Read an Excerpt
Children with Reactive Attachment Disorder
A Quilting Method Approach for Restoring the Damaged Years
By OJOMA EDEH HERR
AuthorHouseCopyright © 2013 Ojoma Edeh Herr
All rights reserved.
The Reality of RAD
Some of us know children who deliberately break or ruin things. We know children who do not seem to feel guilt for their actions. In other words, some children do not seem to have a conscience. We know children who are involved in very dangerous activities while ignoring the possibility of getting hurt. How about other children who may act very innocently when caught in the act of doing something very bad? We know some adults that are considered to be villain without any apparent conscience. These are a few of the realities of Reactive Attachment Disorder.
Keep in mind that not all children with reactive attachment disorder exhibit all of these behaviors, but they may exhibit behaviors that do not seem to make sense to the rest of us. There is hope! It is my sincere expectation that this book may offer suggestions and methods for parents in taking care of their child or children with some of these behaviors.
This foundational chapter may seem dry to some readers; however, this chapter is needed to help establish what the professionals in the field know, when they know it, and what they currently think about reactive attachment disorders. In this chapter I will briefly address some definitions, theories and characteristics surrounding reactive attachment disorder.
I am using the Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) definition in this section. DSM-IV is a professional "book" that provides classification of known mental disorders. DSM-IV provides appropriate categories and criteria for diagnosing these disorders and it is to be used by professionals with appropriate training. In other words, DSM-IV is the "go-to book" with high credibility for all known disorders.
Diagnostic and Statistical Manual of Mental Disorders-Fourth Edition (DSM-IV) uses four diagnostic criteria to explain reactive attachment disorder of infancy or early childhood. These criteria are: A) Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either: (1) persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessive inhibited, hypervigilant, or highly ambivalent and contradictory responses or (2) diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments. B) The disturbance in criterion A is not accounted for solely by developmental delay and does not meet criteria for a Pervasive Developmental Disorder; C) Pathogenic care as evidenced by at least one of the following: (1) persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection, (2) persistent disregard of the child's basic physical needs, (3) repeated changes of primary caregiver that prevent formation of stable attachments. D) There is a presumption that the care in criterion C is responsible for the disturbed behavior in criterion A.
DSM-IV has the following two specific types of RAD: Inhibited Type and Disinhibited Type. Inhibited Type is when criterion A1 predominates in the clinical presentation. Disinhibited Type is when criterion A2 predominates in the clinical presentation.
Reactive Attachment Disorder is a serious disorder that affects children as early as infancy. Reactive attachment disorder can have lasting, damaging effects reaching into other relationships if appropriate, consistent, and ongoing interventions are insufficient or lacking. It is vital that infants and young children develop a secure form of attachment and trusting relationship with their parents or primary caregivers. However, when this attachment is lacking during or after infancy and not intervened effectively, the child may carry this lack of attachment (mistrust) into adulthood, which interferes with other social relationships.
The term reactive attachment disorder was coined through studying the behavior of young children in orphanages and lower income lifestyles with poor family relationships. Professionals concluded that an insecure relationship with a primary caretaker is detrimental to the emotional development of a child. This was further clarified that the child's principal attachment-figure can be filled by others than the natural mother or father for that matter. The child must feel secure in having his/her needs met through creating a relationship with another person at an early age to cognitively, socially, and emotionally develop properly.
Attachment theory, described above is the most common theory used by professionals when writing about or providing treatment for reactive attachment disorder. The attachment theory hypothesizes that, beginning in infancy; children form highly affective relationships or attachments with their primary caregivers that are based on the infant's need for protection, comfort, and nurturance. There are three types of attachments: secure, insecure, and disorganized.
Children with secure attachments feel that their caregivers are physically and emotionally available to them and generally have better developmental outcomes and lower rates of psychopathology than children with insecure or disorganized attachments. Secure attachments provide a "secure base" with the caregiver that fosters safe exploration and learning.
Insecure attachment results from an infant's or child's attempt to maintain proximity to a caregiver who is emotionally unavailable or only intermittently responsive. This insecure attachment would manifest in children in the form of "anxious avoidant", which mean avoiding a caregiver because they are apprehensive and do not know how the caregiver would respond to them. In other children insecure attachment would manifest in "anxious resistant", which mean that these children worry about the caregiver's response. Either way, insecure attachment creates in children an abnormal form of attachment.
