UNIVERSITÉ DE SHERBROOKE
THÈSE PAR ARTICLES
PRÉSENTÉE A
LA FACULTE DES LETTRES ET SCIENCES HUMAINES
COMME EXIGENCE PARTIELLE
DU DOCTORAT EN PSYCHOLOGIE
PAR
©NATALIE MIKIC
CAPACITÉ DE MENTALISATION DES MÈRES ET REPRÉSENTATIONS
D’ATTACHEMENT D’ENFANTS PRÉSENTANT UN TROUBLE RÉACTIONNEL DE
L`ATTACHEMENT
MATERNAL MENTALIZING CAPACITY AND ATTACHMENT REPRESENTATIONS
OF CHILDREN WITH REACTIVE ATTACHMENT DISORDER
CETTE THÈSE A ÉTÉ EVALUÉE
PAR UN JURY COMPOSÉ DE:
Miguel M.Terradas, PhD Directeur de thèse
Professeur
Département de psychologie
Faculté deslettres et sciences humaines Université de Sherbrooke-Campus Longueuil
Julie Achim, PhD Professeure
Département de psychologie
Faculté deslettres et sciences humaines Université de Sherbrooke-Campus Longueuil
Claud Bisaillon, PhD Professeure
Département de psychologie
Faculté deslettres et sciences humaines Université de Sherbrooke-Campus Longueuil
Abstract
The diagnostic criteria for Reactive Attachment Disorder (RAD) have remained fairly constant over the last few decades. However, the most recent change in the fifth version of the Diagnosticand Statistical Manual of Mental Disorders(DSM-5; American Psychiatry Association; APA, 2013) is fairly significant, as the inhibited and disinhibited types of RAD that were found in the previous versions of the manual have been removed. RAD has been replaced with a definition that resembles in some ways the previous inhibited type. Diagnosed in early childhood, this disorder interferes with the child’s ability to form secure relationships withtheir attachment figures and others. One ofthe criteriathat remain constant is that deprivation in the quality of early care is a risk factor for developing RAD. Although physical abuse andextreme neglect may beeasiertoidentify,emotional neglectis more challenging as a variable to understand. There has been less research on RAD regarding the subtle interactions between mother and child. The theory of mentalization explores some of the complications that arise in attachment and relationships to others that are aggravated by neglect,abuse, andtrauma(Bateman & Fonagy 2004). Theinfantrelies onthesensitive attunement and capacity to mentalize of the primary caregiver to help him understand what he is experiencing. The first article uses mentalization and object relations theoryapplied to children with RAD, in order to facilitate an understanding of these children psychologically as well as certain aspects of the relationship with their mothers. The second article presents twocase studies of mother-child dyads of children who have been diagnosed with RAD. The motherandchild were evaluated with instruments that provided informationregardingthe mother’scapacityto mentalizeandthechild’sattachmentrepresentations. The objective of
the case studies were meantto reveal howtheseinstruments could be utilized forthe specific scores, butalsoto illustrate whatis transpiring psychologicallyintherelationship between mother and child. The capacity to mentalize of the mothers was measured with the Addendumto Reflective Functioning Scoring Manual(Fonagy, Steele, Steele, & Target, 1998) appliedto the Parent DevelopmentInterview-Revised(PDI-R; Slade, Aber, Berger, Bresgi,& Kaplan, 2005).The results ofthe mother’s scores for mentalization wereinthelow and questionable range. The attachment representations of the children were evaluated through the use of the Attachment Focused Coding System(AFCS; Reiner & Splaun,2008) appliedtothe Attachment Story Completion Task (ASCT; Bretherton, Ridgeway,& Cassidy, 1990).The results of the instrument revealed that the two children with RAD (inhibited and disinhibitedtype) hadloweredscoresfor Supportive Motherandatendencyfor Avoidant Attachment Behaviourand Communication. The notions of mentalization and attachment representations wereshownto provide a more profound understanding ofthe motherand child dyad. These evaluation methods support considering a larger study to explore the link betweenthe mother’scapacityto mentalizeandthechild’sattachmentrepresentationsin children diagnosed with RAD.
Key words: Reactive Attachment Disorder, mentalization, maternal reflective function, attachment representations, mothers, children, psychoanalytictheory
Sommaire
Les critères diagnostiques dutroubleréactionnel del'attachement(TRA) sont demeurés relativementstablesaucours des dernières décennies. Toutefois,lacinquième version du Manuel diagnostique et statistique destroubles mentaux (DSM-5; American Psychiatric Association; APA, 2013) propose un seul type de TRA, qui correspond au type inhibé de la quatrième version révisée (DSM-IV-TR; APA, 2000), aulieu de distinguer entre deuxtypes, soitinhibé et désinhibé. Diagnostiqué dansla petite enfance,le TRA interfère avecla capacité de l'enfant à former des relations sécurisantes avec ses principales figures d'attachement qui demeure un des critères diagnostiques et unfacteur derisque pourle développement du TRA. Bien quel’abus physique etla négligence extrême soient plus facilesàidentifier,la négligenceau planaffectifest plussubtileet difficileàcomprendre. Peu de recherches portent surlesinteractions subtiles entreles mères et les enfants ayant reçu un diagnostic de TRA. La notion de mentalisationexplorelescomplications qui peuvent survenir dans la relation aux principales figures d’attachement et dans les interactions sociales dans uncontexte d’abuset de négligence(Bateman & Fonagy 2004). Pourêtreen mesure decomprendrece qu’il vit,l'enfant nécessite desfigures d’attachementsensibleset capables de mentaliser. Dans le premier article, les théories relatives aux notions de mentalisation et des relations d’objet sont utilisées pour comprendrele fonctionnement psychologique des enfants etla relation qu’ils entretiennent avecleurs mères chez desjeunes présentant un diagnostic de TRA. Danslesecond article, deux études de cas de dyades mère-enfant ou l’enfant a reçu un diagnostique de RAD sont présentés. Les études de cas avaient pour objectif d’illustrer queles notions de mentalisationet dereprésentation d’attachement
ainsi que lesinstrumentspermettant deles mesurer pourraient être utilisé pour approfondir ce qui passe entrela mère etl’enfantaux plans psychologique et relationnel. Lacapacité de mentalisation des mères participant à l’étude a été mesurée à l’aide de l'Échelle du fonctionnement réflexif (Addendumto Reflective Functioning Scoring Manual; Fonagy et al., 1998) appliquée à l’Entrevue sur le développement du parent (Parent Development Interview-Revised; PDI-R; Sladeetal., 2005). Lesrésultats delacapacité de mentalisation des mères se situent dans les catégories faible ou questionnable. Les représentations d'attachement desenfants ontétéévaluéesen utilisantle Système decotationcentrésur l’attachement (Attachment Focused Coding System. (AFCS; Reiner & Splaun, 2008) appliqué aux Histoires d’attachement à compléter (Attachment Story Completion Task, ASCT; Bretherton, Ridgeway, & Cassidy, 1990). Les enfants participant à l’étude, ayant respectivement un TRA de type inhibé et désinhibé, ont obtenus des scores faibles dans les échelles Mère soutenante et Évitement des comportements et des communications relatifs à l’attachement.Lathéorie etla recherche concernantla notion de mentalisation permettent de mieuxcomprendreles difficultésrencontréeschezles dyades mère-enfant dontlesjeunes présentent un diagnostic de TRA. Les notions de mentalisation et de représentations d’attachement ont permis d’approfondir la compréhension des dyades mère-enfant. Les méthodes d’évaluation utilisées dansla présente étude pourraient être utilisés pour explorerle lienentrelacapacité de mentalisation dela mèreetlesreprésentations d'attachement de l'enfant au sein d’un échantillon pluslarge d’enfants présentant un diagnostic de TRA.
