Understanding Reactive Attachment Disorder in Children

May 1st, 2019

Understanding Reactive Attachment Disorder in Children

By Andy Scholz and Heather Rooney McBride

            In family law cases, attorneys and judges are often presented with children that are in desperate need of mental health services. To properly format or recommend parenting plans that protect these children’s best interests, it is incumbent upon family law practitioners to gain a fundamental understanding of some of the mental health conditions these children could have.

In recent years, the term “Reactive Attachment Disorder” has often been applied to situations where children are displaying severe cases of mental regression or bad behavior. But is Reactive Attachment Disorder the correct term to use for these children, or has it become a generic term that is improperly used to describe other, less severe conditions? This article will give a basic description of what Reactive Attachment Disorder is, along with some of its symptoms and possible treatments, as it is important for family law practitioners, parents and grandparents to gain a better understanding of the Disorder and how to get the best possible help for children in need. 

Reactive Attachment Disorder is a rare but serious condition in which an infant or young child does not establish healthy attachments with parents or caregivers. This inability to form healthy attachments is caused when a child does not receive the proper comfort or support during his or her early years; lack of comfort and support can cause the child’s central nervous system to develop abnormally. This is especially true if the child is raised in a home where there is a high level of stress or chaos. If the child is exposed to stress in the form of hunger or domestic violence, his or her brain os constantly flooded with stress endorphins that are released by the body as part of the “fight or flight” response system. An extended exposure to these stress endorphins can cause a lasting negative impact on the child’s developing brain. However, children can grow up in these stressful or unsafe environments and still develop normally if they have a caregiver to whom they can attach who can provide a feeling of safety. The need to feel safe is fulfilled by simple acts like holding, hugging or signing to an infant. Reactive Attachment Disorder may develop if the child’s basic needs for comfort, affection and nurturing are not met and stable attachments with other humans are not established.  The normal development of the brain of the child is interrupted and affects subsequent relationships a child may try to develop. Unfortunately, mental health professionals believe Reactive Attachment Disorder is a lifelong condition.

The Diagnostic Statistical Manual for Mental Disorders (“DSM-V”) is the manual published by the American Psychiatric Association, and it covers all mental health disorders for both children and adults. Reactive Attachment Disorder is one of the few disorders listed in the DSM-V that can be applied to infants. Family law practitioners and parents involved in child custody cases need to understand that Reactive Attachment Disorder is a very rare disorder. Currently, there are no accurate measures or statistics of how prevalent Reactive Attachment Disorder is among children. However, many experts have concluded that the largest percentage of children with Reactive Attachment Disorder in America can be found among children in the foster care system.[1] It is agreed that Reactive Attachment Disorder begins before the age of five and most often starts in infancy.

Understanding Reactive Attachment Disorder carries with it a need to understand attachment theory. Children are biologically programmed by human evolution to seek protection from their caregivers in times of danger. This profound and functional drive—the desire to “be near Mommy” or “be near Daddy” when scared, sad, or confused—is the subject of attachment theory.[2] Modern-day parents might find it hard to believe that, less than seventy years ago, many mental health professionals thought it was dangerous for parents to provide their children with too much love. It was often thought mothers could over-nurture or coddle their children to the point the children would develop mental health problems. It was not until the works of John Bowlby and Mary Ainsworth in the late 1960’s and early 1970’s when mental health professionals began to understand the importance a child’s attachment to caregivers plays in a child’s mental health development. Without a history of safe caregiving, children’s brains do not develop properly, and this can result in a multitude of problems, including Reactive Attachment Disorder.

If a child has Reactive Attachment Disorder, they are likely to fall within one of two different sub-types:  the inhibited sub-type and the disinhibited sub-type. Children with the inhibited sub-type tend to be emotionally withdrawn and rarely respond or seek out comfort from caregivers. Children with the disinhibited sub-type tend to be overly sociable and will seek out comfort and affection without careful consideration, even from adults who are strangers. This can result in the child constantly asking for help, an inappropriate display of childish behavior or a constant appearance of anxiety. Each of the sub-types presents its own challenges for parents and grandparents. Children with the inhibited sub-type can find it hard to display love towards their caregivers, and that can result in feelings of inadequacy or frustration. Children with the disinhibited sub-type can unknowingly put themselves in dangerous situations or can grow up to act in ways that are impulsive. This lack of forethought can often lead to involvement in the juvenile or adult criminal justice system or even incarceration.

