Continuing Education Activity

The Diagnostic and Statistical Manual 5th Edition (DSM-5) classifies reactive attachment disorder as a trauma- and stressor-related condition of early childhood caused by social neglect and maltreatment. Affected children have difficulty forming emotional attachments to others, show a decreased ability to experience positive emotion, cannot seek or accept physical or emotional closeness, and may react violently when held, cuddled, or comforted. Behaviorally, affected children are unpredictable, difficult to console, and difficult to discipline. Moods fluctuate erratically, and children may seem to live in a fight, flight, or freeze mode. Most have a strong desire to control their environment and make their own decisions. This activity describes the evaluation, diagnosis, and management of reactive attachment disorder and stresses the role of team-based interprofessional care for affected patients.

Objectives:

• Review the presentation of reactive attachment disorder.
• Describe the evaluation of reactive attachment disorder.
• Outline management strategies for reactive attachment disorder.
• Explain how the interprofessional team can work collaboratively to prevent the potentially profound complications of reactive attachment disorder by applying knowledge regarding its presentation, evaluation, and management.

Introduction

The Diagnostic and Statistical Manual 5th Edition (DSM-5) classifies reactive attachment disorder as a trauma- and stressor-related condition of early childhood caused by social neglect or maltreatment. Affected children have difficulty forming emotional attachments to others, show a decreased ability to experience positive emotion, cannot seek or accept physical or emotional closeness, and may react violently when held, cuddled, or comforted. Behaviorally, affected children are unpredictable, difficult to console, and difficult to discipline. Moods fluctuate erratically, and children may seem to live in a “flight, fight, or freeze” mode. Most have a strong desire to control their environment and make their own decisions. Spontaneous changes in the child's routine, attempts to discipline the child, or even unsolicited invitations of comfort may elicit rage, violence, or self-injurious behavior. In the classroom, these challenges inhibit the acquisition of core academic skills and lead to rejection from teachers and peers alike. As they approach adolescence and adulthood, socially neglected children are more likely than their neuro-typical peers to engage in high-risk sexual behavior, substance abuse, involvement with the legal system, and experience incarceration.[1][2][3]

Etiology

The genesis of reactive attachment disorder is encompassed under the designation of traumatic experience; specifically, the severe emotional neglect commonly found in institutional settings, such as overcrowded orphanages, foster care, or in homes with mentally or physically ill parents. Over time, infants who do not develop a predictable, nurturing bond with a trusted caregiver, do not receive adequate emotional interaction and mental stimulation halt their attempts to engage others and turn inward, ceasing to seek comfort when hurt, avoiding physical and emotional closeness, and eventually become emotionally bereft.[4][3] The absence of adequate nurturing results in poor language acquisition, impaired cognitive development, and contributes to behavioral dysfunction.[5]

Epidemiology

Although difficult to accurately assess, recent data suggest a prevalence rate between 1-2%.[6] A data analysis report published by the National Survey of Child and Adolescent Well-Being (NSCAW) indicated that 42% of children removed from their home and placed in an alternate setting met DSM–IV (1994) criteria for a behavioral health disorder. Additional research completed by Landsverk and Garland and cited in Mental Health Treatment of Child Abuse and Neglect: The Promise of Evidence-Based Practice (Shipman, Kimberly, and Taussig, Heather 2009) found that "between one-half and two-thirds of children entering foster care exhibit behavior or social competency problems warranting mental health services."

Research suggests that concordance rates among siblings raised in the same home to be between 67% and 75%.[7] Neither gender nor ethnicity alone appears to be risk factors for developing the disorder; however, African American and multi-racial children experience higher rates of child maltreatment than do their non-minority counterparts which likely translates to a higher incidence of reactive attachment disorder in minority populations.

The National Survey of Child and Adolescent Well-Being, No. 18  (Instability and Early Life Changes Among Children in the Child Welfare System) shows that 79% of children who died because of abuse or neglect in 2010 were younger than the age of 4. During that same year, 48% of children entering the foster care system were also younger than age 5.[7]

Pathophysiology

Since WWII, physicians, psychologists, and attachment theorists have documented the impact of social neglect on physical and emotional development. Experiments completed in the 1940s and 1950s found that maternal deprivation had a profound effect on infant growth, motor development, social interaction, and behavior. In the film Psychogenic Diseases in Infancy (Spitz, 1952), infants deviated from the normal, expected course of development and became “unapproachable, weepy and screaming” within the first 2 months of maternal deprivation. As the deprivation continued, facial expressions became rigid and then flat; motor development regressed, and by the fifth month, infants were “lethargic,” unable to “sit, stand, walk, or talk,” suffered from growth abnormalities, developed “atypical, bizarre finger movements,” and no longer sought or responded to social interaction; 37.3% of the infants died within 2 years. These early experiments became the foundation for Attachment Theory and outlined the constellation of symptoms of what the DSM, Third Edition (DSM–III) would later call reactive attachment disorder.

