Friday, February 1, 2013

Reactive Attachment Disorder

This is the episode where we talk about the thing that we’ve all been waiting for, and the thing that people like to pretend is baby BPD. Reactive Attachment Disorder (RAD for short, but I’m pretty sure rad is the one thing it isn’t).

What is Reactive Attachment Disorder?

First of all let me tell you what Reactive Attachment Disorder is not. It is not the child form of Borderline Personality Disorder. It is a thing that is entirely its own. That being said RAD is:

Reactive Attachment Disorder is a severe disorder in children beginning before the age of 5 that is characterized by exceptionally disturbed and developmentally inappropriate ways of relating socially (in most contexts).  There are two “types”.

  1. Inhibited Form  
  2. Disinhibited Form

RAD is caused by the failure to form normal healthy attachments to primary caregivers early in childhood. This failure is the result of severe early experiences such as neglect, abuse, abrupt separation from caregivers (usually during the 6 month to 3 year age period), frequent changes in caregivers (like in an orphaned foster home scenario), or a lack of caregiver responsiveness to a child’s efforts to communicate. 

“Children with RAD are presumed to have grossly disturbed internal working models of relationships which may lead to interpersonal and behavioral difficulties in later life.” … This is where people tend to jump to the conclusion that the adult result must be BPD. I’m not saying that this is never the case. Certainly it’s feasible that the abuse and neglect that creates RAD could continue to evolve into BPD, but it’s also not necessarily a direct correlation. For instance, if you ask my parents, I was a very content (slightly anxious) child, but I didn’t have any real behavior problems until a little later on in life. I would never have been diagnosed with RAD.

It’s also important to note that while RAD is most likely to occur in relation to neglect and abuse, it’s in no way a guarantee (just like BPD is not guaranteed to develop in cases of abuse and neglect). Some children grow up just fine and are able to form stable attachments and social relationships despite early childhood problems. Unlike many disorders that are marked by genetic components, RAD is specifically based on problematic care and relationship history. This is a disorder entirely created by a child’s environment.

As previously mentioned the core features are severely inappropriate social relating in children.

Disinhibited Form - Indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers (older children and adolescents may also aim attempts at peers).

Inhibited Form  - Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed. [12]

There hasn’t been any conclusive research on why one form arises above the other. There does seem to be a temperament/constitution quality that gives certain children a greater sensitivity to unpredictable and hostile relationships in their environment that makes them more susceptible (just like with BPD and PTSD).  Some kids are more sensitive, some are more robust. When you’re more sensitive you are potentially more susceptible to disturbances in affect regulation.

So what criteria qualify a child for have Reactive Attachment Disorder?

  • Markedly disturbed and developmentally inappropriate social relatedness in most contexts (e.g., the child is avoidant or unresponsive to care when offered by caregivers or is indiscriminately affectionate with strangers)
  • The disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder;
  • Onset before five years of age (there is no age specified before five years of age at which RAD cannot be diagnosed)
  • A history of significant neglect;
  • An implicit lack of identifiable, preferred attachment figure.

ICD-10 also includes some things that the DSM-IV doesn’t

  • Abuse, (psychological or physical), in addition to neglect;
  • Associated emotional disturbance;
  • Poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases (inhibited form only);
  • Evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness in interactions with appropriately responsive, non-deviant adults (disinhibited form only).

 Other things that may contribute to the development of RAD are:

  • A baby cries and no one responds or offers comfort.
  • A baby is hungry or wet, and they aren’t attended to for hours.
  • No one looks at, talks to, or smiles at the baby, so the baby feels alone.
  • A young child gets attention only by acting out or displaying other extreme behaviors.
  • A young child or baby is mistreated or abused.
  • Sometimes the child’s needs are met and sometimes they aren’t. The child never knows what to expect.
  • The infant or young child is hospitalized or separated from his or her parents.
  • A baby or young child is moved from one caregiver to another (can be the result of adoption, foster care, or the loss of a parent).
  • The parent is emotionally unavailable because of depression, an illness, or a substance abuse problem.

Sometimes the circumstances that cause the attachment problems are unavoidable, but the child is too young to understand what has happened and why. To a young child, it just feels like no one cares and they lose trust in others and the world becomes an unsafe place.

So to sum up:

(A) A child must display behavior disturbances of either the Inhibited or Disinhibited Forms of RAD.

