Running Head: REACTIVE ATTACHMENT DISORODER

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Reactive Attachment Disorder
Chalese Meer
!niversit o" !tah
REACTIVE ATTACHMENT DISORODER
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A#stract
The $ur$ose o" this literature revie% is to introduce readers to the disorder& etiolog& $revalence
rates& recommended treatment& and a$$ro$riate interventions "or the Recreational Thera$ist'
Child a#use and neglect a""ects the lives o" man American children and can result in $hsical
in(ur and disa#ilit as %ell as $schological trauma' Reactive attachment disorder )RAD* is
one $ossi#le $schological conse+uence o" child a#use and neglect "or ver oung children&
ounger than , ears o" age' RAD is descri#ed as mar-edl distur#ed and develo$mentall
ina$$ro$riate social relatedness usuall #eginning #e"ore age , ears )Hornor ./01./2*'
3urthermore& a child needs to "eel loved& %anted and cared "or or else sever health conse+uences
can occur leaving the child %ith reactive attachment disorder that can a""ect him4her throughout
their lives'
Keywords: In"ant& Adolescent& Attachment& Theor& Negligent& Detach& Child A#use
REACTIVE ATTACHMENT DISORODER
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Overvie%4Etiolog
In reactive attachment disorder )RAD* the normal #ond #et%een in"ant and $arent is not
esta#lished or is #ro-en' In"ants normall 5#ond5 or "orm an emotional attachment& to a $arent
or other caregiver # the eighth month o" li"e' 6 this age the #ecome easil distressed i"
se$arated "rom these caregivers "or even a "e% hours& even i" another "amiliar $erson is $resent'
I" this #onding $rocess is inter"ered %ith& it can have severe emotional and $hsical
conse+uences "or the child' It most commonl a""ects the child a#ilit to interact normall %ith
others& and the child ma have severe emotional and social $ro#lems that e7tend into adulthood'
There ma #e learning $ro#lems and $hsical $ro#lems such as slo% gro%th and "ailure to
develo$ as e7$ected'
To #etter understand RAD& it is "irst necessar to understand attachment and the theories
associated' Attachment is de"ined as the organi8ation o" #ehaviors in the oung child that are
designed to achieve $hsical closeness to a $re"erred caregiver at times %hen the child see-s
com"ort& su$$ort& nurturance& or $rotection )American Academ o" Child and Adolescent
9schiatr& .::,*' RAD is a DSM1IV1TR diagnosis descri#ed as mar-edl distur#ed and
develo$mentall ina$$ro$riate social relatedness usuall #eginning #e"ore age , ears )American
9schiatric Association )A9A*& .:::*'
The develo$ment o" secure attachment relationshi$s is essential to an individual;s mental health'
Attachment relationshi$s $rovide the "rame%or- "or the "ormation o" an individual;s
sense o" sel" and others that guide their emotional and #ehavioral reactions and set the
course to%ard inter$ersonal com$etence or incom$etence )9oehlmann& .::,*' 6o%l#
)<2=2* "irst utili8ed the term >attachment? to re"er to a secure $hase "ormulation o" in"ant
caregiver relationshi$s' 9rotection& sa"et& and securit are held among the most #asic o"
REACTIVE ATTACHMENT DISORODER
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human needs )Cummings& Schermerhorn& Davies& @oe-e1More& A Cummings& .::=*'
To achieve a health attachment a caregiver should #e nurturing& loving& su$$ortive&
loal& consistent& and $atient' This should #e ver sim$le and natural #ehaviors "or a
$arent to dis$la& #ut un"ortunatel not all $arents are cut out to #e $arents' Hales et al'
)<222* descri#ed man things can inter"ere %ith the #onding $rocess:
Boss o" $arents' The most common cause o" reactive attachment disorder is #eing
or$haned or $ut in "oster care at a ver earl age' The in"ant ma receive care "rom man
$eo$le or #e moved "rom $lace to $lace o"ten' A #ond to a single consistent caregiver
cannot #e "ormed'
Neglect or im$aired caregiving' I" the in"ant is not cared "or consistentl& it %ill not learn
