921: Reactive Attachment Disorder (RAD):
An Overview
Learning Objectives
• Describe how healthy attachment occurs
• Describe the effects of maltreatment and disordered
attachment on brain development, self concept and
behavior
• Define risk factors for and symptoms of Reactive
Attachment Disorder (RAD) and related disorders
• List the recommended approaches for diagnosis and
treatment of RAD and related disorders
• Utilize attachment parenting principles when caring for a
child with RAD
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Agenda
I.
II.
III.
IV.
Introduction
Development of healthy attachment
Effects of unhealthy attachment
Symptoms, diagnosis and treatment of RAD and
related disorders
V. Parenting principles that promote attachment
VI. Closing
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Healthy Attachment
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Poll
Think about your response to separating from the
person(s) you are MOST attached to for 6 months.
What would you want?
A. To feel secure, I would not need any contact.
B. To feel secure, I would want monthly contact.
C. To feel secure, I would want weekly contact.
D. To feel secure, I would want daily contact.
E. To feel secure, I would tell them don’t go!
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How Does Healthy Attachment Occur?
• Watch the First Years
Last Forever clip
• Can you identify the
five main things
parents are doing in
the clip that facilitate
parent/child
attachment?
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Normal Cycle of Attachment
• Infant feels need (hunger, pain, attention)
• Infant is aroused and expresses need (cry)
• Response/gratification (need is promptly met in
nurturing way)
• Relief/relaxation (infant feels relief and relaxes,
develops TRUST)
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Normal Cycle of Attachment
Need
Relief
Relaxation
Arousal
Expression
Response Gratification
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Disordered Cycle of Attachment
•
•
•
•
Infant feels need (hunger, pain, attention)
Infant is aroused and expresses need (cry)
There is no response, or response is angry/punitive
There is not relief/relaxation (infant develops
anger/rage and learns not to depend on caregivers for
need satisfaction)
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Disordered Cycle of Attachment
Need
Discomfort/Fear/
Anxiety
Lack of Trust in
Others & Lack of
Empathy
Arousal
Expression
Apathy
No Response -> Anger
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Continuum of Attachment
SECURE
ANXIOUS
DISORGANIZED
Comfortable with
Resists or
Unable to trust or
closeness and trust ambivalent
be close
about closeness
Felt security
or trust
Lacks remorse
NONATTACHED
Unable to form
emotional
connections
Lacks conscience
Vulnerability
acceptable
Positive working
model
Individuality,
togetherness
balanced
Moderately
controlling and
insecure
Negative
working model
Aggressive and
punitive control
Negative working
model (severe)
Pseudoindependent
Predatory behaviors
Negative working
model (severe)
Extreme narcissism
Rejecting or
clingy
(From: Attachment, Trauma, and Healing, p. 94)
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Effects of Unhealthy Attachment
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Effect on the Brain
• Frontal Lobes
– Manages impulse control,
social reasoning, organization
and planning
• Amygdala
– Assesses threats and danger in the
environment and results in fight, flight
or freeze responses
(Source: Dr. Bruce D. Perry, 2006, The Boy Who was Raised as a Dog)
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Effect on the Brain: Hand Model
Let’s watch Dr. Siegel’s hand model of the brain
– http://www.youtube.com/watch?v=DD-lfP1FBFk
1) What does this mean for children who did not develop
smooth regulation and impulse control as a result of
disrupted attachment early in life?
2) What does this mean for us as parents when we
respond to some of the extreme behaviors exhibited
by children with disordered attachment?
3) How can you use this hand model with children who
struggle with regulating their emotions, impulses and
sensory responses?
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Beliefs: About Self and the World
•
People are untrustworthy and inconsistent
•
The world is chaotic, unpredictable and unsafe
•
Nothing I say or do has an impact, not on others,
myself or situations
•
My needs will only be met through my own efforts:
I have to do it all myself
(Source: Cross, 2003, Dyadic Developmental Psychotherapy)
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Beliefs: About Self and the World (cont.)
•
I am worthless, unlovable and bad
•
I am unsafe and weak
•
Caretakers are unresponsive, unreliable and
dangerous
•
The world is hostile and dangerous.
