FEBRUARY2003

Question: What is Reactive Attachment Disorder of Infancy or Early Childhood?

A: Reactive Attachment Disorder is a serious emotional problem that is usually first observed and diagnosed in children under 5 years of age. A number of preschool children - especially those in foster care - exhibit behaviors that are extremely inappropriate especially as they relate to social interactions. These children are often excessively aggressive, hypervigilant, withdrawn, and/or inappropriately familiar with strangers. Children who experience extreme neglect/abuse, multiple placements, and/or prolonged institutional care with limited opportunities to form selective attachments are at increased risk of developing Reactive Attachment Disorder. Their behaviors often make it difficult for foster parents or even biological relatives to keep them, which increases the likelihood of a change in placement. Disturbances of attachment in the early years may increase the risk for antisocial behaviors in later childhood and adolescence.

Diagnostic criteria for 313.89 Reactive Attachment Disorder of Infancy or Early Childhood:

A) Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1)or (2) 

1) 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.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness) 

2) diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) 

B) The disturbance in Criterion A is not accounted for solely by developmental delay Mental Retardation 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 (e.g., frequent changes in foster care)

 D) There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).

Specify type: Inhibited Type: if Criterion A1 predominates in the clinical presentation Disinhibited Type: if Criterion A2 predominates in the clinical presentation

Interventions

A) What Parents(Biological/Foster) Can Do

 1) Communicate rules in a clear, specific, and action-oriented manner. 

2) Establish the ground rule that the child has to ask about ground rules AHEAD OF TIME if a particular situation comes up that has not been discussed. 

3) Teach the child, over and over, that behavior is connected to choices on the front end and to consequences on the back end. Thus, if the child is unhappy with the consequences that fall his way, the solution is defined as his learning to make better choices. 

4) Teach the child the language of feelings and help her connect her feelings to their causes and to the behaviors she is using to express them. 

5) Maintain a balanced stance between providing empathy for factors in the child's history that compromise his current functioning and maintaining expectations that the child will change his behavior. 

6) Never accept forgetfulness as a valid reason for avoiding responsibilities or consequences. Instead, "forgetfulness" is posed as a choice and the solution is for the child to undertake the task of sharpening his memory in the future.

7) Never accept painful feelings as a legitimate basis for destructive behavior. If the child wants different consequences, he is given the challenge of developing different methods of emotional expression. 

8) Forced Choice: With this strategy, parents give the child two choices, both of which are agreeable outcomes to the parents. Example: choice one: go to bed on time tonight and you get to stay up until your regular bedtime tomorrow night; choice two: for each minute you are late getting in bed tonight, 5 minutes will be taken off your bedtime tomorrow night. The parents then step back and allow the child's behavior to "tell the tale" of what will happen. The advantage of this approach over simply imposing a consequence is that both outcomes stem directly from the child's behavior, whereas it is easier for the child to frame a consequence as coming from the parents' meanness rather than her behavior.

(Lawrence B. Smith LCSW-C,LICSW)

B) What Mental Health Professionals Can Do

 1) Oregon Social Learning Center-Early Intervention: The treatment foster care program at the Oregon Social Learning Center is an early intervention program targeted to the needs of maltreated preschoolers. Foster parents are provided ongoing support and training to help them cope with the challenging behaviors. Foster parents are trained to articulate clear and consistent expectations. Pro-social behaviors are reinforced and effective interventions for negative behaviors are imposed. Overall, there is emphasis on consistency in the foster home, with foster parents using distraction and time-out as the primary behavior management techniques. Because children are usually reunified with their biological parents, both parents are taught the same skills. 

2) Parent training programs: Living with Children, based on Patterson and Guillion's manual, and Problem Solving Skills Training by Spaccarelli, Coller, and Penman; Videotape Modeling Parent Training by Webster-Stratton; Parent-Child Interaction Therapy by Eyberg and McNeil.