The Adopted Child's Inability to Form Relationships
Reactive Attachment Disorder: A Disorder of Attachment or of Temperament?
Maureen E. Wood Rochester Institute of Technology
Reactive attachment disorder (RAD) is one of the few disorders listed in theDSM-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).
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).
Review of Reactive Attachment Disorder
Overview of Attachment TheoryBowlby'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 RADThe 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 SubtypeThe 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 SymptomsThe 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 RADReactive 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.
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.
Attachment or Temperament?
Criticism of the Current Conceptualization of RADStafford 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 TemperamentTemperament 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 TemperamentZeanah 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 theDSM-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.
It seems that there should be difficulty in assessing Reactive Attachment Disorder (RAD) because attachment theory itself may be flawed. There is no way of telling whether the symptoms of RAD are the result of the attachment style or of the child's genetic behavioral disposition. Those trying to diagnose RAD have the assumption that the parent-child relationship actually does influence attachment style.
Can We Use Attachment Theory as a Basis for This "Attachment Disorder"?Joshua C. Balduf
Rochester Institute of Technology
The difficulties experienced in trying to conceptualize RAD may be because there is no way of linking the symptoms with their cause. RAD may not be an attachment disorder because the symptoms described may result from the child's genetic composition. The sensitive or insensitive treatment by the parents during infancy may not even play a role in the child's development of RAD. It may be merely be a behavior resulting primarily from genetic dispositions.
If it is the case that the symptoms described in the DSM are not caused by attachment then RAD would not be an attachment disorder but just a genetic result of personality. There should be consideration of how genes and the treatment of the primary care giver interact. The methods of genetic transmission should be looked at in more detail if we are even to consider RAD an attachment disorder.
There are three models of genetic transmission that can occur (Reiss, 1997). If two of these models are true then this would mean that attachment theory cannot work and RAD would be the result of genetic behaviors and not an attachment disorder. The three models of genetic transmission are briefly described below.
First is the passive model. In the passive model of transmission the genes that influence the parent's sensitivity are passed down to the child. Those same genes are responsible for the child's attachment style. The genes are the reason for both occurrences and attachment style is not caused by the parent's sensitivity. The tendency for the parent to be sensitive to the child is because of their genes and not the environment. The attachment style of the child is because of genes and not because of the parent's treatment of the child. The sensitivity of the parent and the attachment style of the child are completely independent.
Second is the child-effects model. In this model the child's attachment style is caused by genes. It is then the child's attachment style that causes the parent to be sensitive or insensitive. In this model the parent's sensitivity is caused by the child but the child's attachment style is still due to their genetic composition. The child's attachment style is the result of purely genetics the parents sensitivity is only a response to the child's attachment style. Therefore the child causes the parents sensitivity but this does not have any influence on the child's attachment style.
Third is the parent-effects model. In this model the child's behavior is caused by their genes. The child's behavior causes the parent to act either sensitive or insensitive. This in turn will influence what attachment style the child will have. The child's behavior is cause by their genetics but their attachment style is not. The child's behavior evokes the sensitive attitude from the parent. The sensitivity of the parent does determine what the child's attachment style is. This is the only model that allows a parents behavior to mold a child's attachment style and is the only possibility for attachment theory.
Because there are three different ways genetics and sensitive responding by the parents can result in attachment style, it is uncertain which model is accurate. The cause of RAD is theoretically the result of a disruption of the attachment process. There is much debate as to whether the attachment process even has an effect on personality.
The symptoms observed may be the result of genes. This may lead us to believe that RAD is not an attachment disorder at all. Its symptoms are possibly caused by other sources than childhood attachment and it may be false to label RAD as an "attachment disorder." There is poor evidence supporting that attachment is the true cause of RAD.
The difficulties in conceptualization of RAD are because its causes are uncertain. It may not be feasible to diagnose RAD because we are unsure of its true cause. It may be false to classify a disorder with little understanding of the concept and evidence that is inconclusive. The DSM may be presumptuous its definition of RAD.
It is obvious from Wood's analysis that reactive attachment disorder manifests itself during the infancy. But what separates these infants when they are older from the rest of us? How do their relationships and development differ from ours?
