Reactive Attachment Disorder: What it Means for Educational Psychology. Stephen Dean. Educational Psychology 390. Ball State University

Transcription

1 Reactive Attachment Disorder: What it Means for Educational Psychology Stephen Dean Educational Psychology 390 Ball State University

2 2 ABSTRACT This paper will provide an overview of Reactive Attachment Disorder with particular emphasis on how it pertains to educational psychology. The paper will establish the definition and distinct types of the condition, as well as discuss complexities of the diagnostic process. Neurobiological abnormalities with next be discussed, followed by the research-proven causes of the condition. Early childhood recollections and self-reflective viewpoints from children and adolescents with the condition will be examined as well. The paper also will focus on prognosis and treatment options that have shown results in improving the symptoms of Reactive Attachment Disorder. Finally, educational implications will be presented, on how teachers can better serve those students with RAD and foster a positive learning and social environment for the student.

3 3 REACTIVE ATTACHMENT DISORDER: Often teachers have students who are just behavior problems. Many times, they may think that the child is just being troublesome for unknown reasons, and can get frustrated with the student. Likely, this results in outbursts at the child and only exacerbates the problem. Teachers likely don t know that the behavioral symptoms being exhibited are actually not the child s fault, and are a result of Reactive Attachment Disorder. This a very difficult condition to diagnose considering it shares symptoms with other common disorders, and manifests itself in very different ways. However, it is vital that the teacher become aware of the condition in order to attempt to make positive changes in the child s behavior and to foster a positive learning environment. DEFINITION AND DIAGNOSIS OF THE CONDITION Reactive Attachment Disorder (RAD) is characterized by the inability to make loving, lasting relationships. (Chapman, 2002) When children do not form appropriate attachment relationships in infancy and early childhood, adulthood is plagued with difficulty to self-soothe, self-organize, regulate affect, and engage in healthy relationships. The diagnostic criteria for RAD are primarily a markedly disturbed and developmentally inappropriate social relatedness, in most contexts beginning before 5 years of age, which is associated with pathogenic care. (Kemph, 2007, p. 159) These difficulties in adulthood can manifest themselves in having difficulty to hold down a job, engage in long-term romantic relationships including marriage, and pathological lying. The Diagnostic and Statistical Manual of Mental Disorders (4th ed.) (American Psychological Association, 1994) recognizes two subtypes of the condition: Inhibited Type and Uninhibited Type. (Corbin, 2007, p. 540)

4 4 The Inhibited Type describes an inappropriate social relatedness in many contexts, excessive inhibited, hyper vigilant, highly ambivalent and contradictory responses to social or caregiver interactions (Corbin, 2007, p. 540) Subject who possess this type of RAD have difficulty getting close to anyone, including parents, close friends, teachers, and the like. They keep up a wall of defense consistently, and often question motives behind loving actions, asserting there are ulterior motives aimed to hurt them. The Uninhibited Type describes diffuse attachments as manifested by indiscriminate sociability with marked inability to exhibit appropriate selective attachments. (Corbin, 2007, p. 540) Those subjects with the Uninhibited Type of RAD have little difficulty getting very close to everyone around them. They might feel about a stranger on the corner in the same way they feel about their mother, perhaps even calling a woman stranger mom. They would likely tell anyone their deepest secret and consider everyone their best friend. In a study investigating the affects of different stimuli on subject with different types of RAD, subjects with the Uninhibited Type were shown to leave willingly from the caregiver s home with a stranger. (Gleason, 2011) The diagnosis of Reactive Attachment Disorder presents many problems to psychologists. Due to the fact that its symptoms are so subjective and not quantitatively measurable, often RAD can be misdiagnosed as another disorder or go undiagnosed leaving subjects and caregivers frustrated. Reactive Attachment Disorder is distinguished from other developmental disorders by its defining feature of grossly pathogenic parental care. (Corbin, 2007, p. 545) While RAD can look like many other disorders including Childhood Onset Conduct Disorder, Oppositional Defiant Disorder, Attention-Deficit Hyperactivity Disorder, and Autism, it has distinctive causation differences.