(B) That disturbance should not be accounted for soley because of developmental delay (like mental retardation).

(C) Pathogenic care as evidenced by at least one of the following:
  1. persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection 
  2. persistent disregard of the child's basic physical needs 
  3. repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)

 (D) The presumption is that this pathogenic care is responsible for the disturbance of Criteria A.

To be fair to people that like to jump to the conclusion that RAD leads to BPD, they do both have foundations in affect dysregulation, and they’re both marked by relationship attachment problems. The reasons for those problems can even be from similar environments. But BPD also has a clear bio-genetic component and is not necessarily the result of only neglect or abuse (though obviously it can be). Regardless, as with BPD, therapy and learning ways to attach properly are possible. Though usually with RAD the therapy and skill learning focus is on the caregiver not just for the child. Then again, it’s often helpful for our partners to take a therapy session or two to help them understand us and our needs better as well. After all, relationships take two. 

Wednesday, January 30, 2013

Attachment Styles and Close Relationships: An Interactive Survey

Attachment is such a strange thing. I mean, it’s a completely normal and natural part of being human, but then again, I have problems with object constancy so feeling attached feels a little foreign. I want to know the security of that feeling more than, quite a lot of other things, but I’m really unsure what a long lasting secure attachment is like in a relationship. Honestly the closest thing I think I have is my relationship with my sister. You know what, that’s not just close to it, that definitely is a healthy, secure attachment. My brother is up there too. Now I just need to figure out how to do that with people I’m not related too. Sometimes I think the hardest part about developing real attachments and connections is that they take so long to become the firm, permanent thing they should be. I want to know now, but that’s just not the way those kinds of things work. Oh well.

As promised, this is an interactive survey to help you figure out your attachment style. It’s quick. CLICK HERE!

Unsurprisingly fall into the Fearful-Avoidant Quadrant.

“Previous research on attachment styles indicates that fearful people tend to have much difficulty in their relationships. They tend to avoid becoming emotionally attached to others, and, even in cases in which they do enter a committed relationship, the relationship may be characterized by mistrust or a lack of confidence.”

I scored:

Attachment-related anxiety score is 5.60, on a scale ranging from 1 (low anxiety) to 7 (high anxiety).
Attachment-related avoidance score is 6.10, on a scale ranging from 1 (low avoidance) to 7 (high avoidance).

“According to attachment theory and research, there are two fundamental ways in which people differ from one another in the way they think about relationships. First, some people are more anxious than others. People who are high in attachment-related anxiety tend to worry about whether their partners really love them and often fear rejection. People low on this dimension are much less worried about such matters. Second, some people are more avoidant than others. People who are high in attachment-related avoidance are less comfortable depending on others and opening up to others.

That about sums me up in a nutshell. Of course the reasons for why I developed like this are important, varied, and incredibly complex… but things like this can be helpful to show us what we may want to work on a little more.

Tuesday, January 29, 2013

With or Without BPD - Attachment Styles: Adults

Yesterday we talked about Attachment Style in children. I also talked about the Secure Attachment of both children and adults that is the goal for Healthy relationship attachment yesterday. So let’s take a look at where those styles can lead to when we become adults.

Adult Insecure Attachment Styles

Anxious–Preoccupied Attachment

People who are anxious or preoccupied with attachment tend to agree with the following statements: "I want to be completely emotionally intimate with others, but I often find that others are reluctant to get as close as I would like. I am uncomfortable being without close relationships, but I sometimes worry that others don't value me as much as I value them." People with this style of attachment seek high levels of intimacy, approval, and responsiveness from their partners. They sometimes value intimacy to such an extent that they become overly dependent on their partners—a condition colloquially termed clinginess. Compared to securely attached people, people who are anxious or preoccupied with attachment tend to have less positive views about themselves. They often doubt their worth as a partner and blame themselves for their partners' lack of responsiveness. People who are anxious or preoccupied with attachment may exhibit high levels of emotional expressiveness, worry, and impulsiveness in their relationships.