Mots clés : Troubles réactionnel d’attachement, mentalisation, fonction réflexive maternelle, représentations d’attachement, mères, enfants,théorie psychanalytique
Table of contents
Abstract………..………ii
Sommaire………..iv
Acknowledgments………..viii Introduction…....………1
First Article: Mentalization and attachment representations: Atheoretical contributiontothe understanding of Reactive Attachment Disorder………..…...12
Introductiontothe second article……….…………....40
Second article: Understanding maternal mentalizing capacity and attachment representations of children with Reactive Attachment Disorder: Two case illustrations………...………...….45
Conclusion………..……..80
References………..…..85
Appendices………...………....…90
Appendix A: Example of one story fromthe Histoires d’attachement a completer..…..91
Appendix B: Examples of questions from theParent Development Interview-Revised (Version française)………...96
Acknowledgements
I wouldliketothank myfamilyfortheir encouragement and beliefthatI could completesuch an endeavour.I am very gratefultowards my dissertationsupervisor, Dr. Miguel M. Terradas, who guided me with his great knowledgeand kindness.Isincerely appreciate his confidence to allow me to contribute to this most important research project, which I consider a privilege to be a part of. Dr. Terradas enabled me to have liberty in my writing, but atthesametime provided me withthestructure and guidance necessaryto complete my work. I would also like to extend my great appreciation to my sister Katherine andfriend Lianefor proof reading myarticles.Iamthankfultowards my dearfriendand colleague Teresa who encouraged me stronglyto enterthe program and for our exchangesin psychoanalytictheory overthe years.I appreciatethesupportreceivedfrom Sabine and Marc, as we all worked through this challenging process of writing our dissertations. I want to also extend my appreciations to friends and colleagues for their questions over the years and constantinterestin my studies. I am especially grateful tomy teachers and supervisorsin the psychoanalytic seminar psychotherapy program for children and adolescents, which providedastrongfoundationin psychoanalytictheorythatenabled meto write myfirst article. Finally, my sincere gratitude towardsthe mothers and children who participatedinthe research project.
The diagnostic criteria of RAD,that wereinitiallyincluded inthethird version ofthe Diagnosticand Statistical Manual of Mental Disorders(DSM-III, American Psychological Association; APA, 1980), were based on the scientific literature of children who were deprived and institutionalized (Richters & Volkmar, 1994). Zeanah and Emde (1994) proposed the prevalence rate of RAD to be 1 % of the general population. According to the APA(DSM, fourthedition, textrevision;DSMIV–TR, 2000), RAD encompassesan early onset of abnormal social relating with maladaptive behaviours such as excessiveinhibition or ambivalence, and is linkedto pathogenic care. The DSM-IV-TR(APA, 2000), describes children with RAD as having primarily a disturbanceinsocialrelatedness. The onset is requiredto be withinthefirstfive years oflife. There wasconsideredto betwotypes of RAD:inhibited and disinhibited. Children who were classified as having aninhibited type are typically hyper-vigilant orambivalent intheirinteractions. Children who presented witha disinhibited type mayshow diffused attachments or excessivefamiliarity withstrangers. Accordingtothe DSM-IV-TR(2000),the diagnosisrequired evidence of pathogeniccare demonstrated in one of the following areas: a disregard for the child’s emotional or physical needs or repeated changesin caregivers.
The diagnosticcriterioninthe DSM-5 (APA, 2013) hasintroducedsomechanges. RAD children in this newer definition are emotionally withdrawn from adult caregivers and seldom seek and respondto comfort when experiencing distress. These children present with two or more ofthefollowing criteria: minimalsocial and emotional responseto others, limited positiveaffect,episodes of unexplainedirritability,and sadness orfearthat occurs
even when they are with adult caregivers who are non-threatening. The criteria for pathological care has remainedinthe DSM-5, butthere has been some changes regardingthe twotypesand most symptoms appear toresemble the previousinhibitedtype.Those children, who manifestthe symptomsthat were mainly associated withthe disinhibitedtype, are given a different diagnosis in the DSM-5, unrelated to RAD and named Disinhibited Social Engagement Disorder (DSED). The new diagnosis of RAD providessome detailedcriteria that may assist in facilitating the diagnosis. However, it overlooks the previous disinhibited type who may also have difficultiesin attachment. The new classification of DSEDlimitsthe problems of the child as being behavioural and does not include the emotional and attachment difficultiesintheir socialinteractions. This might have some major repercussions onthe diagnosisandtreatment ofchildren who were once diagnosed withthe disinhibited type.
There has been extensiveresearch on attachment disorders and patterns, butless research on RAD, theactualclinical disorder proposed bythe DSM. Attachment patterns have been researched overthelast fifty years beginning with Bowlby and followed by others such as Ainsworth, Main, and Solomon. Ainsworth, Blehar, Waters, and Wall (1978) developed theprocedure calledthe StrangeSituation where a mother andinfant are separated and then reunited in order to understand different types of attachment. Much of the research on attachment classifications used a normal population and focused primarily on attachment behaviours intheinteractions between mother and child.
There are very few studies that assess the attachment patterns in children with attachment disorders. The study by Boriset al. (2004) examined attachment classificationsin children atriskfor having an attachment disorder. The sample was comprised of non-institutionalized children under the age of four and the method used to evaluate their attachment patterns wasthe StrangeSituation. It revealedthatchildren who were classified as secure were less likely to have an attachment disorder. However, a disorganized pattern did notindicate a greaterlikelihood of having an attachment disorder. A meta-analysis completed by Van Ijzendoorn, Schuengal and Bakermans-Kranenburg (1999) explored the frequency of disorganized attachment in clinical and non-clinical populations. The results show that 48 % of maltreated children had either disorganized attachment or attachment behavioursthat were insecure. Thisindicatesthat afairly high number of maltreated children are displaying difficulties with attachment, which can range frominsecureto disorganized.
There has only morerecently begun to be aninterestinthe clinical disorders of attachment(Zeanahetal., 2004). Zeanahand Smyke (2008) emphasize mostly behavioural componentsand they recommendthatclinicalinterviewsfocus onthechild’sattachment behavioursas wellasthe parent-child interactions. The majority ofresearch onattachment disordersisfocused onchildren who have been deprived andinstitutionalized. However, Minnis, Marwick, Arthur, and McLaughlin (2006) highlight theimportance ofalso including non-institutionalized children in the studies. They encourage using an inter-subjective frameworktofacilitatethe understanding ofthe development of RAD.Inter-subjectivity
considersthe development oftheinfant to befosteredthrough variousresponses ofthe caregivers relatedto feelings,thoughts,intentions, and actions (Minnis et al., 2006).
Minnis et al. (2006) emphasize that amongst children living in foster care the incidence of mental health problemsis 45 % withalikelihood of many ofthesechildren having RAD. There are complications regarding the discernment of symptoms of RAD and other diagnosis such as depression and conduct disorder (Haugaard & Hazen, 2004). Byrne (2003) makesreferenceto thelack of clear guidelines for evaluatingthesechildren. The methods ofassessmentand the comprehension of RAD are notconclusive oragreed upon amongst professionals (O’Connor & Zeanah, 2003). These reasons lead to the necessity in researching RADin regardsto further comprehension ofthis complex disorder and proposing valid evaluation methods for clinical diagnosis andtreatment.
There has beenevenlessresearch onattachmentrepresentations of older children with attachment disorders, which differsfromthe attachment patterns that are primarily measured by examiningthe behaviours of younger children. Bowlby (1973)introducedthe concept of internal working models (IWM) orrepresentations ofthe self and other that develop throughearlyinteractions withtheattachmentfigures. Attachmentrepresentations provide an understanding of the child’s internal mental processes through thoughts, affects, and mentalrepresentations ofthecaregiver. The mentalrepresentations ofselfand others constituteschemasthatarereferredto when neededtointerpretsocialsituations(Green, Stanley, & Peters, 2007). Mental representations have been studied and utilized extensively
in psychoanalytic, cognitive, social, and developmental psychology (Blatt, Auerbach, & Smith Behrends, 2008).
