Attachment refers to the intimate bond formed between an infant or very young child and the primary caregiver. Research suggests that this bond, or attachment, is vital to the child’s emotional development. This relationship is important in developing the child’s ability to establish other healthy social relationships.
When infants and children under the age of five show disturbed and developmentally inappropriate social relatedness and do not initiate or respond to most social interactions, a diagnosis of Reactive Attachment Disorder is considered.
The difficulties of children who develop this disorder are due primarily to a grossly deprived environment. There may be repeated changes of caregivers, or caregivers who persistently disregard the child’s physical needs or emotional needs for comfort, stimulation and affection.
Signs and Symptoms
The physical and emotional milestones of children with Reactive Attachment Disorder deviate from expected developmental norms.
- Many of the children appear significantly malnourished.
- They may show a patterns of interaction that are:
- inhibited (frozen watchfulness)
- hypervigilant(resistance to comfort)
- ambivalent (a mixture of approach and avoidance)
- Dullness, listlessness or apathy with a lack of spontaneous activity and reciprocity with the caregiver are often seen
- Some children look sad, unhappy, joyless or miserable
- Older infants show minimal curiosity about their surroundings and little exploratory behavior
- They may show delayed responsiveness to a stimulus that might elicit fright or withdrawal in other children
- Some may shrink from contact; others may exhibit indiscriminate attachments
- Reactive Attachment Disorder may be associated with:
- Developmental delays
- Feeding Disorder of Infancy and Early Childhood
- Pica or Rumination Disorder
Laboratory findings consistent with malnutrition may be present.
Physical examination may document medical conditions, such as growth delay or evidence of physical abuse, that might contribute to, or result from, difficulties in caring for the child.
Reactive Attachment Disorder must be distinguished from:
- Severe Mental Retardation
- Autism Spectrum Disorder Disorders.
These disorders usually occur in the context of a reasonably supportive psychosocial environment whereas Reactive Attachment Disorder is due to a grossly deprived environment.
Autistic Disorder and Reactive Attachment Disorder may seem similar, but a child with autism has a neurologically based disability which impedes expected development in social relationships while a child with Reactive Attachment Disorder has the capacity to comprehend social relationships, but does not function appropriately. In Reactive Attachment Disorder, neglect, not a neurological difficulty, is the causal factor.
Many factors can potentially interfere with the development of attachment between the mother or primary caregiver and the infant-curtailed mother/child interaction, including:
- lack of holding
- poor verbal and sensory stimulation
- inadequate physical care and feeding
- Alcohol and drug use by the caregiver may also affect parenting ability and interfere with the formation of an attachment relationship.
- Certain situations, such as lack of a primary caregiver, prolonged hospital stay, extreme poverty, parental inexperience, and parental social isolation, may predispose a child to developing in a deprived environment that in turn may lead to a Reactive Attachment Disorder.
It must be noted that some children form stable attachments and social relationships despite marked neglect or abuse.
Since it is believed that a strong attachment provides the basis for healthy emotional and social development, children who are deprived of the opportunity to form attachments, due to deprived environments and/or grossly inadequate caregiving, may develop a Reactive Attachment Disorder.
Although epidemiological data are limited, the disorder is uncommon. Because of its association with other disorders it may be underdiagnosed.
According to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) a child must show:
markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5, as shown by:
- persistent failure to initiate or respond to most social interactions, excessively inhibited, hypervigilant or ambivalent and contradictory responses,
- indiscriminate sociability or inability to exhibit appropriate selective attachments.
Neglectful care can be shown by at least one of the following:
- disregard for the child’s emotional needs for stimulation,comfort and affection
- disregard of child’s physical needs
- repeated changes of primary caregiver
The severity and the course of the disorder vary, depending on individual factors in the child and the caregiver, the degree of the associated psychosocial deprivation, the length of time spent in the deprived environment, the nature and adequacy of the intervention, and the age of the child at the time of intervention. Considerable improvement or remission may occur if a disorder follows a continuous course. Possible interventions include, but are not limited to:
- Psychosocial support services, which can include providing homemakers, assessing the capacity of the caretakers, improving the physical condition of the home or obtaining more adequate housing, improving the financial status of the family, and decreasing the isolation of the family.
- Psychotherapeutic intervention, which can include family or marital counseling and medications for associated difficulties. Treatment should target the symptoms, not just the attachment problems.
- Educational/counseling services, which can include mother/infant groups and education to increase awareness and understanding of the child’s needs and improve parenting skills.
- Provisions for close monitoring of the progression of the infant’s physical and emotional well-being.
- Placement with relatives, foster care, or adoption may become alternatives should these interventions be unfeasible.
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Frequently Asked Questions
What does attachment mean? Why is it so important?
Attachment is the gradually developing quality of a reciprocal affectionate relationship between the infant and parent(s), especially the mother or the primary caregiver, during the first year of life. It is believed that a strong attachment provides the basis for healthy emotional and social development, and children who are deprived of the opportunity to form attachments, due to deprived environments and/or grossly inadequate caregiving, will not be able to develop normally.
If a six-month-old infant is not gaining weight and seems listless, does that mean she has Reactive Attachment Disorder?
These symptoms alone do not point to Reactive Attachment Disorder. This disorder, by definition, must be caused by a gross lack of adequate care by the parents or other primary caregivers. Medical evaluation for other possible causes, such as inadequate nutrition, inappropriate levels of stimulation, or possible physical conditions is indicated.
Can Reactive Attachment Disorder be cured?
The sooner the problem is identified and the conditions contributing to the grossly inadequate care and poor environment are changed, the better the chances for a reversal of the disorder.
Do all children who are adopted have Reactive Attachment Disorder?
The majority of adopted children do not have Reactive Attachment Disorder. Children who have been in an institution or other environment in which the caregivers did not provide emotional and sensory stimulation, such as physical holding, talking and interaction with adults, do best when they are adopted as soon as possible. The younger the children are when they are removed from the deprived environment, the better their chances of following a normal developmental track.
Since children with autism often don’t respond to other people, do they also have Reactive Attachment Disorder?
Children with autism do show a lack of responsiveness to people, even to their parents, but most of these children are not apathetic or listless. They may show a preferential interest in inanimate objects and bizarre responses to environmental stimuli, but the deviant course of their development is not due to inadequate or pathological care-taking. A neurological basis for the lack of ability to comprehend normal social relationships is present in autism.