Reactive attachment disorder: usefulness of a new clinical category.
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Adult↗
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Attachment disorders: review and current status.
Developmental research on attachment has flourished in the past 15 years (C. H. Zeanah, 1996). However, there has been relatively scant empirical investigation of disorders in attachment. In this article, the pertinent developmental research on the attachment cycle is delineated and the current status of disordered attachment is examined. A particular focus is given to the conceptualization of the most severe form of disordered attachment, Reactive Attachment Disorder.
Child↗
Development of a brief, clinically relevant, scale for measuring attachment disorders.
A 17-item questionnaire for reactive attachment disorders (RAD) was developed and administered to 182 Scottish children living in foster care. The RAD questionnaire had a good test-retest reliability with an intra-class correlation (ICC) of 0.78 and inter-rater reliability with an ICC of 0.81. Cluster analysis showed that the children fell into three groups, two of which corresponded to the two reactive attachment disorder subtypes. High questionnaire scores for attachment disorders were significantly associated with conduct problems, emotional problems, hyperactivity and problems with peer relations and negatively associated with pro-social behaviour. High overall questionnaire scores for reactive attachment disorder were associated with previous sexual abuse, whereas there was no association with previous physical abuse. High scores for the disinhibited subtype were associated with previous neglect.
Adolescent↗
Temperament and attachment disorders.
Reviewed in this article is research on children with reactive attachment disorder (RAD) who exhibit specific patterns of socially aberrant behavior resulting from being maltreated or having limited opportunities to form selective attachments. There are no data explaining why 2 different patterns of the disorder, an emotionally withdrawn-inhibited pattern and an indiscriminate-disinhibited pattern, arise from similarly aberrant environments. In this article, we consider whether temperamental differences might contribute to the different manifestations of reactive attachment disorder (RAD) in the context of adverse environments. Although the association between attachment and temperament has been studied extensively and has been the subject of spirited debate within the field of child development, there are no extant data on the influence of temperament on the development of attachment disorders. We consider possible directions for research efforts designed to explore the biological underpinnings of the complex phenomenon of attachment disorders.
Adolescent↗
Child abuse and neglect in infancy: sources of hostility within the parent-infant dyad and disorders of attachment in infancy.
The human infant is prepared during fetal life and arrives on the scene ready to participate actively as a partner with the parent in structuring his own development. Parents are normally prepared for this participant activity by achieving a high degree of sensitivity to the signals of distress of and by the infant's affective engagement with them. The meaning of ordinary distress signals is in instances of child abuse and neglect determined by an unconscious mythology which the parent has about the infant, and also by what the parent finds unacceptable in oneself and projects onto the infant. The recent research on mother-infant attachment is reviewed. Landmarks for normal attachment behaviors from birth to age 3 are defined within seven different age groupings, and the psychiatric syndrome, "Reactive Attachment Disorder of Infancy," is described and is found almost universally in failure to thrive without organic cause babies. The diagnosis of Reactive Attachment Disorder is preferable because it leads to appropriate preventive and interventive action.
Adult↗
Clarifying core characteristics of attachment disorders: a review of current research and theory.
Reactive attachment disorder is a relatively new diagnosis that is not well studied. Conflicting ideas about its etiology and presentation pervade the theoretical, research, clinical, and popular literature. Clarifying core characteristics of this disorder and distinguishing them from comorbid conditions are critical for improved diagnosis and treatment of children with attachment problems.
Child↗
Attachment disturbances in young children. II: Indiscriminate behavior and institutional care.
OBJECTIVE: To assess convergence among three different measures of indiscriminate behavior and to assess the relationship of indiscriminate behavior to having an attachment figure and to aggressive behavior among young children living in a Romanian institution. METHOD: Caregivers in the institution were interviewed with semistructured interviews regarding the behavior of 61 children with special emphasis on indiscriminate behavior. The study was conducted in Bucharest, Romania (1999). RESULTS: Substantial convergence among measures of indiscriminate behavior was demonstrated. Indiscriminate behavior was common whether or not these children had a preferred attachment figure. Indiscriminate behavior was independent of aggressive behavior. CONCLUSIONS: Differing explanations for indiscriminate behavior in young children derive from differing interpretations of similar findings rather than different findings with different measures. Indiscriminate behavior was largely independent of aggression in these institutionalized young children. Indiscriminate behavior may represent an independent problem rather than a type of reactive attachment disorder as suggested by DSM-IV criteria.
