Reactive Attachment Disorder

Markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before 5 years

Aetiology

  • Associated with grossly pathological care
    • Persistent disregard for the child's emotional needs for comfort, stimulation and affection
    • Persistent disregard for the child's physical needs
    • Repeated changes of the primary caregivers
  • As a result of this the child has difficulty forming lasting, loving, intimate relationships
  • Accounts for 1% of all children under 5, about 20% of Looked After Children

Risk factors

  • Adverse childhood experiences - abuse, neglect, household dysfunction
  • Increased likelihood if child is orphaned at a young age

Pathophysiology

Subtypes of RAD

Inhibited
  • Refers to children who continually fail to initiate and respond to social interactions in a developmentally appropriate way
  • Interactions are often met with a variety of approaches - avoidance, resisting comfort, hypervigalant or highly ambivalent
  • Example: a child or infant that does not seek comfort from a parent or caregiver during times of threat, alarm, or distress
Disinhibited
  • Refers to a child who has an inability to display appropriate selective attachments
  • Also known as Disinhibited Social Engagement Disorder (DSED)
  • More enduring over time than inhibited subtype
  • Example: a child who displays excessive familiarity with strangers, indiscriminate sociability or lack of selectivity in their choices of attachment figure

Neurobiology

  • Childhood experiences interact with genetics to change the structure of the brain and cause behavioural change
  • Life experiences can dramatically alter the number of neurons, increase or decrease the dendritic branches and the number of synapses
  • In particular, experiences can determine how emotional centres of the brain communicate with the cortex and its higher functioning

Co-morbidity

  • About 50% of children with RAD meet the criteria for one or more co-morbid disorders - emotional disorders, ADHD, behavioural disorders

Clinical presentation

  • Noticable neglectful behaviour by the primary caregiver
    • Not comforting baby or child in distress
    • Not responding to needs e.g. hunger, dirty nappy
  • Inappropriate interaction noticed between the baby or child and the primary caregiver
  • Lack of smiling or responsiveness in the baby or child
    • Does not seek attention or comfort, or resorts to extreme measures to gain attention
    • Rejection of demonstrations of comfort
    • Avoidance of touch or gestures of affection
  • Lack of distress in situations which would be expected to cause distress
  • Indiscriminate, excessive friendliness towards healthcare workers
  • Inconsolable crying
  • Emotional and behavioural difficulties
  • Medical signs can include: malnutrition, growth delay, evidence of physical abuse, vitamin deficiencies, or infectious diseases

Differential diagnosis

  • Conduct disorder - children with CD are able to form some satisfying relationships with peers and adults
  • Depression - depressed children are often able to form appropriate social relations with those who reach out to them
  • ASD - children with ASD present historical and pervasive difficulties, while children with RAD are more able to adapt based on what they get out of certain relationships
    • There is considerable overlap between RAD and ASD - the Coventry Grid can be used to help differentiate between the two
  • ADHD - children with ADHD are more able to initiate and maintain relationships

Investigations

  • Strange Situation - 1-2 years
  • Modified Strange Situation - 2-4 years
  • Attachment Q-sort - 1-4 years
    • Children observed in a number of set environment
  • Story Stem Attachment Profile - 4-7 years
    • Stories with stressful scenarios involving a child and their parents and the children complete them verbally or using toys to enact the story
  • Child Attachment Interview (7-15 years) or Adult Attachment Interview (15 years +) - child asked to describe their relationship with caregivers in various situations

Management

Pre-school

  • Video feedback programme for parents, foster carers, guardians or adoptive parents
  • Parental sensitivity and behaviour therapy
  • Home visiting programmes
  • Parent-child psychotherapy for those who have been or are at risk of maltreatment

School age

  • Parental sensitivity and behaviour training
  • Intensive training and support for foster carers, guardians and adoptive parents
  • Group play sessions - children of primary school age
  • Group-based educational sessions for caregivers and children/young people - late primary school or early secondary school age
  • Trauma-based CBT for those who have been maltreated

Prognosis

  • Onset can be detected as early as 2 months - considerable improvement or remission is possible if the child experiences an appropriately supportive environment
  • If not dealt with early:
    • Developmental delay
    • Reduction in academic achievement - withdrawal, disruptive behaviour, difficulties with relationships
    • Increased risk of contact with youth justice