Minnis and her colleagues (2009) examined attachment representations through narratives of early school age children with RAD in comparisontochildren fromthe general population. They proposed that further research should examine the child’s attachment representations in orderto provideinsightintothesocialandcognitive processing ofthese children. Narratives of attachment were shownto be usefulinfindingclinicalinformation about children who had an externalized disorder andtheir mothers. Green et al. (2007) examined the attachment representations ina sample of high-risk children aged four to nine usingthe Manchester Story Completion Task (MCAST; Green, Stanley, Smith, and Goldwyn 2000), a research protocolinspired fromthe ASCT (Bretherton, Ridgeway,& Cassidy, 1990) narrative assessment. These children were not diagnosed with RAD but they were high-risk children, a factor associated with the development of RAD in the early years. The mother’s were assessedfortheirlevel of atypical parental expressed emotion(EE) and depressed mood. Theterm(EE)expressedemotiontakenfromthestudy of Vaughn and Leff (1976), consists of behaviours and emotionsininterpersonal relationships such as hostility, criticism, andemotional over involvement (ascitedin Green etal. 2007). Mothers who have high expressed emotion(HEE) arefoundto be more hostileand criticaltowardstheirchildren. Theytendto express more anger, haveinappropriate expectations oftheir children as well as intrusive and confrontational behaviours.Disorganized attachmentwas found in 58 % ofthe
cases and very high expressed emotion(HEE)in mothers was associated with moresevere disorganized attachment representations in children.This study points out the importance of looking attheinfluence of maternal care onthe child’s development of attachment.
Studies haveshown maternalinsensitive behaviourto berelatedtoinsecurityin the child’s attachmentrelationships(Cyr, Euser, Bakermans-Kranenburg, & VanIjzendoorn, 2010). There continuesto be a need for further exploration of what factors are involvedinthe type of psychological care children diagnosed with RAD receive that causes such a breakdown in their attachment system and leads to behaviours and emotions that are dysfunctionalin facilitating relations with others.
Mentalizationtheory andresearch provides aninteresting frameworkto applyto children with RADin orderto understandthe essential nature of early relationships and how thisinfluences the child’s mental health and attachment representations. The notion of mentalizationis also usedto comprehend the complicationsthat arisein attachment and relationships that are aggravated by neglect, abuse, and trauma (Bateman & Fonagy, 2004). The concept of mentalizationreferstothe mental processes whichtake place when an individualinterpretstheactions of selfand otherseitherimplicitly (inan unconsciousand spontaneous manner, expressedthrough gestures and behaviours) or explicitly (in a conscious andintentional manner,expressedthrough words), based on meaning of intentional mental states(Allen, 2006). These mentalstatesincludeaffects,thoughts, desires,andintentions. Theinfant relies onthe sensitive attunement ofthe primary caregiver who typicallyhelps the
child to understand what he or she is experiencing. The mother needs to reflect back to the infant his mental states in order for him to understand his own and others’ mental states, as this will assisttheinfantin developingthe ability to mentalize (Fonagy, Gergely,Jurist, & Target,2004).
The capacityto mentalize has been operationalizedforresearch purposes usingthe term reflective function (RF;Fonagy, Steele, Steele, & Target, 1998). The parental reflective function (PRF) is a measure of the caregiver’s capacity to reflect on the current mental state of the self and the child (Slade, 2005). Research has linked the mothers’ reflective function (MRF) totheir own attachmentrepresentations andthe attachment classification oftheir children. Fonagy, Steele, Steele, Moran, and Higgit (1991) revealed that the mother’s attachment representations of her own past relationships predicts the attachment classification of her future infants. Slade,Greinenburger, Bernach, Levy, andLocker (2005) demonstrated that there is a link between the PRF, the quality of the mother-child attachment relationship as well asthe status of theinfant’s attachment. The authors consider thePRF as aninfluential factor fortheintergenerationaltransmission of attachment.
The Psychodynamic Diagnostic Manual (PDM Task Force, 2006) refers to the possibility of more subtle aspects of the parent-child relationship as a possible factor for the development of RAD. The challengesrelatedto potential misdiagnosis,andthe needfor developingevaluation procedures and treatment for RAD children have been pointed out by severalresearchers(e.g., Byrne 2003; Haugaard & Hazan 2004; Minnisetal., 2006). The
theory of mentalization may provide clinicians with a more profound comprehension of the early psychological experiences ofthese children andtheimpact it has on their future relationships.
Thefollowing dissertationiscomprised oftwoarticlesrelatedtothesubject ofthe mother’s capacityto mentalizein children with Reactive Attachment Disorder (RAD) andthe attachment representations ofthese children. The first article provides a critical review ofthe scientificliterature and atheoretical elaboration onthe understanding of RADthrough psychoanalytic and mentalization theory. The second article explores the possible link between the mother’s capacity to mentalize and the child’s attachment representations using two clinical cases. The results of the Parent Development Interview-Revised (PDI-R; Slade, Aber, Berger, Bresgi, & Kaplan,2005) and the Attachment Focused Coding System (AFCS; Reiner & Splaun, 2008) wereanalyzed usingtwocasestudies of motherandchild dyad, throughthe perspective of mentalizationtheory. Botharticlesalso discussedsome ofthe complications involved in the evolving of the definition and diagnosis of RAD. The articles reflect on the importance of understanding and exploring further the underlying psychologicalinfluences ofthisdisorder regardingthe parent andthe child.
Thefirstarticlereviewssome ofthescientificandtheoreticalliteraturerelatedto RAD. The article proposes atheoretical understanding of RADthrough previous and current psychoanalytic theorists who studied and observed early relationships between mothers and theirinfants. More precisely,it reflects on the use of objectrelationstheorists such as
Winnicott and Fairbairn who emphasizedtheimportance ofthe mother’s earlyinteractionsin the psychological development oftheinfant and hisfuture personality. Objectrelations theory waschosento providea more profound understandingthatcould helpthe clinician considertheinternal world ofachild with RAD. The theory of mentalization continuesto developthisline ofthinking,in particularinregardstotheinfantand primarycaregiver throughresearch. Therefore,thesetheories were also used to comprehend what may be transpiring psychologically in the relationship between mother and children with RAD. The article was publishedin 2014in The Bulletin ofthe Menninger Clinic, a peer-reviewed journalthatis knownto havethe principalresearchersinthefield of mentalization. The following providesthe reference forthe article:
Mikic, N., & Terradas, M. M.(2014). Mentalization and attachmentrepresentations: A theoretical contribution to the understanding of Reactive Attachment Disorder. Bulletin ofthe Menninger Clinic, 78(1), 34-56. doi:10.1521/bumc.2014.78.1.34
The second article applies the theory of mentalization to two case studies in order to contribute a more profound understanding oftherelationship between motherandchildin two children diagnosed with RAD. The theory of mentalization finds its parentage in those early psychoanalysts who explored the relationships between mother and infant. Mentalizationtheory was chosento comprehend and elaborate on the attachment relationship between the dyad, because it could also be measured through the use of an instrument. The articlealsoreflects ontherelevancy ofconsideringtwo validatedinstrumentsthatcan be
used as an evaluation method for these children and their mothers. The unit of analysis was the mother child dyad.The mother’s capacity to mentalize was measured by the Addendum to Reflective Functioning Scoring Manual(Fonagy et al., 1998)for use withthe Parent Development Interview-Revised (PDI-R; Slade et al., 2005).The French version of the PDI-R, translated by Ensinkand le groupe de recherche sur l’abus sexuel de l’Université Laval (2002), through the translation/back translation method (Behling & Law, 2000), was used. Theattachmentrepresentations ofthechildren wereevaluated using the AFCS (Reiner & Splaun, 2008)appliedtothe ASCT (Bretherton etal., 1990). The French version ofthe stories (Bisaillon, Achim, Mikic, & Terradas, 2012) and theAFCS manual (Achim, Bisaillon, & Terradas, 2012) were translatedusing the method of translation/back translation(Behling & Law, 2000). The scores and verbal data provide some interesting insights regarding what might be occurring between mother and child andthe psychological aspects ofthese children with RADregardingtheirattachmentfigures. Theresultsalso pointedtotherelevancy of future researchinthis area regarding any possible correlations betweenthe mother’s capacity to mentalizeandtheattachmentrepresentations ofchildren with RAD. Thesecondarticle was submitted for consideration on May 18th, 2015, to the journal Psychoanalytic Psychology. The followingisthe reference ofthe second article:
Mikic, N., & Terradas, M. M. (soumis). Understanding Maternal Mentalizing Capacity and Attachment Representations of Children with Reactive Attachment Disorder: Two Case Illustrations. Psychoanalytic Psychology.