The next issue to consider is how a lack of affection and stimulation can impact a child’s developing brain. The hippocampus is a portion of the brain’s limbic system that is thought to control inhibition, memory and spatial relations. A 2012 study conducted at Washington University in St. Louis found that children of nurturing mothers had hippocampal volumes ten percent larger than children whose mothers were not as nurturing.[3]  This study proved scientifically what is commonly known by people who have spent any time with children—kids need love, comfort, and support to develop properly. Without those things, a baby can grow into a teenager or adult that has profound mental health issues. Dr. Joan Luby, one of the lead researchers for the study said, “We can now say with confidence that the psychosocial environment has a material impact on the way the human brain develops. It puts a very strong wind behind the sail of the idea that early nurturing of children positively affects their development.” [4]

Special attention should be paid to clearly delineating the roles parents, grandparents, attorneys and judges fill when it comes to diagnosing a child’s mental health conditions. While it is tempting to look at a list of symptoms and say, “This child has those behaviors. She must have Reactive Attachment Disorder!”, a true diagnosis can only be made by a qualified and experienced mental health professional. With this in mind, a child with Reactive Attachment Disorder will have usually experienced: 1) a constant disregard for his or her basic emotional needs in things like comfort, stimulation, and affection; 2) a constant disregard for his or her basic physical needs; and 3) repeated changes of the primary caregiver that prevents any stable attachments from forming (e.g., frequent changes in foster care placement). Not all experts agree on the best way to diagnose Reactive Attachment Disorder, but all agree that certain things must be present. The main criteria for a child to be diagnosed with Reactive Attachment Disorder are: 1) disturbed and developmentally inappropriate social relationships beginning before age five, not due to developmental delay; 2) a failure to respond to or initiate social interactions, or being inappropriately friendly and familiar with strangers; 3) a failure of early caregivers to meet the child’s emotional needs for comfort and affection, a failure of early caregivers to attend to the child’s physical needs, and/or repeated changes of the child’s primary caregiver.

The behavioral symptoms of Reactive Attachment Disorder in an infant are commonly thought to be:

  • Withdrawn, sad or listless appearance
    • Failing to smile
    • Lacking the normal tendency to follow others in the room with their eyes
    • Failing to reach out when picked up
    • No interest in play with others or with toys
    • Use of self-soothing behavior (rocking, self-stroking)
    • Calm when left alone

The behavioral symptoms of Reactive Attachment Disorder in toddlers or older children are commonly thought to be:

  • Withdrawing from others
    • Avoiding or dismissing comforting comments or gestures
    • Aggressive behavior towards peers
    • Watching others closely but failing to engage in normal social interaction
    • Failure to ask for support or assistance
    • Social awkwardness
    • Alcohol or drug abuse

When it comes to treatment for a child suffering from Reactive Attachment Disorder, the mental health community has not settled upon a standard practice. There is even controversy surrounding the efficacy of certain psychological interventions such as holding therapy, which is a type of forced therapy where a parent or counselor holds the child until the child stops resisting or until a fixed amount of time has passed.[5]  However, most treatments include one or more of the following: individual psychological counseling; education and resources for parents and caregivers about the condition; parenting skills classes; family therapy; medication for other conditions that may occur, such as depression, anxiety or hyperactivity in the child or parent; and special educational services.

In conclusion, the sad truth is that the best opportunity to study the effects of Reactive Attachment Disorder come under heart-breaking conditions, such as that of the Bucharest orphanages in the 1980’s. Under the forced population growth policies of Romanian President Nicolae Ceaușescu, the orphanages of Bucharest became overflowing, and their conditions were abhorrent.  There were not enough adult supervisors to provide the children with adequate attention or love. The babies and infants would sit in their cribs alone all day with no one to pick them up. The majority of those children have grown up into adults with crippling mental health conditions.

Parents and family law attorneys in southwest Missouri must realize there are children in our area that are growing up in conditions similar to the orphanages in Bucharest. There is a profound need for affordable mental health services for them. Part of the way we as family law attorneys can help these children is to work hard to better understand conditions like Reactive Attachment Disorder and how to identify a child suffering from it. We then have an ethical and moral duty to get these kids the help they need.

            If you know or suspect a child is suffering from Reactive Attachment Disorder who has not sought or obtained help, and the child lives in Missouri, please call the Missouri Department of Social Services hotline at 1-800-392-3738.

            If you or someone you know needs a family law attorney to address issues of child custody or abuse, contact the experienced practitioners at Rooney McBride & Smith, LLC, at 417-708-9681, for your initial consultation today.

[1] https://dx.doi.org/10.1186%2F1753-2000-7-39

[2] Smith, Coffino, Van Horn and Lieberman; Parenting Plan Evaluations: Applied Research for the Family Court (2011).

[3] https://medicine.wustl.edu/news/love-and-the-hippocampus/

[4] https://www.livescience.com/18196-maternal-support-child-brain.html

[5] https://www.thedailybeast.com/the-worst-adoption-therapy-in-the-world