Elsevier

Child Abuse & Neglect

Volume 28, Issue 8, August 2004, Pages 877-888
Child Abuse & Neglect

Reactive attachment disorder in maltreated toddlers

https://doi.org/10.1016/j.chiabu.2004.01.010Get rights and content

Abstract

Objective: To determine if Reactive Attachment Disorder (RAD) can be reliably identified in maltreated toddlers in foster care, if the two types of RAD are independent, and to estimate the prevalence of RAD in these maltreated toddlers.

Methods: Clinicians treating 94 maltreated toddlers in foster care were interviewed regarding signs of attachment disorder at intake in an intervention program.

Results: Using categorical and continuous measures, both types of RAD can be reliably identified in maltreated toddlers. Both continuous scores and categorical diagnoses indicated that a substantial minority of maltreated young children do exhibit signs of attachment disorders sufficient to meet criteria in DSM-IV and ICD-10. The two types were moderately convergent and at times co-occurred in the same child. Prevalence of RAD in this high-risk sample was 38–40%. Indiscriminate/disinhibited RAD was identified in children with and without an attachment figure. Within this maltreated group, toddlers whose mothers had a history of psychiatric disturbance were more likely to be diagnosed with attachment disorders.

Conclusions: RAD may be reliably identified in maltreated toddlers. Emotionally withdrawn/inhibited and indiscriminate/disinhibited types of RAD are not entirely independent.

Résumé

Objectif: Déterminer si les troubles réactionnels de l’attachement (RAD) peuvent être identifiés de façon sûre chez les jeunes enfants placés dans des familles d’accueil, si les deux types de RAD sont indépendants, et si l’on peut estimer la prévalence du RAD chez ces enfants maltraités.

Méthode: On a interrogé les cliniciens qui avaient en traitement 94 jeunes enfants maltraités et placés en famille d’accueil au sujet des signes de troubles de l’attachement au début d’un programme d’intervention.

Résultats: A l’aide de mesures continues et par catégorie, les deux types de RAD ont pu être identifiés de façon sûre chez les jeunes enfants maltraités. A la fois les scores continus et les diagnostics par catégorie ont indiqué qu’une minorité importante de jeunes enfants maltraités montrait des troubles de l’attachement suffisants pour correspondre aux critères DSM-IV et ICD-I0. Les deux types convergeaients modérément et parfois étaient présents en même temps chez le même enfant. La prévalence de RAD chez cet échantillon à haut risque était de 38 à 40%. On a identifié un RAD indistinct ou peu présent chez des enfants ayant ou n’ayant pas une figure d’attachement. A l’intérieur de ce groupe maltraité, les jeunes enfants dont la mère avait un passé posychiâtrique étaient le plus susceptibles d’être diagnostiqués comme présentant des troubles de l’attachement.

Conclusion: On peut identifié de façon fiable le RAD chez les jeunes enfants maltraités. Les types de RAD comportant retrait et inhibition ainsi que absence de distinction et d’inhibition ne sont pas entièrement indépendants.

Resumen

Objetivo: Determinar si el Desorden del Apego Reactivo (RAD) puede identificarse con confiabilidad en los niños maltratados en cuidado sustituto, si los dos tipos de RAD son independientes, y estimar la prevalencia de RAD en estos niños maltratados.

Métodos: Se entrevistaron los clínicos que atendían a 94 niños maltratados en cuidado sustituto en relación a señales de desorden del apego al registrarlos en un programa de intervención.

Resultados: Utilizando medidas categóricas y contínuas, ambos tipos de RAD pueden ser identificados con confiabilidad en los niños maltratados. Tanto los puntajes contínuos y los diagnósticos categóricos indicaron que una minoría substancial de los niños pequeños maltratados si exhiben señales de desórdenes del apego suficientes para confirmar los criterios en el DSM-IV y el ICD-10. Los dos tipos fueron moderadamente convergentes y en algunos momentos co-ocurrentes en el mismo niño. La prevalencia de RAD en esta muestra de alto riesgo fue de 38–40%. RAD indiscriminado/desinhibido fue identificado en niños con y sin una figura de apego. En este grupo de maltrato, los niños cuyas madres tenían una historia de perturbaciones psiquiátricas tenían mayor probabilidad de ser diagnosticados con desórdenes del apego.

