Download Reactive Attachment Disorder:

Attachment and Bonding:
Clinical Implications
Marolyn Morford, Ph.D.
Ph.D.
Sarah Kollat,
Private Practice
Penn State University
State College, PA
University Park PA
CPPA Fall Workshop, September 13, 2014
Main Points
 Attachment
research examines the nature
of ties between a very young child and
caregiver
 The term attachment has been
overextended by population and age when
it is better described as “bonding”
 Attachment treatment follows a separate
path unrelated to research, trying to bridge
a gap between what are emerging
knowledge and real clinical problems
Attachment – Normal
Development
'Attachment system'
The behaviors and physical features and
behaviors of the infant that keep the
caretaking adult near and attending
Includes response preferences of infant that
can begin prior to birth
Essential for survival, biologically based
Closely related to the 'fear system',
activated by threats
Critical Nature of Attachment
 Importance
to survival of young and
of species
 Resilience of critical, adaptive
functions
 Attachment & attachment behaviors
are such a basic survival skill, only
the most extraordinary cases of
extreme deprivation result in no
attachment behaviors developing
 A child is not “unattached”: Children
vary in whether they are securely or
insecurely attached and to whom
Young Child Attachment
“Strange Situation”
Secure – Calm on separation, greets
mother on return: 65%
Ambivalent/resistant – Distress/unsettled
at separation; angry/passive on return: 4050% of children in a low risk sample (Zeanah,
1996)
Avoidant - Active exploration, no checking
with mother; little response to absence or
return of mother: 20% in nonclinical
sample
Disorganized - Little goal-oriented behavior,
Extension from very young children to older
children & adults
Adult Attachments (Bonding)
Self-report, interview, ex.,
http://www.psychology.sunysb.edu/attachment/measur
es/content/aai_interview.pdf
Four main, similar styles of attachment have
been identified in adults:




