13 Reactive attachment disorder in adolescence

1 13 Reactive attachmentdisorder in adolescenceJohn P. Kemph and Kytja K. S. VoellerAbstractReactive attachment disorder (RAD) has received increasing attention as a possi-ble explanation of severe behavioral disturbances in children and adolescents. Itsetiology is hypothesized as related to failure of attachment beginning in the diagnosis of Reactive attachment disorder (RAD) is usually madein early childhood, the diagnosis may be carried over into adolescence . In somecases, the diagnosis may be made for the first time in adolescence if there is suffi-cient information in the history to make the diagnosis retrospectively. It is unlikelythat the diagnosis of RAD can be made in the absence of comorbid diagnoses inadolescence because these children usually have symptoms which meet the crite-ria for other diagnoses, such as attention deficit disorder (ADHD), post-traumaticstress disorder (PTSD), oppositional defiant disorder (ODD), mood disorder , orconduct disorder (CD) by the time they become early or mid-adolescent development, additional diagnostic criteria for other DSM-IV diagnosesmay be observed.

2 Although a comorbid diagnosis of ADHD, ODD, and/or CDmight appear to take precedence over RAD, with the burgeoning information ingenetics it may be useful to know that RAD was present or may still be present inthe symptom complex of an individual patient. This chapter presents an overviewof the issues involved in nosology and possible etiology, with particular emphasison neurobiology and genetics. Case vignettes are used to illustrate the challengesto treatment that these patients and diagnosisThe diagnostic criteria for RAD are primarily "a markedly disturbed and devel-opmentally inappropriate social relatedness, in most contexts beginning before5 years" of age, which is associated with pathogenic care (American PsychiatricAssociation, 2000, p. 130). Two types of RAD are described: (1) inhibited and (2)disinhibited. In the literature on RAD there are many descriptions and seems appropriate, although possibly oversimplified, to state that the basic prob-lem is a disturbance in the child-parent relationship, , in social disturbance in social relatedness continues to be the defining feature of thedisorder, despite evolution of the diagnostic criteria.

3 Diagnostic criteria for RADhave changed across various editions of the Diagnostic and Statistical Manual of160 John P. Kemph and Kytja K. S. VoellerMental disorders of the American Psychiatric Association. For decades "attach-ment" was synonymous with the infant-caregiver relationship. Subsequently, thediagnosis of RAD has come to apply to the child's appearing to have a disturbancein social relatedness to others. The term " Reactive " is used in the sense that thecondition is considered to be a reaction to "pathogenic care," which is defined ascharacterized by "persistent disregard for the child's basic emotional needs forcomfort, stimulation and affection." It is sometimes also associated with "a pro-longed disregard for the child's physical needs" (American Psychiatric Association,2000, p. 130). The constellation of behavioral and physical signs seen in infantswith RAD include lack of a smiling response and lack of an auditory alertingresponse with head-turning towards the caregiver's voice, coupled with abnormalphysical development such as failure to thrive with no apparent physical in successive editions of the DSM refiected a broadening of the diag-nostic criteria and the age groups to which RAD could be applied.

4 In DSM-III(American Psychiatric Association, 1980) the diagnosis basically applied to infantsaged 8 months or less and, therefore, was limited in its application to older the DSM-III-R (American Psychiatric Association, 1987) the age of onset wasextended 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) indiscriminatesocial behaviors. A history of "grossly pathogenic care" was still a required crite-rion. DSM-IV (American Psychiatric Association, 1994) employed a more detaileddescription which took into consideration research findings which indicated thatindividual children respond in different ways to pathogenic care. Some may formselective attachments, while others may develop RAD in situations in which thecare is not "grossly pathogenic.

5 " Therefore, the term "grossly" was eliminated fromthe DSM-IV description of diagnostic criteria. There was no change in the RADdiagnostic criteria in DSM-IV-TR (American Psychiatric Association, 2000), andthe two subtypes designated "inhibited" and "disinhibited" from attachment researchEarly investigators observed infants who had been neglected, abused, or both,and developed hypotheses to account for the profound disturbances in develop-ment they saw. Spitz (1946) called the condition he observed "anaclitic depres-sion in infants." Bowlby (1982) considered the disorder a reaction to attachmentand loss. Provence and Lipton (1962) made further observations on infants ininstitutions. Ainsworth, studying attachment in normal children, developed the"strange situation" procedure which assessed the child's response to a changeinvolving the caretaker (1978).

