Reactive Attachment Disorder Research Articles

Discrimination between attention deficit hyperactivity disorder and reactive attachment disorder in school aged children

We aimed to determine whether it is possible to discriminate between children with attention deficit hyperactivity disorder (ADHD) and children with reactive attachment disorder (RAD) using standardized assessment tools for RAD. The study involved 107 children: 38 with a diagnosis of RAD and 30 with ADHD were recruited through community child and adolescent mental health services (CAMHS) and specialist ADHD clinics. In addition, 39 typically developing children were recruited through family practice. Clinicians were trained to use a standardized assessment package for RAD using a DVD with brief follow-up support. Discriminant function analysis was used to identify the items in the standardized assessment package that best discriminated between children with ADHD and children with RAD. Clinicians’ ratings of RAD symptoms were reliable, particularly when focusing on eight core DSM-IV symptoms of RAD. Certain parent-report symptoms were highly discriminatory between children with ADHD and children with RAD. These symptoms included “cuddliness with strangers” and “comfort-seeking with strangers”. A semi-structured interview with parents, observation of the child in the waiting room and teacher report of RAD symptoms aided diagnostic discrimination between the groups. Clinical diagnosis of RAD can be made reliably by clinicians, especially when focusing on eight core RAD symptoms. Clear discrimination can be made between children with RAD and children with ADHD.

Rebuilding relationships: A pilot study of the effectiveness of the Mellow Parenting Programme for children with Reactive Attachment Disorder

Mellow Parenting is an intensive parenting programme which has been shown to be effective in improving the psychosocial functioning of very vulnerable babies and preschool children. We used a complex interventions model to evaluate its use with school-age children with Reactive Attachment Disorder (RAD), a serious disorder of social functioning associated with maltreatment. The programme had a positive effect on mothers' mental health, but had no measurable effects on symptoms of RAD or on parent-child interaction, although the variation between families after the group suggested that some had responded more than others. Mellow Parenting is an effective programme for vulnerable families with younger children and may be a useful adjunct in the treatment of school-age children with RAD, but it cannot be considered a definite treatment for RAD in this age group. The search continues for safe and effective treatments for RAD in school-age children.

Some reflections on the use of psychiatric diagnosis in the looked after or “in care” child population

The current classification system, DSM-IV, inadequately captures the range and type of psychopathology seen in the "in care" population of children. A combination of pre-natal influences, early interpersonal trauma involving the primary caregiving relationship, disturbed and disrupted attachment relationships and other significant losses and adverse environmental effects produce a complex constellation of symptoms and a pervasive impact on development that is difficult to categorize. The challenges facing DSM-V are illustrated, highlighting unresolved topics such as quasi-autism, reactive attachment disorder and complex trauma.

Residential Childcare Workers' Knowledge of Reactive Attachment Disorder.

Reactive Attachment Disorder (RAD) is associated with a history of 'pathogenic care' therefore residential childcare workers are likely to come into contact with children with this disorder. An 'appropriately supportive environment' may be a mitigating factor in terms of the disorder's severity and duration (Corbin, 2007); therefore it is important that behaviours suggestive of RAD are recognised early and that these children are given the attention they require in the care setting. We aimed to gain an understanding of residential childcare workers' knowledge of RAD to determine if their understanding of RAD was sufficient to recognise RAD-like behaviour. A mixed methods study (qualitative focus groups and whole population survey) was undertaken with residential childcare workers. Liaison with Child and Adolescent Mental Health Services was seen by residential workers as being useful and workers thought their knowledge of mental health problems had improved in recent years. However, less than half of respondents (49.1%) identified RAD from a case history given in the questionnaire. Child and Adolescent Mental Health Services staff and residential workers may need more specialised training on RAD to be able to recognise behaviours suggestive of the disorder and refer appropriately, ensuring the child's needs are met as early as possible.

Reactive Attachment Disorder Symptoms in Adults with Intellectual Disabilities

Background Studies with children suggest that reactive attachment disorder (RAD) is associated with pathogenic early care. Little is known about RAD in adults with intellectual disabilities, many of whom experience adversity and abuse in early life. We investigated whether RAD symptoms occur in this population, and explored whether hypothesized risk factors are associated with higher RAD symptom scores.Method Fifty adults with intellectual disabilities residing in long‐stay hospitals and their carers participated in a questionnaire survey of RAD symptoms, childhood experiences, and disabilities.Results Reactive attachment disorder symptoms were present in this sample, and symptom scores were independently associated with early childhood adversity, diminished with age, but were not associated with cognitive ability, gender, other disabilities, nor number of childhood years in institutional care.Conclusions As with children with RAD, it is possible that some maltreated adults with intellectual disabilities fail to develop stranger anxiety by the usual developmental age. Over decades, they may gradually learn.

