Reactive Attachment Disorder
Symptoms, Causes, Diagnosis Treatment
What is RAD stands for?
REACTIVE - that means your child very often is not even thinking with his Cortex (Upstairs Brain). The child reacts to the situation using a "reptile brain" ("Fight or Flight"). His/her behavior is automatic, geared toward self-protection.
ATTACHMENT is what a healthy child will conditionally do if he/she assesses that the environment is safe enough and if his/her primary caregiver is consistent enough to be relied upon. From the child’s perspective, attachment and trust are inseparable. Attachment is child to adult, occurring within the first 12-24 months of life. Please, note that Attachment and bonding are not the same thing even though they are used interchangeably. Bonding is what a healthy, normal adult will unconditionally do toward a child.
DISORDER - simply put, it is a way of saying your child's behavior is not normal or healthy. The child behaves in a "dis-ordered" way.
Reactive Attachment Disorder Description
Reactive Attachment Disorder (RAD) is a severe disorder of social functioning. It is a condition where a child doesn't form healthy emotional bonds with their caregivers (parental figures), often because of emotional neglect or abuse at an early age.
Children suffering from reactive attachment disorder have issues expressing and managing their emotions (later on in life) along with forming healthy and productive relationships with anyone in their lives. Children with RAD are likely to have a complex presentation of symptoms To learn more about RAD click here
● Superficially engaging, and charming.● Indiscriminately affectionate with strangers.● Reluctant to make eye contact on parents' terms.● Not affectionate on parents' terms.● Cruel to animals, siblings. ● Lack of cause-and-effect thinking. ● A tendency to be on guard (to keep to themselves).● Feeling of detachment.● Bossy - fights for control over everything.● Poor impulse control.● Unwilling to ask for support or assistance.● Poor social cueing.● Impulsivity.● Co-morbidity with speech pathology.● Gaze aversion
● Has a preoccupation with fire, gore, and blood.● Lacks conscience.● Attention-seeking tendencies from strangers.● Self-harming tendencies or behavior.● Inappropriate unfamiliar behavior with the parent or parental figure.● Violating social boundaries.● Engaging in hoarding or gorging on food.● Engaging in stealing.● Engaging in persistent nonsense questions or chatter.● Unwilling to ask for support or assistance.● Absence or lack of empathy.● Insensitivity to pain.● Tactile defensiveness● ADHD [76]● Lying about the obvious *
What are the Symptoms of RAD?
* lying about something that the other person can easily recognize as a lie such as: I didn’t drop the bread – when the other person was standing right there and saw the person drop the bread.
RISK FACTORS:
●. Stressful pregnancy● Difficult birth● Early hospitalization● Abuse or social neglect: The child feels abandoned or alone. Persistent lack of having basic emotional needs met● Food insecurity: The child’s basic needs aren’t being met.●. Lack of hygiene: The child sits in soiled diapers for hours at a time without being changed.● Live in a children's home or other institution● Frequently change foster homes or caregivers: The child’s needs are only being met some of the time, particularly if they don’t know when to expect their caregivers to reward or console them.● Have parents who have severe mental health problems, criminal behavior, or substance abuse that impairs their parenting● Have prolonged separation from parents or other caregivers due to repeated out-of-home placement, hospitalization or death of a primary caregiver [88]
(Source: Mayoclinic, Focus on the Family )
What Causes Reactive Attachment Disorder?
Reactive Attachment Disorder (RAD) does not have a singular cause. Ideally, attachment forms through nurturing interactions with a caring caregiver. However, if these positive experiences are absent or if a child's interactions with their primary caregiver are fraught with stress or trauma, the stress-response system remains chronically activated. This prolonged activation, characterized by elevated levels of stress-related hormones like cortisol, can detrimentally impact healthy brain development, particularly affecting the limbic system. Research indicates risk factors that may contribute to a child's failure to form a bond with their caregivers.
● Feeling of detachment.● Unresponsive behavior.● The tendency to hold back emotions.● Symptoms of withdrawal from the parent or parental figure.● Tendency to avoid any relative or parent.● Failure in seeking affection.● A tendency to be on guard (to keep to themselves).● Feeling of detachment.
