What is RAD, or Reactive Attachment Disorder?
The term "attachment" is used to describe the process that takes place between infants and their care givers during the first two years of life, but it is especially the bond that develops between an infant and his/her caregiver during the first nine to twelve months of life. Mothers and babies engage in a series of interactions in which each is responding to cues from the other. The baby experiences discomfort or a need and protests usually by crying. The mother responds by picking the baby up, making eye contact, talks to and soothes the baby. In response the baby calms and trust develops and begins to interact with the mother and finally rests again before the cycle begins again as the baby experiences discomfort or a need. As this cycle is repeated thousands of times during the first year of a baby's life, a securely attached relationship develops.
When a mother fails to respond, or responds inconsistently, the baby protests even louder. If its needs are not met, eventually the baby will give up and no trust develops and rage develops instead. Severely disturbed attachment cycles produce babies who are apathetic or who are forced to engage in self-stimulation attempting to comfort themselves by compensating for the lack of their mother's care.
Reactive Attachment Disorder is a complex psychiatric illness that can affect young children. It is characterized by serious problems in emotional attachments to others and usually presents by age 5. A parent, daycare provider or physician may notice that a child has problems with emotional attachment by their first birthday. Often, a parent brings an infant or very young child to the doctor with one or more of the following concerns:
- severe colic and/or feeding difficulties
- failure to gain weight
- detached and unresponsive behavior
- difficulty being comforted
- preoccupied and/or defiant behavior
- inhibition or hesitancy in social interactions
Some children with Reactive Attachment Disorder may also be overly or inappropriately social or familiar with strangers. The physical, emotional and social problems associated with Reactive Attachment Disorder may persist as the child grows older.
The cause of Reactive Attachment Disorder is not known. Most children with this disorder have had severe problems or disruptions in their early relationships. Many have been physically or emotionally abused or neglected. Some have experienced inadequate care in an institutional setting or other out-of-home placement (for example a hospital, residential program, foster care or orphanage). Others have had multiple or traumatic losses or changes in their primary caregiver.
Children who exhibit signs of Reactive Attachment Disorder need a comprehensive psychiatric assessment and individualized treatment plan. These signs or symptoms may also be found in other psychiatric disorders. A child should never be given this label or diagnosis without a comprehensive evaluation. Treatment of this complex disorder involves both the child and the family. Without treatment, this condition can permanently effect a child's social and emotional development.
While some therapists have advocated the use of so-called "rebirthing techniques", there is no scientific evidence to support the effectiveness of such interventions. Such unproven and unconventional therapies can also be quite dangerous. Tragically, the use of such techniques has been associated with serious injury and even death.
Parents of a young child who shows signs or symptoms of Reactive Attachment Disorder should:
- seek a comprehensive psychiatric evaluation prior to the initiation of any treatment
- make sure they understand the risks as well as the potential benefits of any intervention
- feel free to seek a second opinion if they have questions or concerns about the diagnosis and/or treatment plan
Reactive Attachment Disorder is a serious clinical condition. Fortunately, it is relatively rare. Evaluating and treating children with complex child psychiatric disorders such as Reactive Attachment Disorder is challenging. There are no simple solutions or magic answers. However, close and ongoing collaboration between the child's family and the treatment team will increase the likelihood of a successful outcome.
As a relatively new diagnosis to the DSM-IV manual, Reactive Attachment Disorder (RAD), also known as Attachment Disorder (AD). It is often misunderstood, and relatively unknown. Expertise is even less available, and normal behavior treatments can very easily add to the symptoms if treated by instinctive patterns. Experts in RAD estimate that this disorder has been misdiagnosed as Bi-Polar Disorder or Attention Deficit Disorder in 40 to 70 percent of the cases.
All to often these individuals grow up untreated and become sociopaths without conscience and without concern for anyone but themselves. This condition was made popular by the recent academy award winning movie "Good Will Hunting." But unlike the movie, the hero, or heroine rarely drives off into the sunset to have a happy ever after life. More realistically, parental dreams are lost, and they grow up uncaring and without social conscience.
Reactive attachment disorder is broken into two types - inhibited and disinhibited. While some children have signs and symptoms of just one type, many children have both.
