Reactive Attachment Disorder (RAD) is a severe attachment disorder that affects young children and is characterized by a failure to form normal attachments to primary caregivers. Children with RAD do not bond with their parents or caregivers and may indiscriminately seek attention from any available adult. RAD is caused by neglect, abuse, or lack of consistent care early in life. It is diagnosed when inappropriate social behaviors emerge before age 5 and are accompanied by a history of disturbed care. Treatment focuses on improving the caregiving environment and responsiveness of caregivers through parenting skills training and therapies that facilitate healthy attachment.

1. Reactive Attachment DisorderShayna RossAdvanced Child Psychology11-20-08

2. History of the attachment theoryJohn Bowlby developed the attachment theory in the 1960sFocused on the early relationship the child has with their primary caregiverInfants are vulnerable and depend on adults for care which ensures the bond will be formedAttempt to maintain physical proximity to attachment figure and will go to the attachment figure for support when doing an individual taskFour types: secure, avoidant, resistant-ambivalent, and disorganizedLyons, H. (2007).

3. Clinical Literature Definition of Reactive Attachment Disorder (RAD) Severe and relatively uncommon attachment disorder that can affect childrenChildren do not form a bond with parent or caregiverLyons, H. (2007).

4. DSM IV Definition of RADMarkedly 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, hypervigilant, 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 attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) (Source: DSM IV)

5. Signs and Symptoms of RADPediatricians are usually the first professional to raise suspicion of RADInfants 18-24 months may show non-organic failure to thrive or they may have abnormal responses to stimuliThe child will look for attention and comfort from any available adult, even strangersThe child will not initiate or accept comfort and attention from familiar people especially when the child is in distressHall, S. and Geher, G. (2003)

6. Signs and Symptoms of RAD RAD is likely to occur with children who are neglected or abused, but just because the child is abused/neglected doesn’t mean they will be diagnosed with RAD without other symptoms or signs. The reason for this is children can still develop stable attachment and relationships regardless of neglect/abuse. Hall, S. and Geher, G. (2003)

7. Causes of RADFailure to form normal attachments to primary caregivers in early childhood Neglect, abuse, sudden separation, frequent change of caregiver, lack of responsiveness from caregiverNot every child who experiences these will be diagnosed with RADAlso you need to take into consideration children are able to form stable attachment and social relationships even if they were abused/neglectedChapman, Sue. (2002).

8. Causes Continued…Based on problematic history of care and social relationshipsAbnormal parentingTraumatic experiencesTemperament of the child may cause unstable relationships with caregivers Chapman, Sue. (2002).

9. Assessment ToolsThere is no universal diagnostic measure used for RAD yetA range of different measures are usedThe strange situation (Mary Ainsworth)Preschool Assessment of AttachmentObservational Record of the Caregiving EnvironmentStem stories, puppets, picturesInterviews: Child Attachment Interview and the Autobiographical Emotional Events DialogueRecently the Disturbances of Attachment Interview has been used. It was developed by Smyke and Zeanah in 1999.Hall, S. and Geher, G. (2003).

10. Diagnosis of RADRAD is one of the least researched disordersIt is very poorly understoodIt is difficult to diagnose because there is no specific course the disorder takes. There are no stages.Initial evaluations can be conducted by psychiatrists, specialist Licensed Clinical Social Workers, psychiatric nurses, and psychologists.Hall, S. and Geher, G. (2003).

11. AACAP’s Opinion on Diagnosing Children With RADThe American Academy of Child and Adolescent Psychiatry (AACAP) states each child who exhibits symptoms of RAD or are diagnosed with RAD need an individualized plan of actionThe AACAP also suggests against labeling the child with RAD without comprehensive evaluations. They feel there needs to be several tests done and several observations before stating the child has RAD. The child’s relationship with it’s caregiver/parent needs to be looked at numerous times before making a diagnosis. Also a diagnosis needs to see the child’s attachment patternsRequires observation of how the child reacts with unfamiliar adultsA comprehensive history of the child’s caregiving environment from a very young age (Pediatricians, teachers, caseworkers, daycares)The AACAP hasn’t resolved the question – can attachment disorders reliably be diagnosed in older children and adultsLyons, H. (2007).