● No sense of familiarity with a parent or parental figures.● Tendency to behave like a child.● Attention-seeking tendencies.● Self-harming tendencies or behavior.● Inappropriate unfamiliar behavior with the parent or parental figure.● Not understanding social boundaries.● Violates social boundaries.● Often act much younger than their age
Disinhibited Social Engagement Disorder
Inhibited Reactive Attachment Disorder
What are the 2 Types of Reactive Attachment Disorder?
Children with reactive attachment disorder are aware of what happens around them, but they don’t respond emotionally to what’s going on.Reactive Attachment Disorder used to be divided into 2 types. In DSM 5 they go as separate items. The difference between the two lies in the Signs and Symptoms of Reactive Attachment Disorders. * DRAD just has been added to DSM 5 as a Disinhibited Social Engagement Disorder (DSED) Children can manifest symptoms from one type, but many children have symptoms of both types [100]
CAUTION: Children with DSED often exhibit the behavior of seeking comfort and attention from almost anyone, often while disregarding the parent or primary caregiver. This indiscriminative behavior puts them at risk of being abducted.
Treatment and Management
If not addressed, RAD can hurt a child's physical, emotional, behavioral, social, and moral development. While there is no standardized procedure, the following components are often included in treatment.
Since children and caregivers benefit from treatment plans, therapies should involve both. Treatment may include:
● Psychotherapy/counseling: A mental health provider works with the child and parents to build healthy emotional skills and reduce problematic patterns of behavior that prevent bonding.
● Family therapy: This therapy involves working together with the child, siblings, and caregiver to develop healthy ways to interact.
● Social skills intervention: This therapy teaches the child how to interact appropriately with other similar-aged children in typical social settings. Parents are usually involved in helping the child use the skills they learn outside of therapy.
● Special education: Special education support for Reactive Attachment Disorder (RAD) might involve improving communication between the school and parents, introducing social skills training, and delivering personalized educational services to meet the child's requirements.
● Parenting skills classes: In these sessions, parents may learn more effective ways of managing their child’s difficult behaviors. [1]
The primary objectives of treatment are to ensure the child:
1. Resides in a safe and stable living environment. 2. Cultivates positive interactions and enhances attachment with parents and caregivers through treatments. [86]
CAUTION: There are some controversial and coercive techniques. These techniques include any type of physical restraint or force to break down what's believed to be the child's resistance to attachments — an unproven theory of the cause of Reactive Attachment Disorder. Abstain from employing any of these techniques.
Reactive Attachment Disorder Prevention
Although it remains uncertain whether Reactive Attachment Disorder (RAD) can be entirely prevented, some strategies may lower the risk of its development. Infants and young children require a stable, nurturing environment where fundamental emotional and physical needs are consistently fulfilled. The following parenting recommendations may be helpful in RAD prevention:
● Engage frequently with your child through playful interactions: regular conversations, maintaining eye contact, and offering smiles.● Learn to interpret your baby's signals (including different types of cries, to understand their emotions and needs effectively).● Provide warm, nurturing interaction with your child (such as during feeding, bathing, or changing diapers).● Respond to your child using a gentle tone of voice, affectionate facial expressions, and physical affection.● Consider participating in parenting classes or volunteer opportunities with your child to acquire skills and knowledge to foster their well-being[91]
Learn more techniques in our RAD Training for Parents class
Prognosis
Despite the intervention, children affected by trauma encounter challenges across various domains of life, ranging from academic performance in classrooms to the formation of a stable self-identity. The traumatic experiences underlying attachment disorders induce a persistent state of stress, impairing their resilience.
Early identification and treatment have demonstrated efficacy in enhancing outcomes; nevertheless, Parent Education and support are crucial. Parents who adopt children from state custody or overseas orphanages should receive education on the ramifications of social deprivation and be linked with service agencies or providers specializing in attachment disorders. [87]
Learn more about RAD
11 Things About Reactive Attachment Disorder That Aren't True
Myth # 1: “Reactive Attachment Disorder is rare or maybe not even real”
There persists a widespread misconception, even among professionals, regarding the legitimacy or prevalence of Reactive Attachment Disorder (RAD). Initially introduced in the Diagnostic and Statistical Manual of Mental Disorders in 1980, RAD's definition is narrow, leading some to advocate for the term "developmental trauma disorder" due to its more encompassing nature.
