Reactive Attachment Disorder:

Etiology, Symptoms, Affected Brain Areas and Treatment

Reactive Attachment Disorder (RAD) is characterized by considerably disturbed and inappropriate social interaction, across situations, that is manifested before the age of five (DSM-IV-R). Evidence for the disorder is usually seen in continuous failure to respond appropriately in social situations (being hypervigilant, inhibited, or ambivalent) and/or inability to develop and exhibit selective attachment to primary caregiver(s) (DSM-IV-R). The causes for the disturbed behavior in Reactive Attachment are associated with the developmental stages of Infancy and Early childhood, when pathogenic care can have profound and lasting effects. DSM-IV outlines three aspects of pathogenic care that explain the disturbance in normal development and behavior: persistent disregard for the child’s physical and emotional needs, as well as repeated changes of primary caregiver and/or surroundings. The connection between pathogenic care and disrupted behavior is compelling and reminds of the critical importance of nurture and effective parenting. Many psychologists have studied in depth child development during the first years of life and reveal that this is an extremely sensitive period for both physical and emotional development and maturation. It is a critical time for cultivating attachment, social skills, developing empathy and understanding basic values.

Maltreatment, no matter whether it is abuse, neglect, abandonment, or witnessing violence, can lead to enduring negative changes in the still developing brain of a child. Each time there is some sort of traumatic experience, the brain suffers a particular change. Many of the brain abnormalities that have been studied in abused and neglected children are located in the left hemisphere. Very often, in children, victims of abuse, there were fewer dendritic connections between different areas in the left hemisphere (Gunnar & Vazquez, 2001). Children that had showed such abnormal results demonstrated self-destructive or aggressive behavior, as well as certain disturbances in behavior, thinking and physiology (higher blood pressure, heart rates temperature, hyper vigilance) (Gunnar & Vazquez, 2001). Studies of neglected children found that their cortex was about 20 percent smaller than that of a control group of subjects (children) who have not suffered neglect (Gunnar & Vazquez, 2001). The data is compelling and reveals that providing stable environment of nurture is of utmost importance. About 1% of children who have developed insecure-ambivalent attachment develop RAD (Lehman and Jegtvig, 2004) and without intervention, support and help, many of these children might grow up to develop Antisocial Personality Disorder and live a disruptive life. Eventually, many of these individuals end up in correctional facilities. This compels helping professionals to promote and teach effective parenting and explain the implications of early childhood stress. In addition, the issue has to be considered within the context of adoption and foster care where, very often, children would be moved often and are being exposed to very different/inconsistent treatment and living conditions.

The non-pharmaceutical treatment of RAD appears to be more successful and beneficial than the behavioral medical model (Lehman and Jegtvig, 2004). It utilizes the attachment model as described by Dr. Daniel Hughes in his book “Building the Bonds of Attachment: Awakening Love in Deeply Troubled Children.” The emphasis is on effective parenting - nurturing holding, eye-contact, providing opportunities for enjoyment, encouragement, unconditional love and being a model for self-regulation abilities (Daniel Hughes). Parents and caregivers are to love, nurture, accept and respect the child, so that he/she can grow healthy and happy. Also, professionals in the helping field need to unite their efforts in attempt to educate people and advocate affective parenting and children’s well-being.

Is it really true that our past is so powerful that it can control our future? It has been the chief task for many psychologists and people in the helping professions to identify different environmental factors and their positive or negative impact on human development. Different developmental theories emphasize the huge importance of early childhood experiences and the quality of the relationship with parents (caregivers) to the health and well being of the maturing individual. Both neglect and abuse in the earlier stages of life can lead to chemical imbalance, delay of mental development, depression or even some psychological disorders. It is crucial for optimal development that stable bonding and attachment are effectively developed in the early stages of life, as this has a lasting effect. If parents fail to create a secure environment and provide emotional support for the child, this can cause negative social interactions in the future, or their overall avoidance.

Many psychologists have studied child development during the first years of life in depth. This is an extremely sensitive period for both physical and emotional development and maturation. It is critical time for cultivating attachment, social skills, developing empathy and understanding basic values. During the first year of a baby’s life, in particular, emotional attachment with the primary caregiver(s) is established. In fact, the bond with the mother starts blooming only within hours of childbirth (Kaitz et al., 1995).

Psychologist Mary Ainsworth (1989) investigates different levels of attachment by observing mothers and their infants in an unfamiliar setting. The mother was asked to suddenly leave the room and then the baby’s reactions were being observed, especially upon the mother’s return. This study described three main types of attachment: securely attached children (enjoying a stable and positive emotional bond), insecure-avoidant attachment and insecure-ambivalent attachment (both depicting an anxious emotional bond). Ainsworth studied this cross-culturally, observing the same behavior and making the same conclusions. Children who are securely attached by the age 1 show more social competence, resilience and problem-solving abilities (Collins and Gunnar, 1990). The importance of both the mother and the father is crucial when it comes to meeting the baby’s affectional needs. Generally, a warm and secure family atmosphere with clear rules and expectations promotes secure attachment for the child (Belsky, 1996). On the other side, failure to meet these needs leads to insecure attachment, where anxiety usually characterizes the relationship. Insecure attachment (ambivalent or avoidant) and negative parental representations are positively correlated with depression in adolescents (Milne & Lancaster, 2001; Ollson, Nordstrom, Arinell & Knorring, 1999). Depressed and ill people tend to repel their family and friend instead of using them as a support group (Alferi, Carver, Antoni, Weiss & Duran, 2001; Coyne & Smith, 1991).

Psychologist Erik Erikson (1963) has also focused on the developmental stages, outlining the different developmental challenges. For the first years of life, the struggle is between forming a basic sense of trust or mistrust. This, once again, would have a lasting effect in life. If ‘trust’ is developed, the baby would become a healthy individual, who is equally able to give and receive love and trusts in other people and ‘good in life’. On the contrary, developing a basic sense of ‘mistrust’ might lower self-esteem and increase perceived distress.

Parents are the first and, probably, the most important support group for the growing individual. Social support that is provided from the parents and their role to create a stable and supportive environment has a long-term effect on health and one’s ability to cope with stressful events (Repetti et al., 2002). One study of college students found that students who reported having a lot of support from their parents were more likely to cope effectively with stressful events (Valentiner, Holahan, & Moos, 1994). Parental support also enabled students to cope better emotionally (Maunder & Hunter, 2001). A longitudinal study of undergraduate Harvard male students demonstrated that those who perceived to have had warm and close relationships with their parents were healthier 35 years later (Russek & Schwartz, 1997). On the contrary, males who did not report warm relationships with their parents in childhood were much more likely to be diagnosed with coronary artery disease, hypertensions, ulcers and alcoholism in Middle adulthood (Russek, Schwartz, Bell & Baldwin, 1998). In adult life, emotional support from a significant, intimate others is most important (Benson, Gross, Messer, Kellum & Passmore, 1991), but negative relationships with parent in earlier stages of life can lead to distress in interpersonal relationships later on.

Dear parents, be there for your baby and never forget there is no such thing as “spoiling an infant”.