5 5 All these disorders exhibit similar behaviors and deficiencies, however these deficiencies are caused by complication intrinsic within the disorder itself not stemming from poor ongoing pathogenic care; the deficiencies would likely be present in any environment. (Sheperis, 2003) Specifically, RAD can be distinguished from Autism by restricted, repeated, and/or stereotypical behavior, which in Autism might be present without pathogenic care or an unloving environment. Because the cause of the disorder is one of the primary factors in accurate diagnosis, Child Abuse, Child Neglect, and/or Parent-Child Relational Problem are often identified in conjunction with the disorder. (Corbin, 2007) Due to the complexity of diagnosis, many psychologists have attempted to created a standardized assessment tool to accurate diagnose the condition. According to a case report by Sheperis, a multitude of assessments should be used. While assessment protocols are controversial in nature, the difficulties faced by mental health counselors assessing children with RAD mandate accurate assessment protocols. We propose a batter of semi-structured interviews, global assessment scales, attachment-specific scales, and behavioral observations to identify attachment-related issues. (Sheperis, 2003, p. 292) Standardized tools of assessment include the Child Behavior Checklist (CBC) for observable behavior, the Behavior Assessment System for Children (BASC) for thoughts and attitudes, the Sutter-Eyberg Student Behavior Inventory Revised (SESBI-R) for severity of conductproblems, and the Reactive Attachment Disorder Questionnaire. NEUROBIOLOGICAL ABNORMALITIES OF RAD During the process of attachment, several brain functions happen that create both biological and psychological changes and maturation. These processes can be divided in to cognitive and affective domains. This neural system includes (most importantly) the

6 6 phenomena and neural processes involved in affect: its expression, its connection with memory, and its regulation. (Corbin, 2007, p. 542) Specialists agree that children who undergo a healthy process of attachment are neurologically shielded from psychopathology, because this condition is associated with ruptures or developmental difficulties associated with attachment. The processes of attachment consist of complex physiological, biological, genetic, and behavioral facets associated with caregiving in early childhood. Despite the preponderance of attention given to abuse over neglect, it is important to note that there is clear evidence that neglect and attachment difficulties in early development may be even more damaging than abuse. (Corbin, 2007, p. 543) The Hypothalamic-Pituitary-Adrenal (HPA) Axis is considered the stress control center of the brain. It is largely responsible for the production and distribution of cortisol, a chemical which aids in mobility of the body for defensive purposes. When the HPA Axis is overly stimulated for extended periods of time because of stress or trauma, it can lead to hypercortisolism in times stress and affective illness throughout life. The hippocampus, amygdala, and limbic system are the primary centers relating to emotional and verbal memory, regulation, and context. The hippocampus is especially susceptible to hypercortisolism because of a high concentration of neural receptors located there. Hypercortisolism is shown to significantly decrease size or even kill neural receptors in the hippocampus. Also, it has been shown that there is decreased hippocampal and amygdalal size in adults who experienced early childhood trauma. Furthermore, significant evidence has been presented that separation from a caregiver in the context of family discord (including mother infant attachment-bond disruption) may have greater effects than even the actual death of a parent. (Corbin, 2007, p. 543) Research also shows that changes in the hippocampus caused by trauma are likely