Secure (~65%)
Anxious–Preoccupied (~15%)
Dismissive–Avoidant ]
Fearful–Avoidant
] (~20%)*
Ein-Dor et al. 2004, for summary
 If
the rate of occurrence of an attribute or
behavior is this high in a nonclinical (20%)
or low risk population (40-50%), can we
confidently say we are talking about a
disorder?
 Could these be normal variants in
response?
Attachment Paradox
Could there be some survival advantage to
an event that is so prevalent in the
population? Is that which is interpreted as
dysfunctional for the individual, protective
for the group?
Benefits to practioners
Deprivation Outcomes
 While
there is some research to suggest
that neglectful and abusive parenting can
be related to externalizing or more
impulsive behaviors in a small proportion
of children, there is no evidence to suggest
that this alone impairs young children’s
ability to form bonds.
Deprivation Outcomes
 More
importantly, there is absolutely NO
evidence that interventions focused on
forcing bonds to form will reduce
externalizing behaviors. Therefore, difficult
children may not be made less difficult by
improving a bond or creating attachmentlike behaviors.
Attachment Dx Categories
Located in DSM 5's Trauma- and Stressor
Related Disorders*:
Reactive attachment disorder
NEW: Disinhibited social engagement disorder
*This category also includes Post traumatic
stress disorder, Acute stress disorder,
Adjustment Disorders.
Differential Dx/Co-occuring
Developmental delays, esp. language and
cognition, stereotypies, other signs of
severe neglect (malnutrition)
DSM-5 Reactive Attachment D/O
313.89/F94.2
Prevalence: Rarely seen in clinical settings;
found in institutions and in severe
neglect/abuse before foster placement.
Even in populations of severe neglect, less
than 2% to 10% of these children (DSM5).
Reminder: This indicates resiliency in the
majority of children!
DSM-5 DIAGNOSTIC CRITERIA FOR
REACTIVE ATTACHMENT DISORDER
313.89/F94.1
A consistent pattern of inhibited, emotionally
withdrawn behavior toward adult
caregivers, rarely or minimally seeks
comfort or responds to comfort when
distressed
DSM-5 DIAGNOSTIC CRITERIA FOR
REACTIVE ATTACHMENT DISORDER
313.89/F94.1
A persistent social and emotional
disturbance characterized by at least 2 of
the following:
•Minimal social and emotional
responsiveness to others
•Limited positive affect
•Episodes of unexplained irritability,
sadness, or fearfulness which are evident
during non-threatening interactions with
adult caregivers
NEW: Disinhibited Social Engagement
Disorder DSED 313.89/F94.2
Actively approaches and interacts with
unfamiliar adults, exhibiting two or more:
reduced reticence approaching and
interacting with unfamiliar adults, overly
familiar verbal or physical behavior in
contrast to age- and culturally appropriate
behaviors, diminished checking back with
caregivers, or willingness to go off with
unfamiliar adult
Both Reactive Att Disorder and
DSED require
Evidence of at least one re: prior care Social neglect or deprivation - persistent
lack of having basic emotional needs for
comfort, stimulation, and affection met by
care-giving adults.
Repeated changes of primary caregivers,
limiting opportunities to form stable
attachments
Rearing in unusual settings that severely
limit opportunities to form selective
Additionally, the child does not meet criteria
for Autism Spectrum Disorder, the
disturbance is evident before age 5, and
the child has a developmental age of at
least 9 months
Serious social neglect is the only known risk
factor for both of these disorders, yet the
majority of such children DO NOT develop
the disorder; Prognosis depends on quality
of caregiving environment following
serious neglect. (DSM 5)
The different editions of DSM consistently
have described these disorders as rare
and have suggested that they are more
often seen in those who have been reared
in deprived, institutional settings.
DSM-5 (APA, 2013) notes that fewer than
10% of children who have been severely
neglected develop RAD, and about 20%
develop DSED (also see Gleason et al.,
2011).
http://www.nasponline.org/publications/cq/42/8/dsm5.aspx
Larger Problem
 When
.
our questions exceed our answers. .
Overextending a concept
 Diagnosis:
Reactive Attachment Disorder,
or “RAD” is a label that has been applied
to many children in the past 10 years, esp.
adopted and foster children
 Treatment: “Specialized” treatments and
“centers” have emerged to work
specifically with children with this label
 Qualified
clinicians become unnecessarily
conservative and shy away from
challenging child cases, assuming there is
a sound basis for the ‘new’ clinical
population and ‘treatments’
 Other clinicians, lacking training (clinical or
empirical) try valiantly to meet the need
Problem: Diagnosis & Treatment
Misapplication of the term occurs often
(overextension)
 DSM-IV or DSM 5 definitions are not
widely disseminated

Problem: Diagnosis &
Treatment
Importance of evaluation of validity and
effectiveness of proposed treatments
Inappropriate or ineffective treatments exist
to treat a questionably applied diagnostic
label
Contributing to the Problem:
 Misattribution
of causality
 Post hoc reasoning
 Confirmation bias
 Single cause assumption (quest for a
Unified Theory)
Criteria for Diagnostic Category
 An
observable, operational definition that
anyone can use and agree with others in
its application
 Distinct from other categories (mutually
exclusive)
 And has predictive utility: We know other
things about the person based on the
application of this category
 Overextension
of a term
 Misattribution of causality
 Post hoc reasoning
 Confirmatory bias
 Single cause assumption (Quest for
“Unified theory”)
 “RAD”
is an example of a label
overextended by some to MANY difficult
behaviors
 Giving the term weak distinguishing or
predictive power
Examples
Oppositional, impulsive, destructive, lies &
steals, is aggressive, hyperactive, selfdestructive, cruel to animals, sets fires, as
poor hygiene, avoids touch, has toileting
problems, is accident prone, high pain
tolerance
Persistent nonsense questions and
incessant chatter
Phony, Great theatrical displays
Sexually act out at a very young age
(seductive clothing, sexual to other children
and animals)”
RAD label also overextended to
caretakers