Reactive attachment disorder as an evolutionary adaptation

This paper suggests that the behaviours associated with the formal diagnosis of the “disinhibited” form of reactive attachment disorder (RAD) might be seen as a functional adaptation rather than a mental health problem, a facultative response enhancing the probability of survival that is triggered by certain conditions. Although disinhibited RAD is most commonly observed in institutionalised children, similar behaviours may also be a part of the emotional difficulties displayed by some fostered and adopted children (the latter includes those once institutionalised), and these may demonstrate not so much a discrete attachment disorder as either the need to fend for oneself following loss of dedicated caregiving or a lack of opportunity to build specific intimate relationships with dedicated caregivers. In many cases this may be inextricably mixed with the neurobiological and psychological seqelae of maltreatment. Indiscriminate attachment behaviour, from this proposed evolutionary perspective, is less a syndrome of mental ill-health than an astute survival manoeuvre following being orphaned, abandoned or fecklessly reared. Such a response, allied to the innate facility to access caregiving from different adults, could be expected to be initiated by specific events as are the other attachment configurations. Classing disinhibited RAD as an adaptation has implications for helping children brought up under extreme duress when their caregiving environment has changed for the better.

Development of a Brief Waiting Room Observation for Behaviours Typical of Reactive Attachment Disorder.

To develop a brief standardised observational schedule for Reactive Attachment Disorder (RAD) in school-age children to aid clinician recognition of these behaviours. A new structured observational schedule for symptoms of RAD was developed using unstructured observation of children in a clinic waiting room setting. The measure's ability to discriminate between a sample of children with RAD and a normative sample was established by comparing scores in these two groups. Children aged 5-8 years (n = 77 [38 RAD cases and 39 controls]) were observed with their primary caregiver in a standardised waiting room setting. A structured observational tool was developed that tested the reliability, sensitivity and specificity of each item. The schedule has good internal consistency (0.75). The individual items on the observational schedule were predominantly highly discriminatory between cases and comparisons, showing both reasonable sensitivity and excellent specificity. Certain questions were dropped due to poor discrimination and/or poor inter-rater reliability. The 10-item observational schedule for RAD in school-age children provides a promising tool for assessment, although further research will be required to evaluate its ability to discriminate between RAD and other disorders.

Forty-four juvenile thieves revisited: from bowlby to reactive attachment disorder

John Bowlby's work on attachment has had a major influence on practice in child and adolescent psychiatry and developed from observations Bowlby made in his clinical work. In a published case series of work with juvenile offenders, he provided a case description of the differing sets of problems that drove his interest. Clinical features described in a subgroup of these offenders, the 'affectionless psychopaths', might be recognized now as reactive attachment disorder (RAD). We scrutinized Bowlby's case series '44 Juvenile Thieves' and compared the aetiology and clinical features of a subgroup of these children with the other 74 cases described by Bowlby. We selected one typical case as an exemplar and provide an edited version here. We then present one composite case from a recent study of RAD and provide a comparison with typically developing children. Of the Bowlby cases, 86% had experienced early prolonged separation from their primary caregivers and had experienced multiple care placements. In total, 10% of clinical comparisons had been similarly separated. In our recent sample, 66% of children experienced separation from primary caregivers compared with none of the comparison group. A similar proportion of our sample of children with RAD had been removed from home as a result of neglect or had experienced other forms of maltreatment. Bowlby beleived that a main aetiological factor in the development of difficulties was the experience of separation. We suspect that a main aetiological factor in both his and our cases is the experience of maltreatment. We suggest that RAD arises from a complex interplay of genetic and environmental triggers.

Dyadic Developmental Psychotherapy: an effective and evidence-based treatment - comments in response to Mercer and Pignotti

This paper describes the evidence base for Dyadic Developmental Psychotherapy as an evidence-based, empirically validated, and effective family-therapy treatment for children with reactive attachment disorder and complex trauma. It is in response to a note by Mercer, Pennington, Pignotti, & Rosa. to our previous paper describing the evidence-base of Dyadic Developmental Psychotherapy. The paper summarizes the extensive empirical literature that describes the effectiveness of such dimensions of Dyadic Develop-mental Psychotherapy as affect arousal and regulation, gradual expo-sure to trauma, parent education and consultation, explaining how the past may be continuing to affect present behaviour, forming and maintaining a therapeutic relationship through therapist acceptance, affirmation, empathy and various other dimensions. The paper presents several generally accepted criteria for determining evidence-based practice and evidence-based treatment and demonstrates how Dyadic Developmental Psychotherapy meets those criteria. These criteria include those developed by Saunders et al., the UK National Health Services system, and the US Preventative Services Task Force system for ranking the quality of evidence. Finally, the paper responds to specific points raised by Mercer et al. indicating those with which we agree and those with which we disagree.

