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Reactive attachment disorder—a theoretical model beyond attachment

Abstract

Despite its importance in public health, reactive attachment disorder (RAD) is an under-researched and little used clinical category. Abnormalities of social relatedness have long been documented in children who have been abused, neglected or institutionalised, but there have been more recent efforts to define these behaviours within the psychiatric nosology. There has been an implicit assumption that the central deficit in RAD is in the attachment system, but this has caused controversy and may have blocked research. We propose that RAD is better construed within the framework of intersubjectivity, which has a central role in the development of core brain and social functions and may also have had an important role in the evolution of a key human characteristic—complex social functioning. This broader framework may potentially explain apparently diverse symptoms such as indiscriminate friendliness and negative or unpredictable reunion responses. Finally, we suggest that a change of name may be useful in progressing the field, but accept that this may be difficult until there is better agreement in the clinical and scientific communities about the core features and aetiology of this disorder.

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References

  1. American Psychiatric Association (1994) Diagnostic and statistical manual of mental disorders, 4th edn. American Psychiatric Association, Washington, DC

    Google Scholar 

  2. Richters MM, Volkmar FR (1994), Reactive attachment disorder of infancy and early childhood. J Am Acad Child Adolesc Psychiatry 33:328–332

    PubMed  CAS  Google Scholar 

  3. World Health Organisation (1992) The ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines World Health Organisation, Geneva

  4. Tizard B, Hodges J (1978) The effect of early institutional rearing on the development of eight year old children. J Child Psychol Psychiatry 19:99–118

    PubMed  CAS  Google Scholar 

  5. Tizard B, Rees J (1975) The effect of early institutional rearing on the behaviour problems of 4 year old children. J Child Psychiatry Psychol 16:61–73

    CAS  Google Scholar 

  6. Spitz RR (1945) Hospitalism: an inquiry into the genesis of psychiatric conditions in early childhood. Psychoanal Study Child 1:54–74

    Google Scholar 

  7. Goldfarb W (1945a) Psychological privation in infancy and subsequent adjustment. Am J Orthopsychiatry 17:247–255

    Google Scholar 

  8. Minde K (2003) Attachment problems as a spectrum disorder: implications for diagnosis and treatment. Attachment Human Dev 5:289–296

    Article  Google Scholar 

  9. Goldfarb W (1945b) Effects of psychological deprivation in infancy and subsequent stimulation. Am J Psychiatry 102:18–33

    Google Scholar 

  10. Minnis H, Rabe-Hesketh S, Wolkind S (2002) Development of a brief, clinically relevant, scale of: measuring attachment disorders. Int J Methods Psychiatr Res 11(2):90–98

    PubMed  Article  Google Scholar 

  11. O’Connor T (2002) Attachment disorders of infancy and childhood. In: Rutter M, Taylor E (eds) Child and adolescent psychiatry. Blackwell, London pp 776–792

    Google Scholar 

  12. Smyke AT, Dumitrescu A, Zeanah CH (2002) Attachment disturbances in young children. I: the continuum of caretaking casualty. J Am Acad Child Adolesc Psychiatry 41(8):972–982

    PubMed  Article  Google Scholar 

  13. Fries ABW, Ziegler TE, Kurian JR, et al. (2005) Early experience in humans is associated with changes in neuropeptides critical for regulating social behavior. Proc Natl Acad Sci 102(47):17237–17240

    PubMed  CAS  Article  Google Scholar 

  14. Chisolm K (1998) A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian orphanages. Child Dev 69:1092–1106

    Article  Google Scholar 

  15. Minnis H, Keck G (2003) A clinical/research dialogue on reactive attachment disorder. Attachment Human Dev 5(3):297–301

    Article  Google Scholar 

  16. Dodge KA, Pettit GS, Bates JE (1997) How the experience of early physical abuse leads children to become chronically aggressive, in developmental perspectives on trauma: theory, research and intervention, 8 edn. University of Rochester Press, New York, pp 263–287

