Reactive attachment disorder (RAD) is defined by DSM-V as a developmentally inappropriate and disturbed attachment behavior that is characterized by underdeveloped attachment towards the primary caregiver. RAD was introduced in the Diagnostic and Statistical Manual of Mental Disorders, third edition (DSM-III) in 1980 and is considered as one of the disorders of infancy as it is thought to occur as early as 9 months of age (American Psychiatric Association [APA], 2013). Attachment could be defined as a predisposition of an infant or child to seek comfort from a specific attachment figure, whom they consider as their primary caregivers. RAD is a condition where there is a lack of a discriminatory or consistent form of attachment (Hardy, 2007).
Maltreatment, abuse and social neglect are some of the causative agents of RAD in infants, which bestows the children with an inability to form normal long-term social relationships; this makes the RAD one of the two (the other being PTSD) mental disorders with a well-defined and proven etiology (Zeanah & Gleason, 2010). Incidentally, not all children who are maltreated tend to develop RAD. Studies have shown that gender, genetic makeup and developmental environment play a certain role in determining the development of RAD and may also influence the type of RAD that the child would develop (Minnis et al., 2007). There are two types of RAD, namely, emotionally withdrawn/inhibited type and indiscriminately social/disinhibited type. Treatment and management therapies such as behavioral management therapy, holding therapy and few novel non-pharmaceutical treatment regimes are under focus for RAD. There are very few large-scale randomized studies to understand the neurobiology as well as the psychopathology of infant maltreatment and subsequent development of RAD. The studies on the long-term effects of RAD are practically non-existent (Mukaddes et al., 2004).
Prevalence of RAD among children
RAD is a rather uncommon disorder and has a prevalence of less than 10%, according to the DSM-V (APA, 2013). This prevalence value has been corroborated by two studies, which revealed that prevalence of RAD in deprived children is 1.4%. The studies suspected that if borderline cases that had the propensity to develop RAD were to be included the prevalence would be up by 2.37% (Minnis et al., 2013). The basis of the type of RAD developed by a child has not yet been elucidated. In a study, it was noted that 31% of the children exhibited emotionally withdrawn RAD, 38% exhibited indiscriminate social RAD and 31% of the kids managed to form preferential attachment to caregivers (Zeanah & Gleason, 2010). Studies have shown that the prevalence of the indiscriminately social/ disinhibited RAD is the most common type of RAD found in both institutionalized children as well as adopted children (Gleason et al., 2011). Preschool kids from foster care home have shown to develop RAD 20 to 40% of the time when compared to preschool kids that grow up with their biological parents (3 to 6%) (Golden, 2009).
Attachment theory
It is imperative to understand the theory and construct of attachment in order to understand what goes wrong in RAD. The attachment theory, developed by John Bowlby, suggests that every infant or child displays four types of attachment, namely, secure, avoidant, resistant-ambivalent, and disorganized-disoriented (Minnis et al., 2009). According to this theory, babies are programmed to form an emotional bond with the primary caregiver right from birth. The need for proximal contact with the primary caregiver or parent continues even after the baby starts individual activities. There are a couple of theories that shed light on the process of attachment. Developmental psychology suggests that the process of attachment gives the child a template to form future relationships. Neuropsychoanalytic studies suggest that the affective contact between a child and the primary caregivers forms a neural pathway in the child’s right hemisphere that instills the ability to form normal relationship later in life (Hardy, 2007).
A secure attachment pattern is a result of a high quality care from the primary caregiver. Under such a circumstance, the child would exhibit positive psychological and physiological outcomes. This positive outcome is contrary to the situation seen in disorganized attachment, which is associated with erratic attachment behavior and is evidently associated with psychopathology (Gleason et al., 2011). Attachment theory only explains the normal forms of attachment that could be expected from children who are brought up in a positive environment as well as children who are maltreated. This framework, although indirect, gives an insight into the neuropsychology of the children suffering from RAD and similar attachment disorders (Hardy, 2007).
Types of RAD
Researchers believe that the two types of RAD are clinically very different owing to their distinctly varied clinical presentation. Studies have shown that children suffering from RAD could develop either of the type or develop both types of RAD, creating three distinct types of the affected population. Studies have also pointed out that the psychopathology of these two types of RADs are so different that they should be classified as two separate mental disorders. There have been very few studies to elucidate the reason for the development of either type of RAD developed by children within the same development environment (Hardy, 2007).
Indiscriminately social/disinhibited RAD
Children with indiscriminately social or disinhibited type of RAD show a radical and indiscriminate friendly attachment not only to their primary caregiver but also to strangers with whom the child is unacquainted. The child is also noted to crave for attention, hypo-vigilant, walking off with strangers and unable to form selective attachments as a normal child would tend to do (Hardy, 2007).
