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Home , Attachment disorder, Nosology

CASE STUDY

Reactive Attachment Disorder of Infancy or Early Childhood

MARGOT MOSER RICHTERS, PH.D., AND FRED R. VOLKMAR, M.D.

ABSTRACT Since its introduction into DSM-Ill, reactive attachment disorder has stood curiously apart from other diagnoses for two reasons: it remains the only diagnosis designed for infants, and it requires the presence of a specific etiology. This paper describes the pattern of disturbances demonstrated by some children who meet DSM-Ill-R criteria for reactive attachment disorder. Three suggestions are made: (1) the sensitivity and specificity of the diagnostic concept may be enhanced by including criteria detailing the developmental problems exhibited by these children; (2) the etiological requirement should be discarded given the difficulties inherent in obtaining complete histories for these children, as well as its inconsistency with ICD-10; and (3) the diagnosis arguably is not a disorder of attachment but rather a of atypical development. J. Am. Acad. Child Adolesc. ,1994, 33, 3: 328-332. Key Words: reactive attachment disorder, maltreatment, DSM-Ill-R

Reactive attachment disorder (RAD) was included in social responsiveness, apathy, and onset before 8 DSM-III in 1980 (American Psychiatric Association, months. Only one criterion addressed the quality of 1980), reflecting an awareness of a body of literature mother-infant attachment. on the effects of deprivation and institutionalization Several aspects of the definition were unsatisfactory on infants and young children (Bakwin, 1949; Bowlby, (Rutter and Shaffer, 1980), and substantial modifica- tions were made in DSM-III-R (American Psychiatric 1944; Provence and Lipton, 1962; Rutter, 1972; Skeels Association, 1987): the age of onset was raised to age and Dye, 1939; Skuse, 1984; Spitz, 1945; Tizard and 5 years, consistent with data on the development of Rees, 1975). Multiple terms have been used to refer selective attachments (although the diagnosis could still to manifestations of the condition including failure be made as early as the first month of life); the failure- to thrive, nonorganic failure to thrive, psychosocial to-thrive symptoms were no longer defining features; dwarfism, maternal deprivation, anaclitic , and the nature of problems in social responsivity were hospitalism, and reactive attachment disorder, with delineated further. The role of psychosocial factors was differences in terms reflecting the interests of differ- emphasized by (1) requiring evidence of pathogenic ent investigators. care and (2) the notion that the condition was reversible The name of the disorder emphasized problems with given appropriate treatment. Children with either men- attachment but the criteria included symptoms such as tai retardation or pervasive developmental disorder were failure to thrive, a lack of developmentally appropriate excluded from the diagnosis. There has been very little empirical work on this concept as such. Case reports of individuals who have Accepted August 10, 1993. experienced grossly pathogenic care have appeared but Dr. Richters is a NIMH postdoctoral fellow in and Dr. Volkmar have not explicitly referred to RAD. Prevalence rates, is the Harris Associate Professor of Child Psychiatry, Psychology and Pediatrics, extrapolated from the maltreatment literature, have Yale Child Study Center, Yale University, New Haven, CT. The authors thank John Richters, Ph.D., and Gary Racusin, Ph.D., for been estimated at approximately 1% (Zeanah and their editorial assistance. Emde, in press). The names and certain details of the cases have been altered to protect the Controversies around the DSM-III-R definition in- identity and confidentiality of the families involved. clude (1) the requirement for a specific etiology, (2) Reprint requests to Dr. Margot Moser Richters, Western Psychiatric Institute and , 3811 O'Hara Street, Pittsburgh, PA 15213. inconsistency with the ICD-10 (World Health Organi- 0890-8567/94/3303-0328$033001001994 by the American Academy zation, 1990) definition in this regard, and (3) the of Child and Adolescent Psychiatry. suggestion that the term ''maltreatment syndrome

328 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY. 33:3. MARCH/APRIL 1994 Reactive Attachment Disorder

