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.

Many studies have investigated the childhood experiences of patients with BPD and revealed that physical and sexual abuse, early separation, inconsistent treatment of a caretaker and neglect are all part of the etiology of BPD. A study of Mary C. Zanarini and others was determined to investigate pathological childhood experience in patients with Borderline Personality Disorder and compare the results to those of patients suffering other Personality Disorders. In the study, of the 358 patients with BPD, 91% reported having been abused (emotionally, sexually or physically) and 92% reported neglect before the age of 18.

More specifically, between 10% and 73% of borderline patients reported having been physically abused by either caretaker or other adult.

Other 16% to 71% reported having been sexually abused, usually by noncaretaker (Zanarini M, 1997). Since such great percentage of patients meeting the criteria for BPD, it may be hypothesized that they also suffer some chronic form of posttraumatic stress disorder (Herman JL, 1987). It was also revealed that it was much more common for BPD patients to report some type of abuse in childhood than patients with other Personality disorders.

Probably the most striking difference in the study between Borderline patients and other Personality disorder patients was observed when sexual abuse was considered. 61.5% of borderline patients reported sexual abuse versus 32.1% of patient suffering other personality disorders. However, it was observed that sexual abuse did not occur isolated from other forms of abuse or neglect. On the contrary, it was just another part of an already disrupted family atmosphere of chaos where series of traumatic events were part of the child’s everyday life (Zanarini MC, 1997).

As a result of the studies of Borderline patients, four variables were clearly distinguished: female gender, male noncaretaker sexual abuse, male caretaker’s neglect and denial of a patient’s feelings, and female caretaker’s inconsistent treatment. All of these are generally associated with the diagnosis of BPD (Zanarini MC, 1997). The fact that most individuals with Borderline diagnoses are women is probably related to the fact that most victims of sexual abuse as children are females, as well. Therefore, there must be some correlation between such stress provoking experiences in early childhood and Borderline Personality adults that is imbedded in stress and neurotransmitter dysregulation (Halgin R, Whitbourne S, 2003).

The effect of child abuse on the brain and the impact of stress hormones on emotional and cognitive development

Maltreatment, no matter whether it is abuse, neglect, abandonment or witnessing violent acts, can lead to enduring negative changes in the still developing brain of a child. Each time there is some sort of trauma, the brain suffers a particular change. So far, research have noted changes in the prefrontal cortex, the cerebellum and the limbic system (Wheeler T, 2006) It is important to point out that infancy and early childhood are times for rapid brain development and formation of dendritic connections. Of course, they continue to develop throughout adolescence an early adulthood, but are even more vulnerable earlier in life (Kalat J, 2003).

The prefrontal cortex is the most anterior part of the frontal lobe of the brain that is involved in critical thinking and judgment as well as any behavior that, in one way or another, depends on the context. Therefore, people with damaged prefrontal cortex often cannot modify their behavior and become inflexible in changing situations, which can make their reactions and behavior too impulsive and socially unacceptable (Kalat J, 2003). Damage to the prefrontal cortex can eventually result in many deficits such as not being able to regulate motivation and efforts as well as impaired short-term and long-term goal-directed behavior. In addition, damage and disruption of prefrontal cortex functions due to any type of abuse may lead to not being able to integrate positive emotions. Thus, the person is stuck in a negative stance of fear and anger, and cannot engage in experiencing positive emotions. Needless to say, this may lead to developing depression, antisocial or borderline personality disorders (Wheeler T, 2006).

The cerebellum is a large structure in the hindbrain that is mainly known for controlling movement, achieving balance and coordination (Kalat J, 2003). However, it also plays a role in attention and emotions, as well as in regulating the limbic system (Wheeler T, 2006). It is important to note that many people with psychiatric disturbances have certain abnormalities in the cerebellum (Wheeler T, 2006). This is probably so, because in cases of childhood abuse the cerebellum is extremely vulnerable to the stress hormones that are present in large amounts during stress, trauma or abuse. The changes that occur then can result in depression or hyperactivity, and inattention. Also, the cerebellum is considered to play a role in suppressing irritability. Therefore, abnormalities or damage to the cerebellum may cause chronic irritability and make the person seek external means, such as drugs, to deal with that (Wheeler T, 2006).