History and Physical

The DSM-5 gives the following criteria for reactive attachment disorder:

• The patient demonstrates a chronic pattern of being emotionally withdrawn and inhibited, which is demonstrated by rarely seeking or responsive to comfort when distressed. 
• There is evidence of a chronic social and/or emotional perturbation characterized by at least two of the proceeding: social withdrawal and minimal responsiveness to others, negative affect, unfounded or inexplicable episodes of irritability, fearfulness, or sadness--or out of proportion reactions to normative stress.
• The patient presents with a history of extremely insufficient care, entailing of one of the following: deprivation or social neglect of basic emotional needs for stimulation, comfort, and affection by caring caregivers; the constant flux of caregivers, resulting in a destabilized home environment; growing up in an unusual setting which limits the ability to form selective attachments
• The child cannot also meet the diagnostic criteria for autism spectrum disorder as the two diagnoses (autism spectrum disorder and reactive attachment disorder) are mutually exclusive
• The behavioral perturbation should manifest prior to the age of 5 years of age
• The child must have a developmental age of at least nine months in order to qualify for the diagnosis

These diagnostic criteria provide an outline of symptoms; however, providers must also recognize the global impact on cognition, behavior, and affective functioning.

Cognition

Abuse in childhood has been correlated with difficulties in working memory and executive functioning, while severe neglect is associated with underdevelopment of the left cerebral hemisphere and the hippocampus.[8][3]

Behavioral

Social skills are below what would be expected of either their chronological age or developmental level. Children with RAD may respond to ordinary interactions with aggression, fear, defiance, or rage.  Affected children are more likely to face rejection by adults and peers, develop a negative self-schema, and experience somatic symptoms of distress. Psychomotor restlessness is common, as is hyperactivity and stereotypic movements, such as hand flapping or rocking.[1][4]

Affective

RAD increases the risk of anxiety, depression, hyperactivity, and reduces frustration tolerance. Ailing children are likely to be highly reactive, even in non-threatening situations.[8]

Evaluation

Clinicians should have a low threshold for referring children with a known history of adoption, abuse, foster, or institutional care to a child psychologist or psychiatrist for a comprehensive biopsychosocial assessment detailing the child’s history, description of the symptoms over time, and direct observation of the parent-child interaction.  Attachment behaviors and signs of secure attachment (e.g., comfort-seeking, good eye contact, child-initiated interaction) should be assessed at every visit. Clinicians should maintain a low threshold for referral to a child development specialist, a child psychiatrist, or a child psychologist.[9]

Treatment / Management

Treatment of RAD requires a multi-pronged approach incorporating parent education and trauma-focused therapy. Parent education focused on developing positive, non-punitive behavior management strategies,  ways of responding to nonverbal communication, anticipation and coping strategies for when triggers arise and parent-child psychotherapy can facilitate bonding and healthy attachment. Empathy and compassion are key elements to building trust. Developing a nurturing parent-child relationship is the cornerstone to overcoming the damage caused by severe neglect and abuse.

Differential Diagnosis

According to the DSM-5, the following differential diagnoses should be ruled out before a diagnosis of reactive attachment disorder:

Autism Spectrum Disorders        

Children on the autism spectrum often exhibit many of the same features as those with reactive attachment disorder; however, restricted range of interest, sensory processing difficulties, and rigid adherence to rituals or routines are specific to autism spectrum disorder.

Intellectual Impairment

For a diagnosis of RAD to be made, the child must have attained a developmental age of at least 9 months, and another medical or mental health disorder must not cause social impairments. Impairments in social relatedness commensurate with developmental age should be viewed as an overall feature of the developmental delay and not solely a response to severe neglect.

Depressive Disorders

Symptoms of anhedonia may mirror many of the withdrawal symptoms of RAD; however, children suffering from depression maintain the ability to attach and to seek and receive comfort from preferred caregivers.

Prognosis

Even with intervention, injured children encounter difficulties in every aspect of their lives; from classroom learning to developing a secure sense of self.  The traumatic situations which lead to the attachment disorder create a persistent state of stress; diminishing their capacity for resilience.  Early identification and treatment have been shown to improve outcomes; however, parent education and support are key.  Parents adopting children from state custody or from overseas orphanages should receive education on the impact of social deprivation and connected with service agencies or providers specializing in attachment disorders.[9] 

Complications

Signs and symptoms of RAD may be missed by providers who are unfamiliar with the child’s history or when the history is unknown. Symptoms may be attributed to common behavioral health disorders such as depression, anxiety, attention deficit-hyperactivity disorder, oppositional defiant disorder, conduct disorder, genetic or neurological disorders, or autism spectrum disorder. Although there is a significant symptom overlap and co-occurrence, treatment for each varies and some treatment methods may exacerbate RAD.

