Reactive attachment disorder

Introduction

Reactive attachment disorder is a rare but serious mental health condition in which infants and young children don't establish healthy bonds to parents or caregivers. Children with reactive attachment disorder typically were neglected or abused in infancy, passed through many foster homes, or lived in orphanages where their emotional needs weren't well met.

Because their basic needs for comfort, affection, nurturing and stimulation weren't met, these infants and children didn't learn how to create loving and caring attachments with other people. They can't give or receive affection.

Reactive attachment disorder is often enmeshed in controversy. Both its diagnosis and treatment are difficult, and parents and caregivers are commonly distressed as they try to cope with the disorder and a seemingly uncaring child. Some nonconventional treatment methods have been associated with the deaths of several children, escalating the controversy. Despite the challenges, a commitment to proven psychiatric treatment may help these children enjoy a better quality of life and develop more stable relationships.

Signs and symptoms

Reactive attachment disorder is broken into two types — inhibited and disinhibited. While some children have signs and symptoms of just one type, many children have both.

Inhibited type
In inhibited reactive attachment disorder, children shun relationships and attachments to virtually everyone. This may happen when a baby never has the chance to develop an attachment to any caregiver.

Signs and symptoms of the inhibited type may include:

• Resisting affection from parents or caregivers
• Avoiding eye contact
• Appearing to seek contact but then turning away
• Difficulty being comforted
• Preferring to play alone
• Avoiding physical contact
• Failing to initiate contact with others
• Appearing to be on guard or wary
• Engaging in self-soothing behavior

Disinhibited type
In disinhibited reactive attachment disorder, children form inappropriate and shallow attachments to virtually everyone, including strangers. This may happen when a baby has multiple caregivers or frequent changes in caregivers.

Signs and symptoms of the disinhibited type may include:

• Readily going to strangers, rather than showing stranger anxiety
• Seeking comfort from strangers
• Exaggerating needs for help doing tasks
• Inappropriately childish behavior
• Appearing anxious

A word of caution
Not all experts agree on the signs and symptoms of reactive attachment disorder. Some attachment therapists use checklists with numerous nonspecific signs and symptoms that go well beyond what the American Psychiatric Association includes in its definition of the disorder. Be cautious when trying to interpret checklists that include such symptoms as lack of eye contact, rage, aggression, lying, stealing, hoarding food, an apparent lack of a conscience, nonstop chatter, and a desire to wield control. These nonspecific symptoms are difficult to apply to any one diagnosis.

Causes

Most children are naturally resilient, and even those who have been neglected, have lived in orphanages or have had multiple caregivers develop healthy relationships and strong bonds. It's not known what causes some babies and children to develop reactive attachment disorder. But a variety of theories about attachment may help explain some of the emotional processes that give rise to the disorder.

Traditional attachment theory says that to feel safe and develop trust, infants and young children need a stable, nurturing environment. Their basic emotional and physical needs must be consistently met. In addition, interactions with babies must be caring and positive, not harsh or negative. For instance, when a baby cries, his or her need for a meal or a diaper must be met promptly with a shared emotional exchange that may include eye contact, smiling and caressing.

A child whose bottle is propped up on his or her chest to self-feed or whose diaper is changed roughly without kind words and warm facial expressions may feel rejected and insecure. When this happens repeatedly, the baby learns that he or she can't rely on adults for nurture and love. The baby becomes distrustful and unattached. Babies who seek comfort from a caregiver but are met with hostility or abuse become confused and conflicted — wanting closeness but turning away from it for fear of rejection or harm.

Some attachment theories suggest that emotional interactions between babies and caregivers actually shape neurological development in the brain. They say that interactions cause the formation of neural networks within the brain that ultimately influence a baby's personality and relationships throughout life. In babies whose needs aren't met with caring and love, these neural networks don't form properly, creating attachment problems.

Risk factors

Reactive attachment disorder is considered uncommon. However, there are no accurate statistics on how many babies and children have the condition. It can affect children of any race or either sex. By definition, reactive attachment disorder begins before age 5, although its roots start in infancy.

Factors that may increase the chance of developing reactive attachment disorder include:

• Living in an orphanage
• Institutional care
• Frequent changes in foster care or caregivers
• Inexperienced parents
• Prolonged hospitalization
• Extreme poverty
• Physical, sexual or emotional abuse
• Forced removal from a neglectful or abusive home
• Significant family trauma, such as death or divorce
• Postpartum depression in the baby's mother
• Parents who have a mental illness, anger management problems, or drug or alcohol abuse

When to seek medical advice

If you think your baby or child may have reactive attachment disorder or you feel that a strong bond isn't developing, consider seeking a medical or psychological evaluation.

