MOOD MOOD DISORDER:DISORDER:

Reactive Reactive Attachment Attachment DisorderDisorder

By :By :

ALVAREZ, ANTHONY L.ALVAREZ, ANTHONY L.

BSN 3-DBSN 3-D

(SSCT)(SSCT)

MOOD DISORDERMOOD DISORDER

MoodMood-is a pervasive and sustained -is a pervasive and sustained emotion that colors ones perception emotion that colors ones perception of the world and how one functions of the world and how one functions in it. Normal variations in mood in it. Normal variations in mood occur as responses to specific life occur as responses to specific life experiences. normal mood experiences. normal mood variations such as sadness, variations such as sadness, euphoria, and anxiety, are time euphoria, and anxiety, are time limited and are not associated with limited and are not associated with significant functional impairment.significant functional impairment.

MOOD DISORDERMOOD DISORDER Mood DisorderMood Disorder

As defined in the As defined in the Diagnostic and Diagnostic and Statistical manual of Mental Statistical manual of Mental DisorderDisorder, 4, 4thth edition, text revision edition, text revision ([DSM-IV-TR]); American ([DSM-IV-TR]); American Psychiatric Association [APA], Psychiatric Association [APA], are are recurrent disturbances or recurrent disturbances or alterations in mood that cause alterations in mood that cause psychological distress and psychological distress and behavioral impairment.behavioral impairment.

Reactive Attachment DisorderReactive Attachment Disorder

Reactive attachment disorder (RAD) is one of the few Reactive attachment disorder (RAD) is one of the few psychological disorders that can be applied to infants psychological disorders that can be applied to infants (Zeanah, 1996). (Zeanah, 1996).

It was first mentioned in the third edition of the It was first mentioned in the third edition of the Diagnositc and Statistical Manual of Mental Diagnositc and Statistical Manual of Mental DisordersDisorders (DSM-III), and has since been included in (DSM-III), and has since been included in the the DSM-IVDSM-IV and the tenth revision of  and the tenth revision of the the International Statistical Classification of International Statistical Classification of DiseasesDiseases ( (ICD-10ICD-10) (Zeanah, 1996). ) (Zeanah, 1996).

Reactive Attachment DisorderReactive Attachment Disorder

Children affected by RAD exhibit an inability to form Children affected by RAD exhibit an inability to form normal relationships with other people as well as normal relationships with other people as well as impaired social development and sociopathic impaired social development and sociopathic behaviors due to the absence of secure attachment behaviors due to the absence of secure attachment formation early in life (Wilson, 2001). formation early in life (Wilson, 2001).

This disorder may be caused by pathogenic care This disorder may be caused by pathogenic care during infancy, including abuse and/or neglect, or it during infancy, including abuse and/or neglect, or it may be caused by frequent changes in a primary may be caused by frequent changes in a primary caregiver, as is often the case with children raised in caregiver, as is often the case with children raised in institutions or foster care (Kay Hall & Geher, 2003).institutions or foster care (Kay Hall & Geher, 2003).

There are two main subtypes of There are two main subtypes of RAD described in the RAD described in the DSM-IVDSM-IV ,  , the inhibited subtype and the the inhibited subtype and the disinhibited subtypedisinhibited subtype (Wilson, (Wilson, 2001). Children with the 2001). Children with the inhibited forminhibited form of RAD of RAD are are emotionally withdrawn and emotionally withdrawn and rarely respond to or even seek rarely respond to or even seek out comfort. Children with the out comfort. Children with the disinhibited formdisinhibited form of RAD of RAD tend to tend to be overly sociable, eliciting be overly sociable, eliciting comfort and affection non-comfort and affection non-selectively, even from adults selectively, even from adults who are strangers (Zeanah, who are strangers (Zeanah, Smyke, & Dumitrescu, 2002).Smyke, & Dumitrescu, 2002).

Overview of Attachment TheoryOverview of Attachment Theory Bowlby's theory of attachment was centered on Bowlby's theory of attachment was centered on

evolutionary thinking. Infants are vulnerable and unable evolutionary thinking. Infants are vulnerable and unable to fend for themselves. Thus, the attachment process is to fend for themselves. Thus, the attachment process is designed to insure the survival of the infant and, in turn, designed to insure the survival of the infant and, in turn, the species (Haugaard & Hazan, 2004). the species (Haugaard & Hazan, 2004).

