My Daughter Doesn't Seem to Attach


Q: My child is 18 months, and she was a very colicky baby (lots of crying and screaming during the first year). I don't feel as if I bonded with her because I was so exhausted and depressed. These days, it is very difficult to comfort her, and she throws a lot of tantrums and is very defiant. I have heard about some children having Reactive Attachment Disorder. Could this be what she has? What can I do at this stage?

A: It is not likely that your daughter has Reactive Attachment Disorder (RAD). The symptoms are similar to some RAD symptoms, but also around ages 2 to 3 these symptoms can be normal. The difficulty comforting her might be a hint of bigger problems, but RAD requires a very large disconnect between caretaker and infant.

RAD has filled a gap in child psychiatry/psychology evaluations. There had always been a percentage of children who were hard to categorize. These were children who seemed to have little or no conscience, but did not seem to be sociopathic (extreme lack of conscience). They engaged in mindless misbehaviors (stealing rings, hoarding food, lying about things that did not matter, misbehaving and even hurting peers and adults and not seeming to understand or care what they have done).

Children with RAD have difficulty forming firm, loving relationships. They seem unable to form genuinely affectionate attachments with anybody. Conscience is either lacking or has large gaps. They do not trust others. There are two sub types: inhibited and diffuse. Inhibited children are hard to comfort, don't cuddle, seem wary of others all of the time as if others are out to do something to them, might just stare at people when a response is expected and might be excessively self-contained and not want to be around people. The diffuse type is one who never meets a stranger, goes up to strangers and talks to them with inappropriate requests or wishes (wants to go home with them, sits on their legs, wants them for a parent, etc.). They might be very flirtatious and chatty. They might seem like angels to people who first meet them.

The signs to watch for in babies are trouble calming emotions (weak crying or excessive crying and rage), poor eye contact, poor cuddling and not responding to touch, not showing recognition of male or female, being a bit sloppy. They might have delays in crawling, walking or gross motor skills.

Older children make poor eye contact, talk without looking at anybody, can be cruel to siblings or animals and are whiny and clingy and demanding of parents. They generally lie and steal, and hide or hoard food. They are generally destructive to property of all sorts. They seem not to learn from experience and ask the same thing over and over. They might be inattentive and do not show reciprocal conversations. With peers there is no give and take play. They either avoid or insist things be their way. They can be superficially charming. They can get excited about fire or destruction to people or things. And with all the above, there is no apparent remorse or guilt, though they can learn to say, "I'm sorry! I'm sorry!" As they get older, both types can learn to manipulate better and better.

RAD occurs because of serious disconnects (lack of bonding) with an infant. The reasons vary: severe pathology in parents, severe neglect and/or abuse as infants or severe illness in the child resulting in separations at birth or in the first year. The big upsurge has been seen with some Eastern European adoptions in which the early infant care in those countries met food and shelter needs, but did not offer the consistent, loving care needed during the first year of life. "Failure to thrive" children might also fit this diagnosis.

Helping these children is not easy and will need to be ongoing for years. Psychological damage in the first year or so of life is hard to repair.

All of the therapies for RAD aim toward helping these children develop responsibility with some sense of caring toward others, to balance effect, to learn to follow rules and to live by societal norms. Therapy has to be very active, confrontational and include parents. It takes a lot creativity on the therapist's and the parents' parts, and results are not guaranteed.

For parents, the rules are to put yourself and siblings first, learn ways to avoid power struggles, do not give the benefit of the doubt to the child and find some respite for themselves that does not reward the child for negative behavior. Web networks are very helpful. A useful Web site to start with is the Attachment Disorders Support group, http:\\\adsg\donts.html.

Gerald Taylor, M.D., is a child and adolescent psychiatrist with Moses Cone Behavioral Health Psychiatric Associates. Submit your questions to "Is My Kid OK?" via e-mail to clearpixel.gif

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