Conclusiones: El RAD puede ser diagnosticado con confiabilidad en los niños maltratados. Los tipos de RAD emocionalmente reservado/inhibido y indiscriminado/desinhibido no son completamente independientes.

Introduction

Following Bowlby’s (Bowlby, 1969, Bowlby, 1973, Bowlby, 1980) seminal attachment theory, and Ainsworth, Blehar, Waters, and Wall’s (1978), operationalization of attachment in toddlers using the Strange Situation Procedure, there have been hundreds of studies published from around the world concerning attachment from a developmental perspective (see Cassidy & Shaver, 1999). The majority of these studies have used Strange Situation classifications as both risk and protective factors in development (Sroufe, 2000; Weinfield, Sroufe, Egeland, & Carlson, 1999). Despite intense interest in the construct of attachment, however, studies of clinical disorders of attachment are only just beginning to appear.

Concerns about clinical disorders of attachment in the scientific literature date back to the early 20th century (see Chapin, 1915), but clinical disorders of attachment first appeared in official psychiatric nomenclatures only in 1980, with the publication of Diagnostic and Statistical Manual—third edition (American Psychiatric Association, 1980). Criteria describing attachment disorders were revised substantially in Diagnostic and Statistical Manual—third edition, revised (American Psychiatric Association, 1987), but only minor changes were made subsequently in Diagnostic and Statistical Manual—fourth edition (American Psychiatric Association, 1994). There also appears to be substantial agreement between the DSM-IV criteria and that of the Tenth Revision of the International Statistical Classification of Diseases (World Health Organization, 1992) defining attachment disorders (Zeanah, 1996). Although there are controversies about the specific characteristics of attachment disorders, there is general consensus that the disorders describe symptom clusters unaccounted for by other disorders (Rutter, 1995, Volkmar, 1999).

Attachment disorders are described as involving a persistent disturbance in the child’s social relatedness that begins before age 5 years and that extends across social situations. In DSM-IV, attachment disorders must be distinguished from pervasive developmental disorders. DSM-IV nosology also ties these disorders etiologically to parental abuse/neglect or to extremes of caregiving, such as children raised in institutions. ICD-10 cautions about making the diagnosis “in the absence of evidence of abuse or neglect” (p. 281). Although “pathogenic care” is central to the disorder, there have been no previous studies of RAD in samples of maltreated children. An initial purpose of the current investigation is to determine how common it is for young, maltreated children to exhibit clinical disorders of attachment.

Two clinical types have been described in DSM-IV and ICD-10: (1) an emotionally withdrawn/inhibited type, in which the child rarely seeks or responds to comfort and fails to demonstrate a preference for a caregiver, and (2) an indiscriminate/disinhibited type, in which the child is oversociable, seeking comfort and affection non-selectively, even from unknown adults, and fails to exhibit expected reticence with unfamiliar adults.

The first study that examined the criteria for RAD in young children was a retrospective review of 48 consecutive cases of children less than 3 years of age who were referred to an outpatient clinic (Boris, Zeanah, Larrieu, Scheeringa, & Heller, 1998). Perhaps because the vast majority of the children in that study were referred to the clinic by child protective services, 42% met criteria for an attachment disorder (using alternative rather than DSM-IV criteria). Not surprisingly, children who met criteria for attachment disorders had significantly more impairments in the parent-child relationship than other clinic-referred children who did not meet criteria for attachment disorders.

