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Dec 7, 2004
Maureen E. Wood
Rochester Institute of Technology

Reactive attachment disorder (RAD) is one of the few disorders listed in the DSM-IV that can be applied to infants. It is a disorder caused by a lack of attachment to any specific caregiver at an early age, and results in an inability for the child to form normal, loving relationships with others. This paper gives a review of the disorder as it is currently understood, including explanation of attachment theory, groups commonly affected by the disorder, and symptoms characterizing RAD. Finally, a critique of the current stance on the conceptualization of RAD is given, with some exploration into whether this disorder is really the result of disturbance in attachment or due to responses and reactions both on the part of the caregiver and the child due to temperament.

Reactive attachment disorder (RAD) is one of the few disorders listed in the DSM-IV that can be applied to infants. It is a disorder caused by a lack of attachment to any specific caregiver at an early age, and it results in an inability for the child to form normal, loving relationships with others. In order to understand RAD as it is viewed currently, it is necessary to briefly explain attachment theory and describe groups commonly affected by RAD and the symptoms characterizing RAD.

Due to the relative newness of reactive attachment disorder as an accepted clinical diagnosis, there are a variety of criticisms of the current conceptualization of RAD. These criticisms are given, with some exploration into whether this disorder is really the result of disturbance in attachment or due to responses and reactions both on the part of the caregiver and the child due to temperament. Stafford, Zeanah, and Scheeringa (2003) point out that the DSM-IV focuses more on a child's aberrant social behavior rather than on a child's disturbed attachment behavior, deemphasizing the significance of attachment in RAD. Also, pathogenic care is described as the etiology for RAD, with little attention given to a biological predisposition to developing the disorder. Although no research has been conducted on the influence of temperament on the development of RAD, current knowledge suggests that temperament may play an important role in the etiology of RAD, and its impact should be investigated further (Zeanah & Fox, 2004).

Review of Reactive Attachment Disorder
Reactive attachment disorder (RAD) is one of the few psychological disorders that can be applied to infants (Zeanah, 1996). It was first mentioned in the third edition of the Diagnositc and Statistical Manual of Mental Disorders (DSM-III), and has since been included in the DSM-IV and the tenth revision of the International Statistical Classification of Diseases (ICD-10) (Zeanah, 1996). Children affected by RAD exhibit an inability to form normal relationships with other people as well as impaired social development and sociopathic behaviors due to the absence of secure attachment formation early in life (Wilson, 2001). This disorder may be caused by pathogenic care during infancy, including abuse and/or neglect, or it may be caused by frequent changes in a primary caregiver, as is often the case with children raised in institutions or foster care (Kay Hall & Geher, 2003).

There are two main subtypes of RAD described in the DSM-IV , the inhibited subtype and the disinhibited subtype (Wilson, 2001). Children with the inhibited form of RAD are emotionally withdrawn and rarely respond to or even seek out comfort. Children with the disinhibited form of RAD tend to be overly sociable, eliciting comfort and affection non-selectively, even from adults who are strangers (Zeanah, Smyke, & Dumitrescu, 2002).

Overview of Attachment Theory
Bowlby's theory of attachment was centered on evolutionary thinking. Infants are vulnerable and unable to fend for themselves. Thus, the attachment process is designed to insure the survival of the infant and, in turn, the species (Haugaard & Hazan, 2004). As long as an infant is well loved and its biological needs are consistently met, he will learn to trust and feel secure with his caregiver, and a healthy attachment will be made (Wilson, 2001). This attachment will continue to influence one's interpersonal relationships throughout life.

Ainsworth expanded on Bowlby's work with the idea that the primary caregiver acts as a secure base for exploration. How well the caregiver meets the needs of the infant will affect the security of the attachment. According to this theory, there are three patterns of attachment, secure, insecure/avoidant, and insecure/resistant (Wilson, 2001). Securely attached infants exhibit little avoidance or resistance to contact with the caregiver and use the caregiver as a secure base for exploration. Insecure/avoidant infants exhibit avoidance of contact with the caregiver and tend to show little preference for the caregiver over a stranger. Insecure/resistant infants exhibit resistance to contact with the caregiver and tend to show more anger and ambivalence than infants in the other two groups (Wilson, 2001).

Children Most Likely Affected by RAD
The DSM-IV requires that children diagnosed with RAD have histories of pathogenic care, meaning experiences of parental abuse and neglect or lack of a consistent caregiver (Zeanah et al., 2004). The ICD-10, although it does not make such a requirement, does warn clinicians against diagnosing a child with RAD unless there is some evidence of pathogenic care (Zeanah et al., 2004). Given such implications, it follows logically that children most likely to have RAD are those that come from abusive families or were raised in foster care or orphanages. Adopted children are more likely to exhibit emotional, behavioral, and educational problems than children who are raised by their biological parents (Kay Hall & Geher, 2003). This is due to the fact that, on average, they have had a greater number of caregivers preventing them from having that crucial experience of forming a strong, secure attachment in infancy.