(Source: Cross, 2003, Dyadic Developmental Psychotherapy)
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Behavior: Attachment Disruption Signs
INFANCY
TODDLER
SCHOOL AGE
ADOLESCENCE
Lack of eye contact Excessive
tantrums
Tantrums continue
Drug/Alcohol abuse
Inability to soothe
Self-Injury
Cruel to animals
Excessive sexual
behaviors (multiple
partners)
Does not express
needs
Overly friendly/ Encopresis/
attentionEnuresis
seeking with
strangers
Slow development
and weight gain
Affectionate on Lying, hoarding,
their own terms stealing,
destruction of
property
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Immediate bonding
and need to attach
with strangers
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Symptoms, Diagnosis and Treatment of
Reactive Attachment Disorder (RAD) and
Related Disorders
 Symptoms of RAD
 Risk factors
 Diagnostic process
 Related disorders
 Recommended treatments
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Symptoms of RAD
• A consistent pattern of inhibited, emotionally withdrawn behavior
toward adult caregivers, evident before age 5, and manifested by
both of the following:
– Rarely or minimally seeks comfort when distressed
– Rarely or minimally responds to comfort offered when distressed
• A persistent social and emotional disturbance characterized by at
least 2 of the following:
– Minimal social and emotional responsiveness to others
– Limited positive affect
– Episodes of unexplained irritability, sadness, or fearfulness which are
evident during nonthreatening interactions with adult caregivers
(Source: DSM-5)
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Symptoms of RAD
• Child has experienced a pattern of extremes of insufficient care
(pathogenic care) as evidenced by at least one of the following:
– Persistent disregard of the child’s basic emotional needs for comfort,
stimulation, and affection (i.e., neglect)
– Persistent disregard of the child’s basic physical needs.
– Repeated changes of primary caregiver that prevent formation of stable
attachments (e.g., frequent changes in foster care)
– Rearing in unusual settings such as institutions with high
child/caregiver ratios that limit opportunities to form selective
attachments
•
Not due to Autism Spectrum Disorder
(Source: DSM-5)
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Risk Factor for RAD:
Social Neglect and Deprivation Due to One or More
of the Following
Neglect
Abuse
Maternal postpartum depression
Parental mental illness
Substance abuse of parent
Inexperienced parent
Inconsistent care giving
Many different caregivers
(Source: Mayo Clinic, 2013)
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Case Vignette
• Using HO#6 (RAD:
Symptoms, Risk
Factors and
Treatment), please
identify the possible
indicators of RAD
• Using HO#5 (Effects:
Brain, Self-Concept
and Behavior), please
identify the possible
beliefs this child might
have based on the
behavior Trisha exhibits
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How Are Children Diagnosed?
• Major focus of
assessment is
obtaining the most
complete history of
caregiving for the child
and evaluating the
attachment between
parent and child
• A full picture of the
child’s behaviors is
obtained
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• Psychiatric evaluation
and/or psychological
evaluation
– Presenting problem
– Child’s history
(psychosocial,
medical, school)
– Family history
– Interview with child
– Interview with
parents
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Diagnosing Challenges and Debates
Is it RAD or another disorder?
• Disinhibited Social Engagement Disorder (due to pathogenic care)
– Attachment may or may not be present
– A pattern of behavior in which the child actively approaches and
interacts with unfamiliar adults by exhibiting at least 2 of the following:
• Reduced or absent reticence to approach and interact with
unfamiliar adults
• Overly familiar behavior (verbal or physical violation of culturally
sanctioned social boundaries)
• Diminished or absent checking back with adult caregiver after
venturing away, even in unfamiliar settings
• Willingness to go off with an unfamiliar adult with minimal or no
hesitation
(Source: DSM-5)
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Diagnosing Challenges and Debates
Is it RAD or another disorder?
• Posttraumatic Stress Disorder (PTSD)
– Symptoms of avoidance and emotional numbing
– Symptoms of intrusive memories (flashbacks/nightmares)
– Symptoms of alterations in cognitions and mood
• Sensory Processing Disorder (SPD)
– Difficulty processing sensory input
– Hyper (over) or hypo (under) in one or more senses
• Mood Dysregulation Disorder (MDD)
– Severe recurrent temper outbursts that are grossly out of
proportion in intensity or duration to the situation
– Three or more times per week in more than one setting
(Source: DSM-5)
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Diagnosing Challenges and Debates
Is it RAD and another disorder?