    Google Scholar 

  17. Arseneault L, Moffitt TE, Caspi A, Taylor PJ, Silva PA (2000) Mental disorders and violence in a total birth cohort. Arch Gen Psychiatry 57:979–986

    PubMed  CAS  Article  Google Scholar 

  18. Minnis H, Pelosi A, Knapp M, Dunn J (2001) Mental health and foster carer training. Arch Disease Childhood 84:302–306

    CAS  Article  Google Scholar 

  19. McCann JB, James A, Wilson S, Dunn G (1996) Prevalence of psychiatric disorders in young people in the care system. Br Med J 313:1529–1530

    CAS  Google Scholar 

  20. Dimigen G, Del Priore C, Butler S, Evans S, Ferguson L, Swan M (1999) The need for a mental health service for children at commencement of being looked after and accommodated by the local authority: questionnaire survey. Br Med J 319(7211):675

    CAS  Google Scholar 

  21. Coid J (1999) Aetiological risk factors for personality disorders. Br J Psychiatry 174(530):538

    Google Scholar 

  22. Holmes J (2004) Disorganised attachment and borderline personality disorder: a clinical perspective. Attachment Human Dev 61(2):181–190

    Article  Google Scholar 

  23. Bell J, Sim M (2004) Placement issues, in children exposed to parental substance misuse implications for family placement, Phillips R (ed). BAAF, London

  24. Howe D, Fearnley S (1999) Disorders of attachment and attachment therapy. Adoption Fostering 23(2):19–30

    Google Scholar 

  25. Boris N, Hinshaw-Fuselier S, Sarah S, Smyke AT (2004) Comparing criteria for attachment disorders: establishing reliability and validity in high-risk samples. J Am Acad Child Adolesc Psychiatry 43(5)

    Google Scholar 

  26. Meltzer H, et al. (2002) The mental health of group of young people looked after by local authorities in England. Report of survey from 2002 by the social survey division of the office for National Statistics on behalf of the Department of Health

  27. Zeanah CH (1996) Beyond insecurity: a reconceptualization of attachment disorders of infancy. J Consulting Clin Psychol 64:42–52

    CAS  Article  Google Scholar 

  28. Chisholm K, Carter MC, Ames EW, Morison SJ (1995) Attachment security and indiscriminately friendly behaviour in children adopted from Romanian Orphanages. Dev Psychopathol 7:283–294

    Article  Google Scholar 

  29. Tizard B (1977) Adoption: a second chance. Open Books, London

    Google Scholar 

  30. O’Connor T, Bredenkamp D, Rutter M (1999) Attachment disturbances and disorders in children exposed to severe early deprivation. Infant Mental Health J 20(1):10–29

    Article  Google Scholar 

  31. Gaensbauer T, Sands K (1979) Distorted affective communication in abused/neglected infants and their caretakers. J Am Acad Child Adolesc Psychiatry 18:236–250

    CAS  Google Scholar 

  32. George C, Main M (1979) Social interactions of young abused children: approach, avoidance and aggression. Child Dev 50:306–318

    PubMed  CAS  Article  Google Scholar 

  33. Main M, Solomon J (1986) Discovery of an insecure-disorganized/disorientated attachment pattern. In: Yogman M, Brazleton TB (eds) Affective development in infancy. Ablex, New Jersey, pp 95–124

    Google Scholar 

  34. Carlson V, Cicchetti D, Barnett D, Braunwald K (1989) Disorganized/disorientated attachment relationships in maltreated infants. Dev Psychol 25:525–531

    Article  Google Scholar 

  35. Green J, Goldwyn R (2002) Annotation: attachment disorganisation and psychopathology: new findings in attachment research and their potential implications for developmental psychopathology in childhood. J Child Psychol Psychiatry 43:835–846

    PubMed  Article  Google Scholar 

  36. van Ijzendoorn MH, Bakermans-Kranenburg MJ (2003) Attachment disorders and disorganized attachment: similar and different. Attachment Human Dev 5:313–320