Attachment Style and Academics: Effects of Ractive Attachment DisorderKathryn M. Howard
Rochester Institute of Technology
A child who has a secure attachment style will explore more of the surrounding world. The child has the confidence that someone will be there to protect him or her if a threat arises during exploration. As Wood stated, children suffering from RAD do not have a secure attachment style and do not freely explore their world, as they are afraid no one will be there for them.
Larose, Bernier, and Tarabulsy (2004) set out to answer those questions. Sixty-two college students were interviewed and the relation between their attachment style, learning dispositions, and academic performance during the transition to college were evaluated. Toddlers with insecure attachments are less enthusiastic, less effective, and show less endurance during a challenging task than secure toddlers (Larose et al., 2004). In previous studies, infants with secure attachments had better academic performance during adolescence, children who were securely attached at age 7 got higher school grades than insecure children from ages 7 to 17, and an insecure attachment style was related to a drop in school marks during the transition from high school to college.
The findings of the Larose et al. (2004) study indicated that secure attachment style protects the student against the negative impact the college transition has on learning style. The results varied based on the type of insecurity. For example, securely attached students experienced more fear of failure at the middle of the first semester in college than at the end of high school, felt less comfortable seeking help from teachers, and gave less priority to their studies. Additionally, insecurely attached students had a decrease in exam preparation and quality of attention. The qualities that pertain to securely attached students relate to emotional and social components, whereas those that pertain to insecurely attached students relate to practical, school-related behaviors.
To summarize the findings, the security of attachment in late adolescence favors security of exploration by providing the student with emotional, cognitive, and behavioral resources that have been shown to favor college success. Students with a more secure attachment style have more characteristics that favor college success than students with an insecure attachment style. To further support this, Larose et al. (2004) found that students with an insecure attachment style had lower grades throughout the first three college semesters.
The Larose et al. (2004) study illustrates how not only the future relationships of an infant with RAD are affected, but also how academic performance is affected in college. The study did not focus on children suffering from RAD specifically, but rather children who were insecurely attached for any reason. Because infants who suffer from RAD are insecurely attached, it can be inferred that RAD in infants predicts poor academic performance in future years.
In "Reactive Attachment Disorder: A Disorder of Attachment or of Temperament?" Wood raised many valid arguments for this new disorder, which is not yet completely understood. The disorder itself is new and is fairly undefined. It is generally difficult to diagnose infants and gage whether or not their behaviors are abnormal. Unlike older people, infants cannot report to the psychologist (or whomever) if they believe that they are experiencing symptoms of RAD. Moreover, maladaptive caretaking can be very difficult to detect or control.
How Valid Is Reactive Attachment Disorder?Helen Huang
Rochester Institute of Technology
Both the DSM-IV and ICD-10's criteria for the disorder are vague and do not draw definite--or even moderately clear--distinctions for when infants' behavior crosses from normal to abnormal. Not only are the criteria for RAD vague, but also they are subjective. The infant clearly cannot state whether he or she experiences symptoms such as a "lack of comfort seeking for distress," "emotion regulation difficulties," or " a willingness to go off with relative strangers," to name a few. The paper also addresses the issue of the temperament of the child and its relation to RAD. What may seem like RAD may have nothing to do with possible abuse, but may be just part of the child's natural temperament. Some children who naturally possess more difficult temperaments may show signs of RAD. The vague criteria can lead to false diagnoses, such as in cases of hypersensitive caretakers or children who originally possess more problematic temperaments. Moreover, given that the diagnosis for RAD includes the presence of a maladaptive caregiver, if a child develops symptoms that are characteristic of RAD but has not suffered any form of abuse, what diagnosis would the child receive?
I was also confused as whether RAD is an infant disorder or a childhood disorder that can be applied to children starting as early as infancy. The behavorial symptoms (some of which apparently include cruelty to animals and other people, destruction of property, gorging on food, abnormal speech patterns, inappropriate sexual behavior) are very hard for infants to perform, so I assume that RAD is not merely a disorder of infancy but also of childhood. Does RAD only develop in infancy, or is infancy merely the typical time of onset? Can RAD develop after infancy, in older children, or even adolescence? It would be interesting to see whether gender plays a role in the development of RAD.
The paper stated that RAD is based on the inability of children to form normal attachments but does not specify whether the children have difficulty forming attachment exclusively with their primary caretaker or if the difficulty extends to the other family members and peers as well. The paper also did not specify if the child is unable to form normal attachments only in relation to the maladaptive caregiver, all other caregivers and family members, or with whomever else they come in contact on a regular basis.