Aggression↗
Behavioural psychopathology of child sexual abuse in schoolgirls referred to a tertiary centre: a North London study.
The sexually abused girls in this study were a sub-sample of a group of girls referred to a Regional Centre for Psychotherapy for the whole of London, North Thames. An inclusion criterion was that they were psychologically symptomatic and so it is likely that they were more problematic cases causing concern in their locality. The control clinical group consisted of referrals to local Child and Family consultation services, were an opt-in matched sample and not a total clinic referral sample. In addition, the reasons for referral covered both child disorder and family problems. It is, therefore, important to bear in mind the differences between these two groups. Certain clear cut findings have emerged from this study. No disorders specific to child sexual abuse in girls were identified but the extent and severity of the disturbance in the sexually abused sample was most striking. In these girls an event (CSA), together with referral because of emotional symptoms, was associated with enhanced severity of disorder and comorbidity particularly with reference to a cluster of disorders comprising post-traumatic stress disorder, depressive disorder, anxiety disorders (general and separation), social phobias and reactive attachment disorder. In the community clinic sample the identified disorders were mainly those of separation anxiety disorders and adjustment. Wide comorbidity was common in the sexual abuse sample and also severity of impairment was notable when compared to the clinic sample. However, because of the selected nature of the abuse group the findings are not generalisable beyond the population from which they emerged. The view is advanced that there are strong grounds for exploring the utility of psychodynamic psychotherapy in similar samples of sexually abused girls. These findings are discussed in the light of the current literature.
Adolescent↗
Clinical disturbances of attachment in infancy and early childhood.
The development of the attachment behavioral system in infancy has been the focus of a wide range of research in the past 30 years. The clinical significance of disturbances in this area of development is currently a major focus for this research. Research on patterns of attachment in infancy has informed understanding of the development of psychopathology in later childhood; insecure-disorganized attachment is recognized as an important risk factor in this regard. The clinical features of reactive attachment disorder in early childhood are also becoming more clear. Finally, knowledge about the intersection between attachment and various risk conditions is growing and should inform clinical judgement about infants and young children requiring intervention. Primary care physicians can use these findings to identify children in need of intervention.
Child, Preschool↗
Predicting level of mental health care among children served in a delivery system in a rural state.
The purpose of this study was to establish benchmark data to assist in identifying factors associated with mental health service needs and level of care for children living in a rural state. Clinical and psycho-social needs and strengths were assessed using retrospective chart review for all children and adolescents (n=150) with symptoms or a diagnosis of reactive attachment disorder who presented to a comprehensive treatment facility between January 1997 and December 1999. Logistic regression was used to predict factors associated with inpatient admission (n=15) vs. community-based care (n=135). Significant individual contributors to the prediction of inpatient care were more limited clinical/psycho-social strengths, history of inpatient use and history of sexual abuse. Although 80 percent of children admitted to inpatient care had a history of hospitalization, two-thirds had no history of receiving community-based services and presented to current treatment with a two-year or longer history of symptoms. Approximately two-thirds of children admitted to inpatient care had a history of sexual abuse; however, one-third of these children had no history of mental health service use and presented to current treatment with a two-year or longer history of symptoms. Findings raise concerns about current efforts in public health education, community awareness and health prevention and early intervention programs for children with mental/behavioral health challenges and children and families at risk for abuse and/or neglect living in rural areas.
Adolescent↗
Disturbances of attachment in young children adopted from institutions.