Some groups include caregiver “symptoms” in
“diagnosis”:
 Feel isolated and depressed.
 Feel frustrated and stressed.
 Are hypervigilant, agitated, have difficulty
concentrating.
 Are confused, puzzled, obsessed with finding
answers.
 Feel blamed by family, friends, and
professionals.
 Feel helpless, hopeless, and angry.
 Feel that problems are minimized by the
helping profession. (Institute for Attachment,
Problems with overextension
 Those
labels do NOT appear in the criteria
for Reactive Attachment Disorder, old or
new
 Some of the labels DO appear in other
diagnostic categories that are better
applied to such children
 These labels are not clinical and are
dangerous in how they make adults think
and feel about the children in their care
 Such
labels can apply to many types of
individuals with their own histories and
problems and do NOT indicate attachment
problems
 Such labels can apply to the parents of
many difficult-to-raise children, including
those with chronic physical health
problems
Controversy about RAD
Diagnosis
Reliability? Not applied consistently by
independent clinicians
 An overfocus on the preconditions (foster
care, adoption) instead of symptoms
 Loss of precision,e.g., when aggression
or defiance = aberrant attachment behs
 Untested alternative therapies are
developed and implemented with no or
problematic results (AACAP Practice Parameters,

JAACAP (2005).
What do different types of
attachment predict?
 Insecure
attachment creates risk for
problems but alone does not cause
problems


In low risk families, less relation between
insecure attachment & later externalizing
problems
In high risk families, more likely relation
between insecure attachment & peer
problems, moodiness, depression &
aggression (Greenberg, 1999)
But…
What are we labelling as “attachment”?
Couldn’t such a large segment of the
population without extreme neglect history
be explained by normal variance and
temperament, among other possibilities?
So…if it’s not RAD, what is it?
Or...
Reframing (and correctly
diagnosing) to reduce fear and
encourage competence in child
and caregiver

OCD
 Depression
 Oppositional Defiant
Disorder
 Conduct Disorder
 Impulse Control
Disorder
 Disruptive Behavior
Disorder
 Generalized Anxiety
Disorder
 Separation Anxiety
Disorder
 Post-traumatic Stress
Disorder
 Pervasive
Developmental Disorder






Asperger’s Disorder
AttentionDeficit/Hyperactive
Disorder
Adjustment Disorder
with Mixed Disturbance
of Emotions and
Conduct
Developmental Delay
(especially cognitive
and language)
Normal Development,
Caretaker-child
Temperament mismatch
Normal Development,
Adaptive behavior
And…
NEW: Disruptive Mood Dysregulation
Disorder, DMDD, 296.99/F34.8
(Depressive Disorders):
Severe recurrent temper verbal or
behavioral outbursts grossly out of
proportion in intensity or duration to
context, inconsistent w/developmental
level, 3+/week.
Mood between episodes is persistenly
irritable or angry nearly every day and
observables by others, not just family, in
at least 2 settings
What we know about diagnosis
 The
term “Reactive Attachment Disorder”
has been applied to a wide range of
behaviors that can be captured more
appropriately with other, existing
diagnostic categories, including 2 new,
more discriminating categories in DSM5
 The
“problem” behaviors may originate
from other causes:
 The child’s genetic or temperamental
tendencies
 The foster/adoptive parent’s
expectations
 The child’s early experiences and
expectations
 Cultural expectations/mismatch
(Rothbaum et al., 2000)
 Other parenting factors
Resilience:
Our goal for any child who has
encountered risks
Defining Resilience
Masten's (2001):
Good outcomes despite serious threats to
adaptation or development
Need for demonstrable risk
Defining Resilience
Can also view it as a diagnosis
Examine Risk Level and Competence Level
Highly vulnerable
Competent
Maladaptive
Resilience
Defining Resilience
Risk Level
Competence Level
Low
High
Low
Highly
vulnerable
Competent
High
Maladaptive
Resilient
Defining Resilience
But what are “good outcomes”?
What does it mean to “do well”?
External Criteria
Masten (2001): “Meeting the major expectations
of a society for the behavior of children of
that age and situation”
These are Salient Developmental Tasks
Defining Resilience
What are salient developmental tasks?
Of childhood?
Of adolescence?
Of adulthood?
Defining Resilience
Internal Criteria
Psychological well-being
Low levels of symptoms
Which is more important to defining
resilience?
External
Internal
Old View of Resilience
Only a few children possess remarkable or
extraordinary strength to overcome
difficulties
Superchildren
New View of Resilience (based
on empirical studies)
“Ordinary Magic”
Resilience is fairly common
Resilience likely to occur if basic systems are
in “good working order”
Basic Systems
What are these BASIC SYSTEMS?
Masten (2001)
Small set of global factors
Connections to caring adults
Cognitive and self-regulation skills
Positive self-views
Motivation
Basic Systems
Why are these systems so important?
What does this imply about interventions for
at-risk children?
Adoption and Resilience
Studying adopted populations presents
many challenges
Variance in the adoptee’s circumstances (Foster
care system, kinship adoption, international
adoption, sibling group adoption, etc.)
Variance in the age of the child at adoption
Variance in the adoptive family’s circumstances
(e.g., presence of biological children, singleparent family, etc.)
Adoption and Resilience
As a result, it is difficult to apply the findings
of specific studies to all adopted children
What do we seem to know?
Early adoption (within first year of life) yields
fewer symptoms
Deprivation early in life can have lasting impacts
on neurological development
Many children improve in their symptoms over
time after placement
Adoption and Resilience
BUT. . .The vast majority of adopted children
develop within the normal range (Palacios &
Brodzinsky, 2010)
How can we help to support normal
development in these children?
Adoption and Resilience
Fostering Resilience: A Mother’s Perspective
Treat specific symptoms
Before that, be certain that these are relevant
symptoms
“Adopted” as a label
Biases that can occur
Ignoring of natural variance in human behavior
Reducing children to one facet of their history and
self
Adoption and Resilience
Although a child’s history offers context that can
aid in understanding their symptoms, we
must be careful to not see their history as a
symptom itself
The mantra still applies:
Each client is a study of one!
Adoption and Resilience
Normalizing remains a strong clinical tool
Adoptive parents need healthy and reasonable
expectations for their relationship with their
children
Attachment will not emerge immediately
Children will revisit and process their experiences in
their birth home/family and/or institution
Parents will not be experts of their children
immediately. . .and that is okay
Adoptive Parents: What to Expect
Attachment will not emerge immediately
Children will revisit and process their
experiences in their birth home/family and/or
institution
Rose-colored glasses
Parents will not be experts of their children
immediately. . .and that is okay
Children will want to understand their origins
This does not mean your relationship with them is
lacking!
Adoptive Parents: What to Expect
Sticks and stones. . .
Be aware of normal developmental changes
Physical
Cognitive
Emotional / Social
Remember: All families struggle, and all families
have reasons to rejoice
Struggles offer the opportunity for specific,
targeted intervention that are evidencedbased
What we know about treatment
 There
is no one treatment (no silver
bullet) for the myriad of problems that are
described in popular discussions of
reactive attachment disorder
Treatment focuses on
 The
problem behavior (one at a time)
 The bond