    Article  Google Scholar 

  37. Main M, Hesse E (1990) Parents’ unresolved traumatic experiences are related to infant disorganized attachment status: is frightened and/or frightening behaviour the linking mechanism? In: Greenberg MT, Cicchetti, Cummings (eds) Attachment in the preschool years, University of Chicago Press, Chicago, pp 161–182

  38. O’Connor TG, Zeanah CH (2003) Introduction to the special issue: current perspectives on assessment and treatment of attachment disorders. Attachment Human Dev 5(3):221–222

    Article  Google Scholar 

  39. Cicchetti D, Toth SL (1995) A developmental psychopathology perspective on child abuse and neglect. Am J Child Adolesc Psychiatry 34:541–565

    CAS  Article  Google Scholar 

  40. Glaser D (2000) Child abuse and neglect and the brain—a review. J Child Psychol Psychiatry 41:97–116

    PubMed  CAS  Article  Google Scholar 

  41. O’Connor T, Rutter M (2000) Attachment disorder behavior following early severe deprivation: extension and longitudinal follow-up. J Am Acad Child Adolesc Psychiatry 39:703–712

    PubMed  CAS  Article  Google Scholar 

  42. Bowlby J (1984) Attachment, 2nd edn. Pelican Books, London

    Google Scholar 

  43. Dunn J (1993) Young children’s relationships: beyond attachment. Sage, Thousand Oaks

    Google Scholar 

  44. Ainsworth MD (1979) Infant–mother attachment. Am Psychol 34:932–937

    PubMed  CAS  Article  Google Scholar 

  45. Green J (2003) Are attachment disorders best seen as social impairment syndromes? Attachment Human Dev 5(3):259–264

    Article  Google Scholar 

  46. van Ijzendoorn MH, Schuengel C, Bakermans-Kranenburgh MJ (1999) Disorganized attachment in early childhood: meta-analysis of precursors, concomitants, and sequelae. Dev Psychopathol 11:225–249

    PubMed  Article  Google Scholar 

  47. Trevarthen C, Aitkin KJ (2001) Infant intersubjectivity: research, theory, and clinnical applications. J Child Psychol Psychiatry 42:3–48

    PubMed  CAS  Article  Google Scholar 

  48. Trevarthen C (1998) The concept and foundations of infant intersubjectivity. In: Braten S (eds) Intersubjective communication and emotion in early ontogeny. Cambridge University Press, Cambridge, pp 15–46

    Google Scholar 

  49. Trevarthen C (1999) Musically and the intrinsic motive pulse: evidence from human psychobiology and infant communication. Musical narrative and the origins of human communication. Musicae Scientae, Special Issue 1999–2000:157–213. Leige: European Society for the Cognitive Sciences of Music

    Google Scholar 

  50. Stern DN (1985/2000) The interpersonal world of the infant: a view from psychoanalysis and development psychology. (Second edition), with new introduction). Basic Books, New York

    Google Scholar 

  51. Marwick H (2004) Development in companionship—the importance of relationships to the development of language and learning. Keynote, Sure Start National Speech and Language Therapy Conference, Warwick

  52. Trevarthen C, Marwick H (1986) Signs of motivation for speech in infants, and the nature of a mother’s support for development of language. In: Lindblom B, Zetterstrom R (eds) Precursors of early speech. Macmillan, Basingstoke, pp 279–308

    Google Scholar 

  53. Hobson RP (1993) Autism and the development of mind. Hove/Hillside, Earlbaum

    Google Scholar 

  54. Stern DN (2004) The present moment in psychotherapy and everyday life. WW Norton and Co, New York

    Google Scholar 

  55. Marwick H (2005) Joint imaginative play with ‘representational others’ in preschool children with autism. Inclusive and Supportive Education Congress, International Special Education Conference, Inclusion: Celebrating Diversity? 1st–4th August 2005. Glasgow, Scotland (http://www.isec.2005.org.uk/isec/abstracts/papers_m/marwick)