Emotionally withdrawn/inhibited RAD
Socially and emotionally withdrawn RAD is marked by the inability of the child to form any kind of attachment to the caregiver and the society, in general. Such children are often hyper-vigilant, untrusting towards others and fail to develop any form of basic social relationships. They may also exhibit inappropriate responses to social stimuli, which can only be defined as being contradictory and ambivalent in nature, indicating poor development of neuropsychological connections in the brain (Hardy, 2007).
Mixed type RAD
Zeanah and Gleason (2010), in their review for DSM-V suggested that a third category of RAD be considered where the child exhibits both disinhibited and inhibited attachment behavior erratically, depending on the stimuli and childhood trauma.
Developmental course of RAD
According to the DSM-V, for a child to be diagnosed with RAD, the onset of the condition must occur before the age of 5 years (APA, 2013). The onset is triggered by social neglect on the part of the parents or primary caregivers who fail to understand the constant need of the child to be held, comforted and stimulated. Such a pathogenic caregiving leads to, over a period, a distinct characteristic behavior where the child refrains from seeking or responding to care in the inhibited type or tries to seek comfort from any stranger in the disinhibited type. The child shows signs of inexplicable sadness, irritation, fearfulness (possibly in the presence of the abusive caregiver), ambivalent thoughts and inappropriate responses to stimuli (Zeanah and Gleason, 2010). The behavior would stabilize and imprint in the child after the age of five, where the child would continue to exhibit the characteristics associated with the type of RAD they develop. Typically, the inhibition or disinhibition shifts from the caregiver to peers during adolescence and adulthood. The patient could refer to a casual acquaintance as a close and dear friend, while failing to see that it is inappropriate (Zeanah and Gleason, 2010). There is currently very little data and research on the course of the disorder.
Psychological concepts of RAD
The early interaction between a child and its caregiver forms a moral framework and template to act upon future interactions. This framework has three parts, namely, cognitive understanding of positive emotions, affective understanding of emotions and their consequences and behavioral development of morality. Morality is characterized by the development of remorse, cognitive understanding between right and wrong and forming socially appropriate relationships. Morality is essential to survive and succeed in a society that is driven by deep rooted and clearly demarcated ‘rights’ and ‘wrongs’. When this framework is incomplete or non-existent due to social deprivation and pathogenic care, the child fails to develop morally appropriate cognitive behavior. The loss of morally appropriate behavior is one of the hallmarks of RAD (Termini, 2009).
Cognitive moral development
Cognitive development regarding morals is gained as positive or negative experiences through interactions with the primary caregiver, usually parents. Such experiences help the child to act upon moral dilemmas that he or she faces in society. Positive interactions help the child in internalizing the concept of right while making the child competent in a socially appropriate way. The negative experiences are also essential in moderation to trigger the development of self-regulatory behavior. However, assertion of parental (especially maternal) power through excessive criticism and forced disciplinary methods have been found to be detrimental to a child’s cognitive development, where the child displayed immature thought process and reasoning capabilities. This concept proves that the quality of care and presence of pathogenic care environment could lead to inappropriate attachment behavior as seen in RAD (Termini, 2009).
Affective moral development
While cognitive development refers to mental internalization of the concept and understanding, affective development refers to the emotional connection to the act. If cognitive development is essential for distinguishing between right and wrong, affective development is imperative to feel the emotions such as remorse, acceptance, guilt and empathy that are related to the right and the wrong moral values. Inductive reasoning is a method used to inculcate the idea of afferent moral values in children, where the parent or the primary caregivers voice their feelings associated with a wrong act done by the child. The method points out the child’s role in causing the feeling and whether it was socially appropriate. Understanding of the intrinsic consequence of one’s act on others would lead to the affective moral development in a child. Children with RAD are often observed to be eccentric, narcissistic and lacking empathy. This observation suggests that children with RAD do not have the emotional connectivity that is seen in the affective moral development of a normal child (Termini, 2009).
Behavioral moral development
Behavioral moral development is said to be positive when the child takes the initiative to act in a prosocial manner, resisting the urge to behave in an antisocial manner. This development is mediated by the exchange of positive behavioral pattern as exhibited by the primary caregiver towards the child during the early phase of development. Studies have shown that maltreated preschool children lacked a moral behavioral framework and had a tendency to engage in antisocial and sadistic acts coupled with lack of empathy. The reason for such a behavior is attributed to a lack of internalization of the concept of moral behavior (Termini, 2009).
Risk factors
Genetic
Minnis et al. (2007) studied a group of dizygotic and monozygotic twins to assess the influence of genes in the development of RAD. They concluded that children with a tendency for inhibition or impulsive behavior had a higher risk for developing RAD. They also put forth that boys were more likely to develop RAD when compared to girls with similar genetic makeup and growth environment. The reason behind this preference is elusive.