Dismissive–Avoidant Attachment

People with a dismissive style of avoidant attachment tend to agree with these statements: "I am comfortable without close emotional relationships.", "It is very important to me to feel independent and self-sufficient", and "I prefer not to depend on others or have others depend on me." People with this attachment style desire a high level of independence. The desire for independence often appears as an attempt to avoid attachment altogether. They view themselves as self-sufficient and invulnerable to feelings associated with being closely attached to others. They often deny needing close relationships. Some may even view close relationships as relatively unimportant. Not surprisingly, they seek less intimacy with relationship partners, whom they often view less positively than they view themselves. Investigators commonly note the defensive character of this attachment style. People with a dismissive–avoidant attachment style tend to suppress and hide their feelings, and they tend to deal with rejection by distancing themselves from the sources of rejection (i.e., their relationship partners).

While it is actually very important for me to feel independent and self-sufficient, I’m starting to realize you can do this, while also enjoying someone else in a close intimate relationship. It doesn’t necessarily negate independence or self-sufficiency. That said, this was the attitude I wanted people to believe about me for a long time. Whether I felt it or not, it was what I showed, and I believed it to be safer.

Anxious-Ambivalent Attachment

As adults, those with an ambivalent attachment style often feel reluctant about becoming close to others and worry that their partner does not reciprocate their feelings. This leads to frequent breakups, often because the relationship feels cold and distant. These individuals feel especially distraught after the end of a relationship. Cassidy and Berlin described another pathological pattern where ambivalently attached adults cling to young children as a source of security (1994).

I definitely relate to this. It’s not even that I’m reluctant; I mean clearly I am, but it’s not a conscious decision. I don’t sit there and say, “I’m going to hesitate about this emotional intimacy,”… it’s usually sparked by feelings of anxiousness and uncertainty that make me hesitate or pull back. 

Fearful–Avoidant Attachment

People with losses or sexual abuse in childhood and adolescence often develop this type of attachment and tend to agree with the following statements: "I am somewhat uncomfortable getting close to others. I want emotionally close relationships, but I find it difficult to trust others completely, or to depend on them. I sometimes worry that I will be hurt if I allow myself to become too close to others." People with this attachment style have mixed feelings about close relationships. On the one hand, they desire to have emotionally close relationships. On the other hand, they tend to feel uncomfortable with emotional closeness. These mixed feelings are combined with, sometimes unconscious, negative views about themselves and their partners. They commonly view themselves as unworthy of responsiveness from their partners, and they don't trust the intentions of their partners. Similarly to the dismissive–avoidant attachment style, people with a fearful–avoidant attachment style seek less intimacy from partners and frequently suppress and deny their feelings. Instead, they are much less comfortable initially expressing affection.

I relate to this one too. It’s almost scary. Even if a partner tells me exactly how they feel and it’s very positive, I have a very difficult time believing they mean it, or understanding why they would mean it. All of this feels very true for me.

Are you starting to recognize yourself in any of these attachment styles? I certainly see characteristics of myself in most of these but even stronger in one or two in particular. Tomorrow I’ll give you an interactive tool to help you determine just where you fall on the spectrum (because you don’t have to be only one or another). 

