Reactive Attachment Disorder

Etiology

The genesis of reactive attachment disorder is encompassed under the designation of traumatic experience; specifically, the severe emotional neglect commonly found in institutional settings, such as overcrowded orphanages, foster care, or in homes with mentally or physically ill parents. Over time, infants who do not develop a predictable, nurturing bond with a trusted caregiver, do not receive adequate emotional interaction and mental stimulation halt their attempts to engage others and turn inward, ceasing to seek comfort when hurt, avoiding physical and emotional closeness, and eventually become emotionally bereft.[4][3] The absence of adequate nurturing results in poor language acquisition, impaired cognitive development, and contributes to behavioral dysfunction.[5]

Epidemiology

Although difficult to accurately assess, recent data suggest a prevalence rate between 1-2%.[6] A data analysis report published by the National Survey of Child and Adolescent Well-Being (NSCAW) indicated that 42% of children removed from their home and placed in an alternate setting met DSM–IV (1994) criteria for a behavioral health disorder. Additional research completed by Landsverk and Garland and cited in Mental Health Treatment of Child Abuse and Neglect: The Promise of Evidence-Based Practice (Shipman, Kimberly, and Taussig, Heather 2009) found that "between one-half and two-thirds of children entering foster care exhibit behavior or social competency problems warranting mental health services."

Research suggests that concordance rates among siblings raised in the same home to be between 67% and 75%.[7] Neither gender nor ethnicity alone appears to be risk factors for developing the disorder; however, African American and multi-racial children experience higher rates of child maltreatment than do their non-minority counterparts which likely translates to a higher incidence of reactive attachment disorder in minority populations.

The National Survey of Child and Adolescent Well-Being, No. 18  (Instability and Early Life Changes Among Children in the Child Welfare System) shows that 79% of children who died because of abuse or neglect in 2010 were younger than the age of 4. During that same year, 48% of children entering the foster care system were also younger than age 5.[7]

Pathophysiology

Since WWII, physicians, psychologists, and attachment theorists have documented the impact of social neglect on physical and emotional development. Experiments completed in the 1940s and 1950s found that maternal deprivation had a profound effect on infant growth, motor development, social interaction, and behavior. In the film Psychogenic Diseases in Infancy (Spitz, 1952), infants deviated from the normal, expected course of development and became “unapproachable, weepy and screaming” within the first 2 months of maternal deprivation. As the deprivation continued, facial expressions became rigid and then flat; motor development regressed, and by the fifth month, infants were “lethargic,” unable to “sit, stand, walk, or talk,” suffered from growth abnormalities, developed “atypical, bizarre finger movements,” and no longer sought or responded to social interaction; 37.3% of the infants died within 2 years. These early experiments became the foundation for Attachment Theory and outlined the constellation of symptoms of what the DSM, Third Edition (DSM–III) would later call reactive attachment disorder.

History and Physical

The DSM-5 gives the following criteria for reactive attachment disorder:

• The patient demonstrates a chronic pattern of being emotionally withdrawn and inhibited, which is demonstrated by rarely seeking or responsive to comfort when distressed. 
• There is evidence of a chronic social and/or emotional perturbation characterized by at least two of the proceeding: social withdrawal and minimal responsiveness to others, negative affect, unfounded or inexplicable episodes of irritability, fearfulness, or sadness--or out of proportion reactions to normative stress.
• The patient presents with a history of extremely insufficient care, entailing of one of the following: deprivation or social neglect of basic emotional needs for stimulation, comfort, and affection by caring caregivers; the constant flux of caregivers, resulting in a destabilized home environment; growing up in an unusual setting which limits the ability to form selective attachments
• The child cannot also meet the diagnostic criteria for autism spectrum disorder as the two diagnoses (autism spectrum disorder and reactive attachment disorder) are mutually exclusive
• The behavioral perturbation should manifest prior to the age of 5 years of age
• The child must have a developmental age of at least nine months in order to qualify for the diagnosis

These diagnostic criteria provide an outline of symptoms; however, providers must also recognize the global impact on cognition, behavior, and affective functioning.

Cognition

Abuse in childhood has been correlated with difficulties in working memory and executive functioning, while severe neglect is associated with underdevelopment of the left cerebral hemisphere and the hippocampus.[8][3]

Behavioral

Social skills are below what would be expected of either their chronological age or developmental level. Children with RAD may respond to ordinary interactions with aggression, fear, defiance, or rage.  Affected children are more likely to face rejection by adults and peers, develop a negative self-schema, and experience somatic symptoms of distress. Psychomotor restlessness is common, as is hyperactivity and stereotypic movements, such as hand flapping or rocking.[1][4]

Affective

RAD increases the risk of anxiety, depression, hyperactivity, and reduces frustration tolerance. Ailing children are likely to be highly reactive, even in non-threatening situations.[8]

Evaluation

Clinicians should have a low threshold for referring children with a known history of adoption, abuse, foster, or institutional care to a child psychologist or psychiatrist for a comprehensive biopsychosocial assessment detailing the child’s history, description of the symptoms over time, and direct observation of the parent-child interaction.  Attachment behaviors and signs of secure attachment (e.g., comfort-seeking, good eye contact, child-initiated interaction) should be assessed at every visit. Clinicians should maintain a low threshold for referral to a child development specialist, a child psychiatrist, or a child psychologist.[9]

Treatment / Management

Treatment of RAD requires a multi-pronged approach incorporating parent education and trauma-focused therapy. Parent education focused on developing positive, non-punitive behavior management strategies,  ways of responding to nonverbal communication, anticipation and coping strategies for when triggers arise and parent-child psychotherapy can facilitate bonding and healthy attachment. Empathy and compassion are key elements to building trust. Developing a nurturing parent-child relationship is the cornerstone to overcoming the damage caused by severe neglect and abuse.

Differential Diagnosis

According to the DSM-5, the following differential diagnoses should be ruled out before a diagnosis of reactive attachment disorder:

Autism Spectrum Disorders        

Children on the autism spectrum often exhibit many of the same features as those with reactive attachment disorder; however, restricted range of interest, sensory processing difficulties, and rigid adherence to rituals or routines are specific to autism spectrum disorder.

Intellectual Impairment

For a diagnosis of RAD to be made, the child must have attained a developmental age of at least 9 months, and another medical or mental health disorder must not cause social impairments. Impairments in social relatedness commensurate with developmental age should be viewed as an overall feature of the developmental delay and not solely a response to severe neglect.

Depressive Disorders

Symptoms of anhedonia may mirror many of the withdrawal symptoms of RAD; however, children suffering from depression maintain the ability to attach and to seek and receive comfort from preferred caregivers.

Prognosis

Even with intervention, injured children encounter difficulties in every aspect of their lives; from classroom learning to developing a secure sense of self.  The traumatic situations which lead to the attachment disorder create a persistent state of stress; diminishing their capacity for resilience.  Early identification and treatment have been shown to improve outcomes; however, parent education and support are key.  Parents adopting children from state custody or from overseas orphanages should receive education on the impact of social deprivation and connected with service agencies or providers specializing in attachment disorders.[9] 

Complications

Signs and symptoms of RAD may be missed by providers who are unfamiliar with the child’s history or when the history is unknown. Symptoms may be attributed to common behavioral health disorders such as depression, anxiety, attention deficit-hyperactivity disorder, oppositional defiant disorder, conduct disorder, genetic or neurological disorders, or autism spectrum disorder. Although there is a significant symptom overlap and co-occurrence, treatment for each varies and some treatment methods may exacerbate RAD.