Reactive

Attachment
Disorder

Wendy, Leora, Lindsay & Nikolai

Reactive
Attachment Disorder
Outline of Presentation
Wendy - History
- Attachment Categories
- Measures of Attachment
- Relationship Between Attachment and Disorders
Lindsay -DSM History, Types and Subtypes
-Symptoms, Co-morbidity, Treatment
Leora

-Risk Factors, Life Span, Complications in Adulthood

-Major Issues in Identification, Diagnostic Measures

Nikolai -Case Study

Poll
Who has had the opportunity to work
with a child diagnosed with Reactive
Attachment Disorder?

CASE STUDY: Kris

Key Features: Kris

Repeated early changes of caregivers: Val,

Yvonne, Karen
Early environment characterized by parents
arguing, likely neglect
Consistently withdrawn and isolated
Does not appear to have significant
attachments with caregivers
Frequent episodes of irritability that lead to
angry outbursts
Small physical size development

Attachment Issues
Effects of Secure Attachment
According to Neufeld and Mat (2005), if the parent is actively attached, the child
will seek contact and closeness with the parent. The resulting attachment will
evolve into emotional closeness and a sense of psychological intimacy which
provides the proper context for child-rearing.

Historical Context
Contribution
1. Children are pre-programmed to
form attachments (survival)
2. A child has an innate need to
attach to one main figure

John Bowlby 1907-1990

3. Long-term consequences of
maternal deprivation

Historical Context

Historical Context
Mary Ainsworth contribution

Mary Ainsworth 1913-1999

Measures of Attachment
Short video of Strange Situation Experiment

http://www.youtube.com/watch?v=DH1m_ZMO7GU

Attachment Categories

Measures of Attachment
MCAST Manchester Child Attachment Story Task
4.5 to 8 years
consists of 5 vignettes
stress-vignettes consist of nightmare, hurt
knee, tummy ache, lost shopping.
Tester starts the story and hands over the
doll for the child to finish the story.
more ethically correct measure of
attachment

CMCAST Computer version of

Manchester Child Attachment
Story Task

Measures of Attachment
Adult Attachment Interview
by
Mary Main
1. C ou ld you start b y h elp in g m e g et orien ted to you r early fam ily situ ation ,
an d w h ere you lived an d so on ? If you cou ld tell m e w h ere you w ere b orn ,
w h eth er you m oved arou n d m u ch , w h at you r fam ily d id at variou s tim es for
a livin g ?
2. I'd like you to try to d escrib e you r relation sh ip w ith you r p aren ts as a
you n g ch ild if you cou ld start from as far b ack as you can rem em b er?
3. N ow I'd like to ask you to ch oose f i
v e ad jectives or w ord s th at ref l
e ct you r
relation sh ip w ith you r m oth er startin g from as far b ack as you can
rem em b er in early ch ild h ood --as early as you can g o, b u t say, ag e 5 to 12 is
fi
n e. I kn ow th is m ay take a b it of tim e, so g o ah ead an d th in k for a
m in u te...th en I'd like to ask you w h y you ch ose th em . I'll w rite each on e
d ow n as you g ive th em to m e.

What Do You Think

Cathys Story
Does this child
have RAD?
Does she have
risk factors?

African Orphanage, Kenya 2012

Historical Context

Historical Context
Intergenerational Transmission of Relational
Behavior
Research indicates that caregiving patterns
have roots in the adaptation of the parent
prior to the birth of the child.
What is the impact of the caregiving
received in the parents childhood on
subsequent parenting?

The power of family-of-origin was the

greatest overall contribution of any variable
to the prediction of parenting.
Cox (1985) in Mash and Barkley, pg. 611

Historical Context
What is the relationship between attachment history and
Reactive Attachment Disorder?

According to Benoit (2004), of the

four patterns of attachment,
disorganized attachment in infancy
and early childhood was
recognized as a powerful predictor
for serious psychopathology and
maladjustment in children.

Who is this?