What are the caregiver’s thoughts about the
child and expectations about the relationship?
The child often has no problems with
attachment; the problem is s/he is not
attached to the presenting caregiver.
 … A friend
reaching for my 18 mo. old
[adopted] daughter asked: “Does she go to
strangers?”
 “Of
course,” I answered, “She’s living with
strangers.”
From L. Melina Raising Adopted Children, Harper Collins, 1998.
 Treatments
should be symptom focused.
 Known effective interventions for the
troubling behaviors are required:
behavior therapy
 cognitive therapy
 family education
 parent training
 as needed, pharmacological approaches

 Beware



of:
Damaging, unproven, coercive “therapies”
Magical thinking involving regression
methods
Ineffective treatments that waste limited
resources and precious time in a child’s young
life
American
Professional Society on the Abuse of
Children (APSAC) Statement
Traditional attachment theory holds that
caregiver qualities are key, such as
 Environmental stability
 Parental sensitivity
 Responsiveness to children’s physical and
emotional needs
 Consistency and a safe and predictable
environment support the development of
healthy attachment
 From
this perspective, improving these
positive caretaker and environmental
qualities is the key to improving
attachment and bonds
CHILD MALTREATMENT
Vol. 11, No. 1, February 2006 76-89
 We
can treat these children most
effectively if we have the assistance of the
caregiver and other adults spending time
with the child.
 We must recognize and address the
emotional and psychoeducational needs of
the caregiving adult as well as the child.
Problems with
“Attachment Therapy”
Lack of informed consent to treatment -where is the advocate for the child?
 No link between attachment research and
current popular treatments
 Illogical and invalid concepts, e.g., that children
must release rage or regress to infancy before
they can be loving
 Unethical targeting of adoptive and foster
parent audience
 Often unlicensed practitioners
 Creation of adult fear of child & erosion of
caregiver confidence

