| Disorders usually first diagnosed in infancy, childhood, or adolescence. |
Reactive Attachment Disorder--
Reactive attachment disorder (also known as "RAD") is the broad term used to describe those
disorders of attachment which are classified in ICD-10 94.1 and 94.2, and DSM-IV 313.89. RAD
arises from a failure to form normal attachments to primary care giving figures in early childhood.
Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from
caregivers after about age 6 months but before about age 3 years, frequent change of caregivers,
or lack of caregiver responsiveness to child communicative efforts. It is characterised by markedly
disturbed and developmentally inappropriate social relatedness in most contexts, beginning before
the age of 5 years. The theoretical base for reactive attachment disorder is attachment theory.
Differential Diagnosis
It should be differentiated from pervasive developmental disorder or mental retardation, both of
which conditions can affect attachment. RAD is likely to occur in the context of abusive or
impoverished childcare although there can be no diagnosis on this basis alone as many children
with such backgrounds do not develop RAD.
RAD should also be differentiated from less than ideal attachment 'styles' or attachment difficulties
which do not amount to the clinical disorder defined as RAD.
RAD was first defined in DSM in 1980. Important modifications have been made but the core remains
the same. The definitions in ICD-10 and DSM-IV-TR are similar but not identical and are under
constant review in this somewhat controversial area. Leading theorists in the field have proposed
that a broader range of conditions arising from problems with attachment should be defined.
Theoretical framework
The theoretical framework for Reactive Attachment Disorder is attachment theory based on work by
Bowlby, Ainsworth and Spitz, from the 1940s to the 1980s. Attachment theory is an evolutionary
theory whereby the infant or child seeks proximity to a specified attachment figure in situations of
alarm or distress, for the purpose of survival. Attachment is not the same as love and/or affection
although they often go together. Attachment and attachment behaviors tend to develop between
the age of 6 months and 3 years. Infants become attached to adults who are sensitive and
responsive in social interactions with the infant, and who remain as consistent caregivers for some
time. RAD requires one or both of the attachment behaviors of proximity seeking to a specified
attachment figure to be missing. There are a number of attachment 'styles' namely 'secure',
'anxious-ambivalent', 'anxious-avoidant', (all 'organized') and 'disorganized', some of which are
more problematical than others, but none constitute
a 'disorder' in themselves.
A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for
subsequent disorders.(AACAP 2005, p1208[1]) There is a lack of consensus about the precise
meaning of the term 'attachment disorder' although there is general agreement that such disorders
only arise following early adverse caregiving experiences.
Children who are adopted after the age of six months are at risk for attachment problems.[2]
Normal attachment develops during the child's first two to three years of life. Problems with the
caregiver-child relationship during that time, orphanage experience, or breaks in the consistent
caregiver-child relationship interfere with the normal development of a healthy and secure
attachment. There are wide ranges of attachment difficulties that result in varying degrees of
emotional disturbance in the child. However, less than ideal attachment styles are not within the
criteria for RAD.
Some authors have proposed a broader continuum of definitions of attachment disorders ranging
from RAD, through various attachment difficulties to the more problematic attachment styles but
there is as yet no consensus on this issue. In particular, Zeanah and Boris, building on the earlier
work of Leiberman, propose three categories; firstly "disorder of attachment" to indicate a situation
in which a young child has no preferred adult caregiver, parallel to Reactive Attachment Disorder as
defined in DSM and ICD in its inhibited and disinhibited forms. Secondly "secure base distortion"
where the child has a preferred familiar caregiver, but the relationship is such that the child cannot
use the adult for safety while gradually exploring the environment. Such children may endanger
themselves, may cling to the adult, may be excessively compliant, or may show role reversals in
which they care for or punish the adult. Thirdly "disrupted attachment." This type of problem, which
is not covered under other approaches to disordered attachment, results from an abrupt separation
or loss of a familar caregiver to whom attachment has developed.[3]
Classification
ICD-10 describes Reactive Attachment Disorder of Childhood, known as RAD, and Disinhibited
Disorder of Childhood, less well known as DAD. DSM-IV-TR also describes Reactive Attachment
Disorder of Infancy or Early Childhood divided into two subtypes, Inhibited Type and Disinhibited
Type, both known as RAD. The two classifications are similar and both include:
* markedly disturbed and developmentally inappropriate social relatedness in most contexts.