(Curtiss, 1977)

(Zenah, 2004)

The Neglect Brain

History - DSM - lll/R

1980 - DSM III
-failure to thrive
-social responsiveness
-onset 8 months
-mother-infant attachment
1987 - DSM III-R
-onset 5 years
1) evidence of pathogenic care
2) reversible condition
-Excl. - PDD, MR

DSM IV
A. Disturbed and devt inappropriate social relatedness
-Before 5 yrs
1.Inhibited- hypervigilant, ambivalent, contradictory
2.Disinhibited-unable to show selective attachments
B. Excl. PDD or MR
C. Pathogenic Care (emotion, physical,
primary caregiver)
D. Criteria C is responsible for disturbed
behaviour in Criteria A
Specify: Inhibited type or Disinhibited type

Types?

Inhibited

Disinhibited

DSM V - Trauma and Stressor

Related Disorders - RAD 313.89
A. Inhibited, emotionally withdrawn
1. rarely seeks comfort when distressed
2. rarely/minimally responds to comfort when
distressed
B. Persistent social and emotional
disturbance
1. minimal social responsiveness
2. limited positive affect
3. episodes: irritability, saddness, fearfulness during non-threatening interactions

DSM V (contd)
C. Extremes of Insufficient care
1. Social neglect/deprivation
2. Repeated change of primary caregivers
3. Unusual setting - limit selective attachments

D. C predicts A
E. Not ASD
F. Before 5 yrs
G. Minimum 9 mths old

DSM V - Specifiers
Persistent: >12 months
Current Severity:
Severe: all symptoms, each symptoms - high
levels

DSM V - 313.89
Disinhibited Social Engagement Disorder
A. Child approaches and interacts with unfamiliar adults
B. Behaviour in A not impulsive (ADHD)
C. Extreme or
Insufficient Care
D. C A
E. min. 9 months

ICD 10

www.who.int/classifications/apps/icd/icd10onlie/

F94.1 Reactive attachment disorder of childhood

-Starts in the first five years of life and is characterized by persistent abnormalities
in the child's pattern of social relationships that are associated with emotional disturbance
and are reactive to changes in environmental circumstances (e.g. fearfulness and
hyper-vigilance, poor social interaction with peers, aggression towards self and others, misery, and growth failure
in some cases). The syndrome probably occurs as a direct result of severe parental neglect, abuse,
or serious mishandling.
Use additional code, if desired, to identify any associated
failure to thrive or growth retardation.
Excl.:
Asperger syndrome (F84.5)
disinhibited attachment disorder of childhood (F94.2)
maltreatment syndromes (T74.-)
normal variation in pattern of selective attachment
sexual or physical abuse in childhood, resulting in
psychosocial problems (Z61.4-Z61.6)

ICD 10
F94.2 Disinhibited attachment disorder of childhood

T74 Maltreatment Syndrome

A particular pattern of abnormal social functioning that arises

during the first five years of life and that tends to persist despite
marked changes in environmental circumstances, e.g. diffuse,
non selectively focused attachment behaviour, attentionseeking and indiscriminately friendly behaviour, poorly
modulated peer interactions; depending on circumstances
there may also be associated emotional or behavioural
disturbance.

T74.0 Neglect or abandonment

Incl.:
Affectionless psychopathy
Institutional syndrome
Excl.:
Asperger syndrome (F84.5)
hospitalism in children (F43.2)
hyperkinetic disorders (F90.-)
reactive attachment disorder of childhood (F94.1)
(http://apps.who.int/classifications/icd10/browse/2010/en#/T74)

T74.1 Physical abuse

Incl.:
Battered:
baby or child syndrome NOS
spouse syndrome NOS

T74.2 Sexual abuse

T74.3 Psychological abuse
T74.8 Other maltreatment syndromes
Incl.:
Mixed forms
T74.9 Maltreatment syndrome, unspecified
Incl.:
Effects of:
abuse of adult NOS
child abuse NOS

Agreement!
DSM IV - RAD - 2 types
1. Inhibited
2. Disinhibited

DSM V - RAD
- Disinhibited Social Engagement Disorder

ICD 10 - RAD
- Disinhibited Attachment Disorder of
Childhood

Symptoms - Infants
-Resistant to being held or touched

-No interest in playing peekaboo or other

interactive games - plays alone

-May seem sleepy or slow to respond

-No interest in playing with toys
-May not seem aware of their surroundings
-May be overly aware and nervous
-When distressed, do not seek comfort or
protection from caregivers