to trust' This includes emotional neglect& %here the caregivers ma -ee$ the #a# clean
and "ed& #ut do not allo% time "or $la and #onding' Ver o"ten this occurs %hen the
$arent or caregiver has a $ro#lem that $revents him or her "rom giving ade+uate&
consistent attention to the in"ant' Such $ro#lems include ma(or de$ression& $schosis&
drug or alcohol a#use& mental retardation& $hsical illness& and $overt' The $arent ma
also have #een a neglected child or ma #e ver oung themselves and sim$l not -no%
ho% to $arent ade+uatel'
A#use or $ain' Even i" an in"ant is getting love and attention some o" the time& it ma not
learn to attach i" it comes to e7$ect $ain on occasion "rom the caregiver' Illness or $ain
that the caregiver cannot ease can have the same e""ect'
9revalence4 Mortalit Rate
REACTIVE ATTACHMENT DISORODER
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It is ver di""icult to measure the $revalence o" RADC Richters and Vol-mar )<220*
estimated the $revalence to #e less than <D o" the general $o$ulation' Ho%ever& studies that
have selected high1ris- $o$ulations have "ound a much higher $revalence' Eeanah and Emde
)<220* retros$ectivel studied all children "rom one !'S' Count %ho entered "oster care
#ecause o" child a#use and neglect #e"ore age 0 ears and /FD o" the children had signs o" RAD
according to DSM1IV criteria' Eeanah and Emde )<220* "ound signs o" attachment disorders to
#e +uite common in maltreated toddlers and that a signi"icant minorit ma have clinical
disorders o" attachment' 3urthermore& children %ho have #een ado$ted and4or raised in
institutions have a much higher ris- o" develo$ing RAD'
Risk factors for
the development of
reactive attachment
disorder
9athogenic care as a result o":
9hsical a#use
Se7ual a#use
Neglect
9arental alcoholism
9arental drug use
9arental mental illness
A#sence o" consistent $rimar
caregiver:
Child
institutionali8ed4or$hanage
3oster care
Maternal4$arental
incarceration
9arental a#andonment
3rom Hornor ./01./2
Treatment
Boving and ca$a#le caregivers $rovide the core o" %hat is needed to hel$ children %ith a
Reactive Attachment Disorder #egin their recover' In such cases& $ro"essional treatment is
necessar' There is no singularl use"ul thera$ "or hel$ing Reactive Attachment Disordered
REACTIVE ATTACHMENT DISORODER
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children recover' Instead& a com#ination o" thera$ a$$roaches ma #e recommended' 9ossi#le
treatments ma include the "ollo%ing: $schoeducational a$$roaches& "amil thera$& individual
thera$& cognitive #ehavioral thera$& and recreational thera$' 6ar-ou-is et al' ).:</* descri#ed
these various $ossi#le treatments "or a childGs Reactive Attachment Disorder "ocus on enhancing
the childGs a$$ro$riate attachment relationshi$s& discouraging ina$$ro$riate4unsa"e attachment
#ehavior& hel$ing to $romote harmonious relationshi$s %ithin the "amil as a %hole& and
increasing the childGs availa#le social su$$orts' The goal o" these interventions is to encourage
the child to develo$ trust in the $ossi#ilit o" consistent loving and sa"e relationshi$sC an
outcome that vastl increases their a#ilit to develo$ a$$ro$riate $eer and romantic relationshi$s
and to $artici$ate in the adult social %orld the %ill one da inha#it'
There is no medication to treat RAD itsel"' Ho%ever& the doctor ma use medication i"
the child has severe sm$toms& such as e7$losive anger or $ro#lems slee$ing' Essentiall
treatment o" RAD has t%o im$ortant goals' The "irst is to ensure that the child is in a sa"e
environment' This is es$eciall im$ortant in cases %here the child has #een a#used or neglected'
The second goal is to hel$ the child develo$ a health relationshi$ %ith an a$$ro$riate caregiver
)@old#erg& .:<.*'
RT Interventions
Although Recreational Thera$ist %ill not #e ma-ing diagnosis "or their $atients it is
im$ortant "or them to #e a#le to identi" the signs and sm$toms o" RAD and ho% to $ro$erl
address the disorder' 9ersons %ith reactive attachment disorder #ene"it "rom a variet o"