In this article, the author describes a discrepancy between popular media accounts of reactive attachment disorder (RAD) and its clinical and scientific description. The literature on serious disturbances of attachment in children adopted out of institutions is reviewed. The author concludes that children adopted from institutions are at dramatically increased risk for disturbances, although the majority of such children do not demonstrate problems. Both the duration of deprivation and the postinstitutional caregiving environment seem to be importantly related to outcome. Inhibited/withdrawn RAD is exceedingly uncommon in children adopted from institutions (at least after 1 or more years), but disinhibited/indiscriminate RAD is quite persistent. Long after children become attached to adoptive parents, a number of them continue to exhibit indiscriminate sociability. Three explanations for this divergence of recovery curves are considered. It is likely that future systematic studies will illuminate many areas that are unclear at this time.
Adaptation, Psychological↗
Thinking about children's attachments.
Disordered parental attachment can commit children to lives characterised by relationship difficulties, behaviour problems, educational failure, and poor self-esteem. It is a major root of trans-generational neglect and abuse and frequently underlies mental health problems, drug and alcohol addiction, homelessness, and crime. Early childhood setting of hypothalamus-pituitary-adrenal axis function appears to contribute to these costly difficulties. More broadly, the concept of attachment can contribute to defining and managing the psychosocial dimension of routine paediatric care. The current under-representation of attachment in paediatric education, practice, and research needs to be rectified.
Adaptation, Psychological↗
[Children aged 0-3 years referred to child psychiatric department. A descriptive epidemiological study].
INTRODUCTION: In a Danish register study the incidence of children aged 0-3 years referred to child psychiatric services in Denmark increased by 30% during 1996-1998. The objective of this study was to further describe 0-3 year-old children referred to child psychiatric departments with a view to distribution of diagnoses, age, sex, and parental mental illness. MATERIAL AND METHODS: Children 0-3 years of age referred to child psychiatric departments in the County of Copenhagen in 1998 and 1999 were described on the basis of the clinical database and hospital records. RESULTS: A total of 159 children were admitted over a two-year period corresponding to an incidence of 0.4%. The ratio boys: girls were 1.3:1. However, with regard to pervasive developmental disorders boys dominated 6:1. Among girls, eating disorders were dominating in the youngest children with ratio girls: boys 5:2. Pervasive developmental disorders were the most common diagnoses in children aged 2-3 years, and the overall incidence of this diagnosis was 0.25 per 1000 per year. The most common diagnosis of the youngest children was Z-diagnoses, and most often these children had mentally ill parents. Attachment disorders, eating disorders, and adjustment reactions were common diagnoses in children with mentally ill parents, but more than half of these children did not have any diagnosis at all. DISCUSSION: The incidence of children with pervasive developmental disorder was found twice as high as observed in a register study covering referrals of children aged 0-3 years from all psychiatric departments in Denmark during 1996-1998. Reactive attachment disorder, eating and adjustment disorder, and Z-diagnosis are the most common diagnoses in the youngest children, and most often these children have mentally ill parents.
Child Development Disorders, Pervasive↗
Rorschach correlates of self-reported attachment dimensions: dynamic manifestations of hyperactivating and deactivating strategies.
We examined associations between self-reported attachment anxiety and avoidance and responses to the Rorschach test. Seventy-two, nonpatient Israeli adults participated in a 2-session study. In the first session, they completed a self-report scale tapping the dimensions of attachment anxiety and attachment avoidance. In the second session, they completed the Rorschach test. The Rorschach was administered and coded according to Exner's (2001) Comprehensive System scoring. We found that self-reports of attachment anxiety were associated with Rorschach scores thought to indicate difficulties in regulating and controlling emotions and self-perceptions of being relatively helpless and unworthy. Self-reports of attachment avoidance were associated with Rorschach scores thought to reflect lack of acknowledgment of need states and maintenance of a grandiose self. We discuss the findings in terms of implicit psychodynamic processes inherent in attachment-system functioning.
Expressed Emotion↗
The differential diagnosis of impaired reciprocal social interaction in children: a review of disorders.