First Article
Mentalization and attachment representations: Atheoretical contributiontothe understanding of Reactive Attachment Disorder
Mentalization and attachment representations: Atheoretical contributiontothe understanding of Reactive Attachment Disorder
Natalie Mikic and Miguel M. Terradas
Author Note
Natalie Mikic, MA, psychologist, Montreal, Quebec, Canada. Miguel M. Terradas, PhD, Professor and psychologist, Department of Psychology, Université de Sherbrooke-Campus de Longueuil, Quebec, Canada.
Copyright © 2014 The Menninger Foundation Natalie Mikic and Miguel M. Terradas (2014). Mentalization and attachment
representations: Atheoretical contributiontothe understanding of reactive attachment disorder. Bulletin ofthe Menninger Clinic: Vol. 78, No. 1, pp. 34-56. (Copyright © 2014 The Menninger Foundation)
Abstract
This article proposes an understanding of Reactive Attachment Disorder (RAD) through psychoanalytic thought and mentalization. RAD is presented followed by a discussion on attachment andthe need for a better understanding ofthis disorder. Theories from British psychoanalytic thinkers are used to describe what might be transpiring in the early relationship between motherandchildinthesechildren. Particularattentionis placed on howtheirinternal objects areinfluenced by a compromised early mother-child relationship.
Keywords: Reactive Attachment Disorder, object relations, mentalization, attachment representations.
British psychoanalysts such as Fairbairn, Winnicott, Bowlby, and Fonagy have addressed the crucial component of the early primary relationship in the development of the self, relations to others,and mental health. Thesetheories helptoillustratetheearlyemotionalandcognitive development of the individual and what elements increase the risks of psychopathology. In this article, certain psychoanalytic concepts are used to elucidate the processes and challenges in the early mother-child relationshipthat can be appliedto children with Reactive Attachment Disorder (RAD). An emphasis is placed on understanding the psychological influence of this early relationship on the inner world of children with RAD. What is the impact for the child who had notreceivedthe necessaryearlycare duringinfancytoallow himtoformsecurerelationsand attachment representations?
Thetheory of mentalizationis usedto conceptualize what might be psychologically challengingforthe mothers ofchildren presentingthis disorder makingit difficultforthemto meet the needs of their children. How does maternal care or its absence influence the formation of mental representations in children with RAD? Mentalization theory, which combines developmental research and psychoanalysis withthe notion of attachment, has significantly contributedto understandingthe development oftheselfinrelationto others. Thistheoryand some ofthe concepts of Winnicott and Fairbairn are usedtoillustrate how animpoverished early relationship influences the development of RAD in regards to sense of identity, symptom formation, andinternalized objects.
Reactive Attachment Disorder: An Overview
The diagnosticcriteria of RAD firstappearedin thethirdedition ofthe Diagnosticand Statistical Manual of Mental Disorders (DSM-III; American Psychiatric Association; APA, 1980) and were positioned on the scientific literature of children who were deprived and institutionalized (Richters &Volkmar, 1994). Richters and Volkmar stressedthat “maltreatment”
was one of the defining factors of RAD and could also be considered another way to name the disorder. The prevalencerate proposed by Zeanahand Emde in 1994 was 1 % ofthe general population (Richters & Volkmar, 1994). More recently, Minnis, Marwick, Arthur, and McLaughlin (2006) emphasizethat amongst childrenlivingin foster caretheincidence of mental health problemsis 45 % with alikelihood of many ofthese children having RAD.
The diagnosis of RAD inthe Diagnostic and Statistical Manualof Mental Disorder, fourth edition, Revised(DSM-IV-TR; APA, 2000) requiresevidence of pathogeniccare demonstrated in one ofthe followingareas: a disregard forthe child’s emotional or physical needs or repeated changesincaregivers. The DSM-IV-TR(APA, 2000) describeschildren with RADas having primarily a disturbance in social relatedness with an early onset of abnormal social relating with maladaptive behaviours such as excessiveinhibition or ambivalence. It requiresthat the onset be withinthefirstfive years oflife. There aretwotypes of RADaccordingtothe DSM-IV-TR (APA, 2000). Children who are classified as having an inhibited type may be hyper-vigilant or ambivalent in their interactions; where as those who present with a disinhibited type may show diffused attachments or excessive familiarity with strangers.
Therecently publishedfifthedition ofthe DSM(DSM-5; APA, 2013) proposessome changesin relationto RAD. This most current diagnosisis reserved for children who demonstrate the criteria ofthe previously namedinhibitedtype: a consistent pattern of emotionally withdrawn behaviourtoward adult caregivers, manifested by children who rarely seek and respondto comfort when distressed. These children present with a persistent social and emotional disturbance characterized by minimal response to others, limited positive affect, and episodes of unexplained irritability, sadness, or fear, that are evident even when they interact with nonthreatening adult caregivers. The DSM-5 (APA, 2013) proposes an alternative diagnosis for children who manifest the symptoms that were mainly associated with the disinhibitedtype, and
introduces the name Disinhibited Social Engagement Disorder (DSED). These children consistently and actively approach and interact with unfamiliar adults and exhibit at least two of thefollowingcharacteristics:reduced orabsentreticenceinapproachingandinteracting with strangers, overly verbal and physical behaviour with unfamiliar adults, diminished or absent checking back with adult caregivers after venturing away in familiar or unfamiliar settings, and willingnessto go off with strangers with minimal or no hesitation. Asinthe DSM-IV-TR (APA, 2000), both psychopathological entities arelinkedto extreme orinsufficient care as evidenced by atleast one ofthefollowing conditions: social neglect or deprivation,repeated changes of primarycaregiversthatrestrict opportunitiesto developstableattachments,and growing upin unusual settings which also severelylimit opportunitiesto form selective attachments. The diagnostic criteria of both psychopathologies, RAD and DSED, are now classified inthe DSM-5 (APA, 2013) as Trauma and Stressor-Related Disorders. Giventhatthe DSM-5 has only recently been published,itistoo earlyto knowto what extentthese changes will facilitatethe diagnosis of children presenting with characteristics associated with RAD.
Haugard and Hazen (2004) listed additional detailed behaviours for each of the different types. Fortheinhibitedtypesome ofthefollowing were described:thechild withdrawsfrom others and does not seek others when heisin physical or psychological pain. He might engagein self-soothing behaviours, has discomfortin socialinteractions, may be aggressivetowards peers, and hides feelings of anger or distress. The disinhibitedtype may act childish, beinappropriately affectionate with others,express distress orseekassistancefor noreason. Thesechildrenare known as having destructive behaviours and poorimpulse control (Hanson & Spratt, 2000). Kay Hall and Geher (2003) foundthatthese children were poorerin empathythan non-RAD children, butscored high onself-monitoring, whichis definedastheabilitytochangetheir behaviour based on “their own desire” (p. 150).
