An appropriate treatment program for a child with multiple challenges requires the participation of several specialists.
Most of the treatment for reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) is provided by primary caregivers (eg, parents or substitute parents) in their everyday interactions with the child. Ideally, these caregivers can rely on the expertise and advice of a mental health professional who is aware of the emotional needs of children, the phenomenology of attachment disruptions, and the need to repair and recreate the sense of security in the child. Referral to a mental health professional may be critical.
Pharmacologic treatment may be helpful for ancillary problems but not for the attachment disorders themselves. No specific diet is indicated; however, many children who have experienced disruptions and early neglect also have feeding disorders and may require treatment. Also, some children may have excessive appetite and thirst.
Psychological and Behavioral Interventions
Play therapy with a child psychotherapist, particularly in the presence of the primary caregivers, may help the child express emotional needs, fears, and anxieties in the context of play. Caregivers may become more sensitive to the issues faced by their child (eg, anger about having been abandoned, maltreated, left alone, or locked up). Also, children may be able to express their dependency needs (eg, to be a baby, to be looked after, or to be soothed) through play.
Several therapeutic ingredients seem to be important in the treatment of RAD and DSED. When caregivers provide these ingredients, the child may experience healthy dependency, come to rely on someone, and begin trust a new person. In other words, the child may become attached. These therapeutic ingredients include the following:
Security, or a sense of psychological safety, helps promote the development of a new attachment relationship. Constant or intense stress and anxiety do not facilitate a sense of security; rather, they promote guarding behavior.
To correct the scars or sequelae of attachment disruption, the clinician, parent, or caregiver must have time and be ready to listen to the child without judging. Limits must be set for the child, but these should be set in the context of empathy and compassion. Only when verbal children feel emotionally secure will they begin talking about what has happened to them (and, probably, to their siblings) and gradually develop trust in the new caregiver.
Stability refers to the permanence of the attachment figure. It takes time for a child to develop trust in a new primary caregiver. After experiencing disruption, children need to learn to recognize their needs and to understand that these needs can be met repeatedly by the same person. It is common for these children to fear that the caregiver will disappear, die, or go away, thus giving rise to another disruption.
Some children take a long time (>1 y) to trust a caregiver again; others trust a caregiver after receiving just a few months of sensitive care. This may be a temperamental feature (eg, orientation toward others versus inwardness) or a reflection of the quality of the match between the child and the new caregiver. Separations and disruptions may reactivate a defensive isolation on the part of the child.
Sensitivity, or emotional availability, refers to attentiveness to the child’s needs. Substitute caregivers should be informed that although the child may or may not be mature cognitively, his or her emotional development is frequently delayed in areas such as emotional expression, attachment, and age-appropriate independence. This delayed development makes emotional availability on the part of the caregiver especially important.
Ideally, over the course of treatment, the child will gradually begin to develop feelings of dependency toward the primary caregiver once he or she learns to expect that the caregiver will be physically and emotionally available at times of crisis. During this process, parents should be cautioned to expect and tolerate occasional regressive behaviors and to view them as signs that the child is psychologically working through earlier phases in development.
For instance, a child who is typically independent and suspicious of others may suddenly express needs for dependency, report fears, want to sleep in the parents’ bed, and wish to be mommy’s little boy or girl. In such cases, the parents should, in a sensitive way, allow the child to express and experience that dependency. It is helpful to encourage parents to think of the child, for the time being, as emotionally younger and as having legitimate emotional needs appropriate for his or her emotional age.
Some children are almost frozen emotionally because with multiple placements and relationships, expressing age-appropriate emotions has not been safe for them. At first, these children might appear to be obedient because they do not express anger and are not prone to emotional outbursts. As time goes by, however, children may start to feel that they can safely express emotions such as anger, jealousy, and neediness, and they may begin to direct temper outbursts, jealousy, and anger toward caregivers upon separation.
In this scenario, things that previously seemed not to matter to the child (eg, whether the caregiver comes or goes) may suddenly become highly upsetting. For example, a child who never seemed to mind separations may strongly protest the parent’s leaving by clinging or going to the parent for comfort. Caregivers should see these behaviors as positive signs that a new attachment and a deeper level of trust have formed because the child now feels safe enough to be able to express his or her developmentally appropriate dependency needs.
No specific pharmacologic treatment exists for RAD or DSED. However, psychopharmacologic agents may be used to address associated problems such as explosive anger, hyperactivity, and difficulty in focusing or sleeping. These agents are used at similar doses and with the same objectives as in other psychological disorders. The ancillary problems are treated with a view to promoting the optimal psychosocial functioning of the child; it should be kept in mind that pharmacotherapy does not specifically address the attachment disorders themselves.
Indications for Hospitalization
There is no specific indication for inpatient treatment of patients with attachment disorders. Occasionally, however, children (in particular, adolescents) may need to be hospitalized for a time so that issues such as mistrust or lack of emotional involvement with others can be addressed.
For instance, an adolescent who has been through multiple placements, foster homes, or group homes may benefit from a period of inpatient treatment, which may help him or her face fears of becoming close to any person.  In-hospital therapy may also help a child work on overcoming the fear of acknowledging dependency needs and the fear of acknowledging desires for attention and affection.
Unfortunately, intermediate- or long-term hospitalization for attachment disorders is no longer available in today’s economic climate. Day hospital care, partial hospital care, and residential care in a placement skilled in treating very disruptive, poorly attached children may be suitable alternatives.
Preventive efforts are essential. Providing support and safe environments to stressed families and single parents is crucial for helping children to have a good early experience and to form appropriate bonds. This is preferable to removal. It is important for child welfare services and the courts to understand that removing a child from parents does harm and is not a benign intervention.
Specialists should be consulted about particular problems that may be associated with experiences of detachment and neglect (eg, excessive eating and drinking), as follows:
Endocrinologist or nutritionist for short stature and malnourishment
Pediatric gastroenterologist to rule out gastroenterologic problems
Over the longer term, child therapy and relational therapy (eg, parent-child or parent-infant) may be useful for many children and caregivers. In particular, new caregivers may need considerable emotional support to deal with challenging and difficult behaviors in their children.
Caregivers may struggle with disciplining the child while trying to foster the child’s ability to relate and trust. Establishing a positively oriented and developmentally appropriate behavioral management program is important for avoiding further punishment or prolonged abandonment in excessive time-outs. In the context of relational play, or narrative therapy, the child can develop a theme that describes what is in his or her mind.
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