This paper explores the psychological disorder known as Reactive Attachment Disorder (RAD). It will investigate how a child diagnosed with RAD will have an inefficient connection with his or her caregiver during an early age. RAD is considered a serious disorder which affects infant and young children who have difficulties establishing healthy relationship with their caregiver or parents. The flawed relationship will affect the child’s ability to establish normal affiliation with other human being. Thus, a child’s rapport was a major determinant in the etiology of the disorder.
The research will briefly discuss the definition, etiology, attachment theory posited by John Bowlby and Mary Ainsworth, attachment styles, criteria for diagnosing the disorder, presenting symptoms, risk factors, and treatments. A Research on Reactive Attachment Disorder of Early Childhood This paper will discuss and explore the psychological disorder known as Reactive Attachment Disorder (RAD). It will investigate how a child diagnosed with RAD will have an inefficient connection with his or her caregiver during an early age.
The flawed relationship will affect the child’s ability to establish normal affiliation with other human being. The research will briefly discuss the definition, etiology, attachment theory posited by John Bowlby and Mary Ainsworth, attachment styles, criteria for diagnosing the disorder, presenting symptoms, risk factors, and treatments. Reactive attachment disorder is “assumed to be the result of pathological parenting and often associated with developmental delays and childhood neglect” (Corbin, 2007, p. 540).
It is considered a serious disorder which affects infant and young children who have difficulties establishing healthy relationship with their caregiver or parents. Thus, a child’s rapport was a major determinant in the etiology of the disorder. This concept was supported when Corbin asserted that, “Attachment theorists agree that attachment security protects psychopathology. Attachment experiences include the complex psychological, biological, genetic, and behavioral facets of the early care-giving environment and concomitant interactive processes” (p. 543).
The two types of RAD is the inhibited and dis-inhibited type (American Psychiatric Association, 2000). The inhibited type described an infant or young child who has “persistent failure to initiate and to respond to most social interactions in a developmentally appropriate way” (APA, p. 128). In contrast, dis-inhibited type described an infant or young child diagnosed with RAD to have “indiscriminate sociability or a lack of selectivity in the choice of attachment figures” (APA, p. 128). To understand RAD, researchers expounded on attachment theory postulated by Bowlby and Ainsworth.
Ainsworth developed Bowlby’s basic principles and with her colleagues categorized attachment into secure and insecure patterns (Wilson, 2001). The secure attachment will entail a healthy relationship of an infant or young child to his or her parents or caregiver. In contrast, the insecure patterns described how an infant or a young child is “less secure about their safety (even in the presence of a caregiver) and unable to derive consistent comfort from their caregiver” (Wilson, 2009, p. 24). Further, insecure patterns were subdivided into avoidant, anxious/ambivalent, and disorganized (Wood, 2005).
The lack of empirical research surrounding the disorder will limit mental health professionals in diagnosing and formulating interventions for RAD. Although limited research and studies were published comprising the disorder, there are enough data to support the existence of reactive attachment disorder. Definition of Reactive Attachment Disorder Reactive Attachment Disorder is a serious disorder that is usually involves an infant and a young child, specifically, “begins before the age of five years” (APA, 2000, p. 129).
Corbin (2007) cited that “The disorder is assumed to be the result of pathological parenting and often associated with developmental delays and childhood neglect” (p. 540). The DSM – IV – TR indicated that “laboratory findings consistent with malnutrition may be present” (APA, p. 128) and physical findings might be associated with medical conditions in connection with extreme neglect that may include but not limited to delay in physical growth, evidence of physical abuse, malnutrition, vitamin deficiencies, or infectious diseases (APA, p. 28). The DSM – IV – TR (APA, 2000) described two subtypes of the disorder which was identified to be caused by pathogenic care as evidenced by persistent disregard of the child’s emotional and physical needs (Corbin, 2007, p. 540). The subtypes are: Inhibited Type – the child persistently fails to initiate and to respond to most social interactions in a developmentally appropriate way. The child shows a pattern of excessively inhibited, hyper-vigilant, or highly ambivalent responses (e. g. frozen watchfulness, resistance to comfort, or a mixture of approach and avoidance). Disinhibited Type – there is a pattern of diffuse choice of attachment. The disturbance is not accounted for solely by developmental delay (e. g. , as in Mental Retardation) and does not meet criteria for Pervasive Developmental Disorder. (pp. 127-128) Risk factors According to the studies done by Mayo Clinic (2011), RAD disorder begins before the age of five, usually starting at infancy. It can affect males or females, any socio economic or cultural backgrounds.