may be more accurate. It is also unclear why children Socially, Rebecca appeared immature and inappro- with mental retardation are excluded since mental priate. Her interactions were dominated by indiscrimi- retardation is presumably not a protective factor, it nate sociability. In addition, Rebecca had difficulty alone does not account for the presence of disturbed modulating her affect, particularly anger, and often social relatedness (Volkmar, in press), and it is inconsis- required assistance to regain control. She was extremely tent with ICD-10, which excludes only pervasive devel- impulsive and demonstrated poor attention and opmental disorder. concentration. Clinicians and researchers agree- that children who Noticeable changes occurred within months after have experienced abuse, , or frequent disruptions she rejoined her mother including improved verbal in primary often exhibit varying degrees of skills and a decrease in disruptive , although cognitive, physical, and social-emotional delays (Aber attentional and social deficits persisted. and Allen, 1987; Alessandri, 1991; Cicchetti and Bar- nett, 1991; Erichon et al., 1989; Hoffman-Plotkin CASE 2 and Twentyman, 1984; Rutter and Tuma, 1988; Sal- zinger et al., 1993). There is also evidence to suggest Jimmy had experienced multiple changes in caregiv- that some of these children respond to therapeutic ers during his early childhood. He moved often as his interventions (Harris, 1982; Powell et al., 1973). After parents were assigned to different military bases, and reviewing the available evidence, Volkmar (in press) because of marital discord, the responsibility for care- suggested that the diagnosis of RAD should be retained giving shifted frequently. His parents eventually di- in DSM-IV because it characterizes a pattern of distur- vorced and from ages 3 to 8 years, Jimmy lived with bance that is not encompassed by other existing diag- his mother and new stepfather. This home environment nostic categories, it identifies a condition that was quite chaotic and probably abusive; after an investi- potentially endures in the child (i.e., apart from the gation by child protective services, and to avoid legal parent-child dyad), and it is clearly an important target proceedings, Jimmy was returned to the care of his for both intervention and research. father and stepmother. The following cases are of children who meet current Upon reunion, Jimmy's father noted unusual behav- criteria for RAD. These may help clarify issues war- iors and developmental problems. Jimmy's speech was ranting further research. characterized by some echolalia and disorganization. We was unable to engage in basic self-care activities, CASE 1 exhibited self-injurious behaviors, and needed constant Rebecca was 6 years old when her mother and supervision. His social interactions were marked by stepfather brought her in for psychiatric evaluation. gaze aversion, unprovoked aggression, and an intense dislike of being touched. His affective responses were Her early childhood was replete with frequent changes unpredictable and labile. He also experienced sleep in primary caregivers. When she was 2 years old, her disturbances and frequent . In school, teach- parents divorced and her father received custody while ers noted poor attention, poor motor coordination, her mother remained overseas with the armed forces. and self-stimulatory behaviors. Cognitive testing con- During her 8-month stay with her father, in what was ducted at age 6 placed Jimmy in the borderline range described as a chaotic environment, Rebecca had no of intelligence. contact with her mother. Mounting legal problems At follow-up 1 year after rejoining his father, Jimmy encountered by her father led to Rebecca's temporary showed significant gains in overall functioning. Cogni- placement with her grandparents before her mother tive testing placed him in the average range of intelli- resumed care. gence, although some learning difficulties remained, Rebecca's physical development was normal but her and there was marked improvement in his language language, cognitive, and social development were de- skills. While there was a decrease in maladaptive behav- layed. Examination identified expressive and receptive ior, his paucity of adaptive skills persisted, particularly language deficits including poor articulation and com- in the social domain where his interactions remained prehension. Cognitive testing suggested mild mental odd, stilted, and indiscriminate, with poor integration retardation. of social-emotional cues.

J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRlL 1994 329

RICHTERS AND VOLKMAR

CASE 3 CASE 4 Maria first received treatment when she was 5 years Shannon was evaluated after being placed in tempo- old, as a result of severe behavioral problems in school. rary foster care by child protective services. Several She was referred for inpatient services at age 8 after children had died under mysterious circumstances while a child protective services investigation substantiated in the care of Shannon's mother. Two other children allegations of physical abuse. Maria had a complicated had been placed in foster homes after unexplained history beginning with mother's problematic preg- . nancy, during which she miscarried Maria's twin at On examination at age 4 years, Shannon appeared 20 weeks. During Maria's birth, her biological father to be much younger than her stated age. She was at the 15th percentile for height and the 10th percentile severely beat two older siblings and was subse- for weight. She exhibited mild delays in fine and gross quently incarcerated. motor skills, as well as problem-solving skills. Her Consequently, Maria was sent to foster care and performance was most delayed in the areas of language, spent her first 8 months of life living with a relative. Her self-care, and social relatedness. Her articulation was mother, suffering from depression, visited sporadically. poor and her vocabulary was limited to approximately Maria's reunion with her mother lasted until she was 20 recognizable words. She demonstrated limited re- 4 years old, when she was sent to live with her god- ceptive skills and could not follow simple verbal instruc- mother while her mother looked for work in another tions. Shannon was not toilet trained and could not town. This arrangement was abruptly terminated after feed herself with a spoon. Socially, she did not under- complaints about Maria's oppositional . Her stand turn-taking in play and exhibited little symbolic mother resumed care for several months before sending play. She was quite withdrawn and did not easily Maria to live with Maria's maternal grandmother. engage with others. Affectively, she was constricted, This placement was also short-lived because of Maria's anxious, depressed, and apathetic. behavior problems. Although significant developmental delays persisted According to her mother, Maria developed normally at follow-up, Shannon showed marked improvement until age 2 or 3 years, when she began to exhibit in her language, self-care, and social skills. She also behavior problems. Her mother and her teachers de- exhibited much brighter affect. scribed Maria as aggressive, oppositional, and impul- sive. According to school reports, Maria had few friends. DISCUSSION She alienated classmates by stealing from them and The children described here experienced grossly initiating physical fights but usually denied guilt and pathogenic care and exhibited multiple developmental showed no remorse for her behaviors. difficulties. Features not identified in the current crite- Maria also exhibited erratic and unpredictable ria for RAD but shared by most of these children swings. Her behavior would fluctuate from clinging and included unusual patterns of language and motor de- hugging to hitting and swearing. During psychiatric lays, failed acquisition of age-appropriate self-care skills, assessment, Maria stated concerns about being "bad" poor attention and concentration, emotional lability, and "crazy" and reported occasionally hearing a voice aggressivity, impulsivity, and oppositionality. These telling her to turn on the television. She also reported complicated and atypical symptom pictures presented transient suicidal ideations and appeared disturbed by a diagnostic dilemma. The children appeared autistic- her lack of peer relationships. like in some respects but were more socially related Unlike the previous two cases, Maria did not evi- than autistic children and were more behaviorally devi- dence any cognitive deficits. Her developmental delays ant than children with language disorders. Using cur- were primarily in the social and behavioral domains. rent nosology, the evaluating clinicians resolved the She exhibited poor daily living skills, below-average dilemma by applying multiple diagnoses in addition coping abilities, limited interpersonal skills, and many to RAD (Specifically, the diagnoses for case 1 included maladaptive behaviors. Maria continues to live with attention-deficit hyperactivity disorder and develop- her mother. mental expressive language disorder; case 2 carried

