixed	Reactive attachment disorder of childhood Disinhibited attachment disorder of childhood	None
Exclusions
No PDD Not explained by developmental delay	No PDD Developmental age > = 9 months	Two attachment disorders are mutually exclusive; no PDD, cannot include other abuse syndromes	None Rule out: affective, relationship, adjustment, psychic trauma disorder

Indiscriminately Social/Disinhibited Reactive Attachment Disorder

In indiscriminate RAD, children show a different pattern of responses to stressors which would usually activate the attachment system. In novel situations or stressful situations, these children tend to be overly familiar with strangers. Whereas a healthy attachment system counterbalances children’s ploratory drive and motivates children to check in with their attachment figure as they explore new places or people, these children may approach strangers and even willingly leave with a stranger. Their proximity-seeking and comfort-seeking behaviors overall are applied indiscriminately. While these children have been described as “overly friendly,” their behaviors do not necessarily represent friendliness or reciprocal social interactions. In fact, the approaches may feel empty or shallow to the other person (24,25).

Other Clinical Forms of Attachment Disorders

Mixed RAD

While the standard nosologies only allow for the presence of inhibited or disinhibited RAD, research in maltreated and institutionalized children has found moderate intercorrelations between disinhibited and inhibited RAD (20,17). The question that remains unanswered is whether there are children who truly manifest features of both types of RAD, or whether there is a spurious problem with measurement. It is possible to imagine that some children with the inhibited type of RAD might passively go off with a stranger, fail to check back with a caregiver and show little reticence with strangers because they are so withdrawn and unresponsive rather because they are actively seeking engagement in a nonselective manner.

Secure Base Distortions

The diagnostic criteria for RAD imply the lack of a focused attachment relationship. However, investigators and clinicians have noted severely disordered attachment behaviors in children who appear to have a focused attachment figure, albeit in the context of a disturbed relationship (22,26). Zeanah and colleagues have proposed a revised set of alternative diagnostic criteria, which explicitly allow for the diagnosis of a reactive attachment disorder when the child’s use of the caregiver as an emotional secure base is distorted (26,27). The
distortions can be of four major types: role-reversed behaviors, provocative self-endangering behaviors, excessive clinginess and restriction in exploration, and excessive vigilance and hypercompliance. In a role-reversed pattern, a child takes on a directive, parent-like role in his or her relationship with a primary caregiver. Provocative self-endangering behaviors, unlike impulsive behaviors, appear to be intended to elicit a response from a parent. While many preschoolers cling to their parent, some children’s clinginess increases exponentially in the presence of strangers, as if the child is not sure the parent will protect him or her. Finally, children can become excessively vigilant or show robotic hypercompliance, sometimes in the context of an unpredictable, harsh parenting style. While these criteria have not been incorporated into diagnostic nosologies, these alternative criteria for RAD can be used to reliably diagnose high-risk children (23) and may be valuable constructs in clinical assessments of attachment behaviors.

Associated Clinical Features

The particular risks and contexts that give rise to RAD also have been associated with other clinical conditions.

Quasi-Autistic Features

Rutter and colleagues described a small subgroup of previously institutionalized children who presented with “quasi-autistic” features, including limited social reciprocity, poor observance of social boundaries and poor social awareness (28). These children, who represented just 6% of the total group of previously institutionalized children, demonstrated several features that distinguished them from typically described autism. The severity of symptoms in these children correlated with the length of time a child spent institutionalized, suggesting an environmental, rather than neurobiological, etiology. Importantly, unlike autism, these symptoms diminished over a course of 2 years following adoption.

Hyperactivity and Inattention

Indiscriminate behavior has been noted to be accompanied by hyperactivity and inattention. While these symptoms are not part of RAD, some have suggested that the inattention and overactivity seen in children with a history of institutionalization and attachment disturbances may reflect an “institutional deprivation syndrome”(29). Rather than invoking traditional ADHD, these investigators suggest this syndrome is directly related to the deprivation of the institutional experience, citing a correlation between attachment disturbances and the levels of the hyperactivity, between duration of institutionalization and inattention/hyperactivity, and the clinical differences in the presentation compared with ADHD.

Failure to Thrive

Failure to thrive has been associated with RAD symptoms since the development of the DSM-III criteria in which growth failure was a criterion. This criterion was dropped subsequently from the DSM because of a lack of face validity as an attachment-related symptom. However, failure to thrive has been shown to be associated with some parental indicators of attachment disturbances (30) and continues to be cited in the clinical guidelines of the ICD-10 (14). While neither necessary nor sufficient as a sign of disordered attachment, it may be an associated finding. Other feeding abnormalities, particularly stuffing or hoarding food, also have been described in maltreated children and may be associated with RAD (21).

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