Reactive Attachment Disorder Treatment & Management
- Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD more...
Medical Care
An appropriate treatment program for a child with multiple challenges requires the participation of several specialists. Most of the treatment is provided by primary caregivers, such as parents or substitute parents, in their everyday interactions with the child. Hopefully, 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.
Play therapy with a child psychotherapist, particularly in the presence of the primary caregivers, may help the child and the caregivers to express the emotional needs, fears, and anxieties of the child in the context of play. Caregivers may become more sensitive to the issues (eg, anger about having been abandoned, maltreated, left alone, or locked up) faced by their child. Also, children may be able to express their dependency needs (eg, to be a baby, to be looked after, to be soothed) through play.
Several therapeutic ingredients seem important in treating inhibited reactive attachment disorder (RAD) and disinhibited RAD. When caregivers provide the ingredients described below, the child may experience healthy dependency, rely on someone, and trust a new person. That is to say, the child may become attached.
- 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 but, rather, promote guarding behavior. To correct the scars or sequelae of attachment disruption, the clinician, parent, or caregiver must have time and be ready, without judging, to listen to the child. Limits must be set for the child, but these should be set in the context of empathy and compassion. Only when the verbal children feel emotionally secure will they begin talking about what has happened to them and, likely, to their siblings and gradually develop trust in the new caregiver.
- Stability refers to the permanence of the attachment figure. The child needs time to develop trust in a new primary caregiver. After disruption(s), these children need to learn to recognize their needs and to learn that these needs can be met repeatedly by the same person.
- The child might fear that the caregiver will disappear, die, or go away, thus leading to another disruption.
- Some children take a long time (more than a year) 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 and is crucial in care taking. Inform substitute caregivers that, although the child may or may not be mature cognitively, the child's emotional development is frequently delayed in areas such as emotional expression, attachment, and age-appropriate independence. Hopefully, during the course of treatment, the child will gradually begin to develop feelings of dependency toward the primary caregiver because the child learns to expect the caregiver will be physically and emotionally available at times of crisis. During this process, caution parents 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. Recommend that the parents, in a sensitive way, allow the child to express and experience that dependency. Encourage parents to think of the child 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. These children might at first appear to be obedient because they do not express anger and are not prone to emotional outbursts. As time goes by, expressing emotions, such as anger, jealousy, and neediness, becomes safe. The caregiver may observe the appearance of temper outbursts, jealousy, and anger toward him or her upon separation. Things that previously did not seem to matter to the child (eg, if the caregiver comes or goes) may suddenly be 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. Encourage caregivers to see these behaviors as positive signs that a new attachment and a deeper level of trust have formed because the child feels safe to express these developmentally appropriate dependency needs.
Surgical Care
No surgical procedures to treat attachment disorders exist.
Consultations
Consult specialists about particular problems that may be associated with experiences of detachment and neglect, such as excessive eating and drinking. Note the following:
- Endocrinologist or nutritionist for short stature and malnourishment
- Pediatric gastroenterologist to rule out gastroenterological problems
Diet
No specific diet is indicated for attachment disorders; 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 (see Physical).
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