* The disturbance is not accounted for solely by developmental delay and does not meet the criteria
for Pervasive Developmental Disorder.
* Onset before 5 years of age.
* Requires a history of significant neglect.
* Implicit lack of identifiable, preferred attachment figure.
There must be a history of 'pathogenic care' defined as disregard of the childs basic emotional or
physical needs or repeated changes in primary caregiver that prevents the formation of a
discrimination or selective attachment that is presumed to account for the disorder. Unusually
therefore part of the diagnosis is history of care rather than observation of symptoms.
In DSM-IV-TR the inhibited form is described as:
* "Persistent failure to initiate or respond in a developmentally appropriate way to most social
interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent, or contradictory
responses, eg the child may respond to caregivers with a mixture of approach, avoidance and
resistance to comforting, or may exhibit frozen watchfulness.
Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to
maintain 'proximity', an essential element of attachment behavior.
The disinhibited form shows:
* "Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit
appropriate selective attachments, eg excessive familiarity with relative strangers or lack of selectivity
in choice of attachment figures"
There is therefore a lack of 'specificity', the second basic element of attachment behavior. The ICD-
10 descriptions are comparable save that ICD-10 includes in its description several elements not
included in DSM-IV-TR as follows:
* psychological and physical abuse and injury in addition to neglect. This somewhat controversial,
being a commission rather than ommission and because abuse of itself does not lead to attachment
disorder.
* associated emotional disturbance.
* poor social interaction with peers.
'Disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in
the same child. The inhibited form has a greater tendency to ameliorate with an appropriate caregiver
whilst the disinhibited form is more enduring. However, the disinhibited form can endure alonside
structured attachment behavior towards the childs permanent caregivers.[4]
Whilst RAD is likely to occur in relation to neglectful and abusive childcare, there should be no
automatic diagnosis on this basis alone as children can form stable attachments and social
relationships despite marked abuse and neglect. Abuse can occur alongside the required factors but
on its own does not explain attachment disorder. It is associated with developed, albeit disorganized
attachment. Within official classifications, attachment disorganization is a risk factor but not in itself
an attachment disorder. Further although attachment disorders tend to occur in the context of
some institutions, repeated changes of primary caregiver or extremely neglectful identifiable primary
caregivers who show persistent disregard for the child's basic attachment needs, not
all children raised in these conditions develop an attachment disorder.[4]
Incidence
RAD is considered to be "very uncommon" under the DSM-IV-TR criteria although there is an
estimate of prevalence amongst children freed for adoption within the USA foster care system of
10%.[5] There has been considerable recent research into prevalence amongst children cared for in
orphanages, particularly in Romania, where conditions of extreme deprivation were not uncommon.
There are no precise statistics on prevalence. According to the APSAC Taskforce Report (2006),
some have suggested that RAD may be quite prevalent because severe child maltreatment, which is
known to increase risk for RAD, is prevalent. The Taskforce did not agree with this view as severely
abused children may exhibit similar behaviors to RAD behaviors and there are several far more
common and demonstrably treatable diagnoses which may better account for these difficulties. Many
children experience severe maltreatment but do not develop clinical disorders. The Taskforce states
that it should not be assumed that RAD underlies all or even most of the behavioral and emotional
problems seen in foster children, adoptive children, or children who are maltreated. Rates of child
abuse and/or neglect or problem behaviors should not serve as a benchmark for estimates of RAD.
