eMedicine Specialties > Pediatrics: Developmental and Behavioral > Medical Topics

Child Abuse & Neglect, Reactive Attachment Disorder

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
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; Linda Helmig Bram, PhD, Child Psychologist, Researcher, Private Practice
Contributor Information and Disclosures

Updated: Oct 14, 2009

Introduction

Background

Attachment disorders are the psychological result of negative experiences with caregivers, usually since infancy, that disrupt the exclusive and unique relationship between children and their primary caregiver(s). Oppositional and defiant behaviors may be the result of disruptions in attachment.

Many children experience the loss of primary caregivers, either because they are physically separated from them or because the caregiver is incapable of providing adequate care. Removal from primary caregivers can cause serious problems by breaking primary attachments, even if alternate caregivers are competent.

Attachment disorders have been described in the psychological and psychiatric literature for approximately 50 years. The condition Rene Spitz called anaclitic depression is now considered an attachment disorder. Spitz observed young children in an orphanage who were fed and kept clean and were initially in good physical condition but who received no consistent affection from a sole caregiver. The long-standing absence of emotional warmth took an enormous toll on the children, primarily on their emotional development but also on their physical growth and development condition. Spitz concluded that providing only for a baby's physical needs is not sufficient for normal development.^1,2

A short while later, John Bowlby, a psychoanalyst interested in the parallels between human infants and animal babies, incorporated Harlow's research on rhesus monkeys into his study of the child's tie to his or her mother. He concluded that separations during the first few months of life negatively affect a baby's psychic organization and that separation from a parental figure causes separation anxiety.^3,4,5

In a film entitled A Two-Year-Old Goes to Hospital, Bowlby shows that an infant goes through several phases in reaction to separation. The infant goes from protest to crying to a sad state and, finally, to a more desolate state of resignation regarding the loss.

Bowlby, the father of attachment theory, produced a report for the World Health Organization (WHO) highlighting the importance of parental sensitivity in adequate child development. Parental sensitivity refers to the ability of a parent to read internal states and emotions in his or her baby and to respond in a positive and supportive manner.

Attachment refers to a set of behaviors and inferred emotions that can be observed in infants. Humans need attachments with others for their psychological and emotional development, as well as for their survival. Early manifestations of attachment include the unique and exclusive relationship between an infant and his or her parents. Parents and infants establish a continuous relationship that has specific features. The quality of this relationship colors the person's relationships for the rest of his or her life.

Both caregiver and baby have biological preprogrammed instinctive equipment to foster their relationship. Most people have a strong attraction and desire to care for babies. In addition, a baby's crying and clinging (signaling behaviors) reinforce the baby's efforts to obtain care and attention. Parents also have instinctive behaviors, such as soothing the crying infant, caressing him or her, making sounds that are appealing to the infant, and mirroring the infant (ie, playfully imitating the baby's facial expressions), all of which trigger tenderness and a maternal instinct.

Attachment develops through repeatedly being looked after and appropriately responded to by the caregiver. This convinces the baby and young child that a person is available to soothe, console, and comfort. Infants may develop attachments to other people who are consistent in their lives; however, the relationship with the primary caregiver(s) plays the most critical role in determining the child's basis for future attachments. The attachment figure(s) cannot suddenly be replaced by any other caregiver because that relationship is unique and stable.

Based on the nature and quality of early attachments, children develop an internal working model of relationships that serves as a template for future relationships. These working models of relationships can be positive (ie, people can be trusted, confided in, helpful in distress) or negative (ie, no one can be trusted, people are not caring, one is all alone in the world). Babies internalize their parents (and other attachment figures) as a secure base. This allows infants to feel internally safe and to confidently explore the world around them. It also allows them to experience positive interpersonal exchanges with other children. The infant can come back to the caregiver to refuel emotionally before proceeding with further explorations.

Reactive attachment disorder

Reactive attachment disorder (RAD), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), requires etiologic factors, such as gross deprivation of care or successive multiple caregivers, for diagnosis.

