Reactive attachment disorder of infancy or early childhood
In reactive attachment disorder, the normal bond between infant and parent is not established or is broken. Infants normally "bond" or form an emotional attachment, to a parent or other caregiver by the eighth month of life. From about the second through the eighth month, most infants will respond to attention from a variety of caregivers, if the caregivers are familiar. By the eighth month, however, normal infants have established a strong emotional preference for one or two primary caregivers. They are distressed if separated from these caregivers for even a few hours, even if another familiar person is present. If this bonding process is interfered with, it can have severe emotional and physical consequences for the child.
Reactive attachment disorder is sometimes called a post-traumatic disorder.
In reactive attachment disorder, an infant or young child has not formed an emotional bond with a parent or other caregiver. This affects the child's ability to interact normally with others. The child may have severe emotional and social problems that extend into adulthood. There may be learning problems and physical problems such as slow growth and failure to develop as expected.
Causes and symptoms
An infant does not know how to form an emotional attachment to another person, any more than it knows how to feed or clean itself. Bonding is a necessary developmental step in a baby's growth. It occurs as the infant is cared for, talked to, played with, and comforted consistently. This helps the infant feel like it knows what will happen every time it sees a certain person. When this process is interfered with, the infant may never learn how to trust or love.
Many things can interfere with the bonding process:
- Loss of parents. The most common cause of reactive attachment disorder is being orphaned or put in foster care at a very early age. The infant may receive care from many people or be moved from place to place often. A bond to a single consistent caregiver cannot be formed.
- Neglect or impaired caregiving. If the infant is not cared for consistently, it will not learn to trust. This includes emotional neglect, where the caregivers may keep the baby clean and fed, but do not allow time for play and bonding. Very often this occurs when the parent or caregiver has a problem that prevents him or her from giving adequate, consistent attention to the infant. Such problems include major depression, psychosis , drug or alcohol abuse, mental retardation , physical illness, and poverty. The parent may also have been a neglected child or may be very young themselves and simply not know how to parent adequately.
- Abuse or pain. Even if an infant is getting love and attention some of the time, it may not learn to attach if it comes to expect pain on occasion from the caregiver. Illness or pain that the caregiver cannot ease can have the same effect.
In disrupted families with more than one child, one child may have reactive attachment disorder while others do not. It is not clear what role personality plays in this problem.
Infants with this problem often resist being held or touched. They may seem sleepy or "slow." They may not seem aware of what's going on around them. They may be slow to gain weight. On the other hand, some appear to be overly aware and nervous.
Young children may seem withdrawn and passive. They may ignore others or respond to others in odd ways. Some may seem overly familiar with strangers and touch or cling to people they've just met. However, they lack empathy for others. Their behavior comes across to others as needy and strange, unlike the normal friendliness of children.
Other symptoms of reactive attachment disorder in children can include the following:
- inability to learn from mistakes (poor cause-and-effect thinking)
- learning problems or delays in learning
- impulsive behavior
- abnormal speech patterns
- destructive or cruel behavior
The prevalence of reactive attachment disorder has been estimated at 1% of all children under the age of five. Children orphaned at a young age have a much higher likelihood of this problem.
The standard manual for mental health professionals in the United States is the Diagnostic and Statistical Manual of Mental Disorders. This manual lists criteria for diagnosing various mental disorders. The most recent edition, the fourth edition text revised, is also known as the DSM-IV-TR. According to the DSM-IV-TR, reactive attachment disorder is diagnosed when the following criteria are met:
- Presence of strange and developmentally inappropriate social interactions, beginning before age five years. The child does not respond to or initiate social interactions in a way that would be developmentally appropriate; instead, the child is either inhibited or is disinhibited in his or her interactions. Inhibited reactions may be excessively vigilant, restrained or ambivalent. (The child may respond to caregivers with a mixtures of approach, avoidance, and resistance to comforting, as an example from the manual.) Disinhibited reactions occur in a variety of social interactions and the child does not discriminate among people he or she chooses as attachment figures. This child will treat near strangers with inappropriate familiarity.
- The child's inappropriate social skills are not due exclusively to developmental delay (as in mental retardation) and the child's symptoms do not meet criteria for a pervasive developmental disorder .
- The child has received care in which his or her basic needs—either emotional or physical— are often unmet, or in which stable attachments have not been able to form (such as when primary caregivers change often).
An infant is diagnosed as having reactive attachment disorder when he or she fails to show signs of bonding to a parent or caregiver by the age of eight months. Infants normally start to follow the parent or caregiver with their eyes and smile in response to attention by about two months. By about five months, the child should reach out to be picked up and obviously enjoy simple interactive games like "peekaboo."
First, the child's safety and physical health must be attended to. A child that is being abused or has been physically neglected may need to be hospitalized. This is done to separate the child from the harmful situation and take care of any medical problems resulting from neglect or abuse.
The next step is to either make the child's home environment stable, or place the child in a more stable home. Child protective services may be brought in at this point. The home situation must be evaluated, and the parents or caregivers assessed for emotional fitness to care for the child. The parents or caregivers may be given training in proper childcare and emotional nurturing. Family therapy may be needed in some cases to help the parents or caregivers and other children in the family.
With a young infant, the parents or caregivers will be encouraged to have a regular schedule for the infant and to spend time each day simply holding and playing with the infant.
Treatment of children who are past infancy is difficult. It is important to find a therapist experienced in the treatment of children with reactive attachment disorder. Most therapists use a mix of techniques. The therapist may seek to help the child relive and work through grief and anger from a prior trauma or loss. Cognitive therapy may be used to help an older child understand and reframe negative thoughts about himself or herself, or about parents or caregivers. If the child is too young to verbalize or think rationally, techniques such as play therapy or art therapy may be used to help bring out and work through feelings. Behavioral therapy may be used to help guide development of wanted behaviors.
There has not been much research to date on the course of this problem. It appears that children who are identified and treated early have a better chance of learning how to form appropriate bonds with other people.
Children who are not treated or who are treated later in life have a greater chance of having permanent problems relating to other people.
Prevention of reactive attachment disorder begins with good parenting. As far as possible, health care providers and families should be on the lookout for any problem that may prevent parents from giving children the structure and attention they need. If a child loses its primary caregivers, a stable environment with consistent attention from one or two caregivers should be provided as soon as possible.
Early identification of reactive attachment disorder is necessary to get help to the child and family as soon as possible. The earlier this problem is identified and treated, the more likely it is that the child will be able to develop healthy patterns of relating to others.
Hales Robert E., Stuart C.Yudofsky, and John A. Talbott, eds. Textbook of Psychiatry. 3rd ed. Washington DC: American Psychiatric Press, 1999.
Sadock, Benjamin J. and Viginia A. Sadock, eds. Kaplan & Sadock's Comprehensive Textbook of Psychology. 7th ed. Philadelphia: Lippincott Williams and Wilkins, 1999.
Association for Treatment and Training in the Attachment of Children (ATTACh). <http://www.attach.org> .
Jody Bower, M.S.W.