However, the following may increase the possibility of developing RAD: living in an orphanage; institutional care; frequent changes in foster care or caregivers; inexperienced parents; prolonged hospitalization; extreme poverty; physical, sexual or emotional abuse; forced removal from a neglectful or abusive home; significant trauma, such as death or divorce; postpartum depression in the baby’s mother; and parents who have mental illness, anger management problems, or drug or alcohol abuse (p. 3). Presenting Symptoms
Symptoms and signs of RAD can be difficult to identify because of the early onset of the disorder and it varies from one child to another. According to the Mayo Clinic (2011), the following are signs and symptoms in infants with RAD: withdrawn, sad, and listless appearance; failure to smile; lack of the normal tendency to follow others in the room with the eyes; failure to reach out when picked up; no interest in playing peekaboo or other interactive games; no interest in playing with toys; engaging in self – oothing behavior, such as rocking or self – stroking; and calm when left alone. ” (pp. 1-2) For young children, the following signs and symptoms have several differential characteristics. Mayo Clinic (2011) cited the following: withdrawal from others; avoiding or dismissing comforting comments or gestures; acting aggressively towards peers; watching others closely but not engaging in social interaction; failing to ask support or assistance; obvious and consistent awkwardness or discomfort; and masking feelings of anger or distress . (p. 2) The Attachment Theory
Attachment theory was posited by Bowlby (1982), one of the pioneers to study early bonding of children with their parents or caregivers. He defined attachment as a child who was “strongly disposed to seek proximity to and contact with a specific figure and to do so in a certain situations, notably when he is frightened, tired or ill” (p. 371). Bowlby was fundamental in forming the basic principles that support the attachment theory. His studies “revolutionized our thinking about a child’s tie to the mother and its disruption through separation, deprivation, and bereavement” (Bretherton, 1992, p. 59). Later, Mary Ainsworth developed and enhanced the basic concepts of Bowlby. She introduced the model of the “secure base from which an infant can explore the world. In addition, she formulated the concept of maternal sensitivity to infant signals and its role in the development of infant-mother attachment patterns” (Bretherton, p. 759). The predominant characteristic of attachment theory is that parents or caregivers are responsive to the needs of their infant or young child’s needs to establish a sense of security (Corbin, 2007).
Wilson (2009) referred to “Behaviors that reflect attachment are associated with high degree of caregiver sensitivity and responsiveness; children have learned that over repeated interaction that their caregivers are a safe, and effective source of comfort” (p. 24). Conversely, since infants and young children are naturally affected by nature, “attachment theorists have argued that temperament might affect the manner in which infants call to their caregivers in times of stress, but the caregiver’s manner of response is believed to be what most affects the quality of the attachment” (Zeanah & Cox, 2004, p. 36).
Another aspect that needs to be accounted for is the relationship between an infant and the caregiver or parents “takes time to develop. Its developmental course appears to be the same across cultures and is the same for infants who are in day care, raised in nuclear families, or reared in social groups” (Haugaard & Hazan, 2004, p. 155). Patterns of attachment There were patterns of attachment postulated for infants and young children that can “predict social adjustment and ability to tolerate stress” (Morrison & Mishna, 2006, p. 470).
They were generally classified as “secure versus insecure with various patterns of insecure attachment (i. . , resistant, avoidant) associated with different antecedents and outcomes” (Wilson, 2009, p. 24). Infants and young children who have secure and organized attachment patterns will be able to distinctly “signal their distress and are easily soothed by their caregivers – are likely to have more positive psychosocial outcomes, less psychopathology and even better physical health across the lifespan” (Morrison & Mishna, p. 470). If the secure attachment pattern was disrupted or not experienced by an infant or a young child it can lead into insecure attachment patterns.
Haugaard and Hazan (2004) asserted that the primary caregiver’s reaction “is inconsistent in responding to his or her infant’s signals for comfort – sometimes responding sensitively but often either not responding or responding in an angry way – the infant is likely to develop an anxious or resistant attachment” (p. 156). Diagnosis A diagnosis of RAD was difficult to accomplish because of limited data of “social and intimate interaction and attachments are not accounted for by other related developmental disorders or delays” (Corbin, 2007, p. 40) such as mental retardation (MR), social phobia (SP), pervasive developmental disorders (PDD), Conduct Disorder (CD), oppositional defiant disorder (ODD), etc. However, the APA (2000) established a set of major criterion to be utilized by mental health professionals to standardized diagnosing clients with RAD. A child or infant must meet the criteria specified in the DSM – IV – TR in page 130. To assist in the reliability of diagnosing clients with RAD the research by Sheperis, Doggett, and Hoda (2003), “The development of an assessment protocol for reactive attachment disorder” was designed to provide comprehensive tool for assessment.
While the study needs improvement and more research, it launched a procedural assessment that assists mental health professionals with the diagnosis of RAD. The protocol comprised of variable evaluation techniques in an attempt to obtain methodical and specific information concerning the case of the client. The protocol included the in-depth interviewing of client and primary caregiver, global rating scales, attachment – specific rating scales, and behavioral observation (Sheperis et al. ).