Another loophole of this paper was the lack of discussion pertaining to treatments or therapies. Treatment is a very important aspect, and it was odd that such an important part of psychology was almost completely excluded from the paper. There was also no mention of possible hereditary or genetic influences, which are also very important and would give great insight to the disorder.
The limitations of this paper, though, may not have been Wood's fault. Because RAD is a new disorder, perhaps the literature on RAD just does not cover aspects such as treatment, heredity, prevalence, gender, or age of onset. I think that RAD, as a disorder, needs to undergo much more research to be understood as a valid disorder. Though the nature of this disorder makes it difficult to study, perhaps future classification modifications and research will give more concrete insight into this new disorder.
"Reactive Attachment Disorder: A Disorder of Attachment or of Temperament?" provided an interesting view of RAD summarized by its analogy to the diathesis-stress model. The focal point of the relatively small amount of research on RAD is, in most cases, on infants and young children. This paper mentioned a question raised by Zeanah (1996), specifically "When do risk factors (insecure attachments) become clinical disorders (attachment disorders)?" Though the paper did not fully addressed this point, the question warrants further investigation. Specifically, when combined with the question of what happens to individuals diagnosed with RAD after childhood, it leads to a theory that a link must exist between RAD and personality disorders.
Reactive Attachment Disorder as a Precursor to Schizoid and Histrionic Personality DisordersPatrick C. Marino
Rochester Institute of Technology
Though little research has been conducted to determine the existence of RAD in adults, it is possible to draw connections between its symptoms and those of personality disorders that have already been recorded in adults. Although RAD may not persist through adolescence and into adulthood, perhaps due to the decrease in a need for attachment to parental figures, the lasting effects may manifest in different forms. Taking the argument one step further and considering the connection drawn between RAD and temperament results in the possibility that temperament is the underlying cause of both RAD and later personality disorders. In other words, as an individual with a temperament that acts as a diathesis to RAD ages beyond childhood, the temperament remains consistent, although it is analyzed and diagnosed differently.
To further illustrate this concept, it may be helpful to consider the similarities between the primary subtypes of RAD and Cluster A and B personality disorders. Children diagnosed with the inhibited form of RAD tend to display apathy toward comfort offered by caregivers and are generally withdrawn. Often these symptoms result from abuse. The tendency to withdraw may be a result of a fear of repeated abuse or of a mistrust of caregivers. These symptoms seem to mirror the characteristics of Cluster A personality disorders, primarily paranoid and schizoid personality disorders. Although paranoid personality disorder accounts for mistrust of others, the most obvious link is to schizoid personality disorder, which is defined by an impaired ability to form proper social relationships due to a lack of desire to form attachments to others.
Similar connections are evident when comparing the disinhibited subtype of RAD to Cluster B personality disorders. As described by Wood, disinhibited individuals tend to display the same high level of comfort and social interaction with all adults, including strangers. This behavior is similar to the relationship behaviors demonstrated by individuals with histrionic personality disorder. Primarily the connection can be drawn between the disinhibited individual's ability to generate a form of attachment with any adult, and the histrionic individual's tendency to consider relationships to be deeper than they actually are.
The concept relating RAD and temperament could be further illustrated by analyzing the ways in which that existing temperament may persist and result in other personality disorders later in life. This theory is clarified further when connections are made between the two major subtypes of RAD and Cluster A and B personality disorders. More specifically, inhibited subtypes tend to display characteristics similar to schizoid personality disorder, and disinhibited subtypes share a connection to histrionic personality disorder.
In the paper "Reactive Attachment Disorder: A Disorder of Attachment or of Temperament?" Wood maked some very strong conclusions, not all of which are supported by the paper. First, Wood advocated using Zeanah's suggestions to modify the DSM diagnostic criteria for Reactive Attachment Disorder. One of Zeanah's main suggestions was that the requirement that the disordered attachment be exhibited across a wide variety of social contexts be dropped. Zeanah suggested that attachment may be expressed differentially in relationships. Wood stated that some children may have no attachments at all, whereas others may form disturbed attachments to caregivers. Having no attachment and disturbed attachment are both signs of an attachment disorder. Part of the severity of Reactive Attachment Disorder comes from the fact that it affects most of the relationships a child forms or is not able to form as a consequence of the disorder. If the requirement that disordered attachments be exhibited across a wide variety of social contexts were dropped, then a child who failed to form a secure attachment with an abusive caregiver but had many secure relationships with friends would be a candidate for RAD. This however may not be an example of RAD, as it would be expected that a child with an abusive or neglectful parent would form a disordered attachment to the others too. The extreme pervasiveness of the disorder, causing disrupted relationships outside the family, is at the heart of Reactive Attachment Disorder. It may not be a wise decision to drop the disordered attachments across a wide variety of social contexts requirement from the DSM, as this would lessen the severity of the disorder.
