What is Reactive Attachment Disorder? Further Discussion

I’ve made a number of statements to the effect that violent or aggressive behavior, lying, stealing, and so on, were not diagnostic of Reactive Attachment Disorder. Some readers disagree strongly with this perspective. Reader Valle Oberg, for example, has been arguing against my position for several days at http://childmyths.blogspot.com/2010/12/federici-v-mercer-story-behind-lawsuit.html.

I’d like to call people’s attention to a paper by Charles H. Zeanah and Anna Smyke from Tulane University, arguably the leading U.S authorities on Reactive Attachment Disorder (Zeanah, C.H., & Smyke, A.T. [2008]. Attachment disorders in family and social context. Infant Mental Health Journal, 29, 219-233). This paper discusses criteria for attachment disorders and compares the DSM and ICD-10 versions, as well as referring to categories suggested by Zeanah in previous work.

In none of this material is there any reference to violent or aggressive behavior, self-injury, lying, cheating , stealing, refusing eye contact, or any of these issues so much stressed by therapists and parent groups outside the mainstream of psychological and psychiatric thought. Zeanah and Smyke come no nearer to these issues than referring briefly to the possibility of risk-taking as one aspect of a RAD-like category.

Zeanah and Smyke discuss measures of inappropriate behavior suggesting a disorder of attachment. They point out three ways in which such measurement has been approached. One method looked at whether children wandered away from caregivers without becoming distressed, whether they approached strangers, whether they were never shy with new adults, whether they were friendly with new adults, and whether they would go off with strangers. A second approach considered whether children failed to differentiate among adults (that is, treated all adults the same way and did not have a preferred caregiver), readily went with a stranger, and failed to check back with a caregiver (i.e., by looking back to them or calling to them as distance between them increased or separation became likely). The third method looked at not having a preferred caregiver, lack of reticence with a stranger, failure to check back, and willingness to go with a stranger. (Once again, none of these methods looks at aggressive behavior, lying, self-injury, etc., etc.)

Zeanah and his colleagues several years ago wanted to develop a technique of assessing preschool children’s attachment to caregivers without depending on parent or teacher reports. They developed what they called the “Stranger at the Door” procedure. One of the researchers knocked at the door of the child’s home, and the caregiver and the child answered the door together. The stranger looked at the child and said, “My name is ____. What is your name? Let’s go for a walk.” Observers coded the child’s behavior in response (if the child was willing to go, they walked a few feet, then came back into the house). Children’s willingness to go with the stranger was greatest in the group who had been institutionalized, but there was also atypical willingness in a comparison group of children who had been in foster care.

The Zeanah and Smyke paper noted that in a group of children adopted from institutions, there were no cases of the inhibited form of RAD, but a “substantial minority” showed the disinhibited type, with less avoidance of strangers and less preference for familiar caregivers than is typical among family-reared children.

In discussing “self-endangering” behavior as an aspect of RAD (the nearest thing mentioned to the claims of aggression and self-injury made by some advocates of an unorthodox view of attachment disorders), Zeanah and Smyke emphasize the possibility that risk-taking is part of a “two person” disorder which is difficult to describe in present language. They raise the issue of possible relational attachment disorders (different from RAD as now defined) that are evident only in the context of the association between the child and a specific caregiver. I would add that this is a very interesting idea with respect to the claims made by members of ATTACh and similar groups that children with RAD behave angelically outside their homes, but are difficult or even dangerous in interaction with their mothers.