Consultations

Consultation and evaluation by a developmental pediatrician, a child psychiatrist, or a child psychologist should be completed before assigning the diagnosis of reactive attachment disorder. Neuropsychological assessments or other psychometric evaluations are useful in identifying discrepancies between chronological age and age-approximate functioning across multiple domains.

Deterrence and Patient Education

Much research has been done on the effects of severe social isolation and neglect on children removed from abusive homes or raised in institutions; however, there is still much work to be done to determine the impact of inadequate caregiving in the home. Psychosocial stressors such as poverty, lack of suitable childcare, parental substance abuse, incarceration, or severe mental illness increase the risk of all forms of abuse, particularly neglect. Parents facing extreme psychosocial stressors may find themselves unable to provide more than very necessities and may lack the healthcare literacy to understand the importance of their infant’s emotional development. Clinicians working with parents and children should be cognizant of the psychosocial factors which may impede a parents’ ability to provide consistent emotional feedback and intervene or refer for additional support when indicated. Healthcare providers should assess for maternal depression and evaluate parent-child interactions during routine appointments.[3]

Pearls and Other Issues

Before 2013, the diagnosis of reactive attachment disorder incorporated inhibited and dis-inhibited subtypes; however; the advent of the DSM-5 heralded the separation of each subtype into separate and distinct diagnoses. DSED represents a second clinical course for children exposed to neglect and abuse. While the clinical picture of RAD is of emotionally withdrawn, unemotional, or even callous children; disinhibited social engagement disorder presents with indiscriminate, overly friendly behavior. Typical fear behaviors such as crying, turning away, or seeking comfort from a preferred adult are absent and are instead replaced with a lack of age-appropriate restraint with acquaintances or strangers. The disinhibited nature of the disorder results in children seeking comfort or care indiscriminately, giving and receiving affection, and seeking attention from any available adult without regard for their safety.[9]

Enhancing Healthcare Team Outcomes

To improve outcomes and provide clinically sound treatment, those tasked with assessing and evaluating children with RAD must be acquainted with the underpinnings of attachment theory,  understand the profound impact of maltreatment on behavior, cognition, and communication. Assessment of social interaction and developmental milestones should be completed following Centers for Disease Control (CDC) or World Health Organization (WHO) guidelines to ensure delays in meeting expected milestones are addressed as early as possible.  Developmental pediatricians, child psychologists, or child psychiatrists can complete comprehensive assessments to narrow the differential diagnosis. Caring for children with RAD requires an interprofessional "wrap around" approach incorporating behavioral health providers to address behavioral challenges, social workers and case managers to assist with resources and referral, speech and language pathologists to address social communication deficits, and rehabilitative services to address motor skill delays caused by severe neglect or abuse. Working together, school personnel and parents can develop an Individualized Education Plan which creates a safe, nurturing environment where affected students can rise to their full potential.

The American Academy of Child and Adolescent Psychiatry developed clinical standards (CS), clinical guidelines (CG), clinical options (OP), or not endorsed (NE). The following guide assessment and treatment of children with reactive attachment disorder.[9]

Recommendation 1. "For young children with a history of foster care, adoption, or institutional rearing, clinicians should inquire routinely about a) whether the child demonstrates attachment behaviors and b) whether the child is reticent with strangers." (CS)

Recommendation 2. The Clinician conducting a diagnostic assessment of RAD and DSED should obtain direct evidence from both a history of the child's patterns of attachment behavior with his or her primary caregivers and observations of the child interacting with these caregivers. (CS)  

Recommendation 3.  The clinician may be aided in making the diagnosis of RAD or DSED by a structured observational paradigm that compares the child's behavior with familiar and unfamiliar adults. (OP)

Recommendation 4.  Clinicians should perform a comprehensive psychiatric assessment of children with RAD or DSED to determine the presence of comorbid disorders (CS)

Recommendation 5. The Clinician should assess the safety of the current placement for previously maltreated children with negative behaviors who are at high risk of being re-traumatized. (CS)

Recommendation 6. The most important intervention for young children diagnosed with RAD or DSED is ensuring that they are provided with an emotionally available attachment figure. (CS)

Recommendation 7. For young children diagnosed with DSED, limiting contacts with non-caregiving adults may reduce signs of the disorder. (OP)

Recommendation 8. Clinicians should recommend adjunctive interventions for children who display aggressive and/or oppositional behavior that is comorbid with DSED. (CS) 

Recommendation 9. Psychopharmacological interventions are not indicated for the core features or RAD or DSED. (NE)

Recommendation 10. Clinicians should not administer interventions designed to enhance attachment that involves noncontingent physical restraint or coercion (e.g., "therapeutic holding" or "compression holding"), ''reworking'' of trauma (e.g., "rebirthing therapy), or promotion of regression for "reattachment'' because they have no empirical support and have been associated with serious harm, including death. (NE)[9]