The Taskforce further point out that according to the DSM, RAD is presumed to be a “very
uncommon” disorder (APA, 1994).[6]
According to Prior and Glaser (2006), in the absence of available and responsive caregivers it
appears that some children are particularly vulnerable to developing attachment disorders. "The
prevalence is unclear but is probably quite rare, other than in populations of children being reared
in the most extreme, deprived settings such as some orphanages."[4] Many children who have
experienced serious maltreatment at the hands of their primary caregiver may have formed a
disorganized attachment which manifests itself in difficult behaviors, but they would not fulfil the
current criteria for RAD. There is a lack of clarity about the presentation of attachment disorders
over the age of 5 years and difficulty in distinguishing between aspects of attachment disorders,
disorganized attachment or the sequalae of maltreatment. [4]
Diagnosis
According to the APSAC Taskforce Report (2006), RAD is one of the least researched and most
poorly understood disorders in the DSM. They make the point that there is little systematically
gathered epidemiologic information on RAD, its "course" is not well established and it appears
difficult to diagnose RAD accurately. Several other disorders, such as conduct disorders, oppositional
defiant disorder, anxiety disorders, PTSD and social phobia share many symptoms and are often
comorbid with or confused with RAD leading to over and under diagnosis. RAD can also be confused
with neuropsychiatric disorders such as autistic spectrum disorders, pervasive developmental
disorder, childhood schizophrenia and some genetic syndromes. Some children simply have very
different temperamental dispositions. The Taskforce specifically state "Because of these diagnostic
complexities, careful diagnostic evaluation by a trained mental health expert with particular expertise
in differential diagnosis is a must (Hanson & Spratt, 2000; Wilson, 2001)". [6]
In the absence of a standardised diagnosis system, many popular, informal classification systems,
outside the DSM and ICD, were created out of clinical and parental experience. These are unvalidated
and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are
found on the websites of attachment therapists. Common features of these lists such as lying, lack
of remorse or conscience and cruelty do not form part of the diagnostic criteria under DSM-IV-TR or
ICD-10.
The Randolph Attachment Disorder Questionnaire or "RADQ" is one of the better known checklists
and is used by attachment therapists and others, but critics consider it lacks specificity and is
unvalidated.[7] The checklist includes 93 discrete behaviours, many of which either overlap with
other disorders, like Conduct Disorder and Oppositional Defiant Disorder or are not related to
attachment difficulties. [8]
Recognised assessment methods of attachment styles, difficulties or disorders include the Strange
Situation procedure (Mary Ainsworth), the separation and reunion procedure and the Preschool
Assessment of Attachment ("PAA", Crittenden 1992), the Observational Record of the Caregiving
Environment ("ORCE") and the Attachment Q-sort ("AQ-sort"). More recent research uses the
Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah, (1999). This is a
semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items,
namely having a discriminated, preferred adult, seeking comfort when distressed, responding to
comfort when offered, social and emotional reciprocity, emotional regulation, checking back after
venturing away from the care giver, reticence with unfamiliar adults, willingness to go off with relative
strangers, self endangering behavior, excessive clinging, vigilance/hypercompliance and role reversal.
[9]
Treatment
There is a variety of effective prevention programs and treatment approaches for attachment
disorder based on Attachment theory. All approaches concentrate on increasing the responsiveness
and sensitivity of the caregiver, or if that is not possible, changing the caregiver. Approaches with a
sound evidential and theoretical base include 'Watch, wait and wonder' (Cohen et al, 1999),
manipulation of sensitive responsiveness, (van den Boom 1994 and 1995), modified 'Interaction
Guidance' (Benoit et al, 2001), 'Preschool Parent Psychotherapy' (Toth et al, 2002) and Parent-Child
psychotherapy (Leiberman et al 2000).[4][1] Other known treatment methods include 'Circle of
Security' (Marvin et al, 2002) and Developmental, Individual-difference, Relationship-based therapy
(DIR) (also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to
treatment of pervasive developmental disorders.
