Reactive Attachment Disorder (RAD)


The profile of children diagnosed with Reactive Attachment Disorder (RAD) is disturbing.  Although the diagnostic criteria speak for themselves, I believe Cline’s (2008) account of life on a RAD unit is as insightful as one can find into some of the “typical profiles” of children diagnosed with RAD.

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The reactive part of RAD is certainly correct, as these children react immediately with rageful outbursts to any feelings of abandonment, slight, or limit setting.  The attachment aspect of the diagnosis is broad.  For whatever reason, children with RAD were unable to bond with anyone.  There was no stability in the relationships they formed from infancy on.  Trust was an issue.  Care, whether physical or emotional, was inconsistent.  There was nothing they could count on, except having nothing to count on.  There was no foundation to build on.  From day one they felt unattended, rejected.  They cried.  They hungered.  They hurt.  As infants, their stresses were not relieved.  Their needs were disregarded.  They were uncomfortable.  Many were hit, used.  They may have been ill at birth and suffered much in the name of medical treatment.  Perhaps they were not touched more than was necessary for basic care.  They may have been intentionally or unintentionally neglected.  They may have been abused physically, sexually, or emotionally.  They may have come from overcrowded orphanages in other parts of the world.  Their parents may have been drug addicts, alcoholics, economically disadvantaged, single parents, or mentally ill-parents who were unable to attach themselves.  (Cline, 2008, expression PROFILES OF RAD)

DSM-IV-TR diagnostic criteria for RAD include the following:  (American Psychiatric Association, Diagnostic and statistical manual of mental disorders, 2000, p. 130)

A)    Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2):

  1. Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hyper-vigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness).
  2. Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachment (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures).

B)    The disturbance in Criterion A is not accounted for solely by developmental delay (MR) and does not meet criteria for PDD.

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)    There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A.

E)     Specify Type

  1. Inhibited type is predominated by Criterion A1
  2. Disinhibited type is predominated by Criterion A2

Although we can not entirely eliminate the possibility of predispositions due to heredity or biological causes, RAD cases will typically present with a clear etiological path to pathogenic care.  There is also evidence that some familial circumstances may provide predisposition to RAD.  In a generational study of caregivers demonstrating unresolved loss and abuse, Zajac and Kobak (2009) found “a consistent association between caregivers’ unresolved loss and teacher ratings of children’s behavior problems… but solely among caregivers who had insecure (dismissing or preoccupied) states of mind.”  (Zajac & Kobak, 2009, p. 182)

RAD is prevalent in the foster care system.  (Schwartz, 2008)  However, children in foster care are not the only high risk group for developing the socio-emotional issues associated with RAD.  A recent study, concerned with the developmental issues impacting military families during deployments, found that young children with a deployed parent demonstrated increased behavior problems during deployment and increased attachment behaviors at reunion (compared with children whose parents had not experienced a recent deployment.  Children in their “deployment groups” had a deployed parent that was gone, on average, half of their lifetime.  These findings were conclusive despite the fact that some military families and children seem to show fewer detrimental effects in response to parent deployment.  (Barker & Berry, 2009)

“While there is no empirically supported treatment for RAD, evidence suggests that children with attachment problems are best served by therapies that promote environmental stability as well as caregiver patience, sensitivity, and consistency.”  (Wilson, 2009, expression Treatment Considerations)  Interventions suggested by Wilson include group-based interventions to encourage parent sensitivity and responsiveness, labeled “Circle of Security,” or direct instruction to guide parental response to child behavior via a “bug in the ear,” labeled Parent-Child Interaction Therapy (PCIT).

Other therapies use coercion, fear, and emotional dysregulation to address concerns in attachment formation.  Although less common, such controversial interventions remain in practice and claim to “cure” attachment disturbances by invasive techniques, such as restraining or confining a child for extended periods of time.  Sometimes called holding, rebirthing, rage, or past-life therapy, such interventions have little empirical support, are theoretically counterintuitive, ethically problematic, and of questionable utility.  (Wilson, 2009, expression Other Therapies)

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References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.

Barker, L. H., & Berry, K. D. (2009, Oct). Developmental issues impacting military families with young children during single and multiple deployments. Military Medicine, 174(10), 1033-1041. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1884841381&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Cline, L. (2008, Jan). Reaching kids with reactive attachment disorder. Journal of Psychosocial Nursing & Mental Health Services, 46(1), 53-59. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1411292941&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Schwartz, L. L. (2008, Summer). Aspects of adoption and foster care. Journal of Psychiatry & Law, 36(2), 153-171. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1602451041&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Wilson, S. L. (2009, Aug). Understanding and promoting attachment. Journal of Psychosocial Nursing & Mental Health Services, 47(8), 23-28. Retrieved from http://ezproxy.bellevue.edu:80/login?url=http://proquest.umi.com.ezproxy.bellevue.edu/pqdweb?did=1835014081&sid=4&Fmt=3&clientId=4683&RQT=309&VName=PQD

Zajac, K., & Kobak, R. (2009, Jan). Caregiver unresolved loss and abuse and child behavior problems: Intergenerational effects in a high-risk sample. Development and Psychopathology, 21(1), 173-188. doi: 10.1017/S095457940900011X

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