The limbic system is the forebrain area next to the brainstem that includes a number of interdependent structures under the cerebral cortex that deal with motivation and is critical for regulating emotions, sexual activity, eating, drinking, anxiety, and aggression (Kalat J, 2003). The hippocampus and the amygdala are essential parts of the limbic system, and are crucially important for controlling the emotional response to a particular situation. They also take part in memory formation and learning (Wheeler T, 2006). Prolonged and continuous exposure to stress hormones can cause serious damage to these parts of the limbic system and, thus, disrupt mood regulation, memory, and one’s way of interpreting the environment. Besides, damage to the limbic system can lead to epileptic seizures and abnormal EEGs that usually affect the temporal lobe of the left hemisphere. Usually, damage to the left hemisphere is associated with poor verbal development, but, more importantly, with aggression, self-destructive behavior and suicide (Wheeler T, 2006).

What is stress? Many things can be considered stressful for an individual, including insufficient nutrition, lack of rest, overstimulation, especially of the fear-related response system, not to mention abuse, neglect or witnessing violence or death (Gunnar & Vazquez, 2001). The prolonged exposure to stress and, therefore, the produced stress hormones in the body, can be very serious and especially harmful to the infants and young children (Gunnar & Vazquez, 2001). In fact, exposure to stress activates two body systems: the autonomic nervous system that prepares the body to react quickly to whatever stimuli in the environment; and the HPA-axis – the hypothalamus, pituitary and adrenal cortex.

The HPA-axis reacts more slowly, but is critically important in prolonged exposure to stressors (Kalat J, 2003). The activation of the hypothalamus stimulates the ‘master gland’ (the pituitary gland) to secrete adrenocorticotropic hormone (ACTH) that, in turn, stimulates the secretion of cortisol. Cortisol is generally regarded as ‘The’ stress hormone. It helps the body mobilize energy and respond to stress quickly, but has negative effects in the long run, since it enhances metabolism and elevates blood sugar levels (Kalat J, 2003). Other stress-related hormones are corticosteroids, corticotrophin release hormone (CRH), epinephrine, norepinephrine and others (Gunnar & Vazquez, 2001). Serotonin is also very important for the adequate coping with stress. Therefore, abnormal function of serotonin is associated with some depression and anxiety-related disorder, such as BPD.

Research has proven that elevated stress hormone levels can cause malfunctions in the amygdala and hippocampus (Gunnar & Vazquez, 2001). Severe or merely constant exposure to stress may lead to the shriveling of certain dendrites in the hippocampus, which can cause its degeneration and malfunction (memory loss and inability to control the release of other stress hormones) (Gunnar & Vazquez, 2001). As a matter of fact, shrunken hippocampus was found in autopsies of children who have experienced repeated abuse or in people who were suffering posttraumatic stress disorder. In addition, disruption of the HPA-axis that is also related to exposure to stress in early age is associated with depression, inattention, and poor memory (Gunnar & Vazquez, 2001). The hippocampus is a particularly vulnerable brain structure, especially during infancy and childhood, when it is still developing (Gunnar & Vazquez, 2001).

If too many stress hormones are being produced in the early stages of development, the developing brain may be permanently damaged, becoming incapable of initiating a normal stress response. It may either overproduce stress hormones, so that the person becomes hyper-vigilant, fearful and always on the alert, or it may underproduce stress hormones so that the person becomes “emotionally flat”, sad and angry (Berger, 2005). A study of Cicchetti & Rogosch (2001) identified a lot of “atypical cortisol regulation patterns” that are obvious among children that have been maltreated (Gunnar & Vazquez, 2001). Studies like this are evidence for the correlation between child maltreatment and the disrupted function of certain brain structures that cause inflexibility in behavior, such as depression, chronic stress, anxiety, aggression and many others that can often be associated with a number of illnesses and disorders, Borderline Personality Disorder among them.

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, hypervigilance) (Gunnar & Vazquez, 2001). Since these could all be characteristics of a borderline personality patient, the results give food for thought as to the relation between abuse in childhood and the development of the disorder.

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).

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”.