Recent studies of children adopted out of institutions in Romania also have found signs of attachment disorders at follow-up. Signs of both patterns of disordered attachment described in DSM-IV have been identified in children adopted from Romanian institutions, although signs of the disinhibited/indiscriminate pattern appear to be far more common than signs of the emotionally withdrawn/inhibited pattern, at least in follow-up studies months to years after adoption (O’Connor, 2002, Zeanah, 2000). On the other hand, in a study of young children still living in an institution in Romania, children demonstrating signs of the emotionally withdrawn/inhibited pattern of RAD were readily apparent (Smyke, Dumitrescu, & Zeanah, 2002). Another purpose of the current investigation is to explore whether both patterns of RAD could be diagnosed in toddlers placed in foster care following maltreatment. In our area, only 40% of children less than 48 months of age who were validated as having been maltreated are removed and placed in foster care (Zeanah et al., 2001). By focusing on toddlers in foster care, we were presumably focusing on a more severely maltreated cohort.

A persistent finding in contemporary studies of formerly-institutionalized children is that indiscriminate behavior seems clearly related to length of time that the child spent institutionalized, but curiously, it persists long after these children have developed attachments in the more favorable caregiving environments of their adoptive homes. Virtually all of the children appear to become attached following adoption, many securely attached, but the level of indiscriminate behavior remains elevated for years (Chisholm, 1998; Chisholm, Carter, Ames, & Morison, 1995; O’Connor et al., 2003; O’Connor, Rutter, & The English and Romanian Adoptees Study Team, 2000). That is, the recovery paths of indiscriminate behavior and attachment appear to diverge (Zeanah, 2000; Zeanah & Smyke, 2002).

In addition, a recent study has documented that signs of indiscriminate RAD may be demonstrated in young children in institutions whether or not they have a preferred attachment figure and whether or not they have signs of emotionally withdrawn/inhibited RAD (Smyke et al., 2002). That is, some currently institutionalized children were rated as having signs of both emotionally withdrawn/inhibited and indiscriminate/disinhibited attachment disorders. A third purpose of the current investigation is to determine how independent the two types of attachment disorders are in maltreated toddlers in foster care.

In keeping with current approaches in the developmental psychopathology of early childhood (Zeanah, Boris, & Scheeringa, 1997), we elected to explore these questions using both categorical and continuous measures of disordered attachment. Thus, we included measures of a continuum of disordered attachment derived from interview ratings, as well as a diagnostic, categorical approach involving DSM-IV and ICD-10 diagnostic criteria. These approaches were used to address the following three questions regarding the reliability and validity of attachment disorders in young children: (1) Can reactive attachment disorder be identified reliably in a sample of maltreated toddlers in foster care? (2) What is the prevalence of disordered attachment in maltreated toddlers in foster care? and (3) Are the emotionally withdrawn/inhibited pattern and the indiscriminate/disinhibited pattern independent of one another?

Section snippets

Participants

All children in a particular parish (county) adjacent to New Orleans, Louisiana, who were less than 48 months of age at the time they were placed in foster care were referred to an intervention program that has been described elsewhere (Larrieu & Zeanah, 1998; Zeanah et al., 2001). For this study, those who were between 10 and 47 months (M = 27.7 months) at the time they were placed in foster care and who were referred between July of 1995 and June of 1998 to the program were included. These 94

Results

Results are organized and reported in the following way. First, we report categorical diagnoses of the three psychiatrists who applied diagnostic criteria to the interview data, including their interrater reliabilities on the categorical data. Second, we reported convergence of the two types of RAD (inhibited and disinhibited). Third, we performed a cluster analysis of the interview ratings to look for patterns of disordered attachment behavior in children. Fourth, we report the convergence

Discussion

Results from this investigation make several important contributions to a growing literature regarding attachment disorders in early childhood. First, both types of RAD were reliably identified in maltreated children. Both elevated continuous scores and categorical diagnoses indicated that a substantial minority of maltreated young children do exhibit signs of attachment disorders sufficient to meet criteria in DSM-IV and ICD-10. These results confirm a previous retrospective chart review study

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