Richters and Volkmar (1994) described several cases of children who met the criteria for RAD, each of whom experienced abuse and/or neglect. Two of the children lived periodically with different relatives, and the other two experienced a combination of foster care and care with relatives. These children exhibited a number of social behavioral issues including impulsivity, aggression, erratic mood swings, oppositional behavior, emotional withdrawal, and self-injurious behavior.

Inhibited Versus Disinhibited Subtype
The DSM-IV mentions two categories of RAD: an inhibited subtype and a disinhibited subtype. The ICD-10 describes the former, emotionally withdrawn subtype as RAD and the latter subtype as Disinhibited Attachment Disorder (DAD) (Zeanah et al., 2004). Generally, the criteria for the inhibited subtype of RAD were generated by studies done on children who were maltreated or abused. Criteria for the disinhibited subtype of RAD were based on research on children raised in institutions (Zeanah, 1996). This is largely based on the fact that inhibited subtype of RAD is more prevalent in maltreated children, and the disinhibited subtype of RAD is more prevalent in children raised in institutions (Zeanah, 2000).

In a study by Zeanah et al. (2004) on RAD in maltreated toddlers, ratings on the two subtypes of RAD were made based on several criteria. The criteria for inhibited RAD were: (a) absence of a discriminated, preferred adult, (b) lack of comfort seeking for distress, (c) failure to respond to comfort when offered, (d) lack of social and emotional reciprocity, and (f) emotion regulation difficulties. The criteria for disinhibited RAD were: (a) not having a discriminated, preferred attachment figure, (b) not checking back after venturing away from the caregiver, (c) lack of reticence with unfamiliar adults, (d) a willingness to go off with relative strangers. Upon rating the children in this study, Zeanah et al. found that the two subtypes of RAD as described by the DSM-IV are not completely independent. Rather, children with RAD may exhibit symptoms of both types of the disorder.

Behavioral Symptoms
The ramifications of the inability of children with RAD to form normal attachments are best illustrated through the many maladaptive behaviors associated with the disorder. Such behaviors include stealing, lying, cruelty to animals and other people, avoidance of eye contact, indiscriminate affection with relative strangers and a refusal to express affection with family members, destruction of property, gorging of food, abnormal speech patterns, lack of remorse, impulsivity, inappropriate sexual behavior, role reversal, and overactivity (Kay Hall & Geher, 2003).

Difficulties in Diagnosing RAD
Reactive attachment disorder is a relatively new disorder, having first been described in the DSM-III, indicating a growing awareness of the negative effects of institutionalization and maltreatment in children and their psychological development (Richters & Volkmar, 1994). Although some improvements were made in describing and diagnosing RAD in DSM-IV , making reliable diagnoses is still a major problem due to disagreement among professionals as to the etiology of RAD and due to issues with differential diagnosis (Sheperis, Doggett, & Hoda, 2003).

Sheperis et al. (2003) described an extensive assessment protocol designed to aid in the reliability of diagnoses of RAD in the absences of a comprehensive tool to assess children for RAD. This protocol consists of child and parent clinical interviews, global rating scales, attachment-specific rating scales, and behavioral observation (Sheperis et al., 2003). Some of the global rating scales included the Child Behavior Checklist, the Behavior Assessment System for Children, and the Eyeberg Child Behavior Inventory. Structured and semi-structured interviews, behavioral rating scales and standardized tests were also utilized as part of the assessment protocol. Such a protocol was well formed in that it incorporates a variety of assessment methods in an attempt to get complete and in depth information regarding the client. However, much research still needs to be done in order to improve the assessment and diagnostic process of RAD as well as to gain greater understanding of the disorder.

Attachment or Temperament?
The current conceptualization of RAD, as described in the DSM-IV and the ICD-10, ties the etiology of the disorder to pathogenic care with an emphasis on socially aberrant behavior across contexts rather than on disturbed attachment behavior. Given the centrality of attachment in psychological development, it is expected that disrupted attachment should be associated with a number of psychological disorders. Thus the question arises of whether there are truly attachment disorders such as RAD or attachment disturbances are best addressed as issues associated with other disorders (Stafford et al., 2003).
Additionally, although temperament is well studied in its relation to attachment formation, there is currently no empirical research on its influence in the development of attachment disorders (Zeanah & Fox, 2004). There are a variety of ways in which temperament, which is at least in part a function of an infant's biological make-up, may directly or indirectly play a significant role in the development and manifestation of RAD.

Criticism of the Current Conceptualization of RAD
Stafford et al. (2003) note that the pervasiveness of attachment as an issue in psychological development poses a fundamental problem in generating an appropriate conceptualization of attachment disorders and their etiology. Because of the significance of attachment formation, it is expected that disruption of the attachment process be associated with a variety of mental disorders. Therefore, Stafford et al. (2003), raise the question of whether attachment should merely be described as an issue associated with certain mental disorders or whether there truly exist disorders, such as RAD, stemming directly from the disruption of attachment early in life. The emphasis of the DSM-IV and ICD-10 further confuse this by emphasizing socially aberrant behavior across a wide variety of contexts rather than focusing on behaviors more directly associated with disturbed attachments (Zeanah 1996).