330 J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 33:3, MARCH/APRlL 1994 REACTIVE ATTACHMENT DISORDER attention-deficit hyperactivity disorder, post-traumatic (1978). Diagnosis requires an assessment of the child- disorder, and developmental expressive language relationship in areas such as comfort seeking, disorder; case 3 received oppositional-defiant disorder, exploratory behavior, affectionate responses, and coop- post-traumatic stress disorder, parent-child problem, erativeness, and evidence that the disorder resides and a rule out for psychotic disorder not otherwise within the child (Zeanah and Emde, in press). This specified; and case 4 garnered and both orientation is distinctly different from the current DSM developmental expressive and receptive language disor- criteria, which focus on pervasive disturbances in social der.) It is incumbent upon researchers to determine relatedness and pay little attention to characteristics of whether (I) there is a constellation of symptoms con- the primary attachment. tributing to a single, parsimonious explanation or if, Powell and Bettes (1992), writing from another in fact, these children are afflicted with multiple Axis perspective on the attachment question, note that stud- I and Axis I1 disorders; and (2) whether the inclusion ies have not established the presence of specific attach- of more symptoms might increase the sensitivity and ment disorders among children diagnosed with RAD. specificity of the diagnostic concept. In addition, they point out that the nonorganic failure- As stipulated in DSM-III-R, a response to therapeutic to-thrive behaviors included in the diagnosis (i.e., gaze intervention is considered confirmatory evidence for abnormality, general inactivity, lack of reactivity to the diagnosis of RAD. In the three cases involving stimuli, rumination, failure to gain weight) have not significant environmental changes reported here, the been causally linked to defective attachments. In fact, children indeed demonstrated marked improvement. evidence from the child maltreatment literature suggests While this seems an imprecise method and clearly that while maltreated children are more likely to exhibit requires empirical validation, response to treatment insecure and confused patterns of relatedness, they may help us understand how RAD differs from other do not necessarily develop a disorder of attachment disorders, particularly the pervasive developmental dis- (Cicchetti and Barnett, 1991; Lynch and Cicchetti, orders, and should continue to be a marker for the 1991). These authors hypothesize that maltreated chil- diagnosis, if not a necessary diagnostic feature. dren develop various attachment styles in their attempts The etiological requirement, i.e., of pathological to cope with inconsistent and problematic parent- care, continues to be controversial. From a practical child relationships. aspect, the children described above demonstrate how The pattern of disturbances exhibited by the children the caregiving histories are often complicated, sketchy, in this paper lends credence to the argument that RAD and incomplete at the time of assessment, making it is not a disorder of attachment as usually defined by difficult to apply the diagnosis. Furthermore, Volkmar developmentalists. The case descriptions conform to (in press) notes how the criterion impedes our ability the DSM-III-R criteria of disturbed social relatedness to determine whether the behavioral features exist in across domains and do not identify specific attachment the absence of severe adversity. Given that inadequate defects in child-caregiver relationships. At the same caregiving exists on a continuum from inexperienced time, the children described do provide clinical evidence to severely abusing parents, it is imperative that research for a constellation of symptoms and atypical develop- demonstrating the relevance and usefulness of retaining ment not captured by other diagnostic categories. They a specific etiology is conducted. appear to represent a subgroup of children whose The question posed by developmentalists is whether primary difficulties are in the area of social relatedness these children suffer from disordered attachments or that are best explained by defects in social-emotional a syndrome of maltreatment. From their perspective, development versus the neurobiological defects more the defining feature of attachment disorders is a pro- characteristic of the pervasive developmental disorders. found disturbance in a child's use of a primary caregiver The findings suggest that the multiple deficits expressed as a source of safety and security (Zeanah et al., 1993). . in this condition are not intractable but rather are Zeanah and colleagues (1993) have proposed a set of quite responsive to treatment, making detection and criteria for attachment disorders that go well beyond diagnosis all the more important; the question of the attachment categories defined by Ainsworth et al. improvement awaits future research.

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