There is considerable controversy over the diagnosis and treatment of attachment disorders
including reactive attachment disorder, by attachment therapists, a form of diagnosis and treatment
that is largely unvalidated and has developed outside the scientific mainstream.[6]These therapies
have little or no evidence base and vary from mild therapeutic work to more extreme forms of
physical and coercive techniques, of which the best known are holding therapy, rebirthing, rage-
reduction and the Evergreen model. In general these therapies are aimed at adopted or fostered
children with a view to creating attachment in these children to their new carers. Critics maintain that
the link between this kind of therapy and attachment theory is at best tenuous.[4] Many of these
therapies concentrate on changing the child rather than the caregiver. (Chaffin et al 2006[10])
Recent research on deprived populations
A 1998 study showed that children adopted from poorly run Romanian orphanages had a higher
frequency of insecure patterns of attachment than control groups, although this difference improved
in the follow-up study 3 years later. [11][12] However they continued to show significantly higher
levels of indiscriminate friendliness.
A later study looked at children adopted in the UK who had suffered early severe deprivation in
Romania, some 'early placed' and some 'late placed'. The 'late-placed' children showed a far higher
incidence of atypical insecure patterns such as displaying both strong avoidant and strong
dependent attachment behavior patterns. [13]
A 2002 study of children in residential nurseries in Bucharest, using the DAI, challenged the current
DSM and ICD conceptualisations of disordered attachment and showed that inhibited and disinhibited
disorders could co-exist in the same child. It also showed higher incidence of RAD in the standard
care group in the institution than in the 'pilot group' receiving more consistent care, or in the non-
institutionalised group. [14]
A 2005 study comparing institutionalised and community children in Bucharest, using
the DAI, again showed significantly higher levels of both forms of RAD in the institutionalised
children, regardless of how long they had been there. Further, only 22% of the institutionalised
children had organised attachments as opposed to 78% of the community children, and all the
children in the community group showed clear attachment patterns as opposed to only 3% in the
institutionalised group. It would appear that children in institutions like these are unable to form
selective attachments to their caregivers. The study also concluded the signs of RAD related to how
fully developed and expressed attachment behaviors are rather than the organisation of
a particular pattern.[15]
There are two important studies relating to high risk and maltreated children in the USA. The first, in
2004, compared ill-treated children in foster care, children in a homeless shelter with their mothers
and low income children in the Head Start programme. The children were assessed using DSM and
ICD and Zeanah and Boris' alternative proposed criteria. The study reports that children from the
maltreatment sample were significantly more more likely to meet criteria for one or more attachment
disorders than children from the other groups, however this was mainly disrupted attachment
disorder rather than DSM or ICD classified disorder. Under DSM and ICD classifications there was
little difference between the foster care and homeless shelter groups.[16]
The second study, also in 2004, was for the purposes of ascertaining prevalence of RAD, whether
RAD could be reliably identified in maltreated rather than neglected toddlers and whether the two
types of RAD were independent. The DAI and DSM and ICD were used. 35% were identified as
having ICD RAD and 22% as having ICD DAD. 38% fulfilled the DSM criteria for RAD. [17]The study
found that RAD could be reliably identified and also that the inhibited and disinhibited forms were not
independent. However, there are some methodological concerns with this study. A number of the
children identified as fulfilling the criteria did in fact have a preferred attachment figure.[4] This study
also showed that mothers with a history of psychiatric problems were more likely to have children
exhibiting signs of inhibited/emotionally withdrawn RAD but mothers with a history of psychiatric
problems and substance misuse had children more likely to exhibit signs of disinhibited/indiscriminate
RAD. [17]
* References provided by request.
Reactive attachment disorder (also known as "RAD") is the broad term used to describe those
disorders of attachment which are classified in ICD-10 94.1 and 94.2, and DSM-IV 313.89. RAD
arises from a failure to form normal attachments to primary care giving figures in early childhood.
Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from
caregivers after about age 6 months but before about age 3 years, frequent change of caregivers,
or lack of caregiver responsiveness to child communicative efforts. It is characterised by markedly
disturbed and developmentally inappropriate social relatedness in most contexts, beginning before
the age of 5 years. The theoretical base for reactive attachment disorder is attachment theory.