Zeanah (1996) made a number of suggestions to improve and clarify the conceptualization of RAD, especially as it is described in the DSM-IV. First, the population of children who may be affected with RAD should be expanded to include children who may be in stable but disordered attachments, not only those who have been subject to maltreatment or unstable caregiving. This requires focusing more specifically on the infant-caregiver relationship. Second, the requirement that the disordered attachment be exhibited across a wide variety of social contexts should be dropped in lieu of the idea that attachment may be expressed differentially in relationships, whether it is disordered or not. A child may develop different relationships with different caregivers. For example, some children may have no attachment relationships at all, and others may have a very disturbed attachment relationship with a primary caregiver.

Finally, more research needs to be done to clearly delineate the difference between insecure attachments and disordered attachments. The question to be asked here is, "When do risk factors (insecure attachments) become clinical disorders (attachment disorders)?" (Zeanah, 1996). By adjusting the current criteria for RAD and by expanding knowledge of the disorder through well organized research, more reliable diagnoses can be made, thus aiding in the treatment of more children affected by RAD.

Overview of Temperament
Temperament is the style in which infants respond to various stimuli and situations (Zeanah & Fox, 2004). Essentially, temperament describes how infants behave in reaction to their environment. Alexander Thomas and Stella Chess were the pioneers in studying temperament and how such differences among infants affect parental reaction during caregiving. According to these researchers, temperament is part of an infant's biological make-up and involves nine dimensions: activity level, regularity of functioning, approach-withdrawal in new situations, intensity of emotional expression, overall valence of mood, adaptability to changes in routine, persistence, distractibility, and threshold of sensory responsiveness (Zeanah & Fox, 2004). Based on these dimensions, Thomas and Chess formulated three types of temperament: difficult, easy, and slow-to-warm-up (Zeanah & Fox, 2004).

Rothbart's theory of temperament proposed that there are two components to temperament: reactivity and regulation. Reactivity includes physiological and behavioral systems that are present at birth, the biological aspect of temperament. Regulation is comprised of activation of neural systems in response to reactivity and environment (Zeanah & Fox, 2004). Kagan's view of temperament was that it is a blend of behavior patterns and physiology (Zeanah & Fox, 2004).

RAD and Temperament
Zeanah and Fox (2004) outlined a number of ways in which temperament may be related to RAD. Effects of temperament on RAD may be none, direct effects, or complex indirect effects. First, temperament may have no effect on RAD whatsoever. It may simply be that RAD is a result of different experiences with caregivers. For example, inhibited RAD may simply be related to neglect and disinhibited RAD may be related to care provided by a number of people and limited contact with any one caregiver (Zeanah & Fox, 2004). Second, RAD may be related to a variety of styles of difficult temperament. Inhibited RAD could be directly related to irritability and negative affect. Such infants may respond to positive social cues with avoidance or distress, later withdrawing from social interaction. Disinhibited RAD may be a result of an impulsive temperament leading into indiscriminate social behavior (Zeanah & Fox, 2004).

Another idea presented by Zeanah and Fox (2004) is that the combination of specific temperamental attributes and specific environmental factors may interact negatively and result in RAD. Similarly, difficult temperament in infants may elicit maladaptive responses from caregivers in times of environmental stress. Finally, Zeanah and Fox (2004) propose that some temperamental characteristics may actually serve as protective factors. Children with a positive affect and a tendency to approach their caregivers for attention will likely be less susceptible to certain disorders such as RAD.

Clearly, the conceptualization of RAD is still in its construction phase. Lack of adequate research on reactive attachment disorder is a hindrance to forming the well-defined definition of the disorder that is necessary for reliability and validity in its diagnosis. I conclude that the suggestions made by Zeanah (1996) to improve the DSM-IV criteria for RAD in combination with continued research in this field will allow more children who are affected by RAD t o be diagnosed and treated.

Based on the research conducted on reactive attachment disorder thus far and on the ideas presented by Zeanah and Fox (2004) regarding temperament, I conclude that RAD is a disorder of attachment that may be affected by a child's temperament. Clearly, the emotional and behavioral difficulties faced by children with RAD are due to severe disturbances in attachment during infancy. Disruption of the fundamental attachment process early in a child's life logically will have detrimental effects on the psychological and emotional wellbeing of that child. The fact that there are many children who face adverse circumstances without necessarily developing RAD is most likely due to individuality. Not everyone will react in the same way to a given situation.

I would compare the etiology of reactive attachment disorder to the diathesis-stress model we discussed in class. A person's temperament in infancy may shape the way he will interact with his caregiver(s) initially, thus perpetuating either a secure attachment or a disordered one. Thus, an infant's temperament may predispose him to developing RAD, acting as the diathesis. Whether or not the child does actually develop RAD is dependent upon his life experience, whether he is exposed to good (or at least adequate) caregiving or is subject to pathogenic caregiving, the stress.

I also believe that temperament may affect the way in which RAD is manifested, whether the child exhibits more symptoms of the inhibited or disinhibited subtype of RAD. Therefore, in the circumstances of pathogenic care, a child's temperament will play some role not only in whether or not he develops RAD, but also the type of symptoms within such a diagnosis that would be prevalent in his case.

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