In inhibited reactive attachment disorder, children shun relationships and attachments to virtually everyone. This may happen when a baby never has the chance to develop an attachment to any caregiver.
Signs and symptoms of the inhibited type may include:
- Resisting affection from parents or caregivers
- Avoiding eye contact
- Appearing to seek contact but then turning away
- Difficulty being comforted
- Preferring to play alone
- Avoiding physical contact
- Failing to initiate contact with others
- Appearing to be on guard or wary
- Engaging in self-soothing behavior
In disinhibited reactive attachment disorder, children form inappropriate and shallow attachments to virtually everyone, including strangers. This may happen when a baby has multiple caregivers or frequent changes in caregivers.
Signs and symptoms of the disinhibited type may include: " Readily going to strangers, rather than showing stranger anxiety
- Seeking comfort from strangers
- Exaggerating needs for help doing tasks
- Inappropriately childish behavior
- Appearing anxious
A word of caution
Not all experts agree on the signs and symptoms of reactive attachment disorder. Some attachment therapists use checklists with numerous nonspecific signs and symptoms that go well beyond what the American Psychiatric Association includes in its definition of the disorder. Be cautious when trying to interpret checklists that include such symptoms as lack of eye contact, rage, aggression, lying, stealing, hoarding food, an apparent lack of a conscience, nonstop chatter, and a desire to wield control. These nonspecific symptoms are difficult to apply to any one diagnosis.
What is Reactive Attachment Disorder?
Reactive Attachment Disorder is a condition where individuals have difficulty forming loving, lasting intimate relationships. They do not trust anyone other than themselves to provide for their needs and safety. These individuals often fail to develop a conscience; do not feel empathy, and having genuine affection for people or pets is beyond their reach.
Children with reactive attachment disorder can be divided into four categories:
The Ambivalent Children
- Are angry, defiant & can be violent.
- Will push affection away to keep control
- Are destructive both with their own belonging and others
- Are extremely difficult children to parent because they sabotage or destroy almost everything positive that happens to them.
- When they want something, they act very affectionate.
- Have few friends if any, although they will say they do, listing several acquaintances - keep friends only for a short time
- Lack the ability to give and receive love
- Lack empathy for others - often cruel to animals and other children.
The Anxious Children
- Tend to be overly clingy, showing extreme separation anxiety when separated from their mothers.
- Incessantly chatters to control conversation
- Appear to be eager to please and are superficially compliant.
- Are often passive aggressive, constantly doing little things wrong, but never doing anything really bad, but frazzling the parents patience and control.
- Usually recover faster than those in the other categories
The Avoidance Children
- Are often overlooked as they are very compliant, agreeable & superficially engaging.
- Lack depth to their emotions & functions - robotic like, not genuine or real in emotional engagement.
- Don't enjoy being around others because they don't feel safe.
- Are Omnipotent - believing that they can care for all their own needs by themselves, and do not need others, especially their mothers.
- Are sullen and openly oppositional, but mostly in a passive aggressive way.
The Disorganized Children
Have highly disorganized behaviour and a bizarre showing a variety of symptoms.
- Hide anger deep inside, they are easier to deal with, harder to treat.
- May have atypical psychosis, bipolar disorder, and other neurological disorders.
- Often will have mental illness in the family history.
- Are excessively excitable (other RAD children are usually moody.)
- Are most difficult to treat in therapy because they have so many different problems and often require medication and out-of-home care.
Other Signs & Symptoms
Signs of Reactive Attachment Disorder in infants may include: weak crying response, rage, constant whining, sensitivity to touch and cuddling, poor suckling response and eye contact, and no reciprocal smile response.
Reactive Attachment Disorder Children may also have these symptoms: lack of conscience development, lack of eye contact except when lying, will not give or receive affection (hugs & kisses), no impulse control, abnormal eating patterns (gorging, hoarding, etc.), constantly making noise of some kind, pacing, and unusual speech patterns (mumbling, robotic, talking softly).
RAD can and has been misdiagnosed as Bipolar disorder, Attention Deficit Disorder, Fetal Alcohol Syndrome, Anti-Social Personality Disorder and Conduct Disorder.
What Causes Reactive Attachment Disorder?