As long as an infant is well loved and its biological As long as an infant is well loved and its biological needs are consistently met, he will learn to trust and feel needs are consistently met, he will learn to trust and feel secure with his caregiver, and a healthy attachment will secure with his caregiver, and a healthy attachment will be made (Wilson, 2001). This attachment will continue be made (Wilson, 2001). This attachment will continue to influence one's interpersonal relationships throughout to influence one's interpersonal relationships throughout life.life.

Ainsworth expanded on Bowlby's work with the idea Ainsworth expanded on Bowlby's work with the idea that the primary caregiver acts as a secure base for that the primary caregiver acts as a secure base for exploration. How well the caregiver meets the needs of exploration. How well the caregiver meets the needs of the infant will affect the security of the attachment. the infant will affect the security of the attachment.

According to this theory, there are three patterns of According to this theory, there are three patterns of attachment, secure, insecure/avoidant, and attachment, secure, insecure/avoidant, and insecure/resistant (Wilson, 2001). insecure/resistant (Wilson, 2001). Securely attached Securely attached infantsinfants exhibit little avoidance or resistance to contact exhibit little avoidance or resistance to contact with the caregiver and use the caregiver as a secure base with the caregiver and use the caregiver as a secure base for exploration.for exploration.

Insecure/avoidant infantsInsecure/avoidant infants exhibit avoidance of contact exhibit avoidance of contact with the caregiver and tend to show little preference for with the caregiver and tend to show little preference for the caregiver over a stranger. the caregiver over a stranger. Insecure/resistant infantsInsecure/resistant infants exhibit resistance to contact with the caregiver and tend exhibit resistance to contact with the caregiver and tend to show more anger and ambivalence than infants in the to show more anger and ambivalence than infants in the other two groups (Wilson, 2001).other two groups (Wilson, 2001).

Children Most Likely Affected by RADChildren Most Likely Affected by RAD The The DSM-IVDSM-IV requires that children diagnosed with RAD have  requires that children diagnosed with RAD have

histories of pathogenic care, meaning experiences of parental histories of pathogenic care, meaning experiences of parental abuse and neglect or lack of a consistent caregiver (Zeanah et abuse and neglect or lack of a consistent caregiver (Zeanah et al., 2004). al., 2004).

The The ICD-10ICD-10, although it does not make such a requirement, does , although it does not make such a requirement, does warn clinicians against diagnosing a child with RAD unless warn clinicians against diagnosing a child with RAD unless there is some evidence of pathogenic care (Zeanah et al., 2004). there is some evidence of pathogenic care (Zeanah et al., 2004). Given such implications, it follows logically that children most Given such implications, it follows logically that children most likely to have RAD are those that come from abusive families or likely to have RAD are those that come from abusive families or were raised in foster care or orphanages. were raised in foster care or orphanages.

Adopted children are more likely to exhibit emotional, Adopted children are more likely to exhibit emotional, behavioral, and educational problems than children who are behavioral, and educational problems than children who are raised by their biological parents (Kay Hall & Geher, 2003). raised by their biological parents (Kay Hall & Geher, 2003).

This is due to the fact that, on average, they have had a greater This is due to the fact that, on average, they have had a greater number of caregivers preventing them from having that crucial number of caregivers preventing them from having that crucial experience of forming a strong, secure attachment in infancy.experience of forming a strong, secure attachment in infancy.

Richters and Volkmar (1994) Richters and Volkmar (1994) described several cases of children described several cases of children who met the criteria for RAD, each who met the criteria for RAD, each of whom experienced abuse and/or of whom experienced abuse and/or neglect. neglect.

Two of the children lived Two of the children lived periodically with different relatives, periodically with different relatives, and the other two experienced a and the other two experienced a combination of foster care and care combination of foster care and care with relatives. with relatives.

These children exhibited a number These children exhibited a number of social behavioral issues including of social behavioral issues including impulsivity, aggression, erratic impulsivity, aggression, erratic mood swings, oppositional behavior, mood swings, oppositional behavior, emotional withdrawal, and self-emotional withdrawal, and self-injurious behavior.injurious behavior.

Inhibited Versus Disinhibited SubtypeInhibited Versus Disinhibited Subtype The The DSM-IVDSM-IV mentions two categories of RAD: an inhibited  mentions two categories of RAD: an inhibited

subtype and a disinhibited subtype. The subtype and a disinhibited subtype. The ICD-10ICD-10 describes  describes the former, emotionally withdrawn subtype as RAD and the the former, emotionally withdrawn subtype as RAD and the latter subtype as Disinhibited Attachment Disorder (DAD) latter subtype as Disinhibited Attachment Disorder (DAD) (Zeanah et al., 2004). (Zeanah et al., 2004).