Differential Diagnosis
It should be differentiated from pervasive developmental disorder or mental retardation, both of
which conditions can affect attachment. RAD is likely to occur in the context of abusive or
impoverished childcare although there can be no diagnosis on this basis alone as many children
with such backgrounds do not develop RAD.
RAD should also be differentiated from less than ideal attachment 'styles' or attachment difficulties
which do not amount to the clinical disorder defined as RAD.
RAD was first defined in DSM in 1980. Important modifications have been made but the core remains
the same. The definitions in ICD-10 and DSM-IV-TR are similar but not identical and are under
constant review in this somewhat controversial area. Leading theorists in the field have proposed
that a broader range of conditions arising from problems with attachment should be defined.
Theoretical framework
The theoretical framework for Reactive Attachment Disorder is attachment theory based on work by
Bowlby, Ainsworth and Spitz, from the 1940s to the 1980s. Attachment theory is an evolutionary
theory whereby the infant or child seeks proximity to a specified attachment figure in situations of
alarm or distress, for the purpose of survival. Attachment is not the same as love and/or affection
although they often go together. Attachment and attachment behaviors tend to develop between
the age of 6 months and 3 years. Infants become attached to adults who are sensitive and
responsive in social interactions with the infant, and who remain as consistent caregivers for some
time. RAD requires one or both of the attachment behaviors of proximity seeking to a specified
attachment figure to be missing. There are a number of attachment 'styles' namely 'secure',
'anxious-ambivalent', 'anxious-avoidant', (all 'organized') and 'disorganized', some of which are
more problematical than others, but none constitute
a 'disorder' in themselves.
A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for
subsequent disorders.(AACAP 2005, p1208[1]) There is a lack of consensus about the precise
meaning of the term 'attachment disorder' although there is general agreement that such disorders
only arise following early adverse caregiving experiences.
Children who are adopted after the age of six months are at risk for attachment problems.[2]
Normal attachment develops during the child's first two to three years of life. Problems with the
caregiver-child relationship during that time, orphanage experience, or breaks in the consistent
caregiver-child relationship interfere with the normal development of a healthy and secure
attachment. There are wide ranges of attachment difficulties that result in varying degrees of
emotional disturbance in the child. However, less than ideal attachment styles are not within the
criteria for RAD.
Some authors have proposed a broader continuum of definitions of attachment disorders ranging
from RAD, through various attachment difficulties to the more problematic attachment styles but
there is as yet no consensus on this issue. In particular, Zeanah and Boris, building on the earlier
work of Leiberman, propose three categories; firstly "disorder of attachment" to indicate a situation
in which a young child has no preferred adult caregiver, parallel to Reactive Attachment Disorder as
defined in DSM and ICD in its inhibited and disinhibited forms. Secondly "secure base distortion"
where the child has a preferred familiar caregiver, but the relationship is such that the child cannot
use the adult for safety while gradually exploring the environment. Such children may endanger
themselves, may cling to the adult, may be excessively compliant, or may show role reversals in
which they care for or punish the adult. Thirdly "disrupted attachment." This type of problem, which
is not covered under other approaches to disordered attachment, results from an abrupt separation
or loss of a familar caregiver to whom attachment has developed.[3]
Classification
ICD-10 describes Reactive Attachment Disorder of Childhood, known as RAD, and Disinhibited
Disorder of Childhood, less well known as DAD. DSM-IV-TR also describes Reactive Attachment
Disorder of Infancy or Early Childhood divided into two subtypes, Inhibited Type and Disinhibited
Type, both known as RAD. The two classifications are similar and both include:
* markedly disturbed and developmentally inappropriate social relatedness in most contexts.
* The disturbance is not accounted for solely by developmental delay and does not meet the criteria
for Pervasive Developmental Disorder.
* Onset before 5 years of age.
* Requires a history of significant neglect.
* Implicit lack of identifiable, preferred attachment figure.
