I recently received an e-mail from a father in Wisconsin who wanted to know my opinion of his family's situation. He had recently received custody of his four children, ranging in age from pre-teens to teen-agers. These children, who had all experienced abuse in their earlier lives, were troubled, and had all recently been diagnosed with Reactive Attachment Disorder. Because I am not a clinical psychologist, I simply suggested some material for the father to read, and expressed my concern about the possibility that this diagnosis might not be correct.
There is much that is still unknown about the long-term effects of early experiences, especially of the emotional relationships that are aspects of attachment. Obviously, no one could ever carry out experimental research on this part of human life. For one thing, we would not take the risk of doing harm to developing humans by interfering with their normal experiences, and for another, it would be far from practical to try to make caregivers behave "to order" toward their children. As a result, research in this area may compare naturally-occurring groups-- for example, children adopted from given situations, compared with non-adopted children-- but it's hard to know whether any differences in personality problems are due to their different experiences, or to other unknown factors. Another option is the correlational study, which does a mathematical analysis of the extent to which poor early experiences go with later personality problems, and good experiences go with good later development. However, there are rarely or never perfect relationships between early experience and later development, and even if there were, it would be impossible to know whether the early events caused the later ones, or whether both were caused by one or more other factors such as the parents' education or mental health.
In a very general sense, it seems to be that there are connections between early attachment experiences and attachment status in toddlerhood (whether a young child can be classified as secure in attachment, insecure in one of a couple of ways, or disorganized). There are also possible connections between early attachment status and childhood antisocial behavior. However, it seems clear that there are factors other than attachment status at work in determining later characteristics, because not every child with problematic attachment status later shows antisocial behavior. The same thing is true when we look at early childhood measures of attachment, and measures of attachment attitudes in adulthood; some insecure children grow up to be secure as adults, apparently having been able to learn healthier attitudes from later experiences with family and friend relationships.
But what about serious mental health problems that are thought to be associated with attachment experiences? Many Internet sites refer to Reactive Attachment Disorder, an emotional disturbance considered to result from problems with early relationships. These sites often use the abbreviation RAD, which I find a matter of concern because using the abbreviation makes it too easy to forget what the longer name tells us-- that we are talking about a disorder of relationships that has occurred in reaction to experiences.
Some Internet sites suggest that it is easy to diagnose Reactive Attachment Disorder by means of checklists, and that older children or teenagers are as easily diagnosed as younger children. They may also convey the idea that violent antisocial behavior is a part of Reactive Attachment Disorder and imply or state that this problem is widespread among adopted children of all ages.
An excellent web site, which defines Reactive Attachment Disorder and provides useful commentary about it, is http://www.behavenet.com/capsules/disorders/reactatt.htm. This site provides the description of criteria for the "official" diagnosis of Reactive Attachment Disorder as given in the Diagnostic and Statistical Manual of the American Psychiatric Association, commonly known as DSM. The DSM criteria emphasize issues of behavior of children toward adults and require a comparison of a given child's behavior to behavior that is developmentally appropriate for that child's age. The diagnosis of Reactive Attachment Disorder can involve either excessive clinging and dependency on adults (excessive for the child's age) or insufficient interest in seeking comfort from adults (insufficient for the child's age). Because there could be many causes for these unusual behaviors, DSM also states that for a diagnosis of Reactive Atrtachment Disorder, there must be a history of inappropriate care, and the behavioral problems must have begun before age 5.
This helpful web site includes a paper reporting the position of the American Academy of Child and Adolescent Psychiatry on diagnosis and treatment of Reactive Attachment Disorder. This paper traces the history of the disorder from the time when it was associated with "failure to thrive", or unexplained poor physical growth in babies. The AACAP paper questions the use of the diagnosis for older children and teens, and states concern with the confusion caused by including antisocial behavior among the criteria used with older children (see p. 11 for this discussion).
There is still much to be learned about the connections between attachment and issues of personality or mental health, and we should not be too quick to assume that there are simple causes for complex outcomes.