Disorganized children or infants are caught between craving proximity and fearing to approach the caregiver. They often exhibit disorganized or contradictory behavior, such as freezing, stilling, or apprehension toward their attachment figures. Of all three types of attachments described above, disorganized children tend to be at the highest risk for later behavioral and emotional difficulties.
Although attachment theory makes it clear that early relationships are important to development, this knowledge does not extrapolate directly to understanding attachment disorders.
Attachments vary across secure, insecure, and disorganized presentations, and each carries a different degree of risk. DSM-IV, however, does not recognize variations in attachments or severity of attachment difficulties as part of the reactive attachment disorder diagnosis. None of the types of attachments delineated in attachment theory directly corresponds with attachment disorders in DSM-IV.
Broaden the Definitions
The attachment theory described above; however, left out a large group of children with reactive attachment disorder. Some children born to two parents who are in middle to upper income brackets have reactive attachment disorders as well. Hearing how children turn on their parents, etc, in the news media today makes one wonder when the disconnection happened within that family. To give us a clearer understanding of what reactive attachment disorder is, we need to broaden the definition. Broaden definition: Children with reactive attachment disorder are those whose basic needs to develop a secure form of attachment and trusting relationship were not met by their parents or caregivers, regardless of race, gender, culture, linguistic backgrounds, religion, and socio-economic status. This definition is broad and inclusive and clear.
It is easy to see how children in the orphanage and foster care system, and those from low socio-economic status, do not have their basic needs met. But how about children from stable two-parent homes' or children from stable middle to upper class homes? This broadened definition looks beyond what parents can physically provide for their children to what children need psychologically. Parents from stable middle to upper class homes may be providing what they think their children need, but if their children's perceptions of their needs differ from what these parents think they need, a gap in the relationship starts to form. As children grow and the perceptions of their needs differ significantly from what their parents provide, they start to detach from their parents emotionally. Attachment disorder is a very complex one and it affects children differently, even if these children have similar backgrounds.
In response to this mismatch between DSM-IV and the clinical population, some clinicians and theoreticians have suggested that the diagnostic criteria for reactive attachment disorder be expanded to include those children who have "secure base distortions." Secure base distortions refer to children who have a selective but highly disturbed relationship with caretakers. Such a conception focuses on the way the child interacts with and uses that caregiver.
Let us look at these basic needs and secured base distortions for a minute. All babies need to be loved, fed, held, changed, played with, etc. Let's assume for a second that all children from "stable" homes get all this attention plus more. How could they have reactive attachment disorder? Every child has a different personality and different perception of the world around them. As they grow from infant to toddler to pre-school, they start to show who they truly are and what they perceive their needs to be. If children's perceptions of their needs differ from what their parents think they need, a gap in the relationship starts to form. As children grow and the perceptions of their needs differ significantly from what their parents provide, they start to detach from their parents emotionally. Caution: This does not mean that all children who rebel in one way or another have reactive attachment disorder! Some children use rebellion as one of the ways to test the boundaries to see how far they can go.
We know that most children with reactive attachment disorder are undiagnosed since the concept of attachment disorder is new. Reactive attachment disorder was mentioned for the first time in DSM-III, and most professionals associated reactive attachment disorder with children in orphanages and the foster care system. However, we know that reactive attachment disorder does not "discriminate", and children from two parent homes and those from middle to upper class homes could have reactive attachment disorder as well. The best way to look at reactive attachment disorder is when there is disconnect between what parents think is best for their children and what those children truly need or when there is disconnect because what parents think their children needs are differ from what children perceived their needs to be. Does that mean that all children who do not agree with their parents have reactive attachment disorder? Absolutely not! It is possible that two children born to the same parents may have different needs; one may have reactive attachment disorder and the other may not have it.
Most children with undiagnosed and untreated reactive attachment disorder end up with criminal behaviors, starting from teenage years into adulthood. Their crimes tend to be in the area that "put them in power." They yearn to have control of their lives and their environments. These children (or adults) may target those they see (symbolically) as having taken the control away from them.
Whether the professionals in the field agree with the types and diagnostic criteria or not, there are two most dangerous challenges relating to reactive attachment disorder: First, reactive attachment disorder is grossly under-diagnosed because some of its characteristics overlap with other disorders, which makes it difficult to differentiate. As stated earlier, many of the children with undiagnosed reactive attachment disorder may end up leading lives of criminal behaviors. This sadly makes sense since most of them do not know right from wrong. For these children, right is what they want to do and wrong is what they do not want to do. The second challenge is discipline. One of the things that children with reactive attachment disorder need is consistent discipline in love, but most of them may not have experienced love. The challenging question in this case is how do we teach these children to differentiate between discipline in love and rejection?