There must be a history of 'pathogenic care' defined as disregard of the childs basic emotional or
physical needs or repeated changes in primary caregiver that prevents the formation of a
discrimination or selective attachment that is presumed to account for the disorder. Unusually
therefore part of the diagnosis is history of care rather than observation of symptoms.
In DSM-IV-TR the inhibited form is described as:
* "Persistent failure to initiate or respond in a developmentally appropriate way to most social
interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent, or contradictory
responses, eg the child may respond to caregivers with a mixture of approach, avoidance and
resistance to comforting, or may exhibit frozen watchfulness.
Such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to
maintain 'proximity', an essential element of attachment behavior.
The disinhibited form shows:
* "Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit
appropriate selective attachments, eg excessive familiarity with relative strangers or lack of selectivity
in choice of attachment figures"
There is therefore a lack of 'specificity', the second basic element of attachment behavior. The ICD-
10 descriptions are comparable save that ICD-10 includes in its description several elements not
included in DSM-IV-TR as follows:
* psychological and physical abuse and injury in addition to neglect. This somewhat controversial,
being a commission rather than ommission and because abuse of itself does not lead to attachment
disorder.
* associated emotional disturbance.
* poor social interaction with peers.
'Disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in
the same child. The inhibited form has a greater tendency to ameliorate with an appropriate caregiver
whilst the disinhibited form is more enduring. However, the disinhibited form can endure alonside
structured attachment behavior towards the childs permanent caregivers.[4]
Whilst RAD is likely to occur in relation to neglectful and abusive childcare, there should be no
automatic diagnosis on this basis alone as children can form stable attachments and social
relationships despite marked abuse and neglect. Abuse can occur alongside the required factors but
on its own does not explain attachment disorder. It is associated with developed, albeit disorganized
attachment. Within official classifications, attachment disorganization is a risk factor but not in itself
an attachment disorder. Further although attachment disorders tend to occur in the context of
some institutions, repeated changes of primary caregiver or extremely neglectful identifiable primary
caregivers who show persistent disregard for the child's basic attachment needs, not
all children raised in these conditions develop an attachment disorder.[4]
Incidence
RAD is considered to be "very uncommon" under the DSM-IV-TR criteria although there is an
estimate of prevalence amongst children freed for adoption within the USA foster care system of
10%.[5] There has been considerable recent research into prevalence amongst children cared for in
orphanages, particularly in Romania, where conditions of extreme deprivation were not uncommon.
There are no precise statistics on prevalence. According to the APSAC Taskforce Report (2006),
some have suggested that RAD may be quite prevalent because severe child maltreatment, which is
known to increase risk for RAD, is prevalent. The Taskforce did not agree with this view as severely
abused children may exhibit similar behaviors to RAD behaviors and there are several far more
common and demonstrably treatable diagnoses which may better account for these difficulties. Many
children experience severe maltreatment but do not develop clinical disorders. The Taskforce states
that it should not be assumed that RAD underlies all or even most of the behavioral and emotional
problems seen in foster children, adoptive children, or children who are maltreated. Rates of child
abuse and/or neglect or problem behaviors should not serve as a benchmark for estimates of RAD.