Monday, January 28, 2013

With or Without BPD - Attachment Styles: Children

Oh attachment. I’m quite attached to all of you dear Readers. I hope you know I appreciate you. Let’s get back to attachment shall we?
Attachment is simply that recognition of a connection that you have with someone. Or should have with someone, like say, a parent or caregiver. John Bowlby devoted extensive research to the concept of attachment, describing it as a "lasting psychological connectedness between human beings" (Bowlby, 1969, p. 194). [1] Bowlby believed that there are four distinguishing characteristics of attachment:
Characteristics of Attachment
1. Proximity Maintenance - The desire to be near the people we are attached to.
2. Safe Haven - Returning to the attachment figure for comfort and safety in the face of a fear or threat.
3. Secure Base - The attachment figure acts as a base of security from which the child can explore the surrounding environment.
4. Separation Distress - Anxiety that occurs in the absence of the attachment figure.
However when there are developmental issues in the relationship between caregiver and child, attachment becomes faulty.  Infants and children don’t just one day make a decision and choose to not attach. It’s learned. When a parent or caregiver is negligent of the childs needs, that child learns that someone is unreliable, that they can’t trust them to be there to provide for their basic human needs. They don’t learn to trust. They don’t learn to attach. If this is left alone, worsens, or is never given a chance to heal it can become a disorder of attachment.
“Drs. Boris and Zeanah use the term "disorder of attachment" to indicate a situation in which a young child has no preferred adult caregiver. Such children may be indiscriminately sociable and approach all adults, whether familiar or not; alternatively, they may be emotionally withdrawn and fail to seek comfort from anyone. This type of attachment problem is parallel to Reactive Attachment Disorder as defined in DSM and ICD in its inhibited and disinhibited forms [we’ll talk about this specifically later].
Drs. Boris and Zeanah also describe a condition they term "secure base distortion". In this situation, the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, may cling to the adult, may be excessively compliant, or may show role reversals in which they care for or punish the adult.
The third type of disorder discussed by Drs. Boris and Zeanah is termed "disrupted attachment". This type of problem, which is not covered under other approaches to disordered attachment, results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed. The young child's reaction to such a loss is parallel to the grief reaction of an older person, with progressive changes from protest (crying and searching) to despair, sadness, and withdrawal from communication or play, and finally detachment from the original relationship and recovery of social and play activities.”
How someone learns to attach to their core group as a child sets the groundwork for how they will learn to attach to others as an adult. So let’s look at some of the ways that these can attach (or not) as children and then tomorrow we’ll look at how those styles evolve in adults. Then I’ll have a fun interactive survey for you that provides a good idea as to the kind of attachment style you may have.  
Attachment Styles are broken down into either Secure or Insecure.
Secure Style
Children: A toddler who is securely attached to its parent (or other familiar caregiver) will explore freely while the caregiver is present, typically engages with strangers, is often visibly upset when the caregiver departs, and is generally happy to see the caregiver return. The extent of exploration and of distress are affected by the child's temperamental make-up and by situational factors as well as by attachment status, however.
Adult: Securely attached people tend to agree with the following statements: "It is relatively easy for me to become emotionally close to others. I am comfortable depending on others and having others depend on me. I don't worry about being alone or having others not accept me." This style of attachment usually results from a history of warm and responsive interactions with relationship partners. Securely attached people tend to have positive views of themselves and their partners. They also tend to have positive views of their relationships. Often they report greater satisfaction and adjustment in their relationships than people with other attachment styles. Securely attached people feel comfortable both with intimacy and with independence. Many seek to balance intimacy and independence in their relationship.
This is the goal. This is what we would consider Healthy Adult functioning in relationships. However many of us tend to lean more towards these….
Insecure Styles  (we’ll start with expressions in Children)
Anxious-Resistant Insecure Attachment
In general, a child with an anxious-resistant attachment style will typically explore little (in the Strange Situation = a new situation that the child has not previously been exposed to) and is often wary of strangers, even when the parent is present. When the mother departs, the child is often highly distressed. The child is generally ambivalent when she returns. This attachment pattern can be caused from the parents lack of affection during infancy and early childhood. These infants are depicted as anxious-resistant insecure when:
"...resistant behavior is particularly conspicuous. The mixture of seeking and yet resisting contact and interaction has an unmistakeably angry quality and indeed an angry tone may characterize behavior in the pre-separation episodes..."
These infants are often seen as demonstrating 'passive' resistance. As Ainsworth et al. (1978) originally noted:
"Perhaps the most conspicuous characteristic of C2 infants is their passivity. Their exploratory behavior is limited throughout the SS and their interactive behaviors are relatively lacking in active initiation. Nevertheless, in the reunion episodes they obviously want proximity to and contact with their mothers, even though they tend to use signalling rather than active approach, and protest against being put down rather than actively resisting release...In general the C2 baby is not as conspicuously angry as the C1 baby."
Anxious-Avoidant Insecure Attachment