activities and interventions' S$eci"icall the recreational thera$ist %or-s %ith the individuals to
im$rove team%or-& communication& trust& service and setting and achieving goals' Individuals
%ith RAD also #ene"it "rom adventure #ased outings such as roc- clim#ing& canoeing& "l
REACTIVE ATTACHMENT DISORODER
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"ishing& %a-e#oarding& and triathlon training' These recreation thera$ interventions are
designed to give teens %ith reactive attachment disorder an o$$ortunit to s$read their %ings
%ithin a su$$ortive environment' During these adventure activities& students are encouraged to
develo$ "riendshi$s and tal- %ith each other'
Recreational thera$ encom$asses man di""erent activities and interventions to
challenge adolescents in e7$eriencing ne% things' Ro$es course interventions are designed to
esta#lish trust& #ut can #e di""icult "or teens and adolescents %ith reactive attachment disorder'
The intervention hel$s adolescents test their #oundaries in "un& sa"e %a %hile #uilding
team%or-' Creative arts )dra%ing& $ainting& ceramics& and music etc'* are essential "or
individuals %ith RAD to o$enl share their emotions and ideas' O"ten& students #ecome more
o$en to creating lasting and meaning"ul attachment %hen the o$en themselves u$ creativel'
Adventure #ased outing tend to hel$ individuals e7$erience humilit and vulnera#ilit in a
$ositive %a& %hile "ocusing on letting do%n their guards and let others in' 6 the
encouragement o" $ushing #eond limitations and unloc-ing "ears in a "un and sa"e %a& $eo$le
%ith RAD %ill #e a#le to ma-e the connection #et%een health and interactive relationshi$s'
Conclusion
Child a#use and neglect is a $ervasive $ro#lem in our societ' In .::/& Child 9rotective
Services received / million re$orts o" sus$ected child a#use and neglect regarding the %el"are o"
,', million children )!'S' De$artment o" Health and Human Services& .::0*' RAD can easil #e
$revented %ith nurturing& love& good care& esta#lish trust& and health $arent #oding' It is
im$ortant to -no% that %ithout treatment RAD can have a negative im$act on a childGs $hsical&
emotional& #ehavioral& social& and moral develo$ment' Children %ith RAD generall are at
REACTIVE ATTACHMENT DISORODER
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higher ris- "or de$ression& aggressive and4or disru$tive #ehavior& learning di""iculties and
#ehavior $ro#lems in school& ina#ilit to "orm meaning"ul relationshi$s& and lo% sel"1esteem'
Ho%ever& %ith treatment& it is $ossi#le "or children %ith RAD to learn to trust others& and to lead
health and $roductive lives'
REACTIVE ATTACHMENT DISORODER
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A$$endi7 I
Classi"ication:
Changes to Reactive Attachment Disorder in DSM1,
No% s$lit into t%o disorders& #ased on DSM1IV su#t$es'
o Reactive attachment disorder
o Disinhi#ited social engagement disorder'
A9A: >6oth o" these disorders are the result o" social neglect or other situations that limit
a oung child;s o$$ortunit to "orm selective attachments' Although sharing this
etiological $ath%a& the t%o disorders di""er in im$ortant %as'?
A9A: Reactive attachment disorder more >closel resem#les internali8ing disordersC it is
essentiall e+uivalent to a lac- o" or incom$letel "ormed $re"erred attachments to
caregiving adults'? There is a dam$ened $ositive a""ectH
Characteri8ed #:
o Emotionall %ithdra%n #ehavior
o Social4emotional distur#ance
o E7$osure to e7tremes o" insu""icient care
o Social neglect4de$rivation& re$eated changes in caregivers& rearing in unusual
settings
REACTIVE ATTACHMENT DISORODER
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Diagnostic criteria for 313.89 Reactive Attachment Disorder of Infancy or Early Childhood
Criteria
A' A consistent $attern o" inhi#ited& emotionall %ithdra%n #ehavior to%ard adult caregivers&
mani"ested # #oth o" the "ollo%ing:
<' The child rarel or minimall see-s com"ort %hen distressed'
.' The child rarel or minimall res$onds to com"ort %hen distressed'
