Daniel F. F. Shreeve - Reactive Attachment Disorder: A Case-Based Approach
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A childs close bond with mother, father, or guardian usually provides a foundation for trust in all future attachments. Children deprived of early and healthy dependency-who do not form normal attachment with their caregivers-may later suffer from Reactive Attachment Disorder (R.A.D.). This childhood disorder is characterized by a general failure in social relationships resulting from pathogenic care. Although first included in the third edition of the Diagnostic and Statistical Manual (D.S.M.-III) in 1980, R.A.D. is one of the more uncommon and understudied forms of psychopathology. Reactive Attachment Disorder: A Case-Based Approach adds to a now growing research base, providing scholars and clinicians with a well-rounded analysis of R.A.D. and suggested treatments. The case-based approach used in this Brief follows the representative case of Jorge, presented as unfolding over time and structured to illustrate challenges of diagnosis, to show examples of co-morbidity, and to provoke reflection on what questions may arise during treatment. Readers are asked to appraise the overlap with other clinical syndromes, the forms of psychotherapy which may apply, and the potential role of psychiatric medications as part of a comprehensive treatment plan.
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Daniel F. F. Shreeve
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Daniel F. Shreeve SpringerBriefs in Psychology Reactive Attachment Disorder A Case-Based Approach 10.1007/978-1-4614-1647-0_1 Springer Science+Business Media, LLC 2012
1. Introduction
Daniel F. Shreeve 1
(1)
The Carilion Clinic, Rehab Building 2017 South Jefferson Street, Roanoke, VA 24014, USA
Daniel F. Shreeve
Email:
Abstract
This exercise introduces the clinician to reactive attachment disorder (RAD), a childhood disorder involving a general failure of social relationship caused by early, grossly pathogenic care. In order to begin a study of such fundamental impediment to attachment in earliest life, we must as students of child psychiatry define what we mean by attachment and also must consider how we will prove a relationship to emotional neglect. A brief introduction to the process of normal, early childhood attachment is essential, before turning to the definition of abnormal attachment and to the topics of differential diagnosis and comorbidity.
Format of the Exercise
This exercise introduces the clinician to reactive attachment disorder (RAD), a childhood disorder involving a general failure of social relationship caused by early, grossly pathogenic care. In order to begin a study of such fundamental impediment to attachment in earliest life, we must as students of child psychiatry define what we mean by attachment and also must consider how we will prove a relationship to emotional neglect. A brief introduction to the process of normal, early childhood attachment is essential, before turning to the definition of abnormal attachment and to the topics of differential diagnosis and comorbidity.
Our representative case of Jorge is presented as unfolding over time and structured to illustrate challenges of diagnosis to show examples of overlapping syndromes and to promote reflection on what questions may arise during treatment. Within the case presentation are additional, brief segments identified as case points which bring in topics related to treatment of RAD so as to add a degree of dimensional realism to the illustration of clinical method. An initial set of test questions follows the case presentation, to enliven the exercise.
A review of the etiology of RAD is necessarily broad and interdisciplinary. Adhering to the biopsychosocial model, the section on etiology will cover current theories divided into biological basis, psychological factors, and social origins. Sections which follow the case presentation serve to illustrate, within limits of space available, the directions of advancing research. One example of the unknown, for instance, is how the experience of deprivation at critical stages leads to RAD for some children, whereas others overcome even severe disadvantage. A related, and equally unanswered question, is whether our definition of secure attachment as normal actually matches with the history of our species, a history characterized by rare periods of peace and frequent episodes of violence or extreme adversity. Recent work on the adaptive advantage of a range of attachment types is presented, as a prelude to further questions about what we are treating.
We return to the topic of the principal role of the psychiatry clinician within an interdisciplinary system of care, in the final sections on treatment of RAD. Many methods of therapy have been applied to this difficult disorder, and the summary is necessarily brief. The section on psychotherapy follows conventional psychiatry categorization into evidence-based treatments, those with professional consensus, and those without evidence which may do harm. A second test on general principals follows, and there is an explanation of answers at the end of the text.
By completing this exercise the interested learner should be able to:
Define attachment behavior in terms of early motherinfant interaction and explain the evolutionary significance of attachment in the species, as well as relate disorders of attachment to psychopathology
Define reactive attachment disorder (RAD) including subtypes, with explanation of the origin and what is generally known about longitudinal course
Define the subtypes of attachment as characterized by Ainsworth and others, and compare these to RAD
Explain major theories of the etiology of RAD and relate them to the explanations for human diversity in the types of attachment
Recognize common comorbidity of RAD and envision how to participate as a psychiatrist on an interdisciplinary treatment team with a real case
What Is Attachment?
Attachment is so familiar to most of us so basic to social life that we may rarely perceive it to be an option. When one reflects on ones own relationships, past or present, attachment cannot be defined as something fixed or immutable. Even for close bonds, the sense of attachment recedes one day, and advances the next. Strictly speaking, attachment is also not equivalent to attachment behavior []. The presence of danger, for example, provokes attachment behavior, but when the environment is constant the attached ones child or adult may draw apart physically or emotionally for a time, perhaps to verify independence, or to gauge the degree of intimacy. Thus attachment itself is a predisposition rather than a behavior. It derives as an accretion of shared moments, such that new events are interpreted in the context of past co-experience. Even when apart, a mental conversation may continue, or the story of a separate adventure is prepared for telling.
We may thus adopt a working definition of attachment as a selective interest in an individual with whom we share new experience with implicit reference to the past together, and whom we will miss if unable to communicate about our responses to something new. Perhaps attachment is best understood in emotional terms when it is interrupted, as we experience distress or longing for the missing loved one. This makes reactive attachment disorder (RAD) all the more difficult to accept in a child, since we would expect a normal dependency on adult figures, related to the need for relatively greater protection in early life. We therefore turn next to the definition of original authors of attachment theory, whose writings comprise the basis for understanding RAD and its treatment.
The Place of Attachment in Nature
An exploration of emerging new theories for RAD may best follow our approach to an example that illustrates the approach to a real case. To assess psychopathology, however, we need a model of normal attachment, and we will review a developmental model of normalcy, which has guided clinicians and families, both at the stage of assessment and in treatment.
Often referred to as the father of attachment theory, John Bowlby [], the infant separated from his attachment figure(s) will usually lose food, water, warmth, shelter, and protection from predators.
Bowlby [] defined stages of attachment for the motherinfant dyad, beginning with the first 3-month period of indiscriminate orientation response to the proximate sources of comfort. In the next several months, the infant recognizes and develops a preference for one or more familiar caregivers. An important influence on the next stage from late in the first year through the third year is the growing ability to ambulate. This gives the child some control over proximity, and conversely there is an advancing capacity to explore the surround, using the mother as a secure home base. Mothers, as part of the attachment system favored by evolution, closely monitor the toddlers advances in independence, as well as state of need, especially need for rescue in times of distress. For this stage, theory of natural selection predicts that fitness of the child increases with appropriate balance of safety and exploration, whereas biological fitness of the parent increases in proportion to sensitivity to the infants immediate state of need.
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