Generally, the criteria for the inhibited subtype of RAD Generally, the criteria for the inhibited subtype of RAD were generated by studies done on children who were were generated by studies done on children who were maltreated or abused. Criteria for the disinhibited subtype of maltreated or abused. Criteria for the disinhibited subtype of RAD were based on research on children raised in RAD were based on research on children raised in institutions (Zeanah, 1996). institutions (Zeanah, 1996).

This is largely based on the fact that inhibited subtype of This is largely based on the fact that inhibited subtype of RAD is more prevalent in maltreated children, and the RAD is more prevalent in maltreated children, and the disinhibited subtype of RAD is more prevalent in children disinhibited subtype of RAD is more prevalent in children raised in institutions (Zeanah, 2000).raised in institutions (Zeanah, 2000).

In a study by Zeanah et al. (2004) on RAD in maltreated In a study by Zeanah et al. (2004) on RAD in maltreated toddlers, ratings on the two subtypes of RAD were made toddlers, ratings on the two subtypes of RAD were made based on several criteria. based on several criteria.

The criteria for The criteria for inhibited RADinhibited RAD were: (a) absence of a were: (a) absence of a discriminated, preferred adult, (b) lack of comfort seeking discriminated, preferred adult, (b) lack of comfort seeking for distress, (c) failure to respond to comfort when offered, for distress, (c) failure to respond to comfort when offered, (d) lack of social and emotional reciprocity, and (f) (d) lack of social and emotional reciprocity, and (f) emotion regulation difficulties. emotion regulation difficulties.

The criteria for The criteria for disinhibited RADdisinhibited RAD were: (a) not having a were: (a) not having a discriminated, preferred attachment figure, (b) not discriminated, preferred attachment figure, (b) not checking back after venturing away from the caregiver, (c) checking back after venturing away from the caregiver, (c) lack of reticence with unfamiliar adults, (d) a willingness lack of reticence with unfamiliar adults, (d) a willingness to go off with relative strangers. to go off with relative strangers.

Upon rating the children in this study, Zeanah et al. found Upon rating the children in this study, Zeanah et al. found that the two subtypes of RAD as described by the that the two subtypes of RAD as described by the DSM-DSM-IVIV are not completely independent. Rather, children with  are not completely independent. Rather, children with RAD may exhibit symptoms of both types of the disorder.RAD may exhibit symptoms of both types of the disorder.

Behavioral SymptomsBehavioral Symptoms The ramifications of the inability of children The ramifications of the inability of children

with RAD to form normal attachments are best with RAD to form normal attachments are best illustrated through the many maladaptive illustrated through the many maladaptive behaviors associated with the disorder. Such behaviors associated with the disorder. Such behaviors include stealing, lying, cruelty to behaviors include stealing, lying, cruelty to animals and other people, avoidance of eye animals and other people, avoidance of eye contact, indiscriminate affection with relative contact, indiscriminate affection with relative strangers and a refusal to express affection with strangers and a refusal to express affection with family members, destruction of property, family members, destruction of property, gorging of food, abnormal speech patterns, lack gorging of food, abnormal speech patterns, lack of remorse, impulsivity, inappropriate sexual of remorse, impulsivity, inappropriate sexual behavior, role reversal, and overactivitybehavior, role reversal, and overactivity

Signs and SymptomsSigns and Symptoms

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 The initial presentation varies according to the child's developmental and chronological age, although it always developmental and chronological age, although it always involves a disturbance in social interaction. involves a disturbance in social interaction. Infants up to about 18–24 months maymay present with  present with non-organic failure to thrive and display abnormal responsiveness to stimuli.

Laboratory investigations will be unremarkable barring Laboratory investigations will be unremarkable barring possible findings consistent with 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 The core feature is severely inappropriate social relating by affected children that involves either indiscriminate by affected children that involves either indiscriminate and excessive attempts to receive comfort and affection and excessive attempts to receive comfort and affection from any available adult, even relative strangers—older from any available adult, even relative strangers—older children and adolescents may also aim attempts at peerschildren and adolescents may also aim attempts at peers—or extreme reluctance to initiate or accept comfort and —or extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when affection, even from familiar adults, especially when distressed. distressed.

While RAD is likely to occur in relation to neglectful While RAD is likely to occur in relation to neglectful and abusive treatment, automatic diagnoses on this basis and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable alone cannot be made, as children can form stable attachments and social relationships despite marked attachments and social relationships despite marked abuse and neglect.abuse and neglect.