12. Diagnostic CriteriaThere are two classifications of RAD; inhibited and disinhibited.Both types include:Disturbed and inappropriate social relatednessDisturbance isn’t accounted for by developmental delay or a developmental disorderOnset before 5 years oldHistory of significant neglectLack of identifiable preferred attachment figureLyons, H. (2007).

13. Inhibited RADFailure to initiate or respond to social interactions, in developmentally appropriate ways Child may respond to caregiver in very undecided ways. Very indecisive on how to react to caregiverInfants not seeking comfort when in danger, alarm or upsetDon’t feel a need to maintain proximity to caregiverHall, S. and Geher, G. (2003).

14. Disinhibited RADChild does not exhibit appropriate selective attachmentsChild develops close relationships with strangersChild doesn’t develop relationships with caregiversHall, S. and Geher, G. (2003).

15. TreatmentTreating parents for mental illness, family therapy, individual therapyShould the child be removed and placed in a safe situationHelp for the family such as financial aid, housing aid, social workTraining for parenting skills and child developmentMonitoring the child’s safety within their home/family environmentTherapy which increases the responsiveness of the child to their caregiversHall, S. and Geher, G. (2003).

16. Hall and Geher StudyParticipants: Caregivers of children with RAD, caregivers of non-RAD children, children with RAD. The parents provided information about the behavior and personality characteristics of their children measured by the RAD scale Hall, S. and Geher, G. (2003).

17. ResultsShowed children with RAD display more violent and detrimental behavior than those children without RADChildren with RAD have more general behavior problems , social problems, withdrawal, anxiety, depression, attention problems, delinquent behavior. Hall, S. and Geher, G. (2003).

18. Tobin, Wardi-Zonna, Yezzi-Shareef StudyInterviews with children and adolescents diagnosed with RAD, about their earliest recollections The children and adolescents were audio tapedTobin, D., Wardi-Zonna, K., Yezzi-Shareef A. (2007).

19. ResultsFound all the recollections were negative about the caregiverNone of the children or adolescents felt they were lovedSome examples of the early recollections:We had fun finger-painting at school; I got grounded for four days because I got paint on my white shirtI did not get up. I wet the bed, and my mom was mad at meWe got taken away from the babysitter because my mom didn’t come home that nightTobin, D., Wardi-Zonna, K., Yezzi-Shareef A. (2007).

20. ReferencesChapman, Sue. (2002). Reactive Attachment Disorder. British Journal of Special Education. Volume 29, No.2. Hall, S. and Geher, G. (2003). Behavioral and Personality Characteristics of Children with Reactive Attachment Disorder. The Journal of Psychology. 137(2), 145-162. Lyons, H. (2007). Attachment Theory and Reactive Attachment Disorder: Theoretical Perspectives and Treatment Implications. Journal of Child and Adolescent Psychiatric Nursing. Volume 20, No. 1, Page 27039.Minnis, H. and Keck, G. (2003). A clinical/research dialogue on Reactive Attachment Disorder. Attachment & Human Development. Volume 5, No. 3, 297-301. Minnis, H., Marwick, H., Arthur, J., and McLaughlin, A. (2006). Reactive attachment disorder- a theoretical model beyond attachment. Child Adolescent Psychology. Page 336-341. Schwartz, E., Reed, S., Davis, A. (2006). Reactive Attachment Disorder: Implications for School Readiness and School Functioning. Psychology in the Schools. Volume 43(4). Shaw, S. and Paez, D. (2007).Reactive Attachment Disorder: Recognition, Action, and Considerations for School Social Workers. National Association of Social Workers. Page 69-95. Tibbits-Kleber, L. and Howell, R. (1985). Reactive Attachment Disorder of Infancy (RAD). Journal of Clinical Child Psychology. Volume 14, No. 4, Page 304-310. Tobin, D., Wardi-Zonna, K., Yezzi-Shareef A. (2007). Early Recollections of Children and Adolescents Diagnosed with Reactive Attachment Disorder. The Journal of Individual Psychology. Volume 63, No. 1.Weir, Kyle N. (2007) Using Integrative Play Therapy with Adoptive Families to Treat Reactive Attachment Disorder: A Case Example. Journal of Family Psychotherapy. Volume 18.Wingert, P. and Nemtsova A. (2007). When Adoption Goes Wrong. Newsweek. Volume 150, Issue 25.