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Go Now Clear List. View most recent trades for the selected time period: Last Trades 4: Most Active in the Pre-Market. Reactive attachment disorder RAD is described in clinical literature as a severe and relatively uncommon disorder that can affect children. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited form".
Due to recent revision in the DSM-5 the "disinhibited form" is now considered a separate diagnosis named " disinhibited attachment disorder ". RAD arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect , abuse , abrupt separation from caregivers between the ages of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts.
Not all, or even a majority of such experiences, result in the disorder. The criteria for a diagnosis of a reactive attachment disorder are very different from the criteria used in assessment or categorization of attachment styles such as insecure or disorganized attachment. Children with RAD are presumed to have grossly disturbed internal working models of relationships that may lead to interpersonal and behavioral difficulties in later life.
There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years. Such research broadened the understanding of the prevalence, causes, mechanism and assessment of disorders of attachment and led to efforts from the lates onwards to develop treatment and prevention programs and better methods of assessment.
Mainstream theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined beyond current classifications. Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver.
Mainstream practitioners and theorists have presented significant criticism of the diagnosis and treatment of alleged reactive attachment disorder or the theoretically baseless "attachment disorder" within the controversial form of psychotherapy commonly known as attachment therapy. Attachment therapy has a scientifically unsupported theoretical base and uses diagnostic criteria or symptom lists markedly different to criteria under ICD or DSM-IV-TR, or to attachment behaviors.
A range of treatment approaches are used in attachment therapy , some of which are physically and psychologically coercive, and considered to be antithetical to attachment theory.
Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the disorder. The initial presentation varies according to the child's developmental and chronological age, although it always involves a disturbance in social interaction. Infants up to about 18—24 months may present with non-organic failure to thrive and display abnormal responsiveness to stimuli.
Laboratory investigations will be unremarkable barring possible findings consistent with malnutrition or dehydration , while serum growth hormone levels will be normal or elevated. The core feature is severely inappropriate social relating by affected children. This can manifest itself in three ways:. While RAD occurs in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect.
However, the instances of that ability are rare. The name of the disorder emphasizes problems with attachment but the criteria includes symptoms such as failure to thrive, a lack of developmentally appropriate social responsiveness, apathy, and onset before 8 months. There is as yet no universally accepted diagnostic protocol for reactive attachment disorder. Often a range of measures is used in research and diagnosis. Recognized assessment methods of attachment styles, difficulties or disorders include the Strange Situation Procedure devised by developmental psychologist Mary Ainsworth ,    the separation and reunion procedure and the Preschool Assessment of Attachment,  the Observational Record of the Caregiving Environment,  the Attachment Q-sort  and a variety of narrative techniques using stem stories , puppets or pictures.
For older children, actual interviews such as the Child Attachment Interview and the Autobiographical Emotional Events Dialogue can be used. Caregivers may also be assessed using procedures such as the Working Model of the Child Interview. This method is designed to pick up not only RAD but also the proposed new alternative categories of disorders of attachment. Although increasing numbers of childhood mental health problems are being attributed to genetic defects ,  reactive attachment disorder is by definition based on a problematic history of care and social relationships.
Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. While similar abnormal parenting may produce the two distinct forms of the disorder, inhibited and disinhibited, studies show that the abuse and neglect was far more prominent and severe in the cases of RAD, disinhibited type.
The issue of temperament and its influence on the development of attachment disorders has yet to be resolved. RAD has never been reported in the absence of serious environmental adversity yet outcomes for children raised in the same environment are the same. In discussing the neurobiological basis for attachment and trauma symptoms in a seven-year twin study , it has been suggested that the roots of various forms of psychopathology , including RAD, Borderline Personality Disorder BPD , and post-traumatic stress disorder PTSD , can be found in disturbances in affect regulation.
The subsequent development of higher-order self-regulation is jeopardized and the formation of internal models is affected. Consequently, the "templates" in the mind that drive organized behavior in relationships may be impacted. The potential for "re-regulation" modulation of emotional responses to within the normal range in the presence of "corrective" experiences normative caregiving seems possible.
There is little systematic epidemiologic information on RAD, its course is not well established and it appears difficult to diagnose accurately. According to the American Academy of Child and Adolescent Psychiatry AACAP , children who exhibit signs of reactive attachment disorder need a comprehensive psychiatric assessment and individualized treatment plan.
The signs or symptoms of RAD may also be found in other psychiatric disorders and AACAP advises against giving a child this label or diagnosis without a comprehensive evaluation. According to the AACAP Practice Parameter the question of whether attachment disorders can reliably be diagnosed in older children and adults has not been resolved.
Attachment behaviors used for the diagnosis of RAD change markedly with development and defining analogous behaviors in older children is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence.
The two classifications are similar and both include:. ICD states in relation to the inhibited form only that the syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. DSM states in relation to both forms there must be a history of " pathogenic care" defined as persistent disregard of the child's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to account for the disorder.
For this reason, part of the diagnosis is the child's history of care rather than observation of symptoms. In DSM-IV-TR the inhibited form is described as persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses e.
The disinhibited form shows diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments e. The first of these is somewhat controversial, being a commission rather than omission and because abuse in and of itself does not lead to attachment disorder. The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is more enduring.
Disinhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same child. The World Health Organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate subdivision.
In regards to pathogenic care, or the type of care in which these behaviors are present, a new criterion for Disinhibited Social Engagement Disorder now includes chronically harsh punishment or other types of severely inept caregiving. The diagnostic complexities of RAD mean that careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential.
RAD can also be confused with neuropsychiatric disorders such as autism , pervasive developmental disorder , childhood schizophrenia and some genetic syndromes. Infants with this disorder can be distinguished from those with organic illness by their rapid physical improvement after hospitalization.
They are unlikely to improve upon being removed from the home. In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the DSM and ICD , were created out of clinical and parental experience within the field known as attachment therapy. These lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists.
However, knowledge of attachment relationships can contribute to the cause, maintenance and treatment of externalizing disorders. Critics assert that it is unvalidated  and lacks specificity. Assessing the child's safety is an essential first step that determines whether future intervention can take place in the family unit or whether the child should be removed to a safe situation. Interventions may include psychosocial support services for the family unit including financial or domestic aid, housing and social work support , psychotherapeutic interventions including treating parents for mental illness, family therapy , individual therapy , education including training in basic parenting skills and child development , and monitoring of the child's safety within the family environment .
Zeanah based on its published parameters for the diagnosis and treatment of RAD. Mainstream prevention programs and treatment approaches for attachment difficulties or disorders for infants and younger children are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. The programs invariably include a detailed assessment of the attachment status or caregiving responses of the adult caregiver as attachment is a two-way process involving attachment behavior and caregiver response.
Some of these treatment or prevention programs are specifically aimed at foster carers rather than parents, as the attachment behaviors of infants or children with attachment difficulties often do not elicit appropriate caregiver responses.
The relevance of these approaches to intervention with fostered and adopted children with RAD or older children with significant histories of maltreatment is unclear.
The terms attachment disorder , attachment problems, and attachment therapy, although increasingly used, have no clear, specific, or consensus definitions. However, the terms and therapies often are applied to children who are maltreated, particularly those in the foster care, kinship care, or adoption systems, and related populations such as children adopted internationally from orphanages.
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