Is Reactive Attachment Disorder a Precursor to Personality Disorder?Katie T. McConky
Rochester Institute of Technology
Second, Wood made somewhat contradictory conclusions with regard to temperament. The first conclusion was that temperament acts as a diathesis for RAD, whereas the second conclusion was that temperament is a deciding factor between which subtype of RAD is developed. If temperament is a diathesis to developing RAD, it would most likely be a difficult temperament according to Thomas and Chess's model of temperament. If a difficult temperament would put a child at greater risk for RAD, then as Zeanah also suggested a temperament characterized by positive affect could serve as a protective factor for RAD. Wood suggested that children with a difficult or more negative temperament when exposed to pathogenic caregiving would develop RAD. This suggests that children without this poor temperament would not develop RAD in the same circumstances. This conclusion is fine on its own, but the next conclusion was that temperament is the determining factor as to which subtype of RAD is developed. If only children with difficult temperaments are susceptible to RAD, then how can temperament determine the type of RAD developed? This would suggest that the subtype associated with a negative temperament would be much more common than the other because these children are more susceptible to RAD. This however is not the case. Wood gave no indication as to what kind of temperament would develop which subtype. A more thorough exploration as to which dimensions of temperament play the most role in developing RAD would be needed to support this conclusion. Additionally, it was stated earlier in the paper that most children who grow up in institutions have disinhibited RAD, whereas children with abusive parents tend to have inhibited RAD. This suggests that the type of RAD developed is most likely caused by the type of stress, either neglect or abuse, not the type of temperament of the child.
Finally, Wood made no mention of treatment for Reactive Attachment Disorder. Learning about what treatments have been effective can aid in developing proper theories for the disorder. If no treatments have been effective in treating the disorder, then maybe Reactive Attachment Disorder is more like a personality disorder in children. The two subtypes described sound eerily similar to common adult personality disorders. The inhibited subtype is characterized by being emotionally withdrawn and rarely responding to or seeking comfort. This sounds very similar to schizoid personality disorder. The disinhibited subtype is characterized by being overly sociable and eliciting comfort and affection non-selectively. This sounds very similar to histrionic personality disorder. If no treatments are shown to be effective for treating RAD, then maybe RAD could better be characterized as a personality disorder of children rather than an Axis I DSM disorder.
Balduf brought up the argument that RAD may not be caused by attachment issues at all but by genetic influences. He presented three models of genetic transmission that could explain the causality of the disorder as being entirely genetic. Although I think that genetics may a very important factor in the development of RAD, I disagree that attachment is not a factor. Also, I think that the best way to improve the conceptualization of RAD is for psychologists to make more definite decisions as to which symptoms must be observed for the disorder to be diagnosed. Although determining causal factors may provide enlightenment into the development of the disorder and possible treatments, for purposes of reliable diagnosis the disorder must first be operationally defined. I hope subsequent editions of the DSM will provide improved definitions of the disorder and what it entails.
Current Conceptualization of RAD Leaves Much to ExploreMaureen E. Wood
Rochester Institute of Technology
Howard's look at a study of adolescents with insecure attachment provided some good insight into possible long-term effects that may befall children who have RAD. I think the findings of the study show how important it is to address RAD, as it has significant implications for the well-being of these children into adulthood.