-Engaging in self-soothing behavior, such as

rocking or self-stroking
-Calm when left alone
-Prefers not to be held

-When caregivers initiate comfort for the

distressed child it does not soothe them

-Ambivalent - Avoids adults/appears

uninterested

-Withdrawn, sad and listless appearance

-Will readily go to strangers
-Failure to smile
-Failure to reach out when picked up
-Lack of the normal tendency to follow others in
the room with the eyes

-Stereotypic Behaviours

http://minddisorders.com

http://www.mayoclinic.com

Symptoms - Children
-Withdrawn and passive
-Ignore others or respond to others in odd ways
-Lack empathy
-Absent expression of positive emotions within
caregiver interactions
-Compromised emotional regulation
-Episodes of negative emotions (fear, sadness,
irritability) that cannot be explained
-Delays in cognition and language
-Stereotypic behaviours
-Other signs of neglect - e.g. malnutrition
-Delays in motor coordination and a pattern of
muscular hypertonicity
-Phenotype - trauma and stressor related conditioned responses (anxiety/fear based externalizing angry and aggressive symptoms)
-Destructive or cruel behaviour
-Unusual eating habits/patterns
http://minddisorders.com; APA, 2013

-Social impulses in RAD disinhibited - different

from ADHD
-Avoiding or dismissing comforting comments or
gestures
-Acting aggressively toward peers
-Watching others closely but not engaging in social
interaction
-Failing to ask for support or assistance
-Obvious and consistent awkwardness or
discomfort
-Masking feelings of anger or distress
-Alcohol or drug abuse in adolescents
-Inability to learn from mistakes (poor cause-andeffect thinking)
-Learning problems or delays in learning
-Impulsive behaviour/lack of impulse control
http://www.mayoclinic.com

Prevalence
1% all children under
5 worldwide (APA, 2013)

Foster care/Orphanages
-38-45% (Zeanah, 2004)
-RAD 1/3 & DSED 2/3
(APA, 2013)

Siblings in foster
care- 67-75% (Zeanah

ICD vs. DSM

et. al., 2004)

DSM IV & ICD

types stable over
time (Glowinski, 2011)

Co- occurrence (co-morbidity)

(Pritchett et. al., 2013)
Reactive Attachment Disorder in the
General Population:
A Hidden ESSENCE Disorder
Chart Title
60
50
40
30
20
10
0
ADHD

ODD

CD

PTSD

ASD

Phobia

Tic

Co-occurrences

Stereotypic Behaviours

Language Delays

(APA, 2013; Zeanah, 2004)

(APA, 2013; Pritchett et. al., 2013)

Cognitive Delays

FASD

(APA, 2013; Pritchett et. al., 2013)

(Zeanah et. al., 2004)

Medical Conditions

Depressive Disorder-RAD
ADHD DSED

(e.g. severe malnutrition)

(APA, 2013)

(Zeahnah, 2004)

Prevention
-Good parenting
-Prenatal Classes - attachment patterns - especially if
you are adopting
-Health Care - on the look out
-Stable environment
-Consistent caregiver
-Foster Care - early identification
-prevent multiple placements
-better emotional support procedures
-improve system efficiency for earlier
adoption (Balasingham, 2012)
-Early Intervention Foster Care project
(Fisher & Kim, 2007 & 2009)
-Abuse, Poverty and Neglect - larger issues

Other Ideas:
-Volunteer with children
-Parents - resources (books,
pamphlets, internet, support groups)
-Active engagement
-Warm, nurturing environment
-Teach children to express feelings
-Verbal and nonverbal responses

(Fisher & Kim, 2007 & 2009)

http://www.minddisorders.com
http://www.mayoclinic.com

Treatment
Infants

Young Children

Hospitalization

Complex therapy

Stable Environment/Home

Cognitive Behavioural
Therapy

Caregiver training attachment

Play Therapy

Family Therapy

ABA

Infants - schedule

Counselling

http://www.mayoclinic.com

http://www.minddisorders.com

Life Span
Prognosis appears to depend on the quality of the caregiving
environment following serious neglect (DSM V, 2013).
It appears that children who are identified
and treated early have a better chance of
learning how to form appropriate bonds
with other people.
Children who are not treated or who are
treated later in life have a greater chance of having
permanent problems relating to other people.

