Paper I wrote for class that applies

Reactive Attachment Disorder

Reactive attachment disorder (RAD) is a developmental disorder listed in the DSM-IV-TR with other disorders found in infancy, childhood, and adolescence. It is usually found in children before age five, the hallmark of the disorder being significantly inappropriate social reaction between the primary caregiver and child and ultimately between the child and others (Hornor, 2008). RAD is a disorder that resides within the wider scope of attachment theory, and this theory must be understood to define, classify, explain, and treat reactive attachment disorder.

Attachment theory is a concept first explored by psychoanalyst John Bowlby that states that the relationship formed between caregiver and child is crucial to the development of awareness of self and others. This establishment of identity influences intrapersonal relations throughout a lifetime (as cited in Fairchild, 2009). Since attachment is formed in early childhood and affects future success in connecting with others, this suggests that a disruption in attachment formation results in negative consequences regarding that success. Reactive attachment disorder is one such disruption.

In the DSM-IV-TR, the American Psychological Association lists RAD as “very uncommon” (as cited in Corbin, 2007). Symptoms of RAD fall under two categories: the inhibited type and the disinhibited type. Both types require the presence of pathogenic care provided by the primary caregivers in order to be classified as reactive attachment disorder. The inhibited type characteristically includes an inability to bond with the caregiver, resulting in both resistance to comfort and the lack of seeking comfort. Children with the inhibited type may appear emotively frozen and uninterested in socializing. Alternatively, the disinhibited type exhibits a readiness to socialize with just about anyone, without special preference for the caregiver (as cited in Hornor, 2009). Like inhibited RAD children, disinhibited children do not rely on the caregiver either. Recent studies show that while inhibited and disinhibited types are listed as mutually exclusive, comorbidity of the types is possible, with one study by Zeanah and Emde (1994) showing that seventeen percent of the sample group showed behavior associated with both types (as cited in Hornor, 2009).

All of these symptoms are abnormal in a caregiver-child relationship. It is typical for young children to form a strong bond to their caregivers in normal family dynamics. A caregiver provides a loving, supportive and predictable environment and the child learns to depend on this. Attachment forms. However, when a caregiver fails to provide such an environment, attachment is less likely to form. This is considered pathogenic care, which increases the risk of RAD. Hallmarks of pathogenic care may include physical abuse, sexual abuse, and neglect; parental alcoholism, drug use, and/or mental illness; or the absence of a stable caregiver, such as in orphanages or when a child passes through a series of foster care facilities (Hornor, 2008). The abnormal behavior of a child with RAD is understood through this lens. While pathogenic care does not necessarily always lead to reactive attachment disorder, all cases by definition require pathogenic care to be considered RAD. Other disorders that may present themselves similarly to reactive attachment disorder are mental retardation and the pervasive developmental disorders (PDD). However, according to the DSM-IV, children with mental retardation are able to form parent-child attachments, and children with a pervasive developmental disorder show “other associated impairments in communication and restricted, repeated, and/or stereotyped patterns of behavior“ according to which disorder the child presents (as cited by Corbin, 2007). Most importantly, children with PDD may have abnormal parent-child attachments even without the presence of pathogenic care giving, which is a necessary facet of RAD diagnosis. Understanding the often harsh, pathogenic backgrounds from which RAD children develop not only helps psychologists distinguish this disorder from others, but it also helps explain the disturbed behaviors they exhibit.

Aside from the vast psychological impact that pathogenic care exerts upon a child, it also has physiological manifestations that are largely irreversible. The DSM-IV states that RAD has affects on physical development that are similar to cases of malnutrition, such as stunted growth (as cited by Corbin, 2007). This connection between the psychological and physiological affects of RAD illustrates the mind and body concept of abnormal psychology. The mind is not inseparable from the body and what affects the mind also affects the body and vice versa. In this case RAD children’s minds are affected by the pathogenic care provided by their caregivers, and their bodies in turn may be stunted from the psychological damage of never having a parental bond with anyone.

Studies on the effects of pathogenic care on the brain show that adults with such a history have a smaller hippocampus and amygdala, with evidence showing a decrease in GABA receptors in the amygdala. This in turn “essentially affects the ability of the amygdala to receive messages to calm itself” (Amini et al. as cited by Corbin, 2007). The affected hippocampus, which influences long-term memory storage, is imprinted with early memories from that pathogenic care model and solidifies a social basis that affects how the RAD child interprets the world from then on (Liggan and Kay as cited by Corbin, 2007). These psychological and physiological changes suggest that if not observed early while the child is still developing, children with RAD will grow up to be adults with RAD, who will suffer from the same symptom of crippled intrapersonal relationships. This mind-body connection helps explain the causes of reactive attachment disorder and allows for a multiple avenues of treatment.

In keeping with the idea of attachment theory, if a child with reactive attachment disorder comes from an environment of pathogenic care, treatment should involve the removal of such care and the supplementation of an environment that coincides with the humanistic mantra of unconditional positive regard. The environment should be reliable, nurturing, and loving, so that attachment is able to form. By offering a counterpart to the developing child’s memory of pathogenic care, it is hoped that new models of social interaction and attachment will form cognitively in the brain, allowing for a more developed sense of self and other.

According to the American Academy of Child and Adolescent Psychiatry, there are three ways to approach this attachment therapy: by working with the caregiver alone, with the caregiver and the child together, or with the child alone (as cited by Fairchild 2009). While all methods rely on changing the pathogenic background, the first two involve attempting to improve the existing parenting techniques to create a healthier caregiver-child dynamic. These methods uphold the family systems perspective of abnormal psychology, which recognizes that the whole family is the patient (Hansell & Damour, 2008). However, maintaining the same caregiver-child pairing can be dangerous for the child and in these cases, removal from that environment is necessary for treatment. From that point, the therapist can utilize the third method of treatment and work with the child alone.

Reactive attachment disorder, a disorder stemming from a disturbed connection between caregiver and child, is best understood within the context of attachment therapy. From understanding and defining the problems of the disorder, psychologists can classify its symptoms and begin to explain the causes behind the disorder. With these explanations, treatment can commence in order to help restore normal attachment patterns in these affected children.

References

Corbin, J. (2007). Reactive attachment disorder: A biopsychosocial disturbance of attachment. Child & Adolescent Social Work Journal, 24(6), 539-552. doi:10.1007/s10560-007-0105-x.

Fairchild, S. (2009). Introduction to a special edition: Attachment theory and its application to practice. Child & Adolescent Social Work Journal, 26(4), 287-289. doi:10.1007/s10560-009-0178-9.

Hansell, J., Damour, L. (2008). Abnormal psychology. Array Hoboken, N.J.: Wiley.

Hornor, G. (2008). Reactive attachment disorder. Journal of Pediatric Health Care, 22(4), 234-239. doi:10.1016/j.pedhc.2007.07.003.