The Psychodynamic Diagnostic Manual (PDM Task Force; Alliance of Psychoanalytic Organizations, 2006) providesa broader definition of RAD andthesymptomsare viewed ona continuum. RADisto be found underthe infancy and early childhood section andthe symptoms range and differfrom being withdrawn and despondent, to overt aggression. There are also consideredto be varying degrees ofcapacitytosustainrelationshipsandemotional depth. The interactions between parent and child can beinfluenced bythe caregiver’s past and current relationships,and beinfused with experiences of anxiety,ambivalence,and despair. Pathological careis not necessarilyarequirement, whichsuggeststhatthereare otherinfluencesapartfrom overt abuse and neglect. The PDM Task Force also describes categories of mental functioningin children amongst which is found the capacitytoforminternal representations, thus referring to the ability to elaborate and maintain generally healthy representations of others. It also refers to the use of the capacity for differentiation and integration as a measure of psychological functioning. Anexample of differentiation would betheabilityto distinguishemotionsfrom belongingtotheself orto others. Children with RAD would be hypothesizedto have poorer mental representations and anincapacity for differentiation duetotheir often early-impoverished relationships.
Attachment Theory and RAD: The Need for Further Theoretical Understanding John Bowlby dedicated his worktoextensivelyexplore theattachment bond between mother and child. Bowlby (1969) proposed that attachment comprises both instinctual behaviour and psychological need. Attachment occurs throughaninnate structurethat bondsthe babytothe motherforthe purposes of survival. Bowlby(1973) emphasizedtheimportance of external reality and that the attachment bond between mother and child had an influence on mental and emotional development. According to Bowlby (1973), the development of healthy attachment is importantfor mental health. Bowlby(1973)introducedtheconcepts oflossandseparationas
well asthe reactions of protest and despairin children, caused by a separation fromtheir parents. He viewedtheconsequences ofloss,separation,andabandonmentas havinganimpact onthe development ofthe personality.
Bowlby (1973) held that individuals create internal working models or representations of the self and others through early interactions with the attachment figures. Hodges, Steele, Kaniuk, Hillman, andAsquith (2009) define mental representations throughthe work of Bowlby and Sternasfollows: “Frominfancy onward,thechild mentally organizesrealityexperience, constructing generalizedrepresentations ofexpectableinteractions ofselfand other”(p. 203). Earlyattachmentisessentialforthe development of mentalrepresentationsthatare helpfulin understandingtheintentions of others (Bleiberg, 2004).Inconsideringchildren with RAD,it would be helpful totryto understand whatis guidingthem mentallytowards actionsthatleadto inhibited or disinhibited type behaviours in relation to others. What are the mental representations,theimages,thoughts,andemotions,lying behindthe behavioursand how did they arise?
Ainsworth, Blehar, Waters,and Wall (1978) developed the now well-studied procedure calledthe Strange Situation wherea motherandinfantareseparatedandthenreunited. The StrangeSituation measuresthe attachment behaviour ofthe childuponthe mother’s return. There are four attachment classifications that have been developed from these observational experiments: securely attached, anxiously attached avoidant, anxiously attached ambivalent/resistant,and disorganized/disoriented (Main & Soloman, 1990).
Theseclassifications have been usefulfor understanding behaviouralaspectsrelatedto attachment. The relationship betweenthe attachment classifications and RAD has not been established,asthere has not yet beenaconclusivestudyconcerningtheattachment patterns observedin children with RAD. Zeanah and Smyke (2008) emphasize mostly behavioural
components and recommend that clinical interviews for children with RAD focus on the child’s attachment behaviours as well as the parent-child interactions. Hall and Geher (2007) created a RAD Scale, which wascomprised ofanexhaustivelist of behavioursthat RADchildren may have. These authors arguethatit was most relevantto focus on behaviours giventhisis whattheir caretakers have the most difficulty with. However,sucha proposition neglectstoconsiderthe children themselves and how they suffer by living with a disorder that is a hindrance to connecting with others, afundamental humantrait whichis essentialfor psychological well being.
There remains a needto further comprehendthe underlying causes of RAD andthe degree of pathogeniccarerelatedtoit has not yet beenclearly understood(Haugard & Hazen, 2004). Minnis and her colleagues(2009) proposethatfurtherresearch on RADshouldinclude the child’s attachment representations in orderto provideinsightintothe social and cognitive processes of these children. There are still unanswered questions regarding the social difficulties ofthesechildreninrelationtotheirrepresentations. Wealso knowthatinchildren with RAD, one ofthe majorcriteriaisabuseand neglect.Itisthereforerelevantto understand howthis potential abuse arisesintheir caretakers and whatthe psychological deficits experienced bythese children are. Thetheory of objectrelationsandlater mentalization will be usedtoexploreand understand some ofthe psychological aspects of children with RAD andtheir mothers.
Using Object Relations Theory to Understand Children with RAD
Object Relations theory provides an interesting perspective regarding the subjective experiences ofinfant and mother. It also contributesto an understanding ofthe wayin whichthe pastinfluencesthe presentin boththe relationship between mother and child, as well as howthe child becomesinfluenced bytheir own past experiences relatedtothe early relationships. Object Relationstheory has been described by Ogden (1983) as “atheory of unconsciousinternal object
relationsin dynamicinterplay with currentinterpersonal experience”(p. 88). Winnicott and Fairbairn, both Object Relationstheorists,alsoconsideredtheactualexperiences oftheearly mother-child relationship anditsinfluence onthe mental health oftheindividual.
RAD children may develop a cognitive and emotional way of being that is highly influenced by the mental states of mother and her ability to see the child as an individual being with separatethoughts and feelings. Presently, we knowthatitisinthe first years oflifethatthe brainis growing and developing rapidly, creating links at a greater ratethan in any other period. Accordingto Schore (2003),theinternal working models are formed duringthe earlier part ofthe preverbal period, andthese representationsinfluencetheindividuals approachto regulating affect throughoutthelifespan. Winnicott and Fairbairn emphasizedtheimportance of mother and early interactionsinthe psychological development oftheinfantand hisfuture personality, which makestheirtheories especially usefulin considering children with RAD. Some ofthe concepts of these psychoanalytic authors will also be used to provide a comprehension for the development of mental representations and howthey might differ for children with RAD.
Winnicott’s Concepts on Maternal Care Applied to Children with RAD
Winnicott’stheoretical orientations were based virtually solely onthe early mother-infant relationship. Infants are naturally completely dependent ontheir mothers, referredto as “absolute dependence” wherethe environmentis of utmostimportance(Winnicott, 1968/2002, p. 72). Winnicott (1945) theorizedthatthe emotional development ofthe baby beginsimmediately after birth; what he referred to as primitive emotional development. The personality begins in a state thatis unintegrated. Sensory experiences of sounds, sights,taste, and smell, which are most often relatedto mother, are described as beingin bits and pieces. Theinfant needsto have experiences given bythe motherin orderto feel they exist. The basiclevel of experienceisthe physical need of being welltakencare of,suchasrockingthe baby,asoothing voice, namingthings,and
holding the baby (Winnicott, 1963). The actual ‘holding’ of all these experiences, both psychological and physical, is what helps to develop symbolic functioning and the organization oftheselfandrelationships. Thelack ofexperiences of holdingcouldleadtotheseimportant functions being compromised.
