Aetiology and the Treatment of Restrictive Attachment Disorder - Research Paper Example

? Current Knowledge on Etiology and the History of Treatment of Restrictive Attachment Disorder Reactive Attachment Disorder (RAD) is a psychiatric condition among children most recently described by DSM-IV as the early onset (before five months of age) of abnormal social interaction, either indiscriminate or inhibited, that is caused by a certain etiologic agent, that cannot be considered as a result of developmental delay, and that is different from other pervasive psychiatric disorders. Genetics, environment and gender were seen to influence the development of RAD, with the condition more inheritable among males, and family relationships significantly affecting the risk for RAD. However, because all symptoms of RAD are also seen among other disorders, and since there is a current lack of a definitive diagnostic tool to determine RAD in a patient, several versions of diagnostic criteria were created in hopes of providing the most reliable diagnostic tool available. The confusion in which criteria to use in the clinical practice led to misdiagnosis and mismanagement of RAD. As a result, the epidemiologic data on this disease does not represent the true prevalence of the condition. In this regard, any epidemiologic knowledge on RAD is derived from theory and extrapolation. Despite this, much of the controversy in RAD results from the extreme attachment therapeutic practices that involve restraint and physical abuse of the children, leading to deaths of several children. Introduction It is agreed upon that children who experienced frequent disturbances in the perception of safety and security during primary care end up having a range of cognitive, physical and social-emotional delays. This is clearly seen among patients with reactive attachment disorder (RAD), which is a psychiatric disease among infants that requires the identification of a specific etiology. Other items in the diagnostic criteria include failure to thrive, social development inappropriate for age, apathy, and onset before eight months of age. The definition of the disease has gone many improvements since its first description. Notably, increased age of onset to below five years old, with or without failure-to-thrive, reversibility of the disease through non-specific attachment therapies, and presence of etiological pathologic condition were the changes implemented onto Diagnostic and Statistical Manual of Mental Disorders III (DSM-III-R), which still was unclear for many practitioners, partly because of its inconsistencies with International Classification of Diseases (ICD-10), since presence of etiology is not a diagnostic criteria in the latter (Richters and Volkmar, 1994; Chaffin, et al., 2006). More recently, the disorder was described in DSM-IV as the early onset of an abnormal social interaction that is caused by a certain instigating event, that cannot be attributed to developmental delay, and that is differentiated from other pervasive development disorders (AACP, 2005). Similar to the first version of these criteria, DSM-IV garnered many criticisms, as it was said that it focused on social rather than attachment abnormalities, and it represented maltreatment syndromes instead of attachment disorders (Boris et al., 1998). As a result, many researchers also made their own diagnostic criteria, which are sometimes too broad, making the occurrence of false-positive diagnoses highly likely. Because of the disagreements in identifying RAD, the disease is not even a current part of DSM or ICD, making this condition an unofficial entity (Chaffin, et al., 2006). As such, the actual prevalence of this disease can only be estimated to be around 1%, and many physicians end up unnecessarily using other psychiatric diagnoses in addition to or replacing RAD (Richters and Volkmar, 1994; Chaffin, et al., 2006). In addition, minimal epidemiological data make theory, anecdotes, case reports, and extrapolation from laboratory research the main sources of information, and the natural course of RAD is also yet to be known (AACP, 2005; Chaffin, et al., 2006). Despite the controversies surrounding the true nature of this condition, RAD is definitely a disease entity different from the other diagnostic categories, because it is a persistent condition that can be managed accordingly (Richters and Volkmar, 1994). Literature on RAD Development of Attachment Normally, neonates recognize their mothers through smell and sound, but their yet primitive brain only warrants whoever the caregiver is to give its basic needs of food, water and warmth. As a result, they do not express any preference for a particular person to provide their needs. At 2 to 7 months of age, infants start to interact with familiar and unfamiliar people. However, during 7 to 9 months, attachment occurs, wherein the infants are more wary against than trusting to unfamiliar faces, while they do not want to be taken away from their usual caregivers (AACP, 2005). Efforts to characterize RAD To resolve the confusion regarding what RAD really is, Richters and Volkmar (1994) described four cases of children with RAD, three females and one male. Similar to DSM-III-R, all these children were considered to have a pathologic condition during the course of their illness, in which they exhibited multiple developmental abnormalities. Most of these abnormalities were unusual language and motor delay patterns, absence of age-appropriate self-care skills, inattention, poor concentration, emotional inconsistencies, aggressiveness, impulsiveness and assertiveness. Three out of the four were also found to improve markedly with a change in their environment. However, the researchers encountered difficulty in establishing the etiology per case, because caregiving histories are likely inadequate for clinical use during the time of interview. Because no standard diagnostic tool for RAD exists (Chaffin, et al., 2006), this may make diagnosis very difficult. After looking into these similarities and differences among RAD cases, it was concluded that RAD children can be described as more sociable than autistic ones, and more behaviorally problematic than children suffering from language disorders (Richters and Volkmar, 1994). Yet, their social habits are also found in extremes, being described as 