Life Span
Full recovery of RAD can
occur when deprivation from
a primary caregiver does not
persist beyond 6 months

Withdrawn/inhibited RAD have

been quite unusual in follow-up
studies of children adopted out of
institutions (OConnor et al.,
2000, 2003), perhaps because the
disorder remits relatively quickly
when adequate caregiving is
provided (Zeanah, 2004)

Complications in adulthood
Complications of RAD can continue into
adulthood and can include:
- Delayed learning or physical growth
- Poor self-esteem
- Delinquent or antisocial behaviour
- Temper or anger problems
- Eating problems, which can lead to
malnutrition in severe cases

Complications
Depression
Anxiety
Academic Problems
Unemployment
Drug and Alcohol
Addiction
Inappropriate sexual
behaviour

Risk Factors
Factors that may increase the chance of developing RAD
includes:
1) Mothers psychiatric history &
substance abuse (Zeanah et. al., 2004)
2) Extreme Poverty
3 ) Living in an orphanage (institutional care) or foster care (or
frequent changes in foster care or caregiving)
4) Natural Disasters (i.e. Haiti more children were placed for
adoption)

Risk Factors
5) Physical, sexual or emotional abuse
6) Prolonged hospitalization
7) Parents who have a mental illness,
anger management problems, or drug
and alcohol abuse
8) Postpartum depression in the babys
mother

Challengers with Conceptualization &

Identification of RAD
1. Are the symptoms associate with RAD
or is it another developmental disorder?
2. Access to health health care for a diagnosis or
treatment
3. Disagreement over diagnosis methods
4. Is the assessment tool reliable?

Challenge # 1
Comorbid Disorder
The symptoms associated with RAD
may confuse many mental health
counselors. The behaviors associated
with RAD are closely related to those of
conduct disorder, oppositional defiant
disorder, autism, PTSD, social phobia,
anxiety disorders and ADHD. Because
of this, reactive attachment disorder
may often be overlooked as a possible
diagnosis.

Challenge # 2
Children with RAD may not have access to health
care systems (i.e. no diagnoses and no
treatment). Many of these children come from
homes of abuse and neglect, therefore they do
not receive access to early intervention
Children who are not treated or who are treated
later in life have a greater chance of having
permanent problems relating to other people.

Challenge # 3
Disagreement over Diagnosis Methods
Not all experts agree on the signs and symptoms of RAD,
or which assessment tool should be used to diagnose
RAD.
Some therapists use checklist with numerous signs and
symptoms that go beyond the criteria spelled out in the
DSM.
One needs to be cautious when trying to interpret the
checklist as it includes symptoms of a number of other
mental health conditions.

Challenge #4
Diagnostic Reliability????
1. DSM IV & ICD 10- reliability?
2. Clinician - reliability?
3. Prevalence in foster care?
4. Co-occurrence of two types?
(Zeanah et. al., 2001)

Diagnostic
Measures
Relationship Problems Questionnaire (RPQ)
Disturbances of Attachment Interview (DAI)
Observational schedule for RAD
Strengths and Difficulties Questionnaire (SDQ)
The Child and Adolescent Psychiatric Assessment,
Reactive Attachment Disorder Module (CAPA-RAD)
(Pritchett et. al., 2013) (Vervoort et. al, 2013)

CASE STUDY: Katharine

Key Features: Katharine

Apprehended by social services (concerns of

neglect and abuse)
Failed foster home placement
Current group home placement
Concerns regarding maternal
psychopathology
Unresponsive to peers
Episodes of irritability
Odd and repetitive behaviours

Further Questions: Katharine

What of potential comorbidity?

What other information would be good to
inquire about?
Does the child meet the age requirements?
Is criteria met for ASD?
Are the conditions met for RAD?

Questions?