CausesCauses Although increasing numbers of childhood mental health Although increasing numbers of childhood mental health

problems are being attributed to genetic defects, reactive problems are being attributed to genetic defects, reactive attachment disorder is by definition based on a attachment disorder is by definition based on a problematic history of care and social relationships. problematic history of care and social relationships. Abuse can occur alongside the required factors, but on its Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. own does not explain attachment disorder.

It has been suggested that types of temperament, or It has been suggested that types of temperament, or constitutional response to the environment, may make constitutional response to the environment, may make some individuals susceptible to the stress of unpredictable some individuals susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years.or hostile relationships with caregivers in the early years.

In the absence of available and responsive caregivers it In the absence of available and responsive caregivers it appears that some children are particularly vulnerable to appears that some children are particularly vulnerable to developing attachment disorders.developing attachment disorders.

There is as yet no explanation for why similar abnormal parenting may produce the two distinct forms of the disorder, inhibited and disinhibited.

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 vary widely.

In discussing the neurobiological basis for attachment In discussing the neurobiological basis for attachment and trauma symptoms in a seven-year twin study, it has and trauma symptoms in a seven-year twin study, it has been suggested that the roots of various forms been suggested that the roots of various forms of psychopathology, including RAD, Borderline of psychopathology, including RAD, Borderline Personality Disorder (BPD), and post-traumatic stress Personality Disorder (BPD), and post-traumatic stress disorder (PTSD), can be found in disturbances disorder (PTSD), can be found in disturbances in affect regulation. in affect regulation.

The subsequent development of higher-order self-The subsequent development of higher-order self-regulation is jeopardized and the formation of regulation is jeopardized and the formation of internal models is affected. internal models is affected.

Consequently the "templates" in the mind that drive Consequently the "templates" in the mind that drive organized behavior in relationships may be impacted. organized behavior in relationships may be impacted. The potential for “re-regulation” (modulation of The potential for “re-regulation” (modulation of emotional responses to within the normal range) in the emotional responses to within the normal range) in the presence of “corrective” experiences (normative presence of “corrective” experiences (normative caregiving) seems possible.caregiving) seems possible.

Like many other papers in this poorly-Like many other papers in this poorly-researched area many new avenues of researched area many new avenues of enquiry are raised.enquiry are raised.

Difficulties in Diagnosing RADReactive attachment disorder is a relatively new disorder, having first been described in the DSM-III, indicating a growing awareness of the negative effects of institutionalization and maltreatment in children and their psychological development (Richters & Volkmar, 1994). Although some improvements were made in describing and diagnosing RAD in DSM-IV , making reliable diagnoses is still a major problem due to disagreement among professionals as to the etiology of RAD and due to issues with differential diagnosis (Sheperis, Doggett, & Hoda, 2003).

Sheperis et al. (2003) described an extensive assessment Sheperis et al. (2003) described an extensive assessment protocol designed to aid in the reliability of diagnoses of RAD protocol designed to aid in the reliability of diagnoses of RAD in the absences of a comprehensive tool to assess children for in the absences of a comprehensive tool to assess children for RAD. This protocol consists of child and parent clinical RAD. This protocol consists of child and parent clinical interviews, global rating scales, attachment-specific rating interviews, global rating scales, attachment-specific rating scales, and behavioral observation (Sheperis et al., 2003). scales, and behavioral observation (Sheperis et al., 2003).

Some of the global rating scales included the Child Behavior Some of the global rating scales included the Child Behavior Checklist, the Behavior Assessment System for Children, and Checklist, the Behavior Assessment System for Children, and the Eyeberg Child Behavior Inventory. Structured and semi-the Eyeberg Child Behavior Inventory. Structured and semi-structured interviews, behavioral rating scales and standardized structured interviews, behavioral rating scales and standardized tests were also utilized as part of the assessment protocol. tests were also utilized as part of the assessment protocol.

Such a protocol was well formed in that it incorporates a variety Such a protocol was well formed in that it incorporates a variety of assessment methods in an attempt to get complete and in of assessment methods in an attempt to get complete and in depth information regarding the client. However, much research depth information regarding the client. However, much research still needs to be done in order to improve the assessment and still needs to be done in order to improve the assessment and diagnostic process of RAD as well as to gain greater diagnostic process of RAD as well as to gain greater understanding of the disorder.understanding of the disorder.