In general, a child with an anxious-avoidant attachment style will avoid or ignore the parent when he or she returns (in the Strange Situation) - showing little overt indications of an emotional response. Often, the stranger will not be treated much differently from the parent. This attachment pattern can be caused from little to no interaction between the parents and the child during infancy and early childhood. These infants are depicted as anxious-avoidant insecure when there is:
"...conspicuous avoidance of the mother in the reunion episodes which is likely to consist of ignoring her altogether, although there may be some pointed looking away, turning away, or moving away...If there is a greeting when the mother enters, it tends to be a mere look or a smile...Either the baby does not approach his mother upon reunion, or they approach in 'abortive' fashions with the baby going past the mother, or it tends to only occur after much coaxing...If picked up, the baby shows little or no contact-maintaining behavior; he tends not to cuddle in; he looks away and he may squirm to get down."
These infants are often seen as demonstrating a mixture of both some avoidance and resistance. Often, though not always, these infants are judged as Disorganized (D). As Ainsworth et al. (1978) originally noted:
"...[the infant] shows a mixed response to mother on reunion, with some tendency to greet and approach, intermingled with a marked tendency to move or turn away from her, move past her, avert the gaze from her, or ignore her...there may be moderate proximity-seeking, combined with strong proximity-avoiding...If picked up, the baby may cling momentarily; if put down, he may protest or resist momentarily; but there is also a tendency to squirm to be put down, to turn the face away when being held and other signs of mixed feelings [i.e., resistance/ambivalence]."
Anxious-Ambivalent Insecure Attachment
Children who are ambivalently attached tend to be extremely suspicious of strangers. These children display considerable distress when separated from a parent or caregiver, but do not seem reassured or comforted by the return of the parent. In some cases, the child might passively reject the parent by refusing comfort, or may openly display direct aggression toward the parent.
According to Cassidy and Berlin (1994), ambivalent attachment is relatively uncommon, with only 7% to 15% of infants in the United States displaying this attachment style. In a review of ambivalent attachment literature, Cassidy and Berlin also found that observational research consistently links ambivalent-insecure attachment to low maternal availability. As these children grow older, teachers often describe them as clingy and over-dependent.
Disorganized Attachment
A fourth category is termed disorganized attachment (Main & Solomon, 1990). It can be conceptualized as the lack of a coherent 'organized' behavioral strategy for dealing with the stresses (i.e., the strange room, the stranger, and the comings and goings of the caregiver) of the Strange Situation Procedure. Evidence has suggested that children with disorganized attachment may experience their caregivers as either frightening or frightened. A frightened caregiver is alarming to the child, who uses social referencing techniques such as checking the adult's facial expression to ascertain whether a situation is safe. A frightening caregiver is usually so via aggressive behaviors towards the child (either mild or direct physical/sexual behaviors) and puts the child in a dilemma called 'fear without solution.' In other words, the caregiver is both the source of the child's alarm as well as the child's haven of safety. Through parental behaviors that are frightening, the caregiver puts the child in an irresolvable paradox of approach-avoidance. This paradox, in fact, may be one explanation for some of the 'stilling' and 'freezing' behaviors observed in children judged to be disorganized. Human interactions are experienced as erratic, thus children cannot form a coherent, organized interactive template. If the child uses the caregiver as a mirror to understand the self, the disorganized child is looking into a mirror broken into a thousand pieces. It is more severe than learned helplessness as it is the model of the self rather than of a situation.
There is a growing body of research on the links between abnormal parenting, disorganized attachment and risks for later psychopathologies. Abuse is associated with disorganized attachment. The disorganized style is a risk factor for a range of psychological disorders although it is not in itself considered an attachment disorder under the current classification.
I was debating whether or not to do the Child and Adult side by side, but they don’t quite match up that way and this post is already getting really long so I’ll leave you with this nice chart breakdown and we’ll get to those Adult Attachment Styles tomorrow!
Child and caregiver behaviour patterns before the age of 18 months[36][38]
Uses caregiver as a secure base for exploration. Protests caregiver's departure and seeks proximity and is comforted on return, returning to exploration. May be comforted by the stranger but shows clear preference for the caregiver.
Responds appropriately, promptly and consistently to needs. Caregiver has successfully formed a secure parental attachment bond to the child.
Little affective sharing in play. Little or no distress on departure, little or no visible response to return, ignoring or turning away with no effort to maintain contact if picked up. Treats the stranger similarly to the caregiver. The child feels that there is no attachment; therefore, the child is rebellious and has a lower self-image and self-esteem.
Little or no response to distressed child. Discourages crying and encourages independence.
Unable to use caregiver as a secure base, seeking proximity before separation occurs. Distressed on separation with ambivalence, anger, reluctance to warm to caregiver and return to play on return. Preoccupied with caregiver's availability, seeking contact but resisting angrily when it is achieved. Not easily calmed by stranger. In this relationship, the child always feels anxious because the caregiver's availability is never consistent.
Inconsistent between appropriate and neglectful responses. Generally will only respond after increased attachment behavior from the infant.
Stereotypies (repetitive gestures) on return such as freezing or rocking. Lack of coherent attachment strategy shown by contradictory, disoriented behaviours such as approaching but with the back turned.
Frightened or frightening behaviour, intrusiveness, withdrawal, negativity, role confusion, affective communication errors and maltreatment. Very often associated with many forms of abuse towards the child.
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