A comprehensive psychiatric evaluation as cited by the mayo clinic (Reactive attachment disorder, 2011) may include but not limited to: Direct observation of the infant’s or child’s interaction with his or her parents or caregivers, details about the infant’s or child’s pattern of behavior over time, examples of the infant’s or child’s behavior in a variety of situation, information about how the infant or child interact with parents or caregivers as well as others, including other family members, an evaluation of the infant’s or child’s home and living situation since birth, and an evaluation of parenting and caregiver styles and abilities. p. 6) Treatments for Reactive Attachment Disorder Currently, there is no standardize treatment plan for RAD. Corbin asserted (2007) that, “literature on individual treatment of RAD is limited” (p. 543). The treatment for RAD usually includes the integration of medications to psychological therapy or counseling, education of primary caregiver or caregivers about the disorder, and training them to efficiently provide a caring, loving, safe, and stable living environment for the child with RAD.
The process of intervention will involve a team of mental professionals that is knowledgeable in attachment disorders. For a successful therapeutic process, it is essential that the primary caregiver will play an active role together with his or her child. The primary therapeutic goal when formulating treatment plan for RAD clients is to make certain that he or she is in a secure environment. This will pave the way into developing positive interactions with the parents or caregivers.
Although “there is no empirically supported treatment for RAD, evidence suggests that children with attachment problems are best served by therapies that promote environmental stability as we as caregiver patient, sensitivity, and consistency” (Wilson, 2009, p. 25). By reason of controversial issues surrounding the treatment of RAD and continuous research, this author will explore and discuss some of the suggested therapeutic interventions for RAD. The following techniques are few of interventions researched by this author: Parent – child Interaction Therapy (PCIT)
PCIT is an empirically supported treatment that utilizes “in – vivo coaching to facilitate the parent – child relationship over the course of 12 to 14 parent – child therapy sessions” (Wilson, 2009, p. 25). According to studies, PCIT was proven to be efficient “for improving and reducing problematic behaviors” (Wilson, p. 25). The process involves the therapist coaching and observing the parent or parents interact with their child while watching through a one – way mirror.
The parent or parents wear a “bug in the ear” during sessions to listen to the therapist direct guidelines on how to formulate responses that will encourage bonding (Wilson, p. 25). The technique utilizes two different aspects of interaction: Child – Directed Interaction. This is applied during the first seven sessions. The therapist will stress the importance of developing and enhancing the parent – child relationship by “child – directed play interactions” which will foster “shared enjoyment and empathic understanding” (Wilson, 2009, p. 25). Parent – Directed Interaction.
This is applied on the second half of the 14 week therapy session. The process will “teach parents how to promote positive behavior and reduce disruptive, negative behavior” (Wilson, 2009, p. 25). Circle of Security The purpose of this technique is to enhance “parental understanding of and response to a child’s attachment behaviors. This intervention includes 20 weeks of group –based intervention to encourage parent sensitivity and responsiveness” (Wilson, 2009, p. 25). During therapy, the interaction of parent or caregiver with the child will be videotaped and later reviewed with the counselor.
During the review, “parents are taught to recognize their interactions through supportive observation of their parent – child exchanges” (Wilson, p. 25). This method is believed to be instrumental “to increased parental responsiveness and improvement in children’s attachment security” (Wilson, p. 25). Person –Centered Therapy The key concepts of person-centered therapy came from Carl Rogers’s early development of the approach (as cited in Corey, 2009) which originated from client-centered therapy. The most important aspect on both is the positive perspective of the human nature.
Every human being is intrinsically good-hearted, “trustworthy, resourceful, capable of self- understanding and self-direction, able to make constructive changes, and able to live effective and productive lives” (Corey, p. 169). This attributes of human resides in all of us, therapist have to open their hearts and soul, and be hospitable to clients to establish a harmonious, therapeutic relationship. The ultimate goal of the person-centered therapy is not to eliminate suffering but rather to assist the client find the answers to their problems independently.
The focus of the therapeutic process is on the child, not the reason why he or she was referred to seek professional mental health. Carl Rogers (as cited in Corey, 2009) emphasized the following characteristics of the therapeutic experience: (1) an openness to experience, (2) a trust in themselves, (3) an internal source of evaluation, and (4) a willingness to continue growing. Encouraging the emergence of these attributes can help the client get rid of the pretenses in his or her life and start being sincere to achieve absolute freedom for self.