• In inhibited RAD, the child does not initiate and respond to social interactions in a developmentally appropriate manner. It is a disorder of nonattachment and is related to the loss of the primary attachment figure and the lack of opportunity for the infant to establish a new attachment with a primary caregiver. Also, a nonattachment disorder may develop because the baby never had the opportunity to develop at least one attachment with a reliable caregiver who was continuously present in the baby's life.
• In disinhibited RAD, the child participates in diffuse attachments, indiscriminate sociability, and excessive familiarity with strangers. The child has repeatedly lost attachment figures or has had multiple caregivers and has never had the chance to develop a continuous and consistent attachment to at least one caregiver. Disruption of one attachment relationship after another causes the infant to renounce attachments. The usual anxiety and concern with strangers is not present, and the infant or child superficially accepts anyone as a caregiver (as though people were interchangeable) and acts as if the relationship had been intimate and life-long.

Attachment disorders independent of DSM-IV

• In reversed attachment, the child becomes the source of comfort to the parent, who is insecure and vulnerable; the relationship is inverted and the infant, although unable to reassure the parent completely, provides the security.
• In angry attachment, a strong relationship exists between parent and infant that is unique and exclusive; however, the relationship is marked by angry features and exchanges. The dyad members are angry with each other but not with other people around them.

Mary Ainsworth developed an attachment classification based on the behavior of infants (typically aged 10-13 mo) in the presence of a stranger during and after a short separation from their primary caregivers.⁶

• Behavioral patterns associated with secure attachments include some distress at separation, preference for a parent over a stranger, and a search for comfort from the parent upon reunion.
• Behavioral patterns associated with insecure attachments, such as avoidant and ambivalent styles, include lack of distress upon separation and avoidance of, or anger toward, mother upon reunion.
• Approximately 65% of American middle-class children are thought to have secure attachments with primary caregivers, whereas 35% exhibit an insecure attachment style. Not all children who show an insecure attachment to primary caregivers are diagnosed with RAD, either because they did not receive pathological care or because their insecure attachment is not severe. The lack of a secure attachment style affects the child throughout life; however, an insecure attachment should not be confused with a disorder. The Ainsworth attachment study is only a suggestion of an internal state of the child. It is not a diagnostic tool for attachment disorders.

Pathophysiology

Inhibited reactive attachment disorder

If caregivers are not reliably or consistently present or if they respond in an unpredictable and uncertain way, babies are not able to establish a pattern of confident expectation. One result is insecure attachment, or a less-than-optimal internal sense of confidence and trust in others, beginning with caregivers. The child then uses psychological defenses (eg, avoidance or ambivalence) to avoid disappointments with the caregiver. This is thought to contribute to a negative working model of relationships that leads to insecurity for the rest of the child's life.

Disinhibited reactive attachment disorder

Young children 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. Children with disinhibited attachment resort to psychological defense mechanisms (eg, relying only on themselves and not expecting to be soothed, cared for, or consoled by adults) to survive. Instead of relying on one person, any sense of fear or loneliness is inhibited and the children develop a pseudocomfort with whoever is available. The child is thought to suppress the conscious experience of fear only as a result of a psychological defense. The child is afraid of trusting anyone and being further disappointed. This pattern can continue into adult life and adversely affect adult relationships.

Frequency

United States

No epidemiologic studies of frequency or prevalence of attachment disorders in children exist; however, statistical data regarding adoptions and foster care placement are available. One might estimate, based on the number of foster care placements and disruptions in relationships, approximately how many children may have attachment disorders.

International

Many children, examples being certain children from Romania and China, have lived in orphanages and have had little opportunity for attachment or they have lived in bleak conditions with multiple caregivers and are emotionally and cognitively deprived. In the midst of such deprivation and so many disruptions in relationships, determining exactly what causes a child to have difficulties in relating and communicating, in development of trust, and in linguistic and cognitive development can be difficult.

Race

No evidence suggests greater prevalence of attachment disorders in a particular racial or ethnic group unless as noted above in specific countries with unusual child care practices.

Sex

No information in the scientific literature suggests that attachment disorders have a sexual predilection.

Age

Onset of attachment disorders is in children younger than 5 years. Typically, the disorder has its roots in infancy. The more serious effects of disruptions in attachment relationships tend to persist and manifest themselves in the preschool and school years. In more muted forms (eg, mistrust and difficulties in establishing supportive, sensitive, and intimate relationships), they last into adolescence and adulthood.

Clinical

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

Physical

• 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

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.
  • 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.
  • 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.

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