References
APA, 2013 Highlights of Changes from DSM-IV-TR to DSM-5 retrieved from:
http://www.dsm5.org/Documents/changes%20from%20dsm-iv-tr%20to%20dsm-5.pdf
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. 5th. Arlington, VA:
American Psychiatric Association; 2013:265-70.
Attchment.org retrieved from: http://www.attachment.org/parents/reactive-attachment-disorder/
Balasingham, S., (2012) An Uncommon Disorder that is fairly Common Among Institutionalized Children, Columbia Social
Work Review (3) pp.66-70

Benoit, D. (2004). Infant-parent attachment: definition, types, antecedents, measurement and outcome. Paediatrics & Child
Health, 9(8), 541-545. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2724160/
Boris, N. W., Zeanah, C. H., Larrieu, J. A., Scheeringa, M., & Heller, S. S. (1998). Attachment disorders in infancy
and early childhood: A preliminary study of diagnostic criteria. American Journal of Psychiatry, 155, 295297.
Charles H. Zeanah, Michael Scheeringa, Neil W. Boris, Sherryl S. Heller, Anna T. Smyke, Jennifer Trapani (2004)
Reactive attachment disorder in maltreated toddlers. Child Abuse & Neglect 28 (2004) 877888. Institute of
Infant and Early Childhood Mental Health, Tulane University Health Sciences Center, 1440 Canal Street TB-52,
New Orleans, LA 70112, USA

References (contd)
Encyclopedia of Mental Disorders (Oct 28, 2013) Retrieved From:
http://www.minddisorders.com/Py-Z/Reactive-attachment-disorder-of-infancy-or-early-childhood.html
Genie : a psycholinguistic study of a modern-day "wild child", Curtiss, S, 1977, Academic Press
Gillberg, C. (2010) The ESSENCE in child psychiatry: Early Symptomatic Syndromes Eliciting Neurodevelopmental
Clinical Examinations Research in Developmental Disabilities 31(6), pp.15431551
Haugaard JJ, et al. Recognizing and treating uncommon emotional disorders in children and adolescents who have
been severely maltreated: Reactive attachment disorder. Child Maltreatment. 2004;9:154.
ICD-10 online, retrieved from: http://apps.who.int/classifications/icd10/browse/2010/en
Main, M. Adult Attachment Interview Protocol. Retrieved from
http://www.psychology.sunysb.edu/attachment/measures/content/aai_interview.pdf

Mat, G. (2004). When the body says no. Toronto: Vintage Canada.
Mash, E., & Barkley, R. (2003). Child Psychopathology (2 nd ed). The Guildord Press. New York, NY.

References (contd)
Minddissorders.com (October, 2013) retrieved from: (
http://www.minddisorders.com/Py-Z/Reactive-attachment-disorder-of-infancy-or-early-childhood.html#ixzz2j1w0LS
p2
)
Neufeld, G., & Mat, G. (2005). Hold on to your kids: why parents need to matter more than peers. Toronto:
Vintage Canada.
OConnor,T. G., Rutter, M.,&The English and Romanian Adoptees Study Team. (2000). Attachment disorder
behavior following early severe deprivation: Extension and longitudinal follow-up. Journal of the American
Academy of Child and Adolescent Psychiatry, 39, 703712.
Pritchett, R., Pritchett, J., Marshall, E., Davidson, C. & Minnis, H. (2013) Reactive Attachment Disorder in the General
Population: A Hidden ESSENCE Disorder, The Scientific World Journal, 2013
doi:
10.1155/2013/818157

Richters M. & Volkmar, F.R., 1994, Reactive Attachment Disorder of Infancy or Early Childhood Journal of
American Academy of Child and Adolescent Psychiatry. 33 (3) pp.328-332
Strange Situation Experiment retrieved from: http://www.youtube.com/watch?v=PnFKaaOSPmk
The Mayo Clinic (October, 2013) retrieved from:
http://www.mayoclinic.com/health/reactive-attachment-disorder/DS00988/DSECTION=prevention

References (contd)
Vervort, E., De Schipper, J.C., Bosman, G. & Verschueren, K. (2013) Screening symptoms of reactive attachment
disorder: evidence for measurement invariance and convergent validity International Journal of Methods in
Psychiatric Research 22(3): 256265 (2013)
doi: 10.1002/mpr.1395
Zeanah, C. H., Larrieu, J. A., Heller, S. S., Valliere, J., Hinshaw-Fuselier, S., Aoki, Y., & Drilling, M. (2001).
Evaluation of a preventive intervention for maltreated infants and toddlers in foster care. Journal of the American
Academy of Child and Adolescent Psychiatry, 40, 214221.