Reactive attachment disorder

History

Reactive attachment disorder was first listed as a formal diagnosis in the DSM-III in 1980, based on studies of children raised in institutions. At that time, it required symptoms to appear before eight months of age and was considered the same as failure to thrive. Both of these conditions were removed in the 1987 DSM-III-R revision. The age of onset was extended to the first five years, and the disorder was split into two types: inhibited and disinhibited.

These changes came from more research on abused and institutionalized children and have been kept in later editions, including the DSM-IV, its 2000 text revision, and the ICD-10 from 1992. The main theory behind current definitions is attachment theory, developed from the 1940s through the 1980s by John Bowlby, Mary Ainsworth, and René Spitz. This theory uses psychological, ethological, and evolutionary ideas to describe typical social behaviors in young children, especially their tendency to seek out a familiar caregiver when scared or upset.

For a child to be diagnosed with reactive attachment disorder, their history and unusual social behavior must indicate they have not formed a selective attachment to a specific caregiver.

Diagnosis

RAD is one of the least researched and most poorly understood disorders in the DSM, with little systematic epidemiologic information and a course that is not well established. Accurate diagnosis is difficult, and there is a lack of clarity about the presentation of attachment disorders beyond age five, as well as difficulty distinguishing RAD from disorganized attachment or consequences of maltreatment. The American Academy of Child and Adolescent Psychiatry (AACAP) advises that children showing signs of RAD need a comprehensive psychiatric assessment and individualized treatment plan, and that the diagnosis should not be given without a thorough evaluation.

Assessment requires direct evidence from serial observations of the child interacting with primary caregivers, history of the child's attachment patterns with those caregivers, observations with unfamiliar adults, and a comprehensive history of the early caregiving environment. In the US, initial evaluations may be conducted by psychologists, psychiatrists, Licensed Marriage and Family Therapists, Licensed Professional Counselors, specialist Licensed Clinical Social Workers, or psychiatric nurses.

In the UK, the British Association for Adoption and Fostering advises that only a psychiatrist can diagnose an attachment disorder, and the assessment must include a comprehensive evaluation of the child's individual and family history. The question of whether attachment disorders can be reliably diagnosed in older children and adults has not been resolved, as attachment behaviors change markedly with development and there are no substantially validated measures for middle childhood or early adolescence.

Treatment

Assessing the child's safety is an essential first step that determines whether intervention can occur within the family unit or whether removal to a safe situation is necessary. Interventions may include psychosocial support services for the family, psychotherapeutic interventions such as treating parents for mental illness, family therapy, and individual therapy, education in basic parenting skills and child development, and monitoring of the child's safety.

The AACAP guidelines recommend that the most important intervention for young children diagnosed with RAD who lack an attachment to a discriminated caregiver is to advocate for providing the child with an emotionally available attachment figure. Assessing the caregiver's attitudes and perceptions about the child is important for treatment selection. After ensuring a safe and stable placement, effective attachment treatment must focus on creating positive interactions with caregivers. Children who meet criteria for RAD and display aggressive and oppositional behavior require adjunctive treatments.

Prognosis

Researchers have not closely tracked how reactive attachment disorder changes over time, and only a few long-term studies exist, all involving children from poorly run Eastern European orphanages. When these children are adopted into normal caregiving homes, the inhibited form of RAD rarely persists. However, the longer a child experienced deprivation, the more severe their attachment problems tend to be. While these children may form compromised attachments with new caregivers, they typically no longer fit the diagnosis for inhibited RAD.

A smaller number of adopted children continue to show indiscriminate friendliness even after receiving better care, and this behavior can last for years, even in those who later develop a clear preference for their new parents. Some also struggle with hyperactivity, inattention, and poor peer relationships. The only study that followed children with indiscriminate behavior into adolescence found they were much more likely to have troubled friendships.

Research on institution-reared children suggests they often appear inattentive and overactive regardless of care quality. One study noted that some institutionalized boys were inattentive, overactive, and socially unselective, while girls, foster children, and other institutionalized children were not. It remains unclear whether these behaviors are part of an attachment disorder.

Did You Know?

• Pediatricians are often the first health professionals to assess and raise suspicions of RAD.
• Infants up to about 18–24 months may present with non-organic failure to thrive and display abnormal responsiveness to stimuli.
• RAD has never been reported in the absence of serious environmental adversity.