Huang brought up a variety of important concerns regarding my presentation of RAD and whether it is a valid disorder. Current definitions of RAD as published in the DSM-IV and ICD-10 are somewhat unclear and thus do not provide clinicians with optimal reliability in diagnosing it as a disorder. Certainly, children so young are unable to easily speak for themselves with regard to difficulties with emotion regulation or other symptoms associated with the disorder; diagnoses are most likely based on parent reports and clinical observations made by psychologists. As for whether RAD is a disorder of infancy or childhood, I think that it is both. What is unique about this disorder is that it can be applied to individuals so young. I think the onset of the disorder is likely to occur during infancy and continues to manifest itself through a variety of symptoms during childhood. I agree with Huang's statement that treatment of the disorder is very important, as are genetic influences on the pathogenesis of RAD. The reason these issues were not addressed in my paper is that I simply did not find any articles addressing them. The majority of research on RAD to date deals with characterizing the disorder operationally and with examining groups that seem to have a higher prevalence of the disorder. The only information I found that addresses the possibility of genetic influence is the article written by Zeanah and Fox (2004) that merely suggested the possibility of temperament as a causal factor, although no empirical research has yet been published to address this.
Marino suggested that RAD may be a precursor to personality disorders. His comparison of the two subtypes of RAD to Schizoid Personality Disorder and Histrionic Personality Disorder were very interesting and certainly warrant further investigation. Perhaps this is something that could be explored in a long-term study that follows children diagnosed with RAD into adulthood. Because of the high comorbidity with many psychological disorders, I think it is very likely that RAD may be a risk factor for the development of such personality disorders.
McConky expressed concern about my conclusions as to the influence of temperament in the pathogenesis of RAD. Perhaps my paper was not clear enough in my explanation for how I think RAD may be affected by temperament. Certainly, temperament is not a black and white issue--there are gradients and individual variations in temperament from one individual to the next. A certain range of temperaments may put an infant at greater risk for developing RAD, and within that range there may be some variants that lead to one subtype of RAD or the other. Again, as I mentioned in response to Huang's commentary, I did not address the issue of treatment for RAD because I did not find any articles providing information on treatment.
Haugaard, J. J., & Hazan, C. (2004). Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: Reactive attachment disorder. Child Maltreatment: Journal of the American Professional Society on the Abuse of Children, 9, 154-160.Hinshaw-Fuselier, S., Boris, N. W., & Zeanah, C. H. (1999). Reactive attachment disorder in maltreated twins. Infant Mental Health Journal, 20, 42-59.
Kay Hall, S. E., & Geher, G. (2003). Behavioral and personality characteristics or children with reactive attachment disorder. Journal of Psychology: Interdisciplinary and Applied, 137, 145-162.
Larose, S., Tarabulsy, G., & Bernier, A. (2005). Attachment state of mind, learning dispositions, and academic performance during the college transition. Developmental Psychology, 41, 281-289.
Reiss, D. (1997). Mechanisms linking genetic and social influences in adolescent development: Beginning a collaborative search. Current Directions in Psychological Science, 6, 100-105.
Richters, M. M., & Volkmar, F. R. (1994). Reactive attachment disorder of infancy or early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 33, 328-332.
Sheperis, C. J., Doggett, R. A., & Hoda, N. E. (2003). The development of an assessment protocol for reactive attachment disorder. Journal of Mental Health Counseling, 25, 291-310.
Stafford, B., Zeanah, C. H., & Scheeringa, M. (2003). Exploring psychopathology in early childhood: PTSD and attachment disorders in DC: 0-3 and DSM-IV. Infant Mental Health Journal, 24, 398-409.
Wilson, S. L. (2001). Attachment disorders: Review and current status. Journal of Psychology: Interdisciplinary and Applied, 135, 37-51.
Zeanah, C. H. (1996). Beyond insecurity: A reconceptualization of attachment disorders of infancy. Journal of Consulting and Clinical Psychology, 64, 42-52.
Zeanah, C. H. (2000). Disturbances of attachment in young children adopted from institutions. Journal of Developmental and Behavioral Pediatrics, 21, 230-236.
Zeanah, C. H., & Fox, N. A. (2004). Temperament and attachment disorders.Journal of Clinical Child and Adolescent Psychology, 33, 32-41.
Zeanah, C. H., Scheeringa, M., Boris, N. W., Heller, S. S., Smyke, A. T., & Trapani, J. (2004). Reactive attachment disorder in maltreated toddlers. Child Abuse & Neglect, 28, 877-888.
Zeanah, C. H., Smyke, A. T., & Dumitrescu, A. (2002). Attachment disturbances in young children II: Indiscriminate behavior and institutional care. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 983-989.