Attachment or Temperament?Attachment or Temperament? The current conceptualization of RAD, as The current conceptualization of RAD, as

described in the described in the DSM-IVDSM-IV and the  and the ICD-10ICD-10, , ties the etiology of the disorder to ties the etiology of the disorder to pathogenic care with an emphasis on pathogenic care with an emphasis on socially aberrant behavior across contexts socially aberrant behavior across contexts rather than on disturbed attachment rather than on disturbed attachment behavior.behavior.

Given the centrality of attachment in Given the centrality of attachment in psychological development, it is expected psychological development, it is expected that disrupted attachment should be that disrupted attachment should be associated with a number of psychological associated with a number of psychological disorders. Thus the question arises of disorders. Thus the question arises of whether there are truly attachment whether there are truly attachment disorders such as RAD or attachment disorders such as RAD or attachment disturbances are best addressed as issues disturbances are best addressed as issues associated with other disorders (Stafford et associated with other disorders (Stafford et al., 2003).al., 2003).

Additionally, although temperament is Additionally, although temperament is well studied in its relation to well studied in its relation to attachment formation, there is attachment formation, there is currently no empirical research on its currently no empirical research on its influence in the development of influence in the development of attachment disorders (Zeanah & Fox, attachment disorders (Zeanah & Fox, 2004). 2004).

There are a variety of ways in which There are a variety of ways in which temperament, which is at least in part temperament, which is at least in part a function of an infant's biological a function of an infant's biological make-up, may directly or indirectly make-up, may directly or indirectly play a significant role in the play a significant role in the development and manifestation of development and manifestation of RAD.RAD.

Overview of TemperamentOverview of Temperament Temperament is the style in which infants respond to Temperament is the style in which infants respond to

various stimuli and situations (Zeanah & Fox, 2004). various stimuli and situations (Zeanah & Fox, 2004). Essentially, temperament describes how infants behave in Essentially, temperament describes how infants behave in reaction to their environment. Alexander Thomas and Stella reaction to their environment. Alexander Thomas and Stella Chess were the pioneers in studying temperament and how Chess were the pioneers in studying temperament and how such differences among infants affect parental reaction such differences among infants affect parental reaction during caregiving. during caregiving.

According to these researchers, temperament is part of an According to these researchers, temperament is part of an infant's biological make-up and involves nine dimensions: infant's biological make-up and involves nine dimensions: activity level, regularity of functioning, approach-activity level, regularity of functioning, approach-withdrawal in new situations, intensity of emotional withdrawal in new situations, intensity of emotional expression, overall valence of mood, adaptability to changes expression, overall valence of mood, adaptability to changes in routine, persistence, distractibility, and threshold of in routine, persistence, distractibility, and threshold of sensory responsiveness (Zeanah & Fox, 2004). Based on sensory responsiveness (Zeanah & Fox, 2004). Based on these dimensions, Thomas and Chess formulated three types these dimensions, Thomas and Chess formulated three types of temperament: difficult, easy, and slow-to-warm-up of temperament: difficult, easy, and slow-to-warm-up (Zeanah & Fox, 2004).(Zeanah & Fox, 2004).

•Rothbart's theory of temperament proposed that there are two components to temperament: reactivity and regulation. Reactivity includes physiological and behavioral systems that are present at birth, the biological aspect of temperament. Regulation is comprised of activation of neural systems in response to reactivity and environment (Zeanah & Fox, 2004). Kagan's view of temperament was that it is a blend of behavior patterns and physiology (Zeanah & Fox, 2004).

RAD and TemperamentRAD and Temperament

Zeanah and Fox (2004) outlined a number of ways in which Zeanah and Fox (2004) outlined a number of ways in which temperament may be related to RAD. Effects of temperament on temperament may be related to RAD. Effects of temperament on RAD may be none, direct effects, or complex indirect effects. RAD may be none, direct effects, or complex indirect effects. First, temperament may have no effect on RAD whatsoever. It First, temperament may have no effect on RAD whatsoever. It may simply be that RAD is a result of different experiences with may simply be that RAD is a result of different experiences with caregivers. caregivers.

For example, inhibited RAD may simply be related to neglect For example, inhibited RAD may simply be related to neglect and disinhibited RAD may be related to care provided by a and disinhibited RAD may be related to care provided by a number of people and limited contact with any one caregiver number of people and limited contact with any one caregiver (Zeanah & Fox, 2004). Second, RAD may be related to a variety (Zeanah & Fox, 2004). Second, RAD may be related to a variety of styles of difficult temperament. of styles of difficult temperament.