  56. Reddy V (1991) Playing with others’ expectations; teasing and mucking about in the first year. In: Whiten A (ed) Natural theories of mind. Oxford, Blackwell, pp 143–158

    Google Scholar 

  57. Bettes BA (2005) Maternal depression and motherese: temporal and intonational features. Child Dev 59:1089–1096

    Article  Google Scholar 

  58. Murray L, Cooper PJ (eds) (1997) Postpartum depression and child development. Guildford Press, New York

    Google Scholar 

  59. Trevarthen C, Aitken KJ, Papoudi D, Robarts JZ (1998) Children with autism: diagnosis and interventions to meet their needs, 2nd edn. Jessica Kingsley, London

    Google Scholar 

  60. Murray L, Kempton C, Woolgar M, Hooper R (1993) Depressed mothers’ speech to their infants and its relation to infant gender and cognitive development. J Child Psychol Psychiatry 34(7):1083–1101

    PubMed  CAS  Google Scholar 

  61. Murray L, Woolgar M, Cooper P, Hipwell A (2001) Cognitive vulnerability to depression in 5-year-old children of depressed mothers. J Child Psychol Psychiatry 42(7):891–899

    PubMed  CAS  Article  Google Scholar 

  62. Kraemer GW (1997) Psychobiology of early social attachment in Rhesus monkeys. Clinical implications. Ann New York Acad Sci 807:401–418

    CAS  Google Scholar 

  63. Harlow HF, Harlow MK, Suomi SJ (1971) From thought to therapy: lessons from a primate laboratory. Am Scientist 59:538–549

    CAS  PubMed  Google Scholar 

  64. Richardson K (1995) Evolution and development. In: Oates J (ed) The foundations of child development. Blackwell/The Open University, Oxford

    Google Scholar 

  65. Shore AN (1998) The experience-dependent maturation of an evaluation system in the cortex. In: Pribram KH (ed) Brain and values: is a biological science of values possible? Erlbaum, Mahwah, NJ pp 337–358

    Google Scholar 

  66. Trevarthen C (2001) Intrinsic motives for companionship in understanding: their origin, development and significance for infant mental health. Infant Mental Health J 22(1–2):95–131

    Article  Google Scholar 

  67. Blaffer Hrdy S (1999) Mother nature Chatto and Winduss, New York

  68. Porges SW (1997) Emotion: an evolutionary by-product of the neural regulation of the autonomic nervous system. In: Carter CS, Lederhendler II, Kirkpatrick B (eds) The integrative neurobiology of affiliation (Annals of the New York Academy of Sciences 807). New York Academy of Sciences, New York, pp 62–78

    Google Scholar 

  69. Tronick EZ, Als H, Adamson L, Wise S, Brazelton TB (1978) The infant’s response to entrapment between contradictory messages in face-to-face interaction. J Am Acad Child Psychiatry 17:1–13

    PubMed  CAS  Article  Google Scholar 

  70. Murray L, Trevarthen C (1985) Emotional regulation of interactions between two-month-olds and their mothers. In: Field TM, Fox NA (eds) Social perception in infants. Norwood NJ, Ablex, pp 177–197

    Google Scholar 

  71. Dance C, Rushton A, Quinton D (2002) Emotional abuse in early childhood: relationships with progress in subsequent family placement. J Child Psychol Psychiatry 43:395–407

    PubMed  Article  Google Scholar 

  72. Greig A, Howe D (2001) Social understanding, attachment security of preschool children and maternal mental health. Br J Dev Psychol 19:381–393

    Article  Google Scholar 

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Acknowledgements

We are grateful to Christine Puckering, Joyce Minnis, Chris Gillberg, Danya Glaser, Amanda Burston and Valerie Murray for comments on earlier drafts.

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Correspondence to Helen Minnis.

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Minnis, H., Marwick, H., Arthur, J. et al. Reactive attachment disorder—a theoretical model beyond attachment. Eur Child Adolesc Psychiatry 15, 336–342 (2006). https://doi.org/10.1007/s00787-006-0539-2

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Keywords

  • foster care
  • service use
  • costs