REACTIVE
ATTACHMENT
DISORDER
CONTROVERSY-In General
 Little evidence to support DX or TX.
 Comorbidity with other Axis I & II is so
significant that it gets lost.
 DX may disappear in DSM V
 Emerging info on genetic,
neurophysiological and neuroanatomical
data on early stress will shape our
understanding of attachment disruption.
References
 American Academy of Child and
Adolescent Psychiatry
 National Child Traumatic Stress Network
– DSM V
RAD
 “ is the clinical disorder that defines
distinctive patterns of aberrant behavior
in young children who have been
maltreated or raised in environments that
limit opportunities to form selective
attachments.”
ACAP Practice Parameters
(American Academy of Child and Adolescent Psychiatry)
 Children with RAD
 Extreme neglect
 Abnormal social behaviors
 Lack of responsiveness
 Excessive inhibition
 Hypervigilance
 Indiscriminate sociability
 Disorganized attachment behaviors
Etiology
 Early Care – after 6 mos but before 3 yrs
 Persistent disregard of child’s basic
emotional needs for comfort, stimulation and
affection
 Persistent disregard of child’s basic physical
needs
 Repeated changes of primary caregiver
What is known
 Attachment disturbance can occur in
residential settings where infants must
rely on a large number of caregivers
 Lack of attachment is rare
 Does not occur without serious neglect
 Stressed kids seek comfort from
caregiver
 RAD kids resist comfort
What is known
 Persistence over time unlikely
 Attachments are compromised
 Indiscriminate sociability
 These kids a handful for adoptive parents
 No validated measures for middle
childhood, adolescence and adulthood
 Dx relies on history
Problems with DX
 No clinical data establishing Efficacy of
Dx
 Little TX research
 Little longitudinal research
 No solid outcome research
Problems with Dx –DSM V?
 Is attachment a disorder of diagnosis?
OR
 Is RAD a symptom of neglect and trauma
that fits into a Developmental Trauma
Disorder?
National Child Traumatic
Stress Network
Developmental Trauma
Taskforce
Developmental Trauma
Disorder
 Exposure
 Multiple or chronic
 Abandonment
 Betrayal
 Sexual assaults
 Neglect
 Coercive practices
 Emotional abuse
 Witnessing
Developmental Trauma
Disorder
 Subjective experience





Rage
Betrayal
Fear
Resignation
Shame
Developmental Trauma
Disorder
 Triggered pattern of repeated
dysregulation in response to trauma cues
 Some type of PTSD
 Affect
 Somatic
 Behavioral
 Cognitive
 Relational
 Self-care
Developmental Trauma
Disorder
 Regulation Strategy
 Anticipation
 Coping
 Restorative
 Disorganized
Developmental Trauma
Disorder
 Impact on other Disorders
 Substance Abuse
 Bipolar
 Depression
 Somatization
Developmental Trauma
Disorder
 Expectations
 Negative self-attribution
 Loss of protective caretaker
 Loss of protection of others
 Loss of trust in the system to protect
 Expecting to be victimized in future
Developmental Trauma
Disorder
 Functional Impairment
 Scholastic
 Familial
 Peer
 Legal
 Vocational
Attachment and Trauma

“The security of attachment bonds seems to
be the most important mitigating factor against
trauma-induced disorganization. In contrast,
trauma that affects the safety of attachment
bonds interferes with the capacity to integrate
sensory, emotional and cognitive information
into a cohesive whole and sets the stage for
unfocused and irrelevant responses to
subsequent stress.” (van der Kolk, 2003)
Core Features
 Excessive attempts to receive comfort
and affection
OR
 Extreme reluctance to initiate or accept
comfort or affection
Additional Features
 Disturbed and developmentally
inappropriate social relatedness
 Not as a result of a developmental delay
 Onset before age five
 Requires a history of significant neglect
 Lack of identifiable, preferred attachment
figures
AACAP Guidelines for TX
 Provide an emotionally attachment figure
 Assess caregivers attitude toward and
perceptions about the kid
 Creating positive interactions with
caregivers
 Kids with aggressive or oppositional
behaviors will require other Tx
Trauma Processing
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
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
Safety
Stress Reducing Resources
Surface and Engage trauma
Transfer therapeutically (“Forget”)
Review child’s formulation of trauma
Maslow’s Hierarchy
Maslow’s Hierarchy