6 In the strange situation, the baby is exposed to twobrief separations from its mother and a brief exposure to a stranger. Ainsworthobserved "coherent" and "incoherent" patterns of response to this stressful situ-ation. Infants with "coherent" responses fell into three subtypes: "secure type" Reactive attachment disorder in adolescence 161infants communicated interactively with their mothers and were able to use themother as a secure base for exploration. The other two coherent subtypes weredescribed as "insecure avoidant" and "insecure resistant." Infants manifestingan "incoherent response" showed evidence of disorganized attachment , definedas freezing, appearing fearful in the presence of the mother, engaging in stereo-typy and "contradictory behavior." Subsequent research has shown that attach-ment patterns formed in infancy tend to be stable over time, even into adulthood(Waters et al.)

7 , 2000), although they are subject to change in response to the vicis-situdes of development. The relationship between various types of attachmentand psychopathology is complex, and empirical research in this area is still inits early stages. Disorganized attachment has been associated with aggressionand disruptive behavior later in development (Lyons-Ruth, 1996) and with dis-sociative symptoms (Ogawa, Stroufe, Weinfield, Carlson and Egeland, 1997).While youngsters who do not have attachment disorders are likely to be securelyattached, those who have disorganized attachments do not necessarily developattachment disorders (Boris et al., 2004).There have been few studies on the reliability of RAD diagnoses. Using theirown diagnostic criteria, which differ slightly from those of the DSM, researchersin infant psychiatry have been able to demonstrate that attachment disorders canbe reliably diagnosed in high-risk samples of young children (Boris et al.

8 , 2004).Overlap with other disordersRAD can be confused with other disorders . Some children with disturbances insocial relatedness have communication problems that can be classified as a lan-guage disorder . Presumably the longer the child is deprived of normal languagestimulation, the more severe the communication problem becomes. Richters andVolkmar (1994) suggest that, when communication problems are present, thediagnosis should be considered one of atypical development rather than a disor-der of attachment , per with RAD may become disruptive and disorganized with poor affectregulation and poor frustration tolerance, as well as inattention, impulsivity, andhyperactivity. By the time these children reach adolescence , they have often accu-mulated 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 associ-ated with following two case vignettes are examples of adolescents with #1A 14-year-old girl was brought, by her adoptive parents, to an outpatient psy-chiatric clinic because of their concern about recent changes in her had been adopted at 7 years of age by a middle-aged couple after theirown children had grown up.

9 This couple felt that they were ready to accept162 John P. Kemph and Kytja K. S. Voellerthe challenge of raising a problem child. This child had been neglected andabused by her natural parents, and she had behaved aggressively and destruc-tively in several foster homes. Initially these adoptive parents had taken thischild into their home as a foster child. They had been given the history of herprevious pathogenic care and difficult behavior and her diagnosis of were instructed to provide a warm and loving environment, as this wasconsidered her greatest need at that time. The couple was successful in provid-ing a supportive environment in spite of the child's testing the limits of theirpatience periodically, and they proceeded to adopt her. After the reassuranceprovided by the adoption, the relationship between the child and parents con-tinued to improve until some typical adolescent peer interactions other girls in her school, with whom she had become acquainted,formed a clique and rejected her.

10 At the same time, because she had blos-somed into an attractive young girl, boys showed her increased she started dating the boys and became sexually behaviors prompted her parents to seek help at an outpatient clinic,where they were provided with counseling from a social worker and medicalcare for the girl from a psychiatrist. She was given the comorbid diagno-ses of RAD, ADHD, ODD, and mood disorder , not otherwise specified. Theparents were supported in their attempts to set limits on these behaviors,and the child was given therapy that was aimed to improve self esteem andimpulse control. She was also given several trials of psychotropic therapeutic program provided by the clinic and the parental interventionwere not successful in controlling her sexual acting out. She became moreoppositional and refused to see both her therapist and her psychiatrist.