Initially,thereisanexperience ofcomprehendingthe world, whicharisesin parts. The infant slowlylearns andintegrates different aspects oftheir environment. Itis possibletoimagine that if the baby does not get the safe aspects of holding, soothing voices, and naming of things thenallthe bitsand piecesareexperiencedaschaoticandtherefore havetrouble being made sense of and integrated properly. It could be questioned that some children with RAD were not receiving,evenfromthe beginning,the veryfundamentalsto helpthemto makesense ofthe world andtheir environment. The worldinits veryinfantile stagesis experienced as chaotic, and forsomechildren with RAD, what mayensueisan unpredictablefeelingrelatedto others.In particular,the RADchildren who hadexperienced veryearly neglect duetotheincapacity of their primary caregiverto attendtotheir needs. This mightinfluencetheir abilityto rely ontheir mentalrepresentations when needed attimes, asthey may be poorlyformed or not easily accessible, especially whenthere was an absence of mother. Asthese children were not helpedin havingthe parts made whole by mother,this could also explain disorganizedstates, hyper-vigilance, and ambivalenceintheirinteractions.
Accordingto Winnicott’s observations (1945), infants at approximately five or six months reveal actions with more of a purpose that denote a possible understanding that objects have an insideandan outside. Hereisthe beginning ofthecomprehension ofthe other. Gradually,the baby begins to learn that the other, that is typically mother, also has an inside, and he becomes curiousaboutthisinsideandthe moods of mother. The next phaseinvolvesintegration;the experience of having all the parts together, creating an integrated meaning as the baby feels as a
whole unitand developsasense ofselfand other. This willeventuallyleadtothe necessary developmental phases of separation from mother and realization of ‘not me’, which help in the capacityto form object relations (Winnicott, 1963).
Children with RAD may not havethe supportthey needinthe earlyrelationshipto developthis phase. Thisimportant experienceinvolvesthe sense of being known. Itisthe mother who needsto knowandfeelthe baby,sothatthe babycan havethefeeling of beingfelt by another as having his own existence. Children with RAD may struggle with being ableto understandthe complexityinvolvedin self and other differentiation. They seemto have difficulty in understanding others, considering their needs or empathizing (Kay Hall & Geher, 2003). It is sociallychallengingtointeract withanother whenachild does notseethe otherasa beingin their ownright, butrather an extension oftheself.It could be hypothesized that withthis awareness of separateness (or‘not me’) beginsthe experiencing oftheformation of object relations:theinternal representations ofthe self and other.
Children withthe disinhibitedtype of RAD have difficulties with boundaries;theyare sometimes experienced by others as beinginvasive. They also have difficulty distinguishingtheir own desireto have arelationship andthe desire ofthe other. Sadly,these children cannot differentiate others to the extent that even strangers can provide a false sense of closeness. The inhibitedtype onthe other hand, may have difficultiesestablishingarelationship with others. They may have a fear of proximitytothe other, which might create feelings of engulfment, and a needtoseparatefrom othersin orderto beabletofully differentiate. Thesechildren do not typically experience a consistent nurturing motherto helpthe baby feel felt and known, andthus safe enoughto createlovinginternal representations and a clear sense of self andidentity.
Inthe veryearlystages of mothering, Winnicott (1956) referredtoaconditioncalled primary maternal preoccupation. It is a highly intuitive state that exists prior to delivery and in
the first few weeks ofthe baby’slife. This stateinvolves deep empathy:imagining herselfinthe baby’s place. It alsoinvolves being ableto sensethe baby’s needs, which facilitates, accordingto Winnicott,afeeling of oneness between motherandinfant. This oneness may beequivalentto the attachment bond.
Winnicott(1968)explainedthatthe mother willinevitablyfailinansweringthe baby’s needs at alltimes, but what mattersisthe abilityto repairthese failures, whichis known as good enough mothering. Theseexperiences offailuresturnedintosuccess helpthe babyfeelsecure where asthe experience of deprivation results from very few opportunities of experiencing repair (Winnicott, 1968).Itisimportanttoconsiderthat oftentimesthose mothersthatfailare not tryingto deliberately hurt or stunttheinfants development. Mothers have storedsomewheretheir ownexperiences of whatit wasliketo bea babyandto have beencaredforanditisthese experiencesthatinfluencethe process ofcaringfor herchild(Winnicott, 1965). Based onthis premise, we can supposethatthose mothers who have not hadthe care or experiencedtheir own needs met by another, may be more at risk at not being ableto respondtotheir babies needs.
Likewiseinfantsareslowly beginningto developtheir ownexperiencesand memories. These “memory systems” will either help the infant have confidence in the world or not (Winnicott, 1965; p. 6). RADchildren have oftenexperiencedenvironmentalfailureas wellas deprivation dueto abuse and neglect. They may have verylittle confidenceinthe world because theirinternal objects or mentalrepresentationscontain negative material;contentthatisladen with fear, anger, and rejection. When these mental representations are used against new experiencesthe old patterns are feltto repeatthemselvesthus affectingtheir abilityto enterinto a healthy new relationship and expecting oftenthe same patterns of negativity.
Winnicott(1963) viewedeachindividualas possessinga true self thatisencouragedto developthroughasafeenvironmentand goodenough mothering. A mother whoignoresthe
needs ofthe baby andinterpretsit as something of her own, createsimpingements (Ogden, 1983). This may requirethe babyto defenditself againstthese experiences and develop a second aspect of the personality known as the false self, which is able to protect thetrue selffrom annihilation (Winnicott, 1963). The falseself accomplishes differentfunctions. Children with RAD ofthe inhibitedtype, whotendto shareless ofthemselves and withdraw from others, may have created a false self that protects them. They may be afraid to share core aspects of the self with others. The hyper-vigilance and cautious nature manifested by these children could be understood as a fear ofrevealingtheirtruethoughtsandfeelingsto others. Weretheir needsso neglectedthat they assume nobody cares? Children with RAD ofthe disinhibitedtype, althoughthey are usually more expressive, may also be hiding behind a falseidentity. Dothey use aspects oftheir false self as a mask to make superficial connections to others, and thus their real self is protected? These children have difficultyidentifyingtheir own emotional needs and appeartotakeinthe emotions of others withlittle discrimination. Their demands or needs may appear asthose ofthe parentthat were overwhelming, and now they might act out so that others can feel the deprivation that was passed on to them, in the form of projective identification. These experiences of hurt or lack of care from others, surely leads to feelings of abandonment, hopelessness, and mistrust in relationships.
Fairbairn’s Notion of the Rejecting Parent Internalized: The Internal Objects of Children
with RAD
Fairbairn(1941) moved awayfromthelibidotheory of classical psychoanalysis and proposed a theory of development, which relied on the understanding of early object relationships. This psychoanalystregardedindividualsas being motivatedtoseek objects not pleasure;in other words, motivated byrelationships with others(Fairbairn, 1943). Fairbairn introducedthe notion of objecttwofold,referringtotheactual personinrealityas wellasthe
internalized image of the person in the mind (Grotstein & Rinsley, 1994). Grotstein and Rinsley suggestthat for Fairbairn objects were created based on reality with slight modifications based on phantasy relatedtothe external person. The more suffering and neglectthat occurred early on,the more the child needs to rely on internal objects to cope. Object relations were pivotal in shaping the personalityfor Fairbairn.Itisthis view ofinternal objectsthatis espoused here, asit resonates most with providing a comprehension of what children with RAD may experience. The theories developed by Fairbairn aidsin understanding what happens whenthe earlyinterpersonal relationship between mother andinfant falters, and howthis affectsthe developing child’s feelings andinternal objects.
Fairbairn(1941)theorizedthat healthy mature developmentandrelationshipsinvolves initiallyidentification andlater differentiation fromthe object. Identification was associated with infantile dependence andtakingin, while differentiationinvolvedgiving and mature dependence. Thereisa developmentalcontinuum betweeninitiallytakinginthe objecttoa more mature stance of giving to the object. A healthy attachment bond, which includes proper maternal care, allowsforthelearning ofreciprocitythroughexchanges between motherandinfant. Children with RAD haveexceptional difficulties withsocialreciprocity, whichis part ofthe process of differentiation and animportant developmental phase forlearning howto bein relationships. The phase of differentiation may also involve understanding and developing empathy, consideration ofthe other,andthat others havetheir own minds,feelings,andthoughts.Ifthisis notfurther developed,thenthere could be consequencesinlater relationships.