1) indiscriminate or uninhibited type, which is having excessive effort to receive comfort and attention from any older person, even strangers, 2) emotionally withdrawn or inhibited pattern, which is exaggerated reluctance to give and receive comfort and affection, even from familiar adults and especially when stressed, or 3) both (Boris et al., 1998; AACP, 2005; Chaffin, et al., 2006). It is said that the second type is rare among institutionalized children, which are more likely to exhibit the indiscriminate type. These children, upon growing up, will have poor relationship among his or her friends. In contrast, maltreated children usually have the inhibited pattern of RAD (AACP, 2005). Influences in RAD What then could have caused the normal attachment procedures during child development to make the wrong turn into developing RAD? Minnis et al. (2007) studied 13, 472 twins to determine genetic, environmental and gender influences on the development of attachment disorders. Briefly, the researchers asked the participants to answer a questionnaire, on which a factor analysis and behavioral-genetic model-fitting analysis were used to differentiate attachment disorder from other childhood behavioral and emotional problems, and determine the role of genetics to RAD, respectively. The results showed that attachment disorder is a separate disease entity, and is different from conduct problems, hyperactivity and emotional problems. In addition, genetics seemed to provide a strong influence in the development of attachment disorder, particularly among males. Environmental cues may also play a role in the development of RAD. According to Boris, et al. (1998), the closeness of family was a significant predictor of attachment disorder status. Reliability and Validity of RAD diagnostic criteria Through a retrospective case review, Neil Boris and his team (1998) tried to determine which among the many diagnostic criteria is most suitable in diagnosing RAD. In summary, 48 clinical case summaries from an infant psychiatry clinic were looked into by four clinicians, who were asked to rate whether DSM-IV or alternative criteria were met in the clinical cases. According to three of the four rates, 48% of the clinical cases met the criteria for one or more subtypes of attachment disorders. Using the study, it has been shown that alternative diagnostic criteria are more reliable than DSM-IV criteria for RAD. This criteria was also valid as it was able to show abnormal social functioning among infants with attachment disorders than those with other disorders. Finally, the researchers found that identification of an etiological agent does not play a significant role in the increasing the reliability of diagnosis of RAD. Thus, it was suggested that this is removed as an inclusion criteria in RAD diagnosis using future DSM versions. Problems with attachment disorder diagnosis A consequence of the obscurity of RAD is the corresponding difficulty of physicians to provide the best possible care to those that have it, and to support these patients’ caregivers in management. The use of the relatively new and ambiguous attachment therapy is risky, because the advantages and consequences of using it are not yet scientifically validated. In fact, some types were reported to be causing more harm than good. In the study of Chaffin, et al. (2006), which looked into the effectiveness of the attachment therapies available, it was found that misdiagnosis is highly possible because of unfamiliarity with the disease and the general nature of its diagnostic characteristics. For example, it cannot be taken that a child in under child welfare care has RAD, because his or her behavioral and social changes can be attributable to acute stress, which does not equate to RAD. Culture also seems to have an effect onto whether or not a behavior or social activity is deemed to be abnormal or not. As well, they corroborated the finding of Richters and Volkmar (1994) that inaccurate and incomplete history is prone to misdiagnosis, since assessments will be made on a few particular points of the history of illness, instead of doing it on the long-term behavior of the patient. As well, the absence of any verifying diagnostic tools is prone to fostering what is known as diagnostic fad, in which any psychiatric conditions remotely similar to RAD is diagnosed as such just because many such diagnoses were made in that current setting. Problems with attachment disorder treatment Attachment therapeutic techniques include holding therapy, deep tissue massage, aversive tickling, punishment, and forced eye contact. These procedures are rampant despite minimal evidence of therapeutic effect. Probably much talk was generated by the deaths of children undergoing attachment therapy, with techniques such as suffocation, restraint and forcibly increasing the child’s fluid intake that proved to be fatal. The parents ignored the children’s suffering, because it was thought that those with RAD are manipulative and only feigning pain and difficulty. Although these resulted to imprisonment and to advocacy of certain groups against such practices, many still resort to such abusive acts, possibly because of desperation. Other possible reasons of why guardians resort to such abusive techniques are 1) belief in their therapeutic abilities, 2) negative perception about their child with RAD, and 3) non-belief to safer alternative practices (Chaffin, et al., 2006). References American Academy of Child and Adolescent Psychiatry. (2005). Practice Parameter for the Assessment and Treatment of Children and Adolescents with Reactive Attachment Disorder of Infancy and Early Childhood. J. Am. Acad. Child Adolesc. Psychiatry, 44(11), 1206-1219. Chaffin, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., Zeanah, C., Berliner, L., Egeland, B., Newman, E., Lyon, T., LeTourneau, E., and Miller-Perrin, C. (2006). Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems. Child Maltreatment, 11(1), 76-89 Minnis, J. Reekie, J., Young, D., O’Connor, T., Ronald, A., Gray, A., and Plomin, R. (2007). Genetic, Environmental and Gender Influences on Attachment Disorder Behaviors. British Journal of Psychiatry, 190, 490-495. Richters, M. M. and Volkmar, F. S. (1994): Reactive Attachment Disorder of Infancy or Early Childhood. J. Am. Acad. Child Adolesc. Psychiatry, 33(3), 328-332 Read More