Consider getting an evaluation if your baby or child:

• Prefers not to be held
• Usually likes to play alone
• Doesn't seek out physical contact
• Avoids you
• Will readily go to strangers
• Seems uninterested in you

Screening and diagnosis

A thorough medical and psychological evaluation is in order when it's thought that a baby or child may have reactive attachment disorder. The disorder can be similar to other disorders, including autism, developmental disorders, social phobia, conduct disorders and attention-deficit/hyperactivity disorder. In fact, a child with reactive attachment disorder may also have other disorders as well.

A complete and thorough evaluation should include:

• The baby's or child's pattern of behavior over time
• Examples of behavior in a variety of situations
• The baby's or child's relationship with parents or caregivers as well as others, including other family members, peers, teachers and child care providers
• The home and living situation
• Parenting and caregiver styles and abilities

To be diagnosed with reactive attachment disorder, a baby or child must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

The main criteria for the diagnosis of reactive attachment disorder include:

• Disturbed and developmentally inappropriate social relationships beginning before age 5
• Failure to respond to or initiate social interactions, or being inappropriately friendly and familiar with strangers
• Failure of early care to meet the baby's or child's emotional needs for comfort and affection, failure of early care to attend to the child's physical needs, or repeated changes in the primary caregiver

Consider getting a second opinion if you have questions or concerns about the diagnosis or treatment plan.

Complications

Without treatment for reactive attachment disorder, a child's social and emotional development may be permanently affected.

Complications and related conditions may include:

• Developmental delays
• Malnutrition
• Eating problems
• Growth delays
• Relationship problems in adulthood
• Drug and alcohol addiction
• Depression
• Anxiety
• Unemployment or frequent job changes
• Academic problems
• Aggression
• Inappropriate sexual behavior
• Lack of empathy
• Temper or anger problems
• Bullying or being bullied
• Trouble relating to classmates or peers

Treatment

Treatment of reactive attachment disorder often involves a mix of psychotherapy, medications and education about the disorder. It may involve a team of medical and mental health providers with expertise in attachment disorders. Treatment usually includes both the baby or child and the parents or caregivers.

Goals of treatment are to help ensure that the baby or child has a safe and stable living situation and that he or she develops positive interactions with parents and caregivers. Treatment can also boost self-esteem and improve peer relationships.

There's no standard treatment for reactive attachment disorder. However, it often includes:

• Individual psychotherapy
• Recreation therapy or occupational therapy
• Family therapy
• Education of parents and caregivers about the condition
• Parenting skills classes
• Medication for other conditions that may be present, such as depression, anxiety or hyperactivity
• Residential or inpatient treatment for children with more serious problems or who put themselves or others at risk of harm
• Special education services

Because symptoms of reactive attachment disorder can last for years, treatment may be long term. Parents and caregivers also may want to consider seeking professional treatment or counseling for themselves or other family members to help cope with the stress of having a child with reactive attachment disorder.

Nonconventional treatments
Some forms of treatment of reactive attachment disorder remain highly controversial, and this has heightened in the last several years after the deaths of several children were attributed to these methods. Some of these methods are sometimes called re-parenting, re-birthing, and compression or holding treatment, and they often involve physical restraint. However, not all of these methods are used the same way by all practitioners.

The American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, and the American Professional Society on the Abuse of Children have all denounced as dangerous and unproven any practices that involve tightly wrapping, binding or holding children while forcing eye contact, intentionally triggering a rage, or ignoring pleas about breathing difficulties.

Prevention

While it's not known if reactive attachment disorder can be prevented with certainty, there may be ways to reduce the risk of its development.

• If your baby or child has a background that includes orphanages or foster care, educate yourself about attachment and develop specific skills to help your child bond.
• If you lack experience or skill with babies or children, take classes or volunteer with children so that you can learn how to interact in a nurturing manner.
• Be actively engaged with babies and children in your care by playing with them, talking to them, making eye contact or smiling at them, for example.
• Learn to interpret your baby's cues, such as different types of cries, so that you can meet his or her needs quickly and effectively.
• Don't miss opportunities to provide warm, nurturing interaction with your baby or child, such as during feeding, bathing or diapering.
• Teach children how to express feelings and emotions with words. Lead by example, and offer both verbal and nonverbal responses to the child's feelings through touch, facial expressions and tone of voice.
• If you're an adult with attachment problems, it's not too late to get professional help. Getting help may prevent you from having attachment problems with your children, who otherwise may also be at risk.

Coping skills

If you're a parent or caregiver whose baby or child has reactive attachment disorder, it's easy to become angry, frustrated and distressed. You may feel like your child doesn't love you — or that it's hard to like your child sometimes.

You may find it helpful to:

• Join a support group to connect with others facing the same issues
• Find respite care so that you can periodically have downtime if caring for your child is particularly troublesome
• Be willing to call for emergency help if your child becomes violent
• Continue friendships and social engagements
• Practice stress management skills
• Acknowledge that the strong or ambivalent feelings you may have about your child are natural
• Take time for yourself through hobbies or exercise
• If your child was adopted, reach out to your adoption agency for attachment resources