Reactive Attachment Disorder and Attachment Disorders

At the extreme end of the attachment disorders continuum is Reactive Attachment Disorder (RAD). Attachment can vary from normal (or healthy) on one end of the continuum, to mild or weak on the other end, to extreme end as characterized by RAD. In the figure below, "Issues" refer to that area where your teen or child has attachment issues but not severe enough to fall into the RAD range.

Attachment refers to the ability to form healthy relationships. These children (teens, adults) have difficulty forming developmentally appropriate social relationships.

Most often a problem with adopted children, attachment problems can be brought about by trauma, abuse, or neglect. In general, attachment problems begin because of a lack of healthy attachment to the primary care giver in the first two years of life. 

Healthy attachment

Healthy attachment is characterized by emotional security and trust in relationships. For the new born baby there is a "dance" of emotional attunement that occurs between mother and child. It begins with the mother-child relationship that extends through the first four years of life, with the first two years being extremely critical. This dance involves the responsiveness of mother and child to non-verbal and verbal signaling as the baby learns to recognize emotions and their meanings, is loved, and nurtured.

As the child grows, he or she learns to break away from the mother and to explore the environment around him. Returning back to his mother's safety for reassurance. In this way the foundation for individuation and healty independence is laid as well as intimacy.

Weak attachment

Weak attachment is indicated by the child that

• needs to control the adults around them, especially the emotions and behaviors of caregivers
• continually engages in power struggles and is compulsive about winning them
• repeatedly say "No" as a means of empowering themselves
• cause emotional and/or physical pain to others
• maintain a negative concept of self
• limited ability to regulate their emotions (affect)
• avoid mutually give-and-take games, laughter, and fun with others
• seem determined not to ask for help or to need others
• negatively reacts to praise, love, attempts to make them feel special or worthy
• are very shame-based in their self-image

AJ's Story

One of the adolescents, age 12, with which we worked delighted in emotionally abusing his peers, was incredibly controlling with others, including his parents, and could care less about relations with others. He had minimal empathy. His parents could come or go. It made little difference to him. His world was completely ego-centric. AJ was a blooming personality disorder in the making with a scary mix anti-social, histrionic, and narcassistic traits.

Toward the end of our therapeutic relationship he was aware of how he affected others and his total selfishness. He was brutally honest about himself and his motivation. The best we could do in therapy was to make him aware of how his behaviors and words affected others so that at least he could make conscious choices about his manipulations and actions.

We wished there could have been a happy ending to AJ's story. But the clinical truth seems to be that after 10 years of age or so, the attachment "damage" is not ameanable to therapy. This may because there have been permanent changes in the teen's brain that are irreversable.

Neurological Changes

Research indicates that normal attachment may be required for optimal brain development (Schore, 2002). Again, weak attachment appears to be caused by trauma, abuse, or neglect during infancy or early childhood. These traumatic attachments result in neurological imprinting which involves the developing limbic and the autonomic nervous systems. Such imprinting results in permanent changes in the neural pathways and neurophysiology.

There is increasing suspicion that it is the mirror neuron system that is affected (Rajmohan and Mohandas. 2007) as mirror neurons play important roles in bonding and empathy.

RAD

The Diagnostic and Statistical Manual IV R gives the following symptoms for Reactive Attachment Disorder of Infancy or Early Childhood:

A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either,

1. persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilent, or highly ambivalent and contradictory responses (e.g. the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness)
2. diffuse attachements as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures)

B. The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder.

C. Pathogenic care as evidenced by at least one of the following:

1. persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection
2. persistent disregard of the child's basic physical needs
3. repeated changes of primary caregiver that prevents formation of stable attachments (e.g., frequent changes in foster care)

D. There is a presumption that the are in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbance in Criterion A began following the pathogenic care in Criterion C).

There are two subtypes. Inhibited Type with the predominant disturbance is the persistent inability to form healthy and appropriate attachments. Disinhibited Type in which there is indiscriminate and inappropriate attachments.

Treatment

Traditional psychotherapeutic approaches are ineffective with these children and teens. Many can attach better to animals than humans. In another case, for example, the client was more attached to her pet dog than to the rest of her family. This ability to attach somewhat to animals can be a starting point for such teens and children. Equine Assisted Psychotherapy is useful in this regard.

As emphasized in AJ's story above, beyond the age of about 10 or so years, most clinicians, if they are honest about it, have little success in facilitating major changes with attachment disorders because of the imprinting aspect. That is, the changes seem to be hard-wired into the neuronal circuitry by that time.

Daniel Hughes in his book, Facilitating Developmental Attachment, presents an integrative psychotherapeutic approach which combines Ericksonian Utilization theory, emotional engagement in spite of conflicts and resistance, focusing on the natural attachment sequence (feelings of closeness to mother, experiencing a break in the relationship, followed by re-estabilishing the relationship). It relies very much on relationship building between therapist and child and between child and parent in the therapy sessions. He include physical contact with the therapist in the form of holding and caresses. This works well for young children but not so much for teens.  He also utilizes psychodrama in parents, child and therapist play different roles.

Unfortunately his book is directed toward adopted and younger children. However, there is a lot of good material in his book that applies also to teens. Especially note his chapters for parenting these children and teens. For more details on this and treatment strategies, we refer you to his book:

Facilitating Developmental Attachment: The Road to Emotional Recovery and Behavioral Change in Foster and Adopted Children

References

Hughes, Daniel. 2004. Facilitating Developmental Attachment: The Road to Emotional Recovery and Behavioral Change in Foster and Adopted Children. Rowman & Littlefield Publishers NY. 264 pp.

Rajmohan V, Mohandas E. 2007 Mirror neuron system. Indian J Psychiatry [serial online]  [cited 2008 Dec 15];49:66-9. Available from: http://www.indianjpsychiatry.org/text.asp?2007/49/1/66/31522

Schore, A. N. 2002. Dysregulation of the right brain: a fundamental mechanism of traumatic attachment and the psychopathogenesis of posttraumatic stress disorder. Australian and New Zealand Journal of Psychiatry 36 (1): 9-30.

Index to Teen Problems and Issues:

• Anxiety Disorders

• Adoption

• Attachment and RAD
  
• Asperger's
  
• Non-verbal Learning Disability

• Depression
• Bi-Polar
• Cyclothymia
• Dysthymia

• ADHD
• LD

• Conduct Disorder
• Oppositional Defiance

• Anger
• Drugs and addiction

• Abuse

• Children of Divorce
• Parent-Teen Relationship

• Problems Sibling
• Relationship Problems