Impairment in reciprocal social interaction in children that is less severe than autism can be difficult to diagnose due to the variety of developmental pathways that may lead to this problem. Seven childhood disorders are reviewed that include impaired reciprocal interaction: multisystem developmental disorder, nonverbal learning disability syndrome, semantic-pragmatic disorder, attachment disorders (including a developmental theory of limbic system damage), multiplex developmental disorder, schizoid personality disorder, and pervasive developmental disorder not otherwise specified. Clarification is needed for most of the disorders in the areas of operationalized criteria, assessment tools, and documenting causal relationships.
Child↗
Infantile depression, nonorganic failure to thrive, and DSM-III-R: a different perspective.
A controversy exists regarding the classification of nonorganic failure to thrive within the psychiatric nomenclature. There are a number of DSM-III-R diagnoses that may be applied to NOFTT, including Reactive Attachment Disorder of Infancy (RADI) and Major Depressive Disorder (MDD). The behaviors characteristic of NOFTT are symptomatic of depression, and are similar to those exhibited by infants with anaclitic depression as well as those of the adult with depression. The correspondence of the behaviors of NOFTT and the DSM-III-R criteria for Major Depression are reviewed, as are the conceptual and therapeutic reasons to view NOFTT infants as suffering from Depression.
Adult↗
Children in foster care: mental health, service use and costs.
OBJECTIVE: To assess the prevalence of mental health problems in children in foster care, their families' use of services and the associated costs. METHODS: Information on mental health problems, service use and costs was collected, by postal questionnaires and home interviews, on 182 children, their foster carers and teachers from 17 local authorities in Central Scotland. RESULTS: Over 90% of the children had previously been abused or neglected and 60 % had evidence of mental health problems including conduct problems, emotional problems, hyperactivity and problems with peer relations. When compared with 251 children from local schools, the children in foster care had significantly higher symptom scores for Reactive Attachment Disorder. Those children with highest scores for mental health problems were attracting a high level of service support from a wide range of agencies, except Child and Adolescent Mental Health Services (CAMHS). Costs were associated with learning disability, mental health problems, and a history of residential care. CONCLUSIONS: Children in "mainstream" foster care are at greater risk of mental health problems, and are attracting greatest costs, but CAMHS are not successfully targeting these problems. CAMHS may need to develop new models of service delivery.
Adolescent↗
Inhibition of GH in maternal separation may be mediated through altered serotonergic activity at 5-HT2A and 5-HT2C receptors.
The hyposecretion of growth hormone (GH) in maternal separation (MS) of rat pups is remarkably similar to the specific suppression of GH secretion to evocative tests in infants diagnosed with Reactive Attachment Disorder of Infancy (RADI). Growth hormone-releasing factor (GRF) and somatostatin (SS) provide opposing regulation of GH secretion, and both are modified by noradrenergic and serotonergic stimuli in neonatal and adult rats. In this study, GRF administration reversed MS-induced suppression of GH secretion in 10-day-old pups, but this action of GRF was prevented by pretreatment with cyproheptadine (Cypro), a serotonergic antagonist. The normalization of GH secretion after return to the dam was not altered by pretreatment with SS. Indirect 5-HT agonists, fluoxetine (FLX) and 5-HTP, both stimulated GH secretion in 10-day-old pups. All mixed serotonin- and 5-HT1A-receptor agonists suppressed GH secretion in 10-day-old pups. Antagonists Cypro and ketanserin (Ket) suppressed FLX-induced GH secretion. In contrast, only Cypro suppressed 5-HTP-induced GH secretion. Maternal separation inhibited GH secretion stimulated by 5-HTP, but not by FLX. The serotonergic pathway acting on 5-HT2A receptors may be obligatory for GRF-mediated stimulation and is sensitive to inhibition by Cypro. In addition, a Ket-sensitive serotonergic parallel pathway acting on 5-HT2C receptors may also stimulate GH secretion by acting on GRF or SS. However, only the obligate 5-HT2A pathway appears to be suppressed in MS. These data and observations by others indicate that specific suppression of GH secretion in MS may derive from a reduction in GRF release through noradrenergic neurons, possibly impinging upon serotonergic terminals in the hypothalamus. This study may also provide insight into mechanisms by which GH secretion is suppressed in humans with RADI.
Animals↗