The Taskforce further point out that according to the DSM, RAD is presumed to be a “very
uncommon” disorder (APA, 1994).[6]
According to Prior and Glaser (2006), in the absence of available and responsive caregivers it
appears that some children are particularly vulnerable to developing attachment disorders. "The
prevalence is unclear but is probably quite rare, other than in populations of children being reared
in the most extreme, deprived settings such as some orphanages."[4] Many children who have
experienced serious maltreatment at the hands of their primary caregiver may have formed a
disorganized attachment which manifests itself in difficult behaviors, but they would not fulfil the
current criteria for RAD. There is a lack of clarity about the presentation of attachment disorders
over the age of 5 years and difficulty in distinguishing between aspects of attachment disorders,
disorganized attachment or the sequalae of maltreatment. [4]
Diagnosis
According to the APSAC Taskforce Report (2006), RAD is one of the least researched and most
poorly understood disorders in the DSM. They make the point that there is little systematically
gathered epidemiologic information on RAD, its "course" is not well established and it appears
difficult to diagnose RAD accurately. Several other disorders, such as conduct disorders, oppositional
defiant disorder, anxiety disorders, PTSD and social phobia share many symptoms and are often
comorbid with or confused with RAD leading to over and under diagnosis. RAD can also be confused
with neuropsychiatric disorders such as autistic spectrum disorders, pervasive developmental
disorder, childhood schizophrenia and some genetic syndromes. Some children simply have very
different temperamental dispositions. The Taskforce specifically state "Because of these diagnostic
complexities, careful diagnostic evaluation by a trained mental health expert with particular expertise
in differential diagnosis is a must (Hanson & Spratt, 2000; Wilson, 2001)". [6]
In the absence of a standardised diagnosis system, many popular, informal classification systems,
outside the DSM and ICD, were created out of clinical and parental experience. These are unvalidated
and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are
found on the websites of attachment therapists. Common features of these lists such as lying, lack
of remorse or conscience and cruelty do not form part of the diagnostic criteria under DSM-IV-TR or
ICD-10.
The Randolph Attachment Disorder Questionnaire or "RADQ" is one of the better known checklists
and is used by attachment therapists and others, but critics consider it lacks specificity and is
unvalidated.[7] The checklist includes 93 discrete behaviours, many of which either overlap with
other disorders, like Conduct Disorder and Oppositional Defiant Disorder or are not related to
attachment difficulties. [8]
Recognised assessment methods of attachment styles, difficulties or disorders include the Strange
Situation procedure (Mary Ainsworth), the separation and reunion procedure and the Preschool
Assessment of Attachment ("PAA", Crittenden 1992), the Observational Record of the Caregiving
Environment ("ORCE") and the Attachment Q-sort ("AQ-sort"). More recent research uses the
Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah, (1999). This is a
semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items,
namely having a discriminated, preferred adult, seeking comfort when distressed, responding to
comfort when offered, social and emotional reciprocity, emotional regulation, checking back after
venturing away from the care giver, reticence with unfamiliar adults, willingness to go off with relative
strangers, self endangering behavior, excessive clinging, vigilance/hypercompliance and role reversal.
[9]
Treatment
There is a variety of effective prevention programs and treatment approaches for attachment
disorder based on Attachment theory. All approaches concentrate on increasing the responsiveness
and sensitivity of the caregiver, or if that is not possible, changing the caregiver. Approaches with a
sound evidential and theoretical base include 'Watch, wait and wonder' (Cohen et al, 1999),
manipulation of sensitive responsiveness, (van den Boom 1994 and 1995), modified 'Interaction
Guidance' (Benoit et al, 2001), 'Preschool Parent Psychotherapy' (Toth et al, 2002) and Parent-Child
psychotherapy (Leiberman et al 2000).[4][1] Other known treatment methods include 'Circle of
Security' (Marvin et al, 2002) and Developmental, Individual-difference, Relationship-based therapy
(DIR) (also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to
treatment of pervasive developmental disorders.
There is considerable controversy over the diagnosis and treatment of attachment disorders
including reactive attachment disorder, by attachment therapists, a form of diagnosis and treatment
that is largely unvalidated and has developed outside the scientific mainstream.[6]These therapies
have little or no evidence base and vary from mild therapeutic work to more extreme forms of
physical and coercive techniques, of which the best known are holding therapy, rebirthing, rage-
reduction and the Evergreen model. In general these therapies are aimed at adopted or fostered
children with a view to creating attachment in these children to their new carers. Critics maintain that
the link between this kind of therapy and attachment theory is at best tenuous.[4] Many of these
therapies concentrate on changing the child rather than the caregiver. (Chaffin et al 2006[10])
Recent research on deprived populations
A 1998 study showed that children adopted from poorly run Romanian orphanages had a higher
frequency of insecure patterns of attachment than control groups, although this difference improved
in the follow-up study 3 years later. [11][12] However they continued to show significantly higher
levels of indiscriminate friendliness.
