Reactive Attachment Disorder following Early Maltreatment: Systematic Evidence beyond the Institution
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Reactive Attachment Disorder (RAD) remains one of the least evidence-based areas of DSM and ICD nosology. Recent evidence from severely deprived institutional samples has informed review of RAD criteria for DSM-V; however, this data is not necessarily generalizable to expectable child environments in the developed world. We provide the first systematic study of this important syndrome in maltreated non-institutionalized adolescents from a high-income country. 153 high-risk adolescents in English out-of-home Looked After Care (LAC: mean age 174 months, SD 23, 52 % male) and 42 low-risk (LR) community controls (mean age 168 months, SD 18, 38 % male) were assessed for RAD behaviors. Data on maltreatment and care history were collected from social work reports and concurrent psychopathology from caregiver report. Triangulated data sources informed independent researcher ratings of adaptive functioning. LAC adolescents showed high prevalence of RAD behaviors. Factor analysis showed four symptom groups; Disinhibited Indiscriminate, Attention Seeking, Superficial Relationships and Unpredictability. RAD was associated with multiple maltreatment experience, earlier entry to care and increased rates of psychopathology. Superficial Relationships and Attention Seeking factors showed strong independent association with particularly pervasive functional impairment. Disinhibited RAD behaviors are identifiable with high prevalence in non-institutionalized high-risk adolescents. They are strongly associated with psychopathology and functional impairment. Retention of this subtype in DSM-V is supported. Findings on the inhibited subtype in adolescence are less persuasive. RAD behavior is a relevant marker of developmental impairment, has significant clinical implications and is deserving of further study within non-institutionalized risk populations.
KeywordsReactive attachment disorder Adolescence Maltreatment Diagnosis
This research was supported by a UK Department for Education grant to the CaPE project. Dr Kay was supported on a funded PhD studentship from the University of Manchester, the UK Youth Justice Board and the Medical Research Council. We acknowledge the collaboration and support of the CaPE study team; Professor Nina Biehal, Professor Ian Sinclair, Jo Dixon and Elizabeth Parry of the University of York and Dr Justine Rothwell, Anna Roby, and Dharmi Kapadia from the University of Manchester. We record grateful thanks to Dr Richard Emsley of the University of Manchester for providing statistical support and consultation during the analysis and preparation of this paper.
Conflicts of Interest
The authors declare that they have no conflict of interest.
- Achenbach, T., & Edelbrock, C. (1983). Manual for the child behavior checklist and revised child behavior profile. Burlington: University of Vermont.Google Scholar
- American Psychiatric Association. (1980). Diagnostic and statistical manual of mental disorders (3rd ed.). Washington: American Psychiatric Publishing.Google Scholar
- Biehal, N., Clayden, M., Stein, M., & Wade, J. (1995). Moving on: Young people and leaving care schemes. London: HMSO.Google Scholar
- Biehal, N., Dixon, J., Parry, E., Sinclair, I., Green, J., Roberts, C., et al. (2012). The care placements evaluation (CaPE) evaluation of multidimensional treatment foster care for adolescents (MTFC-A). Department for Education. https://www.education.gov.uk/publications/standard/publicationDetail/Page1/DFE-RB194. Accessed 20th March 2012.
- Boris, N. W., Hinshaw-Fuselier, S. S., Smyke, A. T., Scheeringa, M. S., Heller, S. S., & Zeanah, C. H. (2004). Comparing criteria for attachment disorders: establishing reliability and validity in high-risk samples. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 568–577.PubMedCrossRefGoogle Scholar
- Goldfarb, W. (1945). Effects of psychological deprivation in infancy and subsequent stimulation. The American Journal of Psychiatry, 102, 18–33.Google Scholar
- Gowers, S. G., Harrington, R. C., Whitton, A., Lelliot, P., Beevor, A., Wing, J., et al. (1999). Brief scale for measuring the outcomes of emotional and behavioral disorders in children: Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA). The British Journal of Psychiatry, 174, 413–416.PubMedCrossRefGoogle Scholar
- Green, J., & Goldwyn, R. (2002). Annotation: attachment disorganisation and psychopathology: new findings in attachment research and their potential implications for developmental psychopathology in childhood. Journal of Child Psychology and Psychiatry, 43, 835–846.Google Scholar
- Horan, S., Kang, G., Levine, M., Duax, C., Luntz, B., & Tasa, C. (1993). Empirical studies on foster care: review and assessment. Journal of Sociology and Social Welfare, 20, 131–154.Google Scholar
- Kreppner, J., Kumsta, R., Rutter, M., Beckett, C., Castle, J., Stevens, S., et al. (2010). IV. Developmental course of deprivation-specific psychological patterns: early manifestations, persistence to age 15, and clinical features. Monographs of the Society for Research in Child Development, 75, 79–101.PubMedCrossRefGoogle Scholar
- Lyons-Ruth, K., Bureau, J. F., Riley, C. D., & Atlas-Corbett, A. F. (2009). Socially indiscriminate attachment behavior in the Strange Situation: convergent and discriminant validity in relation to caregiving risk, later behavior problems, and attachment insecurity. Development and Psychopathology, 21, 355–372.PubMedCrossRefGoogle Scholar
- Meltzer, H., Gatward, R., Corbin, T., Goodman, R., & Ford, T. (2003). The mental health of young people looked after by local authorities in England. London: The Stationery Office.Google Scholar
- Minnis, H., Green, J., O’Connor, T. G., Liew, A., Glaser, D., Taylor, E., et al. (2009). An exploratory study of the association between reactive attachment disorder and attachment narratives in early school-age children. Journal of Child Psychology and Psychiatry, 50, 931–942.PubMedCrossRefGoogle Scholar
- Noble, M., Wright, G., Dibben, C., Smith, G. A. N., McLennan, D., Anttila, C., et al. (2004). The English indices of deprivation 2004 (revised). London: Office of the Deputy Prime Minister.Google Scholar
- Sadiq, F. A., Slator, L., Skuse, D., Law, J., Gillberg, C., & Minnis, H. (2012). Social use of language in children with reactive attachment disorder and autism spectrum disorders. European Journal of Child and Adolescent Psychiatry. doi: 10.1007/s00787-012-0259-8.
- World Health Organisation. (1992). The ICD-10 classification of mental and behavioral disorders: Clinical descriptions and diagnostic guidelines. Geneva: World Health Organisation.Google Scholar
- Zeanah, C.H., & Gleason, M.M. (2010). Reactive attachment disorder: A review for DSM-V. American Psychiatric Association. http://www.dsm5.org/Proposed%20Revision%20Attachments/APA%20DSM-5%20Reactive%20Attachment%20Disorder%20Review.pdf. Accessed 1 April 2011.