The bond between a child and mother/primary caregiver is essential during the first three years of life. Without this bonding the child will not have learned how to feel trust, love, compassion and empathy. These four survival skills are crucial to develop into a loving, caring child and adult. Fifty percent of our survival skills are learned during the first year, twenty-five percent during the second and the last twenty-five percent is learned from 3 years of age and on. Below is a list of circumstances that can prevent this necessary bond from forming.
- Abandonment, abuse, neglect in the first three years of life
- Maternal alcohol/drug use
- Lack of attunement between mother and child
- Young, or inexperienced mother with poor parenting skills
- Maternal ambivalence toward pregnancy
- Multiple primary caregivers/ foster care system
- Institutionalized - orphanage adoption
- Inconsistent/inadequate day care
- Separation from Birth Parents - death, divorce
- Genetic disposition
- Separation from birthmother due to hospitalization, incubator, etc which prohibit adequate touch
- Undiagnosed/Untreated painful illness (ear infections, colic, hernia, etc.)
- Birth Trauma/ Traumatic prenatal experience
- Mother with chronic depression
I had had heard of the terms before, but until I agreed to take my 12-year-old nephew in, "reactive attachment disorder", sometimes known as "detachment disorder", or simply "attachment disorder", held no personal significance to me.
My wife and I took our nephew in to live with us in January of 2002. While we knew, and anticipated that there would be significant problems, we had no idea as to the extent of his disability.
Our nephew was diagnosed with Reactive Attachment Disorder, or RAD, shortly after coming to live with us and, despite the fact that this is a disorder that was barely on my screen of consciousness prior to that time, my wife and I have both come to understand it quite well.
Making it go away was another matter entirely.
As a paramedic for more than twenty years, I had come to appreciate signs and symptoms pointing to specific diagnoses, yet I was astounded to see how closely and how clearly our nephew fit the pattern for reactive attachment disorder. I only wish that treating the problem were as easy as diagnosing it appeared to be
Through books, tapes, classes, and conferences, my wife and I have devoured all of the useful information we can find on attachment disorders and, as we have learned more, we've added to this site. If you've just begun your own search for ways in which you can help your child, we understand what you are looking for, and believe that this will be a good place to start. We have included links to books that may be helpful and to other useful sites we've found on the Internet. We've also created a support board on Delphi Forums, and you can find a link to it in our Books and Resources section, along with other support forums on the subject.
Please be careful, however. Reactive attachment disorder is a newly recognized disorder - and as such, some of the available information is confusing and may appear contradictory. Treatments vary from traditional therapy to centers selling a quick fix. While I cannot evaluate the efficacy of each of these claims, my best guess is that the most useful therapy for a kid with reactive attachment disorder will be something in between.
We've chosen to remain somewhat anonymous on this site - not because we're trying to hide anything, and certainly not because we're ashamed - but because we live in a fairly small town, and we don't want any of our nephew's friends and acquaintances happening upon this site while surfing the web and making the connection between him and his disorder. Although reactive attachment disorder requires that he have little or no privacy within our home, outside of the home it is another matter, and it is clear to me that the reactive attachment label wouldn't make his already difficult relationships any easier.
After more than three years of attachment therapy and RAD parenting, I am pleased to report that our nephew is doing much better, so much so that his therapist recommended that he was no longer in need of regular therapy sessions.
He has learned empathy and responsibility. He has developed reasonable cause and effect thinking, and he has learned to make good choices, none of which implies that he always chooses to make the good choice. His emotional age has become unstuck and he is developing rapidly. While he still angers easily, he has made great progress in learning to control his anger and even to make reasonable argument in the midst of it. It has been months since he has become violent; and we hope, pray, and even dare to believe that we are beyond that.
For this, I would like to thank Stephanie, his therapist; Dr. Dan Hughes, who followed his treatment carefully, even meeting with us a couple of times; the authors of the several books from which we have gleaned the answers to many of the problems we faced; ATTACh, for putting on such a wonderful conference in Pittsburgh in 2004; everyone on our RadKid support forum, for being there to listen and to give advice; my wife, who persevered even when I was weak; and especially my nephew, for not giving up on himself, as he threatened to do many times.
While we still have work to do, I believe that we've made it through to the light.
I'll be happy to answer any questions to the best of my ability, or to refer you to someone who can. Better yet, join us in our forum, hosted by Delphi Forums.
-- ken & michelle anderson