Inhibited RAD could be directly related to irritability and Inhibited RAD could be directly related to irritability and negative affect. Such infants may respond to positive social cues negative affect. Such infants may respond to positive social cues with avoidance or distress, later withdrawing from social with avoidance or distress, later withdrawing from social interaction. Disinhibited RAD may be a result of an impulsive interaction. Disinhibited RAD may be a result of an impulsive temperament leading into indiscriminate social behavior (Zeanah temperament leading into indiscriminate social behavior (Zeanah & Fox, 2004).& Fox, 2004).

•Another idea presented by Zeanah and Fox (2004) is that the combination of specific temperamental attributes and specific environmental factors may interact negatively and result in RAD. Similarly, difficult temperament in infants may elicit maladaptive responses from caregivers in times of environmental stress.• Finally, Zeanah and Fox (2004) propose that some temperamental characteristics may actually serve as protective factors. Children with a positive affect and a tendency to approach their caregivers for attention will likely be less susceptible to certain disorders such as RAD.

Treatment Treatment Assessing the child's safety is an essential first step that Assessing the child's safety is an essential first step that

determines whether future intervention can take place in determines whether future intervention can take place in the family unit or whether the child should be removed the family unit or whether the child should be removed to a safe situation. to a safe situation.

Interventions may include Interventions may include psychosocial support psychosocial support services for the family unitservices for the family unit (including financial or (including financial or domestic aid, housing and social work support), domestic aid, housing and social work support), psychotherapeutic interventionspsychotherapeutic interventions (including treating (including treating parents for mental illness, family therapy, individual parents for mental illness, family therapy, individual therapy), therapy), educationeducation (including training in basic (including training in basic parenting skills and child development), and parenting skills and child development), and monitoring of the child's safety within the family monitoring of the child's safety within the family environment environment

In 2005 the American Academy of Child and Adolescent Psychiatry In 2005 the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W. Boris and C.H. Zeanah) laid down guidelines (devised by N.W. Boris and C.H. Zeanah) based on its published parameters for the diagnosis and treatment based on its published parameters for the diagnosis and treatment of RAD.Recommendations in the guidelines include the following:of RAD.Recommendations in the guidelines include the following:

1.1. "The most important intervention for young children diagnosed "The most important intervention for young children diagnosed with reactive attachment disorder and who lack an attachment to a with reactive attachment disorder and who lack an attachment to a discriminated caregiver is for the clinician to advocate for discriminated caregiver is for the clinician to advocate for providing the child with an emotionally available attachment providing the child with an emotionally available attachment figure."figure."

2.2. "Although the diagnosis of reactive attachment disorder is based "Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child, assessing the caregiver's on symptoms displayed by the child, assessing the caregiver's attitudes toward and perceptions about the child is important for attitudes toward and perceptions about the child is important for treatment selection."treatment selection."

3.3. "Children with reactive attachment disorder are presumed to have "Children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. After grossly disturbed internal models for relating to others. After ensuring that the child is in a safe and stable placement, effective ensuring that the child is in a safe and stable placement, effective attachment treatment must focus on creating positive interactions attachment treatment must focus on creating positive interactions with caregivers."with caregivers."

4.4. "Children who meet criteria for reactive attachment disorder and "Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require who display aggressive and oppositional behavior require adjunctive (additional) treatments."adjunctive (additional) treatments."

Mainstream prevention programs and treatment Mainstream prevention programs and treatment approaches for attachment difficulties or disorders for approaches for attachment difficulties or disorders for infants and younger children are based on attachment infants and younger children are based on attachment theory and concentrate on increasing the theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different that is not possible, placing the child with a different caregiver.caregiver.

These approaches are mostly in the process of being These approaches are mostly in the process of being evaluated. The programs invariably include a detailed evaluated. The programs invariably include a detailed assessment of the attachment status or care giving assessment of the attachment status or care giving responses of the adult caregiver as attachment is a two-responses of the adult caregiver as attachment is a two-way process involving attachment behavior and way process involving attachment behavior and caregiver response. Some of these treatment or caregiver response. Some of these treatment or prevention programs are specifically aimed at foster prevention programs are specifically aimed at foster carers rather than parents, as the attachment behaviors carers rather than parents, as the attachment behaviors of infants or children with attachment difficulties often of infants or children with attachment difficulties often do not elicit appropriate caregiver responses do not elicit appropriate caregiver responses

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