An integration of theory, science and reflective clinical practice in the care and management of attachment-disordered children: A Triple-A approach

The formation of functional attachments is a critical developmental task of infancy and early childhood. Attachments play a significant role in the development of a child’s enduring beliefs about self, other and world (Attachment Representations). Infants become attached to the people who provide physical and emotional care on a continuous and consistent basis. Quality of care and the infant’s early experiences influence the type of attachment the infant develops. When care is grossly deficient and early experiences are characterised by physical and emotional distress, the infant’s attachment to its caregiver is also disturbed. Children who display markedly disturbed and developmentally inappropriate social relatedness in most contexts, and who have experienced grossly deficient care, might accurately be diagnosed with Reactive Attachment Disorder (RAD) or Disinhibited Attachment Disorder (DAD). Attachment-disordered children pose a substantial care and management challenge to all who care for and work with them in the home and educational contexts. Successful management of these children and the remediation of their attachment difficulties are predicated on understanding what function their apparently antisocial and defensive tendencies serve and approaches that support the development of functional attachments. Key roles are attributed to cortical arousal, attachment representations and beliefs about accessibility to needs provision in the diagnosis and remediation of attachment disorders. Drawing from observations of caregiving practices that promote functional attachments in infancy, strategies are presented for the home and classroom that address elevated cortical arousal levels, promote secure attachment representations and reassure the child regarding accessibility to needs provision.

Adoptive Mothers’ Perceptions of Reactive Attachment Disorder Therapy and its Impact on Family Functioning

The purpose of this qualitative study was to explore adoptive mothers’ perceptions of attachment therapy and its impact on family functioning. Sixteen mothers were interviewed 3 years after therapy. Analysis of the data revealed two sets of parental perceptions: first, attachment therapy was consistently supportive, emotionally painful, and physically safe; second, therapy preserved family structure, mothers remained committed to their children, and parenting was continuously stressful. This study highlights the need for further research on the treatment of children with attachment disorders and is not intended as a treatise on the efficacy of attachment therapy as a treatment modality.

Understanding and Promoting Attachment

Interest in early relationships has led to increased use of terms such as attachment disorder, attachment problems, and attachment therapy when describing behavioral/emotional regulation in young children. Unfortunately, such terms are vague and lead to clinical confusion and diagnostic inaccuracies. This article will introduce attachment theory, with a discussion of reactive attachment disorder and implications for treatment of children who have problems with social-emotional development.

An exploratory study of the association between reactive attachment disorder and attachment narratives in early school‐age children

To explore attachment narratives in children diagnosed with reactive attachment disorder (RAD). We compared attachment narratives, as measured by the Manchester Child Attachment Story Task, in a group of 33 children with a diagnosis of RAD and 37 comparison children. The relative risk (RR) for children with RAD having an insecure attachment pattern was 2.4 (1.4-4.2) but 30% were rated as securely attached. Within the RAD group, children with a clear history of maltreatment were more likely to be Insecure-Disorganised than children without a clear history of maltreatment. Reactive attachment disorder is not the same as attachment insecurity, and questions remain about how attachment research informs clinical research on attachment disorders.

A Preliminary Investigation of the Effectiveness of Attachment Therapy for Adopted Children with Reactive Attachment Disorder

The purpose of this preliminary investigation was to examine the effectiveness of attachment therapy for adopted children diagnosed with Reactive Attachment Disorder (RAD). Although attachment therapy is widely utilized in the practice community, outcomes of such therapy have not been well documented. In this study a pretest–posttest one-group design was used with a sample of 24 adopted children who received attachment therapy from trained, licensed therapists. Therapy was funded by the Georgia Office of Adoptions under a contract with a non-profit adoptive parent advocacy group which provided training of therapists and direct services to families. RAD was measured with the Randolph Attachment Disorder Questionnaire (RADQ), Third Edition; functional impairment was measured with the Child and Adolescent Functional Assessment Scale (CAFAS). Statistically significant decreases in scores on the RADQ and CAFAS from pretests to posttests indicate improvement for the children who received therapy. In spite of methodological limitations, the current study adds to the limited knowledge about effective treatment for RAD.

Psychiatry, Third Editionedited by Allan Tasman, Jerald Kay, Jeffrey A. Lieberman, Michael B. First, and Mario Maj. Hoboken, N.J., John Wiley & Sons, 2008, 2880 pp., $340.00.

ajp.psychiatryonline.org This book will be especially appealing to people who liked college philosophy and want to have another go at it in a more condensed format that is a little more relevant to their work. For many clinicians, delving into the ultimate meaning of making diagnoses, prescribing treatment, and changing people may feel a bit like driving a car on a busy freeway while contemplating why the road has eight lanes, what the laws of physics are that make the car run, whether an alternative-fuel vehicle would work better, what forces led to our insistence on driving everywhere ourselves and using up so much oil, and so on. These are important questions that may have an impact on where we will drive next, but if we reason all this out while negotiating traffic, we may feel distracted and might even miss our exit. The gap between everyday practice and the ultimate meaning of what we do as clinicians was brought home to me when a very capable neurologist friend of mine told me about a patient he had just referred. “Perhaps you can explain the question she asked me,” he said. “She wanted to know what your philosophy was. ‘Is he a psychopharmacologist, a behaviorist, a Freudian, a Jungian, or a cognitive therapist? What is his orientation toward mental illness?’” “‘He’s a doctor,’ I told her. ‘He’ll prescribe whatever treatment makes the most sense.’”