Despite the terminology debate, the behaviors and symptoms exhibited by affected children are undeniably real. RAD symptoms often overlap with those of other disorders such as post-traumatic stress disorder, anxiety, depression, and attention deficit hyperactivity disorder (ADHD). However, discussions among parents raising children with RAD reveal shared experiences that cannot be fully explained by alternative diagnoses.
RAD exists on a spectrum and is more prevalent than commonly perceived. Research indicates that 38-40% of toddlers in foster care who have experienced maltreatment meet the diagnostic criteria for RAD. Considering that 40% of the general population is classified as having an insecure attachment style, it's evident that RAD is not rare. The prevalence may even be higher if the diagnostic criteria were refined and if studies extended to older children in foster care.Myth # 2: “They’re a total sweetheart, maybe the parent is the problem” (otherwise known as, “They’re not that way with me”)
● Reactive Attachment Disorder (RAD) often manifests differently outside the home compared to within it and even varies in the child's interactions with their mother versus their father.
● Symptoms are typically outwardly expressed with the primary caregiver, often the mother, who becomes perceived as a nurturing enemy.
● These symptoms are frequently mistaken for those of other disorders such as post-traumatic stress disorder, anxiety, depression, and attention deficit hyperactivity disorder (ADHD).
● Most children with RAD have experienced some form of abuse, neglect, inconsistent caregiving, or painful separation before the age of 3, leading them to unconsciously mistrust their primary caregiver's ability to care for or support them.
● Children with RAD only feel secure when they are in control, leading them to reject the primary caregiver and exert efforts to maintain control as a means of survival.
● Rather than having their needs met through healthy relationships with their parents, children with RAD rely on manipulation and triangulation to influence others without genuine emotional closeness. Consequently, they may appear charming to teachers, relatives, and family friends, presenting a vastly different image from what their primary caregiver experiences.
● Others must heed the experiences of the primary caregiver. Although they may not observe the same behavior, dismissing the caregiver's reality can leave them feeling isolated and misunderstood.Myth # 3: “Only adopted children get Reactive Attachment Disorder”
Reactive attachment disorder or RAD is associated with adopted children. It can sometimes develop even when an adoption occurs in the first few days after birth if there is a disruption in the baby’s support by a caregiver for more than a few days. Life situations other than adoption can also create disruptions in early childhood that can cause RAD. So, even biological children can develop the disorder. These children often get misdiagnosed by healthcare professionals, including physicians and therapists, who may not have the experience or training to recognize early attachment issues.
And yes, RAD can be difficult to diagnose people need to listen to the primary caregiver. You may never see the child they see, but by dismissing their reality, you are making them feel misunderstood and alone.Myth # 4: “But he’s not violent; it can’t be reactive attachment disorder.”
As mentioned above, Reactive Attachment Disorder is a spectrum. Not all children with reactive attachment disorder are violent, hurt animals, or set fires. Because of this, many of us – and the professionals we see – fail to diagnose reactive attachment disorder early enough in cases that are not so blatant or severe.
Children get misdiagnosed when clinicians dismiss the possibility of reactive attachment disorder simply because the child wasn’t adopted or in the foster care system or an orphanage.
No matter the level of severity, symptoms of reactive attachment disorder disrupt relationships and require support for families as well as for a child. Most children with RAD push against attachment figures, need control, triangulate, manipulate, lie, and steal in ways that are far from neurotypical. Other behaviors, including violence to oneself or others, may or may not occur depending on the severity of the child's disorder.Myth # 5: “All they need is love”
We are taught – and the general public believes – that all children need is love and a stable home. Sadly, it’s not that easy. Children with reactive attachment disorder unconsciously fear attachment and are threatened by love. Forcing attachment before the child feels safe or has learned to give up control and let their parents parent them usually backfires and makes the problem worse (see "Myth #7: All they need is some therapy" below).