Splitting occursinanearly phase ofinfant development whentheinfantiscompletely dependent onthe object (Fairbairn, 1941). Theterm splitting referstothe structure ofthe psyche being splitintwo or more parts either occurringinthe ego or relatedtotheinternalized object or both (Rycroft, 1968/1995). The split ego creates a part of the self that is less known, where as a
splitting of the object relates to opposite feelings of good and bad towards the object, which are difficulttointegrate. Aninfantthat feels rejected by mother will view the objectas mostly rejecting, with occasionalacceptance (Fairbairn, 1941). Thereisasplitting oftheinternalized object, andthis occursinthe ego oftheinfant as well,to cope withthis splitting. An objectthatis rejecting might be a neglectful or emotionally absent parent or one whoisintrusive or physically abusive, asis frequentlythe case ofthe parents of children with RAD. Itis difficultto viewtheir parents as bad and fearful, because by doing so it would then become arduous and confounding to maintaintherelationship withthemthatis necessaryforsurvival. Therefore,insteadthey introject the object (parent) inside and see it as part of their own self. Sadly, these children will feel they are the ones who are bad and unlovable. They may feel that if they were not this way, their parents would be moreloving. The child may alsoidealizethe object, asthe so-called good object,to allow himto feel better. He can dothis byidentifying withthe object oridealizingitto gain approval.
The theoretical formulation of Fairbairn regarding the development of schizoid personalities provides an interesting conceptualization to use for the early development of RAD. Fairbairn (1941) took an interest in the structure of schizoid personalities, whom he regarded as having a predominately split ego. He conceived the ego as being initially formed by ego-nuclei, different partsthateventuallyintegratealongthechild’s development. Fairbairnsuggestedthat schizoid personalities have more difficulties with this process of integration, which relies on the early relationship to help them in the formation of the ego. They also have difficulty obtaining a maturestage of developmentandareconflicted between wantingto moveawayfrominfantile dependence and allthe while holding ontothis phase. The object feels frustrating yet alluring at the sametime (Fairbairn, 1944).
Fairbairn (1941) emphasizedthat whatis most needed bythe childisto feel genuinelove fromthe parent andthatinturn have hislove be felt as acceptable. The schizoid personality was described as having experiencedinthe early relationshipthattheirloveis felt as a destruction of the object. They have a greater need to internalize the object and hold on to an infantile state of dependence becausetheycannottrustthe objectsinreality. Fairbairn believedthatthe greatest trauma a child can faceinvolvesthe frustration of not havingthe desireto beloved and accepted met. In a study that examined the early recollections of children with RAD, Tobin, Wardi, and Yezzi Sherif (2007) observed that their emotional needs was most frequent for “to be cared for andloved” andthe feelingthat was most attained forit were greatest for “frustrated not met” (p. 4). Fairbairn consideredthat when neither oftheseconditions were metinchildhood,aberrant relationships are formed. This might provide a fundamental explanation for children who struggle intheir relationships with others or cannot form attachmentsto new caregivers.
Thereisa parallel betweentheschizoidtypethat Fairbairnspeaks ofandchildren with RAD who have not developed healthysafeattachment bondsto others, which may partially developthrough a sense of not feeling or beingloved. Therefore,theylearnto not botherto direct theirlovetoexternal objectsand mayrely more ontheirinternal ones. They may physically avoid others and withdraw, as is found in the inhibited type. However, the disinhibited type also withholdsreallove by not differentiating between one personandthe next. Bothreactionsare relatedtoafear oflove orcloseness,and bothtypes mayact outaggressivelyasa means of pushingthelove object further,therefore rejectingthe other before experiencing rejection. Thisis done toavoidthere-traumatization offeelingasthoughtheirloveis notacceptable,the object loss,andattimes,afeeling ofloss oftheego. Thesechildrensimply do notfeelsafeintheir relationshipsleadingto unidentifiable overwhelming feelings as well as acting out.
Fairbairnlearnedfrom his work withchildren who hadsufferedtrauma orexperienced living in chaotic environments, that psychopathology arose through a deficit in the environment (Grotsteinand Rinsley, 1994). Fairbairn(1943) noticedthatthesechildrentendto have bad internalized objects and due to the identification with them in early childhood, they themselves also feel bad and shameful. Itis difficultto distinguishthe bad object outside fromthe bad object inside. Fairbairn observedthatchildren he had worked withfrom homes ofabuseand neglect, rarelyeveradmittedthatthey had bad parents. Thisisa phenomenonthat probably mostchild clinicians have experienced when working with children. The object, mother or father, could be disappointing, butthechildcopes withthis byinternalizingandidentifying with whatis bad, fearful or shameful about the object, which allows him to idealize the real objet. Some children with RAD, perhaps more sointhe disinhibitedtype, may frequently useidealization as a defense. Theyidealizetheir parent despitethe negligenceand maltreatment,asa way of beingableto integrate and fabricate what seemsto be a good object. This may be what helpsthemtryto enter into newrelationships withlittle discriminationintheinitialstages. However,theidealization mayeventuallyturninto disappointmentand devaluation ofthe other, becausethere was never truly a constant good objectthat wasintegrated. The child needs his parents and depends onthem despitethe rejection and painthey cause.
If RAD children areliving withsuch confoundinginternalrepresentations,this could explainsome oftheinteractionsthey have with others. The hyper-vigilanceandambivalence foundin children with RAD might beinfluenced by attachmentrepresentationsthatleadto feeling very cautious about others. Each new relation seems to be marked by mental representationsthatsomething bad might occur. Accordingto Fairbairn(1943),thechild who internalizesrepresentations ofaggressionin others may be morelikelytotakeanaggressive stanceto defendagainst othersconsideredaggressive. Theidentification ofthechild withthe
aggressor might also explain the aggressive behaviour and the acting out frequently observed in RAD. Lastly,the painfulinternalizedrejecting object may holdthe child backfromfeeling confidentin relationships andtrustthatthey will not be abandoned.
Mentalization, Attachment, and the Comprehension of RAD
Theconcept of mentalizationreferstothe mental processes whichtake place when an individualinterpretstheactions of otherseitherimplicitly (inan unconsciousandspontaneous manner, expressed through gestures and behaviours) or explicitly (in a conscious and intentional manner, expressed through words), based on meaning of intentional mental states (Allen, 2006). These mental statesinclude affects,thoughts, desires, beliefs, andintentions. Theinfant relies on thesensitiveattunement ofthe primarycaregiver who typically helps thechildto understand what he or she isexperiencing. The mother needsto reflect backtothe infanthis mental statesin order for him to understandhis own and others’ mental states,asthis will assist theinfantinthe capacityto mentalize (Fonagy, Gergely, Jurist, & Target, 2004).
Fonagy, Steele, Steele, Moran, and Higgit (1991) demonstrated that the mothers’ representations oftheir own past relationships predictthe attachment classification oftheir future infants. These authors hold that a child’s reflective self, the capacity to think in terms of mental states, develops as a response to the caregiver’s capacity to mentalize. Those parents who have the capacitytothink abouttherelationship using mental processes will have a moresecure relationship withthe child (Fonagy et al., 1991). The sensitivity and comprehension oftheinfant mental worldisimportantin developingasecureattachment. Theseauthors also point outthat affect regulationis relatedtothe development of mental representations.