DSM-IV lists diagnostic characteristics criteria when assessing children for Reactive Attachment Disorder (RAD) with two subtypes: Inhibited and Disinhibited. An individual must exhibit noticeably troubled and developmentally inappropriate social behaviors. Inhibited behavior is marked by a failure to initiate and/ or respond to social interaction in a way that is developmentally appropriate. Disinhibited behavior is evidenced by an inability to display and form appropriate attachments to others. Another part of the diagnostic criteria is that the inappropriate social behavior cannot be linked to a developmental delay or a pervasive developmental disorder. The final element in the diagnostic criterion is that there must be evidence of parental/guardian disregard for the child's emotional and/or physical needs. Furthermore, there may be repeated adjustments to the child's primary caregiver resulting in unstable attachments. There must also be evidence that these things are causing the inappropriate social behavior (Floyd, Hester, Griffin, Golden, & Canter, 2008).
According to Sheperis, Renfro-Michel, and Doggett (2003), reactive attachment disorder characteristics include, low self-esteem, lack of self-control, anti-social attitudes and behaviors, aggression and violence, and among other things, a lack of ability to trust, show affection, or develop intimacy. Children who are characterized as having reactive attachment disorder may also struggle with cause and effect thinking. This difficulty is also seen in children who have Attention Deficit Hyperactivity Disorder. It is sometimes difficult to accurately diagnose reactive attachment disorder due to the similarities in characteristics between reactive attachment disorder and other disorders. Reactive attachment disorder can go undiagnosed because it can appear to be childhood or adolescent depression. It is essential that evaluators perform careful assessments and observations of specific characteristics when diagnosing children with reactive attachment disorder.
One question that both parents and professionals ask is, "When do I ask for an evaluation of the child for possible reactive attachment disorder?" The evaluation process for reactive attachment disorder does not do any damage to the child; therefore, when in doubt, ask a psychiatrist who treats children and adolescents with reactive attachment disorder for their professional views. If your child exhibits some of the behaviors listed earlier, such as stealing, lying, damaging property, smearing feces, sabotaging situations, embarrassing/humiliating their caregivers, harassment, self abusive behaviors, etc. then it might be appropriate to ask for an evaluation.
Children who have Reactive Attachment Disorder display specific behaviors. These behaviors can range from mild to severe depending on each individual child. Some children can be self-destructive, suicidal, self-defeating, and engage in self-mutilation. Children with reactive attachment disorder may be pathological liars who are highly capable of manipulating others. Engaging in stealing is also a behavior that may be present in children with reactive attachment disorder. There are many cases of children with reactive attachment disorder who have been sexually abused in some way. If this is the case, the child may display voracious behaviors like sexualized attitudes and play, as well as excessive masturbation. Educators should be aware that children may or may not display these sexual behaviors. Educators should also be cognizant of the fact that children with reactive attachment disorder may feel that they are victims even as they display victimizing behaviors to others.
Children with reactive attachment disorder tend to have difficulty regulating their own behaviors. This may be displayed in failed attempts to regulate impulses, behaviors, and emotions. It is essential for parents/caregivers and educators to understand this inability to self-regulate because it is very important to teach and in some cases model self-soothing and self-regulatory behaviors. Children with reactive attachment disorder may have difficulty understanding social boundaries. This difficulty may result in behaviors such as invading another individual's private space, rejecting appropriate displays of affection and/or engaging in overt displays of affection with the aim of receiving a reaction. It is essential for parents/caregivers and educators to constantly model appropriate social boundaries and to address any possible inappropriate social interactions. Children with reactive attachment disorder have tremendous challenges in the area of developing trust and intimacy. Intimacy is generally threatening to a child with reactive attachment disorder. The inability for children with reactive attachment disorder to gain positive feelings from social relationships can lead to depression.
Excerpted from Children with Reactive Attachment Disorder by OJOMA EDEH HERR. Copyright © 2013 Ojoma Edeh Herr. Excerpted by permission of AuthorHouse.
All rights reserved. No part of this excerpt may be reproduced or reprinted without permission in writing from the publisher.
Excerpts are provided by Dial-A-Book Inc. solely for the personal use of visitors to this web site.