The therapist’s function and role is to create a welcoming environment for the client to achieve personal, spiritual, and emotional growth. It is crucial for the therapists to present themselves with the right attitude, their whole being serves as the instrument for healing. They have to be sincere, true to themselves and to the client. These can be reinforced by being congruent, accepting, and empathic. The therapist plays the major role of directing the client for a positive change. Behavior Therapy
The behavior therapy view human nature based science that involves the systematic and structured approach to counseling (Corey, 2009, p 237). A formal assessment is an integral element in Behavior therapy; it is a means to determine the client’s behaviors that are anticipated to be revolutionize. During the initial treatment session, the therapist will assist the client determine specific measurable treatment goals. The client’s active role in the therapeutic process is highlighted by their decisions regarding their objectives.
Goals must be clear, concrete, understood, and agreed on by the client and the therapist (Corey). The defining characteristic of behavior therapy is utilizing therapeutic techniques that were empirically supported and evidence-based. The techniques and methods have been well researched and tested with different populations and a wide array of disorders (Corey, 2009). There are numerous techniques in behavior therapy; each one was designed for a specific problem and clientele.
The following are some of the techniques and procedure in behavior therapy: 1) operant conditioning techniques, 2) relaxation training and related methods, 3) systematic desensitization, 4) in vivo exposure and flooding, 5) eye movement desensitization and reprocessing, 6) social skills training, 7) self-modification and self-directed behavior, 8) multimodal therapy: clinical behavior therapy, 8) mindfulness and acceptance-based cognitive behavior therapy, and 9) integrating behavioral techniques with contemporary psychoanalytical approaches (Corey).
Narrative Therapy Narrative Therapy concept is based on an assumption that the identity of a person is shaped by the accounts of his or her life found in stories or narratives (Corey, 2009). The technique views human nature as being able to interpret their life stories meaningfully which in turn considered as the “truth’ (Corey). It believes that human beings are healthy, competent, resourceful, and have the ability to construct solutions to solve their own problems utilizing their creative and imaginative thoughts.
The key concepts to consider with Narrative therapy are: focus of narrative therapy, the role of stories, and learning with an open mind (Corey). A study by May (2005) on “Family attachment therapy: healing the experience of early childhood maltreatment” supported the importance of narrative therapy to infants and young children diagnosed with RAD. She asserted that A coherent narrative reflects the child’s ability to make sense of life.
The left hemisphere of the brain is used to tell the events of the story, whereas a right hemisphere functions is necessary to incorporate the subjective, social, and emotional meaning of the internal life of the characters. (p. 222) The therapeutic goal of Narrative therapy is to make clients describe their life experiences in new and fresh dimensions to be able to have a different perspective of possibilities (May, 2005). The therapist’s role and function is to become an active facilitator during the narration of the client’s life story.
To be an effective facilitator, the therapist needs to have the concepts of care, interest, respectful curiosity, openness, empathy, contact, and charm. Narrative therapist adopts a “not-knowing” position to empower clients to be experts about their own life (Corey, 2009). The therapeutic relationship between the therapist and the client in Narrative therapy is vital to the success of the therapeutic process.
The relationship involves collaboration, compassion, reflection, and discovery. Controversial and Coercive Techniques According to the Mayo Clinic (2011, p. ), there are some unproven treatments of RAD that up to this day debatable and need more studies to prove it efficacy. It includes but not limited to: re – parenting or re-birthing; tightly wrapping, binding or holding children; withholding food or water; forcing a child to eat or drink; and yelling, tickling or pulling limbs, triggering anger that finally leads to submission. Conclusion In conclusion, the early attachment process of infants and young children with their primary caregivers are critical in preventing and detecting the prevalence of reactive attachment disorder.
A child with the disorder has high probability of neglect, abuse, or in a lot of circumstances (such as foster children) constant change of primary caregivers. This author has difficulty completing this course work because of the nature of the disorder. The evolution of time changes the society especially the structure of a standard family. Several centuries ago, the man was considered the “bread winner” and goes to work to provide for the family and the wife was expected to stay home and be the primary caregiver for their children.
As years goes by, the human beings lifestyle change, the modernization, and the economy contributed to making adjustments to a standard family structure. Both husband and wife work, majority of children was taken care by extended family, nanny, and daycare. This author wonders if these changes in our environment contribute to the prevalence of RAD. As a working mother herself, this author is interested in doing studies on finding preventive and effective intervention techniques for clients diagnosed with RAD.
This author believes that RAD symptoms overlap and can be confused with other mental disorders, because of the uncommonness of the disorder there will always be a higher probability of misdiagnosis. There is a need to conduct additional research on cases surrounding attachment disorders to prevent this from happening. At the moment, the lack of empirically supported assessment protocols and treatment interventions limit mental health professionals in diagnosing and treating the disorder efficiently. This also caused comprehensive misunderstanding of RAD in the healing profession (Sheperis, Renfro-Michel, & Doggett, 2003).