David M. Callahan, Ph.D.
Providing Psychological Services to
Cape Cod and Southeastern Massachusetts
Understanding Reactive Attachment Disorder
Reactive Attachment Disorder is believed to be the result of difficulties within the early parent-child relationship that interrupt the normal development of bonding and attachment between parent and child. Due to a variety of factors that can interrupt the capacity of a parent to respond to a child, or for a child to be able to integrate and accept the nurturance of a parent, a child can be left with an inability to experience love and support from others in a mainstream way. As a result of the disruption of normal attachment processes, the child’s brain actually becomes wired in a way that is substantially different from that of the more typical child.
In a normally progressing development of attachment capacities, much of the child’s initial activity is geared toward forming a relationship and bond with the caregivers that fosters a sense of love and reciprocity in their relationship. Within the context of that love, a child develops a sense of faith and trust in the environment, as the caregiver reliably provides for the child’s needs in response to the child’s expressions of distress. It is believed by neuroscientists that the brain enters the world still largely malleable and capable of change. It is suspected that in the earliest months, most likely the first 7 to 9 months, the brain is wiring itself in response to the development of relationships. In essence, the brain learns how to love and attach, and how to respond to a loving and caring individual. When the environment proves to be unreliable, inconsistent or unresponsive, it is believed that the brain utilizes its capacities differently, often becoming more focused on gaining resources than developing close attachment to a caregiver. For example, a child who might otherwise express mild distress about hunger learns to engage in more dramatic reactivity in order to acquire the attention of an otherwise unresponsive caregiver. This process essentially “wires in” an intensity of response that is disparate from that of the typical child, triggering behaviors that are likely more intense and dramatic than those seen in a child whose sense of attachment is more secure. As the focus of the brain activity shifts from development of love to seeking of resources, the capacity to see other people in an emotionally connected and empathic way becomes interrupted, most often partially but perhaps at times fully blocking the capacity of an individual to form genuine and mutual love and reciprocity. Thus, other people become potential sources of resources, but are not perceived as objects of love and emotional connection.
Due to the lack of mainstream attachment capacities, a child with Reactive Attachment Disorder will typically focus the majority of his or her energy in the meeting of basic physical and/or emotional needs. Such children often become very fixated on the extent to which others are able to provide for them, and will act somewhat indiscriminately affectionately towards people whom they see as potential resources. On the other hand, such children will often be quite egocentric, prone to behaviors such as stealing and lying in order to meet their needs. The major element that is missing in such circumstances is an awareness that such negative behaviors have an ongoing, deleterious effect on their relationships. Since the child lacks a fundamental sense of attachment, there is no ongoing experience of the quintessential “ebb and flow” of relationships. Instead, the child’s focus is on immediate gratification, with little concern for the impact of that behavior over the long-term. This lack of awareness of long-term relationship dynamics means that a child will engage in whatever behavior seems efficacious in the moment, regardless of whether that has long-term consequences for their lies. A child caught “red-handed” may engage in a rather blatant and indefensible lie in hopes that lying will somehow extricate themselves from a situation in which discipline might occur. The lack of awareness that such lies undermine trust and will have longer term consequences results in the child having an apparent lack of concern for the impact of those behaviors. If the behavior has some potential to work, a child will engage in it, regardless of whether it may create problems down the line, as there is no true experience of the long-term continuity of relationships. Each moment is experienced as its own event. One analogy is to see that such a child’s life as more akin to a PowerPoint presentation than a movie, with each slide being independent and unrelated to the ones both before and after.
The lack of empathy and reciprocity that these children show creates several atypical behaviors. In addition to somewhat pointless stealing and lying, often children with Reactive Attachment Disorder prove to be very difficult to both reward and punish. They are somewhat under responsive to praise, but it is difficult to motivate such children through the use of normal affection. Even rewards can be treacherous, as they can be perceived more as entitlements than as a response to desirable behavior. Such children will often be rather impervious to punishment, finding it at best unimpressive and at its worst, an expression of rejection that is perceived as a threat. It is believed that the reward systems of such children function differently from those of the typical individual, resulting in it being quite challenging to develop behavior plans that are effective for such persons.
Because these children present with such anomalous behaviors and atypical underlying neuropsychological functioning, it is important that providers be cognizant of their unique needs. Treatment of Reactive Attachment Disorder is indeed a somewhat specialized venture, with interventions that are directly tailored to their individual needs. The most efficacious intervention appears to be an attempt to develop “attunement,” which involves reworking the way that children experience reward and punishment. Briefly put, parents are trained to provide unemotional responses to problematic behaviors, but with straightforward and often firm limit setting. The limit setting is combined with acknowledgement of the emotional need that the child was expressing through the misbehavior, which can vary from a desire to test the caregivers reliability to take care of the child, to fear of closeness due to the potential danger of rejection, to overresponse to disappointments due to that being perceived as rejection, to a number of other unique characteristics. The emotions are acknowledged in such a way as to be supportive and therapeutic rather than punitive. The child is then provided an opportunity to make amends, apologize or otherwise resolve the conflict. It is believed that the acceptance of the negative emotions combined with an opportunity for a child to restore his or her dignity will eventually, after multiple, extensive repetition, begin to rework the child’s sense of attachment. The goal of the attunement process is to develop a sense of secure and reciprocal connection that will engender a sufficient sense of safety that the child can begin to form a legitimate bond. This can be a very lengthy process, with many fits and starts, but over the long-term it is believed that there can be some improvement in the extent to which a child can form legitimate connections. There is a wonderful book entitled “Rebuilding the Bonds of Attachment” by Daniel Hughes that describes such a process in one child.
Learning to engage in the attunement process is often very challenging for caregivers. One must suppress more typical responding, such as escalating in one’s anger in response to misbehavior, in order to make this process work. It is also clear that many children with Reactive Attachment Disorder are particularly skilled at generating negative responses from adults, as they will engage in behaviors that indeed seem quite deliberately vindictive and unkind. Thus, working with a therapist who is skilled in this area, and recognizing that support for the caregiver is often as important as intervention for the child, is strongly recommended. There are many psychological conditions that can be treated through the somewhat generalized skills of the typical therapist. It is my opinion that Reactive Attachment Disorder is a condition that requires very specific expertise, as typical psychotherapy relationships are based on the assumption of the ability to form a mainstream bond between therapist and client. However, as the child with Reactive Attachment Disorder has a different way of connecting to others, a therapist who is aware of that dynamic and able to adjust his or her typical interventions is often essential.
