International adoption:
Concerns for pediatric providers
Lisa Albers, MD, MPH

What are 'attachment', Reactive Attachment Disorder and attachment therapy?

'Attachment' is a theoretical construct developed by Bowlby and Spitz early in the twentieth century to describe a relationship between an infant and a primary care taker, manifest in certain behaviors. The initial theory resulted from their observations of infant behavior in the setting of profound maternal and sensory deprivation. Clinicians and researchers since this time have described infants who do not present with a pattern of 'secure attachment' with their primary caretaker (or caretakers) as being at significant risk for later impairments in social relationships, attachments, trust and intimacy. (Bowlby, 1951; Spitz 1945).

A range of appropriate and inappropriate attachment behaviors have been described as infants learn to explore the world with gradually less proximity to a familiar caregiver. Ideally, during one's early days, weeks and months of life, an infant's caregiver provides him or her with a secure environment that serves as a safe and secure base from which to explore the outside world. Interactions between an infant and one or more caretakers occur multiple times per day and thousands of times during infancy. Any single interaction is not critical, but the general quality of interactions over time does impact a child's perception of the world with respect to where he or she can or cannot get his needs met. In addition, it is unlikely that early experiences can be 'erased' but there is not felt to be an 'absolute' critical period beyond which all children are likely to have 'attachment problems' if they have not formed a positive attachment relationship.

As is typical of many behavioral diagnoses, extreme difficulties with attachment have been defined as a disorder by clinicians and researchers. "Reactive Attachment Disorder of Infancy or Early Childhood" is described in the Diagnostic and Statistical Manual of Mental Disorders: Fourth Edition (DSM-IV-TR). According to the DSM-IV-TR, "Reactive Attachment Disorder" (or "RAD") is a term used to describe a child who displays "markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 and is associated with grossly pathological care."

Children who present with disordered attachment patterns, as manifest by specific behaviors, have often been abused, neglected, traumatized or generally deprived of critical developmental experiences with positive adult attachment figures. Children who have missed these early childhood experiences during critical times may develop patterns of extreme defensiveness with interpersonal relationships, excessive social inhibition, hypervigilance, and ambivalent responses relating to people. In addition, more extreme behaviors such as aggression, defiance, destructiveness, rage, depression, and indiscriminant attachments to others (without depth or meaning) may be seen.

Clinicians and researchers are currently facing an increasing demand to address the needs of children who have suffered early attachment difficulties leading to behaviors consistent with the diagnosis of Reactive Attachment Disorder, but unfortunately therapies for these disorders are not proven. Attachment therapy is not a single therapy, but ideally a multidisciplinary informed approach to assisting families with children who present with severe attachment-related difficulties. Ideally, 'attachment therapy' is a collective set of therapeutic interventions ranging from individual, family and group therapeutic approaches to the more controversial 'holding therapy approaches.' Of note, no 'holding therapies' have been reported in peer reviewed journals.

	For more information about medical issues in international adoption or to refer a patient to the Adoption Program at Children’s Hospital Boston, call (617) 355-7971 or e-mail nichol.nagim@tch.harvard.edu.