Therearetwo pre-mentalizing modes offunctioningthatexist priorto developingand experiencingthecapacityto mentalize(Target &Fonagy, 1996). Thefirst modeisthe psychic equivalent mode that involves thinking that what is being experienced internally is also
happening outside (Fonagy & Target, 2000). The pretend mode encompasses experiencing feelingsandideasthatare merelyrepresentationaland havelittleimpact onthe outer world (Fonagy & Target, 2000). This can be consideredto be a developmental model, asthe capacityto mentalize and integrate the inner and outer world, develops normally in the fourth or fifth year (Fonagy et al., 2004). Forthisto occur,the child needsto havethe cognitive capacity to understandthoughts and feelings andthese mental states would needto be reflected bythe object (parent) withconsistency. The parent,typicallythe mother, whois oftenthe primarycaregiver would haveto already possess a healthy understanding of psychic reality.
Mentalization theory and research focuses on the essential component of early relationships on mental healthandisalso usedtocomprehend thecomplicationsthatarisein attachment and relationships to others that are aggravated by neglect, abuse, and trauma (Bateman & Fonagy,2004). Fonagy and Target (2008) proposethat failuresin mentalization can occur duetoattachmenttraumainchildhood. Wecould presumethatchildren with RAD who had suffered abuse and neglect are frequently deprived of this process of learning about mental states,thusleadingto potential difficultiesin mentalizing.Inconsideringthesocialchallenges found in children with RAD, it can be easily observed that they are compromised in their ability to mentalize regarding others.
It has been demonstrated that there is a link between the maternal capacity to mentalize, the quality ofthe mother-child attachmentrelationship as well asthe status oftheinfant’s attachment (Slade, Greinenburger, Bernach, Locker, & Levy, 2005). Slade et al. consider parental mentalizing capacity as aninfluential factor fortheintergenerationaltransmission of attachment. This important research may also have much to share regarding children with RAD. Given that theemotional development ofchildren with RADis marked by deprivation;itis plausiblethat
this phase of reading ofemotions, whichalsorequiresattunement onthe part of mother,is compromised.
Inthesocial biofeedbacktheory ofaffect mirroring,itis emphasized thatin orderfor affect mirroring to be successful, the caregiver needs to reflect the infant’s emotional state and also showitis notthe caregiver’s (Gergely & Watson, 1996; Fonagy et al., 2004).Thisis known as “markedness”;the emotional display needs to show it is not really happening in the caregiver but rather belongstotheinfant (Gergely &Watson, 1996, p. 1197). Matching emotional displays thatlackthis“markedness”andaretooaccurate will overwhelmtheinfant; negativeaccurate emotion willincreaseratherthanregulate affect. Fonagyetal.(2004) proposethatthesocial biofeedback modelissimilarin natureto various psychodynamicformulationsrelatedtothe early motherinfant relationshipincludingthose foundin object relations.
Accordingto Fonagyand Target(2008),theabilityto mentalizerequiresa“symbolic representational system of mental states” (p. 18). Thisis developedthrough repeated experiences with the primary caregiver, usually the mother, who needs to be able to identify and understand mental statesinthe childin orderto reflectthem backto him. The most significant problems with mentalizingis usually foundininfancy wherethere has been few experiences given bythe parent to helptheinfant developasense ofself(Fonagy & Target, 2000). Thisleadsto more often experiencing aninternalizedimage ofthe mother as opposedto having a representation of mental statesthat should have been mirrored by mother. Some parents have difficulties with attunement due to their mental health, personality structure or personal experiences and trauma (Fonagy & Target, 2000).
A mother who may operatein whatis known asthe psychic equivalence mode may frequently exaggeratethe baby’s affect. This, for example, might be a mother who when she feels the distress ofthe baby, experiences andthustransmits even more distress. A frequent echoing of
the child’s state, withoutmetabolizing his or her affects,is what mightleadto psychic equivalent mode (Fonagy and Target, 2000). A psychological position that tends to compromise the ability to distinguish ones ownthoughts and feelings from external reality.
Ifthe parent provides an unrelated affecttotheinfant, thenitis aninaccurate re-presentation of the infant’s affect (Fonagy et al., 2004). This unrelated affect may belong to the parent or may be dissociatedandavoidreflectingthechild’saffectentirely. Thiscould bea parent who operatesfrequentlyin a pretend mode. Shouldthis continue overtime, thenthe representation created is notatallrelatedtotheself oftheinfant, andthusresultsinalesser connectionto her own emotion leadingto“distorted self representations”. These experiences are relatedto the development ofa false self. (Fonagyetal., 2004; p. 194). Receivingthistype of affect mirroring mayleadto a pretend mode ofthinking wherethoughts and feelings are experienced asrepresentationsthat are completelyseparatedfromreality(Fonagy & Target, 2000).
The pretend mode ofthinking seemsto reflect children with RAD oftheinhibitedtype who may retreatintheirinner world and rely more significantly ontheirinternal representations even thoughthey may have beenfearful. Theytrustless whatis outside, perhaps having had a neglectful or psychologically absent motherthey unconsciously presumethatthereis no pointin making contact with others since they will not be received or understood. Leroux and Terradas (2013) postulate that parents who have difficulties with pre-mentalizing modes might influence the development of RAD symptoms. Theauthors also explore the possibility that the equivalent mode ofthinking mayexplainsome ofthe behaviours ofthe disinhibitedtype who have not experiencedthe abilityto differentiatetheir emotionsfrom others and also have difficulties respecting boundaries. The desperate need for proximity might be relatedtotheir strong needto usethe otherto helpthem cope withintolerable or disconnected emotions.
Fonagy et al.(2004) describe a phenomenonthatinvolvestheinternalization ofthe object’s mental statethatis not connectedto one’s own self. This overtime can developintothe alien self; something becomes distorted in the perception of other as belonging to the self. The selffeelsinherently bad, whichisa most distressingfeelingforany child. Children with RAD appeartostruggle with distinguishing what belongstotheself andthe other duetosevere complicationsintheir early relationships.
Conclusion
This article has put forth a theoretical perspective from object relations and mentalization theory that could help in the understanding of RAD. An attempt has been made to propose that RAD children have developed mental representations that lead to challenging emotional experiencesand behavioursinrelationto others. Theevaluation of the mother’scapacityto mentalize and it’s influence on the attachment representations of children with RAD could have muchto contributeto our understanding of RAD. Evaluatingthe attachmentrepresentations could help clinicians understand the feelings, cognitions, and perceptions of children with RAD in relation to significant others. Minnis and her colleagues (2009) have encouraged the examination of the attachment representations of these children to better understand their cognitiveandsocial processes. These mayinturncontributetoa psychological perspectivefor further understanding these children and thus eventually have an impact on treatment. Based on some ofthe points surfacedinthis article,the following questions are proposedto be relevantto furtherexplore: Whatisthecapacity of mentalizationthat mothers ofthesechildrentypically possess? Could RAD children be clouded by negative internal representations, which they have become dependent ontocopeinthe world ofrelations? Do children with RAD have poorly developedrepresentations of others andthe self, whichinfluencetheir abilitytoform new healthyrelationships? Thiscouldexplainsome ofthechallenging behavioursthateither keep
themselves at a distance as found in the inhibited type or enmeshed with the other as might be expectedinthe disinhibitedtype.
Given what we knowaboutchildren with RAD,the hypothesisthatthesechildrenare more dependent ontheirinternalized objects, and atthe sametime confused and overwhelmed by themseemsa plausible one. Children with RAD may not have developedasense ofselfthat allowsthemto engage freely and comfortablyin relationships,to distinguish what belongstothe self and what belongsto others. Thus either creating a blurred sense of boundaries as foundinthe disinhibitedtype ora distancingthatisfoundintheinhibitedtype. Thesechildren have not receivedthe support necessaryintheir early attachment relationshipsto facilitatetheir emotional development. The difficultiesfoundintheseearlyrelationships mayleadtoacquiring mental representationsthatare notconstructiveinthe development ofasecuresense oftheselfand others.