Reactive Attachment Disorder is a complicated disorder that is difficult to treat, even by experienced professionals. Every day parents don’t stand a chance on their own, no matter how much love they have to give.Myth # 6: “You just need to parent them XYZ way”
Parents raising children with reactive attachment disorder are often judged as too rigid and strict because our children need high structure and supervision typical of younger children. On the other hand, others may judge us as spoiling our children if they witness tantrums or yelling from the child.
RAD is a very complicated disorder that is difficult to treat, even by experienced professionals. Every day parents don’t stand a chance on their own, no matter how much love they have to give.
There is no magic parenting style that will heal our children. Yes, parents are part of the puzzle, but parenting alone is not the fault or the cure. Judging us when people haven’t walked in our shoes is extremely hurtful and isolating for us.
“There is a myth that proper parenting will change the child's behavior,” one parent who took the survey says. “RAD results from trauma that impacts the development and physiology of the brain. No one would go to a child's oncology ward and tell the parents that if they just did a better job their child would not have this condition. Yet, this is the message I hear all the time. It is cruel."Myth # 7: “All they need is some therapy (or medications)”
Many think talk therapy and maybe some medications are magic bullets for troubled children. Both can be helpful, but finding practitioners experienced in dealing with reactive attachment disorder who know the right approaches is extremely difficult.
For therapy to be effective, the child must want to change, and the therapist must understand the disorder. “Children with moderate to severe RAD typically need to be outside the home for treatment because everyone in the home is suffering,” says Forrest Lien, LCSW, a counselor who spent the last three decades of his career working with children with developmental trauma and their families. “A lot of attachment folks will push the attachment relationship with the mom rather than looking at the whole breakdown of the family system."
“With effective RAD therapy, the clinician works with the child to give up trying to take control and to allow themselves to feel vulnerable with their attachment figures and to count on their parents to guide them and direct them,” he continues. “That’s like saying to these kids, ‘Give up all your survival tools and trust me.’ To them that feels like dying.”
Meanwhile, children seeing a psychiatrist are often misdiagnosed with things like ADHD and treated with the wrong medications, which you can read more about here.Myth # 8: “Reactive attachment disorder is incurable”
Without proper treatment, reactive attachment disorder can continue for several years and may have lifelong consequences [232]While many children don’t get the help they need or are not yet to the place where they want to change, there are success stories. Of course, success looks different for each person and family. Still, there is hope.
Myth # 9: “My kid does that, too”
One of the most frustrating aspects for parents of children with Reactive Attachment Disorder (RAD) is when parents of biological children dismiss concerning behaviors with statements like, "That's just typical kid behavior," or "My child does that too." While extreme cases of RAD, involving violence or dangerous acts, may garner more attention, caregivers of children with less severe behaviors often encounter this dismissive response.
An effective way to convey the challenges of parenting a child with RAD is to liken it to the difference between a drip of water from a faucet versus a constant, forceful stream from a firehose. While neurotypical children may occasionally lie or get into trouble at school, children with RAD often exhibit these behaviors chronically and at a heightened intensity. Parents of RAD children frequently face reports from school about behavioral issues several times a week, making nearly every moment spent with their child feel like a struggle. This level of difficulty is far from typical.Myth # 11: “They will grow out of it”
Reactive attachment disorder is a lifelong condition. Treatment and support for the child help them develop healthy relationships throughout their life and can improve their emotional and social well-being [85]
Why some "Traditional Methods" don’t work
As Dr. Van der Kolk stated clearly, "It does not reach the parts of the brain most impacted by trauma. If it doesn’t reach them, it can’t heal them." In other words, trauma changes the brain.
Traditional parenting methods operate on the assumption of a healthy attachment between parent and child, where trust and safety are firmly established. It further assumes the Trust between the child and the caregiver. The child feels secure at home and can trust their parent's intentions when disciplined.
Grounded in Social Learning Theory, traditional parenting strategies rely on the idea that children learn to decrease undesirable behaviors through consequences and acquire new desirable behaviors through rewards.