Editorial: Attachment, development and quality of life

This issue includes the 2008 Emanuel Miller Lecture on attachment presented by Prof. Sir Michael Rutter and the practitioner review on quality of life in child mental health by Coghill et al., as well as other papers pertaining to closely related issues of interest, including papers on screening for childhood mental health problems, prosocial development, empathy and psychopathic traits, sibling relationships, parent groups for young children with behaviour difficulties, school-based intervention to reduce aggression, face processing among adolescence with conduct disorder and early markers and maternal sensitivity as associated with attachment in young children with Autism Spectrum Disorders (ASD). No doubt that Emanuel Miller would have been pleased to read this collection of papers which relate nicely to the transactional model of development (Sameroff & Chandler, 1975). Rutter, Kreppner and Sonuga-Barke raise some important questions regarding the state of the art research and its application in the field of attachment. They outline five key landmarks in the development of attachment theory including the differentiation of attachment from love made by Bowlby, the creation of the Strange Situation Procedure by Ainsworth to assess various forms of attachment (secure, insecure – ambivalent, insecure avoidant) between young children and their caregivers, a representational level of attachment in addition to the behavioural level, the addition of the disorganized category to the three aforementioned categories, and the introduction of the diagnostic category of Reactive Attachment Disorder. The authors state that “in itself, insecurity is not an indication of disorder or even maladjustment” (p. 530). Therefore, attachment as conceptualized and assessed in children with typical as well as atypical development does not “incorporate the whole of social relationships and behaviour” (p. 530) but rather is one aspect of social relationships. Today we know that children with ASD with all their social difficulties and impairments, not only discriminate among adults, but also form secure attachments with their mothers (Rutgers, Bakermans-Kranenburg, van IJzendoorn, & van Berckelaer-Onnes, 2004). Whereas the 50% rate of secure attachment in samples of children with ASD is lower than the 65–70% in normative samples, it is still surprisingly high, suggesting that insecure attachment and ASD may be somewhat independent of one another, and this may be true for other disorders as well. Even in the case of Reactive Attachment Disorder (RAD), which may intuitively suggest an insecure attachment pattern, it is well documented that adopted children can reveal both secure attachments toward their adoptive parents and signs of RAD at the same time (Chisholm, 1998; O’Connor et al., 2001). Thus attachment may be best viewed as one component of social and emotional development and not as encompassing the whole of social relationships and behaviour, nor as explaining or as a prerequisite of psychopathology. It is perhaps more appropriate to view secure attachment as a protective factor and insecure attachment as a risk factor. The interaction and transaction of disposition and context are important contributors to the continuity and discontinuity in attachment classifications and to the independence of attachment classifications on the one hand, and typical development and diagnostic entities on the other hand. Moreover, attachment security and insecurity may be best conceptualized as contributing positively or negatively, respectively, to the quality of life in children with typical development as well as in children with various diagnoses because secure attachments help all children to more fully actualize their developmental potential, whereas insecure attachments may inhibit such actualization.

Reactive attachment disorder and cognitive, affective and behavioral dimensions of moral development.

This study investigated the relationship between reactive attachment disorder (RAD) and the three dimensions of moral development: cognitive, affective and behavioral. Case vignettes were used to assess moral development of typical children (n = 35), and children with a history of adoptive or foster care who did (n = 20) and did not (n = 18) meet the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR; APA, 2000) diagnostic criteria for RAD. Several multivariate analyses of variance (MANOVAs) were conducted with group (RAD, Non-RAD, and control) and the dimensions of moral development. Results indicated that children with RAD exhibit more concern for external punishment and find unrealistic solutions to transgressions compared to the control group. Results are explained utilizing attachment theory, children’s temperament and characteristics of RAD.

Introduction to a special issue on the assessment of children with reactive attachment disorder and the treatment of children with attachment difficulties or a history of maltreatment and/or foster care.

Introduction to a special issue on the assessment of children with reactive attachment disorder and the treatment of children with attachment difficulties or a history of maltreatment and/or foster care.

Nonverbal processing and social competency in children with reactive attachment disorder.

Nonverbal processing and social competency in children with reactive attachment disorder.

Screening measures for children and adolescents with reactive attachment disorder.

Screening measures for children and adolescents with reactive attachment disorder.