7 7 irreversible. The ability of the right and left hemispheres of the brain may also be diminished. The middle parts of the corpus collosum in boys who had been abused or neglected were significantly smaller than those of controls. (Corbin, 2007, p. 544) CAUSES OF REACTIVE ATTACHMENT DISORDER As discussed earlier, Reactive Attachment Disorder is a condition which presents the subject with difficulty of deficiency in the ability to make and keep meaningful, loving relationships. The disorder is caused by extended trauma in the earlier stages of life causing abnormalities in the chemical balance of the subject s brain. Specifically the sorts of trauma that would cause RAD include extended or repeated separation from the birth mother; undiagnosed, unresolved, or untreated painful illness; frequent moves and/or placements; emotional, physical, sexual, and/or ritual abuse; inconsistent or inadequate care (neglect); and attachment disordered parents. The first year of life is when the child begins to develop trust and love when the primary caregiver repeatedly and consistently provides for the child s needs. (Chapman, 2002) It is very important that the caregiver provide a sense of stability both in parenting styles and in physical and emotional environments. When the child is exposed to an unstable home life where the caregiver is not consistently present or where the physical environment is constantly changing or precarious, the child has much more difficulty building trust that its needs will be met, and therefore achieve a sense of psychological calm; where the child knows everything will be ok. Aside from deliberate and obvious child abuse that would result in RAD, parenting styles that are unintentionally careless or subject the child to an inconsistent environment (like multiple significant others within small amount of time) are just as harmful as abusive relationships.

8 8 A study done by Tobin, Wardi-Zonna, Yezzi-Shareef, showed that, based on early recollections of children and adolescents with Reactive Attachment Disorder, the two most popular views in the category I am were alone/alienated and in trouble. Furthermore, within the category Others are the most popular responses were absent/abandoning and hostile/punishing, and within Events are, unfair and frustrating/confusing were the most popular viewpoints. (Tobin, 2007, p. 91) This study provides important insight into the attitudes and feelings of those afflicted with the condition on other, themselves, and events around. Understanding these viewpoints is critical to the analysis and prediction of behavioral patterns, as well as serving as an outward manifestation of the emotional effects of the disorder. Some situational specific scenarios provided in the aforementioned study were typical in illustrated unstable and/or abusive home lives, authoritarian parenting styles, and physical environments. I am - I remember when my older sister told me I was adopted. If I am adopted who is my mother? Does she love me? Others are - We got taken away from the babysitter because my mom did not come home that night, - I was sleeping, and he came in and wanted oral sex; I didn't want to be there because of the stuff he did to me Events are - We had fun finger-painting at school; I got grounded for four days because I got paint on my white shirt. - I remember getting taken away from my sisters when my mom got in a fight with some guy. (Tobin, 2007, pp ) COMMON SYMPTOMS ASSOCIATED WITH RAD Most symptoms associated with Reactive Attachment Disorder are caused by an attempt on the part of the subject to avoid rejection, pain, or to create a situation of security and stability. Broad behavioral characteristics of the Uninhibited Type and Inhibited Type were presented

9 9 earlier. The Uninhibited Type sees subjects being overly friendly and establishing a deep attachment to near perfect strangers, while the Inhibited Types sees subjects struggling to get emotionally close to anyone including parents and close friends. Specific behavioral attributes that might alert one to the presence of RAD include absence of appropriate eye contact; indiscriminately affectionate; superficially charming; lack of ability to give and take; over-clinginess and unreasonable demands; extreme control issues; destructiveness; cruelty and severe teasing and taunting (of people and animals); ability to split partners; persistent lying in the face of truth; lack of normal fear and impulse controls; absent, or weakly developed, cause and effect thinking; concrete thinking and lack of cognitive integration; poorly developed conscience; speech and developmental delays; persistent chatter and needless nonsense questioning; abnormal eating patterns; elimination problems (soiling, wetting); poor peer relationships; and/or unhealthy interest in blood, death or fire. (Chapman, 2007) These problems are attributed to the imbalance of chemicals in the brain previously discussed. Due to the fact that the centers of the brain effected are the ones that deal with memory, self-regulation, and affective constructs, those with RAD have trouble learning from previous mistakes, weighing out pros and cons of important life decisions, seeking out advice from a trusted source, and reacting rationally to situations of conflict or threat. Clinicians such as Shore (1994) and Hughes (1997) suggest that the neural networks of the traumatized child are hard-wired to these forms of red alert, providing a limited choice of responses to perceived threat. (Chapman, 2007, p. 93) Reactive Attachment Disorder can manifest itself in cognitive and anatomical symptoms as well. Low intensity of care and prolonged duration of exposure to social deprivation were found to be associated with higher levels of disturbed attachment, delays in physical growth and

