Reactive Attachment Disorder Clinical Presentation

  • Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD   more...
 
Updated: Mar 30, 2012
 

History

Rene Spitz noted that children in orphanages were prone to physical illness and had decreased appetites. They exhibited some stereotyped movements, self-stimulation, and an empty look in their eyes. They lacked normal responses of interest when people came close. They cried vaguely or softly many times a day and seemed unhappy. Many of these children seemed depressed and unresponsive to initiatives for interaction, as if they were resigned to their situation of affective deprivation. These children also had a much higher mortality rate than noninstitutionalized pediatric populations.

A history of gross neglect, lack of contingent responses, and little or no attention, interaction, and affection are required to establish a diagnosis of inhibited reactive attachment disorder (RAD). For a diagnosis of disinhibited RAD, a history of multiple caregivers, sequential changes in caregiver, disruptions in relationships, and placement with different people for considerable periods must exist. The child does not develop preferential attachments and secure base behavior toward a specific person but instead develops an undifferentiated closeness with anyone who approaches the child.

  • Inhibited reactive attachment disorder
    • Failure to thrive
    • Poor hygienic condition
    • Underdevelopment of motor coordination and a pattern of muscular hypertonicity because of diminished holding
    • May appear bewildered, unfocused, and understimulated
    • Blank expression, with eyes lacking the luster and joy that is usually observed
    • No evidence of the usual responses to interpersonal exchanges
      • Appearance of not knowing body language
      • Does not pursue, initiate, or follow up on cues for an exchange or interaction.
      • No exploration of another person's face or facial expression
      • Does not approach or withdraw from another person
      • May avoid eye contact and protest or fuss if a person comes too close or attempts to touch or hold them (have developed avoidant behaviors because they do not expect interaction and have learned not to interact when an adult approaches)
  • Disinhibited reactive attachment disorder
    • Instead of caution, excessive familiarity or psychological promiscuousness with unknown persons
    • Can give hugs to anyone who approaches them and go with that person if asked
    • May approach a complete stranger for comfort, food, to be picked up, or to receive a toy
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Physical

No specific physical signs of attachment disorder exist. Nevertheless, indirect indicators may be present, such as the following:

  • Signs of physical maltreatment, such as old fractures or bruises
  • Effects of undernutrition and rashes because of not changing diapers frequently
  • A syndrome characterized by excessive appetite in children who have been in several foster homes
  • Excessive appetite and excessive thirst in children who experience severe stress
  • Flattened back of the head because left in bed much of the time in cases of nonattachment
  • If severe, growth retardation
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Causes

Multiple situations can lead to attachment disorders.

Inhibited RAD

Young children who are exposed to multiple caregivers simultaneously or sequentially do not easily experience the sense of security associated with unique and exclusive long-standing relationships. No opportunity exists to trust one person because past relationships were interrupted, disrupted, or consistently unreliable. Note the following factors:

  • Gross neglect
  • Gross insensitivity in the caregiver
  • Abandonment by caregiver at the peak of attachment needs (end of first year of life)
  • Repeated abandonment by caregiver

Disinhibited RAD

Promiscuous or disinhibited attachment disorders have a phenomenology opposite that of inhibited attachment disorders. This is the most common type of attachment disturbance in clinical settings. Many children with this condition have been placed in multiple foster homes or have lived with different relatives; their parents are unable to create a sense of permanency in their lives. Many of the parents experience legal problems, engage in illegal drug use, abuse alcohol, or have personality disturbances, which make them unable to provide stability for the child. Note the following factors:

  • Multiple caregivers sequentially or concurrently
  • Multiple disruptions in attachment relationships
  • Several changes in foster home placement

Risk factors

Risk factors are the same as those associated with poor parenting, maltreatment, and neglect. A number of psychosocial factors place some children at particular risk, such as caregivers who abuse drugs, who have multiple unmanageable stressors, or who have been maltreated or have experienced multiple attachment disruptions themselves.

Genetics factors are also significant.[10]

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Contributor Information and Disclosures
Author

Roy H Lubit, MD, PhD  Assistant Clinical Professor, Mount Sinai School of Medicine; Clinical Faculty, Department of Child Psychiatry, New York University School of Medicine; Private Practice

Roy H Lubit, MD, PhD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Coauthor(s)

J Martin Maldonado-Durán, MD  Principal Investigator for Child and Family Center, Department of Psychiatry, Child and Adolescent Division, Family Service and Guidance Center

J Martin Maldonado-Durán, MD is a member of the following medical societies: Kansas Medical Society

Disclosure: Nothing to disclose.

Linda Helmig Bram, PhD  Clinical Instructor in Psychology, Department of Psychiatry, Cambridge Health Alliance, Harvard University Medical School; Staff Psychologist, Boston Institute for Psychotherapy, Rice Center for Young Children and Families

Linda Helmig Bram, PhD is a member of the following medical societies: American Psychological Association and National Register of Health Service Providers in Psychology

Disclosure: Nothing to disclose.

Specialty Editor Board

Carol Diane Berkowitz, MD  Executive Vice Chair, Department of Pediatrics, Professor, Harbor-University of California at Los Angeles Medical Center

Carol Diane Berkowitz, MD is a member of the following medical societies: Alpha Omega Alpha, Ambulatory Pediatric Association, American Academy of Pediatrics, American College of Emergency Physicians, American Medical Association, American Pediatric Society, and North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Carrie Sylvester, MD, MPH  Senior Child and Adolescent Psychiatrist, Sound Mental Health

Carrie Sylvester, MD, MPH is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry

Disclosure: Nothing to disclose.

Chief Editor

Caroly Pataki, MD  Professor of Clinical Psychiatry and Behavioral Sciences, Department of Psychiatry, Division Chair, Child and Adolescent Psychiatry, Keck School of Medicine of the University of Southern California

Caroly Pataki, MD is a member of the following medical societies: American Academy of Child and Adolescent Psychiatry, New York Academy of Sciences, and Physicians for Social Responsibility

Disclosure: Nothing to disclose.

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of former coauthor Teresa Lartigue, PhD, to the development and writing of this article.

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