Children who have endured neglect, abuse, and inconsistent parenting tend to anticipate such treatment from all adults, as it aligns with their familiar experiences. They may strive to prevent emotional closeness with others, leading to confusion and difficulty with typical, healthy parenting practices, which may feel unfamiliar and unsafe to them. These children often harbor fear towards their parents or caregivers and have developed coping mechanisms that are sometimes illogical, counterintuitive, and regrettably, self-destructive.
Examples of some "Traditional Methods" and why they don't work
“Time outs”
are ineffective because adopted children need “time-ins.” They need ongoing interaction with the people who love them. Sending a child to be alone with instructions to calm down, think about what she has done, and not come back until she’s ready to behave makes no sense. Read more>>
Behavior Charts
are problematic for adopted children for two reasons. The first is that it seems nonsensical to be rewarded for behaviors that are not exceptional. For example, making the bed, not having a tantrum in a store, and taking out the trash — these are behaviors that are reasonable to expect. Read more>>
Love Withdrawal
occurs when parents withdraw emotionally and physically to change a child’s behavior. This rarely works well as a form of discipline even with well-attached children. It will not work as a form of discipline for adopted children. Read more >>
Deprivation
Depriving a child of things seldom works with a previously abused child because the child rarely truly needs whatever is being taken away. Read more>>
Grounding
Parents who use grounding as a method of discipline are also working at a disadvantage. The child may be used to doing whatever he wants without getting permission. If he’s not grounded he assumes he can still do anything that hasn’t been specifically ruled out. Read more>>
Corporal Punishment
This article series on nurture and discipline would not be complete without a discussion of spanking. Responding to an adopted child in anger or disciplining him while you are angry will not result in the healing and change of behavior that you desire. Indeed, previously abused children are comfortable with you becoming angry. Anger keeps the emotional distance between you. Read more>>
Better Understand the Caregivers
While raising a child with RAD, primary caregivers often:
● Must remain calm yet vigilant about the physical and mental wellness of the whole family amid incessant arguing and bouts of rage from the child● Attempts to attach emotionally to the child are repeatedly rejected● Are falsely accused of abuse, neglect, etc. by the child due to the nature of the disorder (to reject attachment)● Are blamed by and ostracized from their community, friends, and family due to the confusing and deceiving nature of RAD, including false allegations● Lack of personal and professional support due to an overall lack of accurate education and training about RAD● Notice negative changes within self and family outside of their control● RAD is a serious mental health disorder that inhibits a child's ability to trust primary caregivers and leads to maladaptive self-protective behaviors. Those raising children with RAD often develop post-traumatic stress disorder (PTSD)*
Source: *[200]*Children with RAD often feel a need to be in control and may exhibit argumentative, bossy, or/and defiant behavior [201]
The following Letters will help you to understand the real-life challenges of caregivers of RAD children.
Dear Teacher Of My Reactive Attachment Disorder (RAD) Child/TeenOpen Letter to a Therapist from a mom of a child with Reactive Attachment Disorder.
What Are the Complications of Reactive Attachment Disorder?
If not treated, this condition can permanently affect the child's ability to interact with others. It can be connected with:
● Developmental delay (mentally and physically).● Behavioral and emotional problems like depression, anxiety, anger management issues, post-traumatic stress disorder, and personality disorders.● Eating disorder (as a result of neglect from home).● Substance use disorder (alcohol, drugs, etc.)● Relationship issues and Social rejection (with peers, parents, adults, or later with personal relationships).● Self-harming tendencies.● Trouble in school (learning and/or behavioral problems). ● Risky behavior, like early or frequent sexual activity.
Resources:
● Reactive Attachment Disorder. Cleveland Clinic ● INSIDE: Understanding How Reactive Attachment Disorder Thinks and Feels● Parenting a Child with Attachment Issues● The Adoptive Journey: An Honest Look at What You Really Need to Know● Parenting Reactive Children or Youth● Unique Challenges● Adopting an Abused Child● Adoption and Attachment Issues● iCliniq The Virtual Hospital ● Reactive Attachment Disorder (webMD)● Reactive Attachment Disorder-Overview (Mayoclinic) ● 10 Things People Say About Reactive Attachment Disorder That Aren't True (and Hurt Families)● www.ransomforisrael.com
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