• Posttraumatic Stress Disorder (PTSD)
• Sensory Processing Disorder (SPD)
• ADHD
– Inattention and/or hyperactivity-impulsive behavior
(Source: DSM-5)
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Types of Treatment
• RAD treatment must focus on supporting attachment
• Many children diagnosed with RAD also experienced
trauma due to neglect and/or abuse
• History of controversy exists regarding treatments
• Research continues to determine the most effective modes
• Types of treatment available:
– Attachment-based therapies
– Trauma-informed therapies
– Neurologically-based therapies
– Ancillary therapies (OT, Speech/Language)
– Medication to treat conditions such as sleep
disturbances, anxiety, etc. No one medication for RAD
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Types of Treatment
Attachment-Based
Trauma-Informed
• Facilitates attachment
through nurturing,
structure, attunement,
empathy, support, positive
affect, reciprocity, and
sometimes holding to
reduce “alarm” reaction
• Example: Theraplay
– Ann Jernberg in ‘60s
– http://www.theraplay.or
g/
•
•
•
•
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Psychotherapy
Play therapy
Art therapy
Equine therapy
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Types of Treatment
Neurologically-Based
OT and Meds
• EMDR
• Watch Colleen West and
EMDR with children
• Occupational therapy to
address sensory
integration issues
• No known “family” of
medications for RAD
• Medications only used to
treat specific issues such
as sleep disturbances,
anxiety, etc.
– http://www.emdrinacti
on.com/short-videosintroduction-emdr
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Parenting Principles that Promote
Attachment
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Resource/Adoptive Parents Play a Critical
Role in the Healing Process
• Parenting with warmth
and support
• Disciplining to
facilitate trust and
safety
• Collaborating with
professionals and
engaging in treatment
approaches
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Parenting Principles: Warmth and Support
• Acknowledge mixed feelings of child
• Allow expression of feelings
• Let child know how much you care
• Provide clear explanations for
visitations and any moves
• Dispel magical thinking common in young children
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Parenting Principles: Warmth and Support
• “Read” child’s cues to build trust
• Reframe behaviors as grief/loss
• Accept regression (feel safe to do so)
• Allow mingling of scents between households and
caregivers, especially for younger children
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Parenting Principles: Discipline
• Supervise, supervise, supervise for prevention
• Create a low stress environment
• Routines are KEY; use pictures or words to list
sequence of routines
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Parenting Principles: Discipline
• Teach the child calming techniques (slow breathing,
movement) and help the child calm down periodically
throughout the day to minimize meltdowns
• Use time IN not time out
– Young child on your lap, facing outward
– Older children in same room as you
– Offer specific praise when child is calm
• Give the child one concise direction at a time, monitor
that it is followed, provide specific praise
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Parenting Principles: Collaboration
• Attend all team meetings to create a network of
support
• Follow guidelines recommended by caseworkers and
therapists
• Strive for consistency in all settings of the child’s life
• Ensure that any school accommodations are followed
• Birth parents are key members of the team
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What Advice Would You Give These
Resource/Adoptive Parents?
• Divide into small groups and read the case vignette on
HO# 8 (Parenting Principles that Promote
Attachment)
• Respond to the following questions :
1) How can these parents collaborate as a team with the
child’s caseworker to move treatment toward a focus
on attachment and addressing the trauma the child
experienced?
2) What principles of parenting would you emphasize in
this situation?
3) What discipline approaches would you emphasize?
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What’s the #1 Take Away Message for You?
• Healthy attachment
• Effects of unhealthy
attachment
• Symptoms, diagnosis
and treatment
• Parenting principles
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Useful Websites
• Adverse Child Experiences Study
– http://www.acestudy.org
• The Institute for Attachment and Child Development
– www.instituteforattachment.org
• National Child Traumatic Stress Network
– http://www.nctsn.org/
• Trauma Center
– www.traumacenter.org
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Additional Readings
• Cline, F., & Fay, J. (2006). Parenting with Love and Logic. Colorado
Springs, CO: NavPress.
• Perry, B. D., & Szalavitz, M. (2006). The Boy Who Was Raised as a
Dog: And Other Stories from a Child Psychiatrist's Notebook: What
Traumatized Children Can Teach Us About Loss, Love and Healing.
New York: Basic Books.
• Siegel, D., & Hartzel, M. (2004). Parenting from the Inside Out:
How a Deeper Self-Understanding Can Help You Raise Children
Who Thrive. NY: Penguin Books.
• Thomas, N. (1997). When Love Is Not Enough: A Guide to
Parenting Children with RAD. Glenwood Springs, CO: Families by
Design.
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