Another study suggested that the 7-repeat variant of the 48 bp VNTR polymorphism in the D4 dopamine receptor (DRD4) gene could be a marker for the development of attachment disorders. Children with such a polymorphism were estimated to be four times more like to be insecure or disorganized in attachment. The scientists also noted that a -521 C/T promoter polymorphism present in the children with the 7-repeat variant of the 48 bp VNTR polymorphism acted as an enhancer for the manifestation of the condition (Gervai, 2009).
Environmental
The most obvious risk factor for development of RAD has been found to be the quality of care provided by the primary caregivers to the child in the early years of development. A responsive and sensitive caregiver who not only heeds to the child’s emotional, physical and psychological demands but is also sensitive to the changes in the demand is more likely to steer the infant and child into a positive developmental mode. An unresponsive and abusive caregiver is more likely to create a negative developmental environment that decreases internalization of moral concepts and initiates inappropriate attachment behavior (Gervai, 2009).
Diagnosis of RAD in children
Diagnostic criteria
According to the DSM-V, the diagnostic criteria for RAD have been divided into 4 major categories with 3 minor categories. Category A suggests that the child would exhibit consistent emotionally withdrawn/inhibitory attachment behavior towards the primary caregiver, which is characterized by the lack of comfort seeking behavior as well as lack of response to comfort. Category B mandates that an emotional disturbance seen in the child’s temperament must be a characterized by at least two of the following reasons: limited positive behavior, inexplicable irritability, sadness or fear and reduced social responsiveness to others. Category C describes that the child must have experienced insufficient care owing to social neglect, constant change in primary caregivers or raised in a high child to caregiver ratio environment. Category D describes that the developmental settings of C must be the reason for the behavior in A. The child must be less than 5 years of age with a minimum developmental age of 9 months for diagnosis of RAD. The child must not be suffering from autism spectrum disorder (ASD) (APA, 2013).
Differential diagnosis
The symptomology of RAD is similar to ASD, intellectual developmental disorder and depressive disorders. Therefore, care must be taken to make a differential diagnosis before confirming the diagnosis for RAD (APA, 2013).
Treatment and management techniques for RAD
Play therapy
Play therapy is a process to release built-up negative emotions via play time. Children who have suffered trauma or maltreatment often use playing with toys as a way of reliving the trauma. Researchers believe that play therapy helps the children heal over a period of time by letting the negative energy diffuse through each session of play therapy. Playing with miniatures, making wet sand models and sand trays are some of the common methods of implementing play therapy. An ideal setting would be a 150 to 200 sq. ft. of enclosed play area, child safe furniture and easily accessible play things. As children with RAD are prone to inexplicable erratic behavior, therapists recommend a gradation four step procedure to control the misbehavior. The first step would be to explain to the child why he or she is feeling angry; the second step would be to point out the limit of the behavior; the third is to suggest an alternative; and the fourth step is to end the sessions owing to continues misbehavior. Play therapy has the flexibility of location and thus can be conducted in a safe environment for the child to truly express and heal (Schaefer, 2011).
Psychoeducation for caregivers
Psychoeducational therapy is a didactic (based on moral instructions) treatment method that focuses on teaching the caregivers the basis of RAD, the various disconnected problems areas and a solution to integrate all for an insight into their child’s mind. The therapy is provided over 10 to 12 sessions of 45 minutes to 60 minutes each week. The children are eased into play sessions while the parents and caregivers are educated about their child’s behavior and actions. The therapists usually top this off with few behavioral techniques that the caregivers and parents need to apply at home for continuing the therapeutic effects (Mukaddes et al., 2004).
Behavioral management therapy (BMT)
BMT is one of the widely used therapies in ASD and ADHD. However, in RAD, the BMT also provided to the caregivers so that they can elicit more compliance from the children suffering from RAD. BMT has been found to be effective in RAD, though there is a need for more research in this area. BMT is conducted over ten sessions for the caregivers and the children to increase concentration, instill discipline, reduce disruptive behavior, reduce aggression, etc. (Buckner, Lopez, Dunkel & Joiner Jr., 2008).
Dyadic developmental psychotherapy (DDP)
DDP aims at creating a safe therapeutic environment in which the child feels safe enough to open up about past trauma. Very young children may not be able to access their fears and trauma, which makes the healing difficult. Therefore, the primary goal of DDP is to ensure that the child is placed in an accepting environment that help them discover their true feelings through play time along with readying the child to trust their primary caregiver. The caregivers are encouraged to accept the child’s affects (emotions) and are trained for continuing treatment outside the therapy sessions. DDP is more focused on the experience outcomes rather than the vocalization of thoughts (Becker-Weidman, 2008).
Conclusion
RAD is an attachment disorder that has been documented to arise because of maltreatment by the primary caregiver. The disorder is thought to manifest itself as early as 9 months of age and is categorized as RAD only if the symptoms are visible before the age of 5 years. However, the symptoms persist beyond toddlerhood and well into adulthood. There is a dire need for more studies on the neurobiology of the disorder and treatment options to manage RAD.
References
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