6' A $ersistent social or emotional distur#ance characteri8ed # at least t%o o" the "ollo%ing:
<' Minimal social and emotional res$onsiveness to others
.' Bimited $ositive a""ect
E$isodes o" une7$lained irrita#ilit& sadness& or "ear"ulness that is evident even during
nonthreatening interactions %ith adult caregivers'
C' The child has e7$erienced a $attern o" e7tremes o" insu""icient care as evidenced # at least
one o" the "ollo%ing:
<' Social neglect or de$rivation in the "orm o" $ersistent lac- o" having #asic emotional
needs "or com"ort& stimulation and a""ection met # caring adults
.' Re$eated changes o" $rimar caregivers that limit o$$ortunities to "orm sta#le
attachments )e'g'& "re+uent changes in "oster care*
/' Rearing in unusual settings that severel limit o$$ortunities to "orm selective attachments
)e'g'& institutions %ith high child to caregiver ratios*
D' The care in Criterion C is $resumed to #e res$onsi#le "or the distur#ed #ehavior in Criterion A
)e'g'& the distur#ances in Criterion A #egan "ollo%ing the lac- o" ade+uate care in Criterion C*'
E' The criteria are not met "or autism s$ectrum disorder'
REACTIVE ATTACHMENT DISORODER
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3' The distur#ance is evident #e"ore age , ears'
@' The child has a develo$mental age o" at least nine months'
Note:
Specify i" ersistent: The disorder has #een $resent "or more than <. months'
Specify current severit: Reactive Attachment Disorder is s$eci"ied as severe %hen a child
e7hi#its all sm$toms o" the disorder& %ith each sm$tom mani"esting at relativel high levels'
Ada$ted "rom American 9schiatric Association: Diagnostic and Statistical Manual o" Mental
Disorders& ,th ed& te7t rev Arlington& VA'& American 9schiatric Association& .:</'
REACTIVE ATTACHMENT DISORODER
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Re"erences
American Academ o" Child and Adolescent 9schiatr' ).::,*' 9ractice $arameter "or the
assessment and treatment o" children and adolescents %ith reactive attachment disorder'
Journal of the American Academy of Child & Adolescent Psychiatry& 44, <.:=1<.<2'
American 9schiatric Association' ).:</*' Diagnostic and statistical manual of mental disorders
),th ed'*' Arlington& VA: American 9schiatric 9u#lishing'
American 9schiatric Association' ).:::*' Diagnostic and statistical manual of mental disorders
)0th ed'& te7t rev'*' Iashington& DC: Author'
6ar-ou-is& A'& Reiss& N' S'& A Dom#ec-& M' )n'd'*' Reactive Attachment Disorder Assessment
and Treatment 1 Childhood Mental Disorders and Illnesses' eacti!e Attachment
Disorder Assessment and "reatment # Childhood $ental Disorders and %llnesses'
Retrieved Ma .2& .:<0& "rom htt$:44%%%'grace$oint%ellness'org4/J1childhood1mental1
disorders1and1illnesses4article4<0,<<1reactive1attachment1disorder1assessment1and1
treatment
Cummings& E' M'& Schermerhorn& A' C'& Davies& 9' T'& @oe-e1More& M' C'& A Cummings& K' S'
).::=*' Inter$arental discord and child ad(ustment: 9ros$ective investigations o"
emotional securit as an e7$lanator mechanism' Child De!elopment& &&, </.1<,.'
@old#erg& K' ).:<.& Ma /<*' Reactive Attachment Disorder' 'e($D ))C' Retrieved Ma .J&
.:<0& "rom htt$:44%%%'%e#md'com4mental1health4mental1health1reactive1attachment1
disorder'
REACTIVE ATTACHMENT DISORODER
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Hales Robert E., Stuart C.Yudofsk, a!d "o#! $. %albott, eds. Textbook of Psychiatry.
3rd ed. &as#'!(to! )C* $+er',a! -s,#'atr', -ress, 1999.
Hornor& @' ).::F*' Reactive Attachment Disorder' Journal of Pediatric *ealth Care& ++)0*& ./01
./2'
9oehlmann& K' ).::,*' Re$resentations o" attachment relationshi$s in children o" incarcerated
mothers' Child De!elopment& &,, =J21=2='
Richters& M' M'& A Vol-mar& 3' R' )<220*' Reactive attachment disorder o" in"anc and earl
childhood' Journal of Child & Adolescent Psychiatry& --, /.F1//.'
!'S' De$artment o" Health and Human Services& Administration "or Children and 3amilies'
).::0*' Child $altreatment +..4/ Iashington& DC: @overnment 9rinting O""ice'