13 Reactive attachment disorder in adolescence

Reactive attachment disorder (RAD) has received increasing attention as a possible explanation of severe behavioral disturbances in children and adolescents. Its etiology is hypothesized as related to failure of attachment beginning in infancy. Although the diagnosis of reactive attachment disorder (RAD) is usually made in early childhood, the diagnosis may be carried over into adolescence. In some cases, the diagnosis may be made for the first time in adolescence if there is sufficient information in the history to make the diagnosis retrospectively. It is unlikely that the diagnosis of RAD can be made in the absence of comorbid diagnoses in adolescence because these children usually have symptoms which meet the criteria for other diagnoses, such as attention deficit disorder (ADHD), post-traumatic stress disorder (PTSD), oppositional defiant disorder (ODD), mood disorder, or conduct disorder (CD) by the time they become early or mid-adolescent ages. During development, additional diagnostic criteria for other DSM-IV diagnoses may be observed. Although a comorbid diagnosis of ADHD, ODD, and/or CD might appear to take precedence over RAD, with the burgeoning information in genetics it may be useful to know that RAD was present or may still be present in the symptom complex of an individual patient. This chapter presents an overview of the issues involved in nosology and possible etiology, with particular emphasis on neurobiology and genetics. Case vignettes are used to illustrate the challenges to treatment that these patients present. Definition and diagnosis The diagnostic criteria for RAD are primarily "a markedly disturbed and developmentally inappropriate social relatedness, in most contexts beginning before 5 years" of age, which is associated with pathogenic care (American Psychiatric Association, 2000, p. 130). Two types of RAD are described: (1) inhibited and (2) disinhibited. In the literature on RAD there are many descriptions and definitions. It seems appropriate, although possibly oversimplified, to state that the basic problem is a disturbance in the child-parent relationship, i.e., in social relatedness. The disturbance in social relatedness continues to be the defining feature of the disorder, despite evolution of the diagnostic criteria. Diagnostic criteria for RAD have changed across various editions of the Diagnostic and Statistical Manual of 160 John P. Kemph and Kytja K. S. Voeller Mental Disorders of the American Psychiatric Association. For decades "attachment" was synonymous with the infant-caregiver relationship. Subsequently, the diagnosis of RAD has come to apply to the child's appearing to have a disturbance in social relatedness to others. The term "reactive" is used in the sense that the condition is considered to be a reaction to "pathogenic care," which is defined as characterized by "persistent disregard for the child's basic emotional needs for comfort, stimulation and affection. " It is sometimes also associated with "a prolonged disregard for the child's physical needs" (American Psychiatric Association, 2000, p. 130). The constellation of behavioral and physical signs seen in infants with RAD include lack of a smiling response and lack of an auditory alerting response with head-turning towards the caregiver's voice, coupled with abnormal physical development such as failure to thrive with no apparent physical cause. Changes in successive editions of the DSM refiected a broadening of the diagnostic criteria and the age groups to which RAD could be applied. In DSM-III (American Psychiatric Association, 1980) the diagnosis basically applied to infants aged 8 months or less and, therefore, was limited in its application to older children. In the DSM-III-R (American Psychiatric Association, 1987) the age of onset was extended up to less than 5 years of age. Also, instead of a detailed list of symptoms, the criteria consisted of the presence of either of two patterns of social relatedness: (1) excessively inhibited, ambivalent interactions with others, and (2) indiscriminate social behaviors. A history of "grossly pathogenic care" was still a required criterion. DSM-IV (American Psychiatric Association, 1994) employed a more detailed description which took into consideration research findings which indicated that individual children respond in different ways to pathogenic care. Some may form selective attachments, while others may develop RAD in situations in which the care is not "grossly pathogenic. " Therefore, the term "grossly" was eliminated from the DSM-IV description of diagnostic criteria. There was no change in the RAD diagnostic criteria in DSM-IV-TR (American Psychiatric Association, 2000), and the two subtypes designated "inhibited" and "disinhibited" remained. Contributions from attachment research Early investigators observed infants who had been neglected, abused, or both, and developed hypotheses to account for the profound disturbances in development they saw. Spitz (1946) called the condition he observed "anaclitic depression in infants. " Bowlby (1982) considered the disorder a reaction to attachment and loss. Provence and Lipton (1962) made further observations on infants in institutions. Ainsworth, studying attachment in normal children, developed the "strange situation" procedure which assessed the child's response to a change involving the caretaker (1978). In the strange situation, the baby is exposed to two brief separations from its mother and a brief exposure to a stranger. Ainsworth observed "coherent" and "incoherent" patterns of response to this stressful situation. Infants with "coherent" responses fell into three subtypes: "secure type" Reactive attachment disorder in adolescence 161 infants communicated interactively with their mothers and were able to use the mother as a secure base for exploration. The other two coherent subtypes were described as "insecure avoidant" and "insecure resistant. " Infants manifesting an "incoherent response" showed evidence of disorganized attachment, defined as freezing, appearing fearful in the presence of the mother, engaging in stereotypy and "contradictory behavior. " Subsequent research has shown that attachment patterns formed in infancy tend to be stable over time, even into adulthood (Waters et al., 2000), although they are subject to change in response to the vicissitudes of development. The relationship between various types of attachment and psychopathology is complex, and empirical research in this area is still in its early stages. Disorganized attachment has been associated with aggression and disruptive behavior later in development (Lyons-Ruth, 1996) and with dissociative symptoms (Ogawa, Stroufe, Weinfield, Carlson and Egeland, 1997). While youngsters who do not have attachment disorders are likely to be securely attached, those who have disorganized attachments do not necessarily develop attachment disorders (Boris et al., 2004). There have been few studies on the reliability of RAD diagnoses. Using their own diagnostic criteria, which differ slightly from those of the DSM, researchers in infant psychiatry have been able to demonstrate that attachment disorders can be reliably diagnosed in high-risk samples of young children (Boris et al., 2004). Overlap with other disorders RAD can be confused with other disorders. Some children with disturbances in social relatedness have communication problems that can be classified as a language disorder. Presumably the longer the child is deprived of normal language stimulation, the more severe the communication problem becomes. Richters and Volkmar (1994) suggest that, when communication problems are present, the diagnosis should be considered one of atypical development rather than a disorder of attachment, per se. Children with RAD may become disruptive and disorganized with poor affect regulation and poor frustration tolerance, as well as inattention, impulsivity, and hyperactivity. By the time these children reach adolescence, they have often accumulated numerous comorbid diagnoses such as ADHD, and/or ODD, and/or CD, and/or PTSD. Also, one of the several mood-disorder diagnoses may be associated with RAD. The following two case vignettes are examples of adolescents with RAD.