By: Dr. Vijay Subramaniam
This past week in the clinic, I encountered a patient with reactive attachment disorder. Having learned little about this disorder in medical school, I searched the internet for journal articles and studies. What is reactive attachment disorder? It’s a disorder that causes affected individuals to have difficulty forming relationships or exhibiting positive emotions with caretakers, siblings, friends, co-workers, and significant others. Learning about this disorder took me back to a Beatles song my uncle often played, All We Need Is Love, and I was reminded that a lack of it early in our lives as an infant and later as a child can be fatal or lead to developmental changes.
Why does this disorder happen? Reactive Attachment Disorder, abbreviated as RSD, is caused by neglect or abuse of an infant or child due to poor emotional bonding with caregivers, food restrictions, physical harm, or inappropriate touching. What causes a caregiver to do this? The caregiver may have an intellectual disability, have a personal history of abuse or neglect, be isolated, or be a first-time teen parent. Children in orphanages, residential programs, or going through the foster system may also develop RSD due to frequent changes in caregivers. RSD was first documented in the 1940s and 1950s through experiments that showed a lack of mother-infant bonding led to devasting effects on infant growth, motor development, social interaction, and behavior. A 1952 film called Psychogenic Disease in Infancy depicted this impact on infants during the first two months in a hospital ward, leading to changes in the operation of hospitals, homes, and childcare after 37% of these infants died within two years. These early experiments became the foundation for Attachment Theory, which would later be divided into RSD and another disorder called Disinhibited Social Engagement Disorder, or DSED. However, while patients with RSD present with poor attachment to others, and patients with DSED present with overly friendly behavior and unrestrained attachment to strangers after suffering from neglect or abuse during childhood.
What symptoms should you look for if you’re concerned about RSD? Children with RSD will commonly have poor eye contact with and avoid caregivers, avoid physical contact, be difficult to comfort, have random episodes of irritability, fear, or sadness, and prefer to be alone rather than interact with others. The abuse suffered in childhood may result in poor short-term memory and executive functioning, poor social skills, and hyperactivity such as hand flapping and rocking.
How is the condition diagnosed? To diagnose RSD, a physician must first rule out autism spectrum disorder, as autism can present with similar repetitive behaviors, decreased interest in social interaction, and a lack of interest in developing bonds with caregivers and peers. Symptoms of RSD may also present similarly to those of depressive disorder, anxiety, ADHD, conduct disorder, and intellectual impairment and must also be ruled out. If concerned about RSD, a primary care doctor will refer a patient to a child psychiatrist for a formal evaluation in which the patient’s history and symptoms will be recorded along with the interaction between the parent and child. During this observation of the parent-and-child interaction, the clinician evaluates the patient’s eye contact, comfort-seeking behavior, and the child's initiation of interaction with the parent.
Early intervention with caregiver education and trauma-focused therapy can help patients better communicate with others, develop coping skills, and nurture relationships with caregivers. Parents adopting children should be made aware of the symptoms of RAD, the importance of early treatment and therapy, individualized education plans, and available resources such as service agencies. Working together as a team, caregivers, doctors, therapists, and school faculty can help provide the empathy, support, and encouragement needed to build meaningful relationships. After all, just as the Beatles referenced in their song, love is so critical to our development and survival as human beings.
References:
Rene A. Spitz (1951) The Psychogenic Diseases in Infancy, The Psychoanalytic Study of the Child, 6:1, 255-275, DOI: 10.1080/00797308.1952.11822915
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