A later study looked at children adopted in the UK who had suffered early severe deprivation in
Romania, some 'early placed' and some 'late placed'. The 'late-placed' children showed a far higher
incidence of atypical insecure patterns such as displaying both strong avoidant and strong
dependent attachment behavior patterns. [13]
A 2002 study of children in residential nurseries in Bucharest, using the DAI, challenged the current
DSM and ICD conceptualisations of disordered attachment and showed that inhibited and disinhibited
disorders could co-exist in the same child. It also showed higher incidence of RAD in the standard
care group in the institution than in the 'pilot group' receiving more consistent care, or in the non-
institutionalised group. [14]
A 2005 study comparing institutionalised and community children in Bucharest, using
the DAI, again showed significantly higher levels of both forms of RAD in the institutionalised
children, regardless of how long they had been there. Further, only 22% of the institutionalised
children had organised attachments as opposed to 78% of the community children, and all the
children in the community group showed clear attachment patterns as opposed to only 3% in the
institutionalised group. It would appear that children in institutions like these are unable to form
selective attachments to their caregivers. The study also concluded the signs of RAD related to how
fully developed and expressed attachment behaviors are rather than the organisation of
a particular pattern.[15]
There are two important studies relating to high risk and maltreated children in the USA. The first, in
2004, compared ill-treated children in foster care, children in a homeless shelter with their mothers
and low income children in the Head Start programme. The children were assessed using DSM and
ICD and Zeanah and Boris' alternative proposed criteria. The study reports that children from the
maltreatment sample were significantly more more likely to meet criteria for one or more attachment
disorders than children from the other groups, however this was mainly disrupted attachment
disorder rather than DSM or ICD classified disorder. Under DSM and ICD classifications there was
little difference between the foster care and homeless shelter groups.[16]
The second study, also in 2004, was for the purposes of ascertaining prevalence of RAD, whether
RAD could be reliably identified in maltreated rather than neglected toddlers and whether the two
types of RAD were independent. The DAI and DSM and ICD were used. 35% were identified as
having ICD RAD and 22% as having ICD DAD. 38% fulfilled the DSM criteria for RAD. [17]The study
found that RAD could be reliably identified and also that the inhibited and disinhibited forms were not
independent. However, there are some methodological concerns with this study. A number of the
children identified as fulfilling the criteria did in fact have a preferred attachment figure.[4] This study
also showed that mothers with a history of psychiatric problems were more likely to have children
exhibiting signs of inhibited/emotionally withdrawn RAD but mothers with a history of psychiatric
problems and substance misuse had children more likely to exhibit signs of disinhibited/indiscriminate
RAD. [17]
* References provided by request.
You have adopted a girl who is 9 years old from the Foster Care system.
You know that she has lived in 10 different homes with 10 different sets
of caregivers in her lifetime, and she has witnessed domestic violence, as
well as been abused and neglected. You are busy preparing dinner for
your family. Click begin to see a video of a situation. After you watch the
situation, you must choose a response. Your goal is to respond in a way
that helps build a healthy attachment, while keeping parent and child
anger levels down. There are three meters to measure your progress,
parent anger, child anger, attachment. Try to keep the anger meters low,
and the attachment meter high. When you've finished the activity, return
to the Parenting Activities page to try again. Good luck!
You know that she has lived in 10 different homes with 10 different sets
of caregivers in her lifetime, and she has witnessed domestic violence, as
well as been abused and neglected. You are busy preparing dinner for
your family. Click begin to see a video of a situation. After you watch the
situation, you must choose a response. Your goal is to respond in a way
that helps build a healthy attachment, while keeping parent and child
anger levels down. There are three meters to measure your progress,
parent anger, child anger, attachment. Try to keep the anger meters low,
and the attachment meter high. When you've finished the activity, return
to the Parenting Activities page to try again. Good luck!
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