10 10 cognitive development, and later psychopathology. (Kemph, 2007, p. 164) Many of these problems are things that teachers will potentially need to handle in the classroom. It is important for teachers to be able to identify or at least recognize the possibility that the student in question has a mental disorder and to react appropriately, whether inside of class or by contacting the proper authorities with reasonable suspicion of child abuse and/or neglect. PROGNOSIS AND TREATMENT OPTIONS As previously mentioned, changes in the neurobiology of the brain and rebalancing of the HPA may never be possible for those with RAD, however that does not mean that treatment and improvement are not possible so subjects can live normal, fulfilling lives with meaningful and loving relationships. Factors associated with improvement include the length of time in which the child was exposed to pathogenic care, into what sort of environment they child lives in permanently, and their emotional constitution. At age 6 years, some children manifested normal social and cognitive development, whereas other did not. This finding suggests that some children are constitutionally more vulnerable than other to early pathogenic environments and treatments. (Kemph, 2007, p. 164) Recently, there has been much research on treatment options, however the main goal of the majority of them is to enhance current attachment relationships, create new attachment relationship, and reduce problematic symptoms and behaviors. Studies have been done to conclude that psychoeducation, behavior modification, and cognitive management of symptoms. It is also believed that caregiver involvement in the treatment process (when appropriate) is crucial to positive treatment outcomes. Furthermore, interventions designed to increase self-

11 11 esteem and self-efficacy may improve functioning. (Hardy, 2007) Some therapeutic methods have been condemned by the American Psychological Association, including re-birthing therapy where the child s limbs are restrained and the head of the child is put in the lap of the therapist to maintain eye contact. The child is then barraged with question as to who is in control of the situation. These practices have no peer-reviewed, or conclusive scientific evidence for symptomatic alleviation. (Kemph, 2007) Some evidence has shown improvement via play therapy, during which the subject is encouraged to form an attached relationship to the therapist via sessions of free play where the therapist engages the child in exercises in self-discovery and the like. The patient began to show pleasure upon seeing the therapist; share information, thoughts, and feelings spontaneously; attempt to maintain proximity to the therapist; and show anxiety at separation. During this time, the patient also began to show increased positive behaviors outside of therapy. (Hardy, 2007, p. 34) Some other attachment therapy activities include holding (the positioning of the child across the lap of the therapist or parent to engage eye contact while discussing issues of past abuse or neglect, while not restraining the child s limbs), narrative therapy, parenting skills training, EMDR, psychodrama, and/or neurofeedback based on the assessment and treatment needs of the individual child. Unfortunately, none of these methods have proven to be more effective than the others in coping with or reversing the effects of RAD. (Wimmer, 2009) EDUCATIONAL IMPLICATIONS Teachers will certainly come in to contact with students who suffer from Reactive Attachment Disorder. It is very important for teachers to understand this disorder in order to recognize symptoms, understand how the child views the world, and how they may react to classroom activities and management measures. If the child feels threatened, there will likely be