Problems, cont.
 Lack
of understanding of child’s
developmental needs
 Lack of understanding of child’s adaptation
process
 Expectation of immediate bonding and
interpretation of resistance as “attachment
disorder”
 Physically and emotionally intrusive,
thereby retraumatizing an abused or
neglected child and delaying development
What treatment is recommended?
 Treat
the behavior and the bond (not the
same issue)
 If presented with a child with a history of
attachment disruption, do not immediately
assume treatment is necessary. Base
interventions on symptom presentation:
What behaviors are troubling to the child &
the caregiver?
 Do think about the caregiver-child
Recommended approaches focus
on caregiver behaviors
 Give
the child (a sense of) more control,
don’t take control away from the child. Do
give control in areas the caregiving adult is
comfortable with (give child benign
choices).
 Enhance the sensitivity of the adoptive
parent to the child rather than the child to
the parent (Dozier et al., 2002)
 Help the adult articulate what they want
out of this relationship and help them
Reduce caregiver’s expectation for rapid
change and increase their acceptance of
the child’s basic temperament and
developmental needs (Dozier et al. 2002)
 Unlink the contingency between the child’s
behavior and the permanency of the
placement
 Emphasize positive reinforcement and
positive exchanges of affection on the
child’s terms, rather than the parents’ (Speltz,

2002, Dozier, et al. 2002).
Treat the relationship

Teach caregiver how to interact with child,
to encourage bonding, cooperation,
addressing child’s developmental level &
emotional needs, using positive verbal
comments, planned ignoring, teaching
parent how to implement child directed
interactions and parent directed
interactions (Dozier, et al., 2002; Eyberg &
McNeill, 2003; Webster-Stratton & Hancock,
1998)
Treat the relationship
 Increase
the caregiver’s competence
and confidence through training: Start
small

Teach caregiver behavior therapy with
child, including behavior substitution,
differential reinforcement of incompatible or
other behaviors, anxiety reduction
techniques, such as gradual exposure,
anxiety hierarchy and related treatments
Treat the relationship, cont.

Cognitive behavior therapy in the family
context to assist with parental reframing,
negative cognitions, expectations, and
problem solving (W-S & H): Examine the
thoughts the caregiver is having about the
child & doubts about their own parenting
ability: “You can parent this child.”


Teach parent how to implement positive
behavior management in home providing
consistent rewards for appropriate behaviors
(W-S&H, E&M, Barkley): for ex., giving
attention for the positive behaviors the child is
able to do, rather than for the failures
Provide skill instruction with child for
emotional regulation (e.g., anger
thermometer) and social skills deficits,
including teaching child how to give parent
positive feedback
Participant clinical examples
Summary
Attachment research has moved beyond the
biological basis of infant and caretaker
interactions and extended to older age
groups and populations, altering the clarity
of the term that bonding might describe
Some groups have extended the term to and
created interventions for a broad range of
behaviors better described by known
problems with effective treatments
Both researchers and some working
professionally with children, especially
those children in foster care or adopted,
do not address the very strong role
resilience plays in growth and
development
 We
can
 Be rigorous and curious in our use of
diagnoses and treatments provided to
children, especially those who have no
other advocates, as well as their families


Be confident in providing treatment that
is tailored to the specific problem
Educate families and professionals to
resist the tendency to pathologize or
predict a child’s future from her/his
current behavior or past
Treat the relationship/bond between the
parent and child, recognizing the
responsibility for the interaction weighs
more heavily to the adult caretakers
Remember the primary factor as the
resilience of children (and adults).
Resources
for parents & therapists
 www.help4adhd.org
(‘Diagnosis & Trtmt’
link)
 www.chadd.org
 www.effectivechildtherapy.com
(‘Learning Center’ link)
 www.promisingpractices.net
 http://www.apa.org/pi/cyf/cyfnews.html
 www.bpkids.org
 www.cachildwelfareclearinghouse.org
Parent Training Programs:
 www.pcit.org
 www.incredibleyears.com
 www.triplep-america.com
 Trauma focused: www.tfcbt.musc.edu