12 12 behavioral problems, and the teacher needs to be aware that the child is not a bad kid or deliberately misbehaving. Instead the child is constantly in defense-mode and always looking to protect their psyche both consciously and subconsciously. When teachers become aware that they have a student with RAD, they need to make specific management and instructional modifications in order to give the child the best environment for learning, and to reassure them that school is a safe place, and the teacher is someone they can trust. In a case study, specific school modifications for a child named Anna with RAD are described in detail. Freed from the desperate struggle to convince everyone that she was undeserving of help, Anna s academic progress after re-nurturing was rapid and friendships developed. At school, a room was set aside for her to use during breaks so she could escape from teenage life, should she choose, with no danger of ridicule. Crying was met with affirmation that her worry was genuine and she was allowed time out to deal with her feelings, returning to class when ready. (Chapman, 2007, p. 93) The same study also describes that a seemingly small case of calling out the child for a small classroom management issue, could likely have an enormous reaction on the child causing huge feelings of shame and lead to the child reverting back to protective measures, causing tantrums or the like to ensue. (Chapman, 2007, p. 94) The author encourages teachers to encourage and reassure the student that this is not a life or death situation which the students brain imbalance is telling them, - but that it is a small issue. Do not assume that the teenager can accurately distinguish between big problems and small problems. Chapman (2007) also encourages teachers to think toddler to students with Reactive Attachment Disorder, because emotionally the student is more like a toddler than a teenage. Specifically, inviting these students to help you set up the room, meanwhile explaining the plan for the class would reduce vigilance in these students. Also, establishing a clear routine for entering the room and beginning with a simple, achievable, and immediate opening activity with both focus all students but reassure those with the condition that they can be successful in the coming lesson. (p. 94)

13 13 Arranging the room in such a way as to maintain eye contact and well as offer small, appropriate physical confirmation that the students is doing well (a tap on the shoulder) could serve to lessen the student s anxiety and the assure them that they are doing well. This can be done discreetly and without disrupting the flow of the lesson. Also, implementing a nonverbal, early-warning system will help to instill a sense of self-regulation in the students without making them feel ashamed or cause them to overreact. (Chapman, 2007, p. 94) Aside from the teacher s professional obligation to provide the best education they can for every student that enters the classroom, the teacher is also morally and legally responsible to report all suspected cases of abuse to the proper authorities. Being able to identify the behavioral symptoms of RAD, can help the teacher determine if there is reasonable suspicion to report cases. But after the teacher has made the report they need to be able to immediate know what classroom management and instructional modifications to make in order to foster a positive learning environment for the student.

14 14 BIBLIOGRAPHY Chapman, S. (2002). Reactive attachment disorder. British Journal of Special Education, 29(2), 91. Corbin, J. (2007). Reactive Attachment Disorder: A Biopsychosocial Disturbance of Attachment. Child & Adolescent Social Work Journal, 24(6), doi: /s x Gleason, M., Fox, N. A., Drury, S., Smyke, A., Egger, H. L., Nelson III, C. A., &... Zeanah, C. H. (2011). Validity of Evidence-Derived Criteria for Reactive Attachment Disorder: Indiscriminately Social/Disinhibited and Emotionally Withdrawn/Inhibited Types. Journal of The American Academy of Child & Adolescent Psychiatry, 50(3), doi: /j.jaac Hardy, L. T. (2007). Attachment Theory and Reactive Attachment Disorder: Theoretical Perspectives and Treatment Implications. Journal of Child & Adolescent Psychiatric Nursing, 20(1), doi: /j x Kemph, J. P., & Voeller, K. S. (2007). Reactive attachment disorder in adolescence. Adolescent Psychiatry, Sheperis, C. J., Doggett, R., Hoda, N. E., Blanchard, T., Renfro-Michel, E. L., Holdiness, S. H., & Schlagheck, R. (2003). The Development of an Assessment Protocol for Reactive Attachment Disorder. Journal of Mental Health Counseling, 25(4), 291. Tobin, D., Wardi-Zonna, K., & Yezzi-Shareef, A. (2007). Early Recollections of Children and Adolescents Diagnosed with Reactive Attachment Disorder. Journal of Individual Psychology, 63(1), Wimmer, J., Vonk, M. M., & Bordnick, P. (2009). A Preliminary Investigation of the Effectiveness of Attachment Therapy for Adopted Children with Reactive Attachment Disorder. Child & Adolescent Social Work Journal, 26(4), doi: /s