Reactive Attachment Disorder

[David Baxter PhD]

Reactive attachment disorder
By Mayo Clinic staff
July 16, 2009

Reactive attachment disorder is a rare but serious condition in which infants and young children don't establish healthy bonds with parents or caregivers.

A child with reactive attachment disorder is typically neglected, abused, or moved multiple times from one caregiver to another. Because the child's basic needs for comfort, affection and nurturing aren't met, he or she never establishes loving and caring attachments with others. This may permanently alter the child's growing brain and hurt their ability to establish future relationships.

Reactive attachment disorder is a lifelong condition, but with treatment children can develop more stable and healthy relationships with caregivers and others. Safe and proven treatments for reactive attachment disorder include psychological counseling and parent or caregiver education.

Symptoms
Reactive attachment disorder begins before age 5. Signs and symptoms of the disorder may begin when the child is still an infant.

Signs and symptoms in babies may include:

• Withdrawn, sad and listless appearance
• Failure to smile
• Lack of the normal tendency to follow others in the room with the eyes
• Failure to reach out when picked up
• No interest in playing peekaboo or other interactive games
• No interest in playing with toys
• Engaging in self-soothing behavior, such as rocking or self-stroking
• Calm when left alone

Signs and symptoms in toddlers, older children and adolescents may include:

1. Withdrawing from others
2. Avoiding or dismissing comforting comments or gestures
3. Acting aggressively toward peers
4. Watching others closely but not engaging in social interaction
5. Failing to ask for support or assistance
6. Obvious and consistent awkwardness or discomfort
7. Masking feelings of anger or distress
8. Alcohol or drug abuse in adolescents

As children with reactive attachment disorder grow older, they may develop either inhibited or disinhibited behavior patterns. While some children have signs and symptoms of just one type of behavior, many exhibit both types.

1. Inhibited behavior. Children with inhibited behavior shun relationships and attachments to virtually everyone. This may happen when a baby never has the chance to develop an attachment to any caregiver.
2. Disinhibited behavior. Children with disinhibited behavior seek attention from virtually everyone, including strangers. This may happen when a baby has multiple caregivers or frequent changes in caregivers. Children with this type of reactive attachment disorder may frequently ask for help doing tasks, have inappropriately childish behavior or appear anxious.

There's little research on signs and symptoms of reactive attachment disorder beyond early childhood. It may lead to controlling, aggressive or delinquent behaviors, trouble relating to peers, and other problems. While treatment can help children and adults cope with reactive attachment disorder, the changes that occur during early childhood are permanent and the disorder is a lifelong challenge.

When to see a doctor
If you think your child may have reactive attachment disorder, see a doctor. You may start by visiting your family doctor. However, if your child likely has reactive attachment disorder or another mental health problem, you'll need to see a doctor who specializes in the diagnosis and treatment of mental illness (psychiatrist) for a complete evaluation.

Consider getting an evaluation if your baby or child:

1. Prefers not to be held
2. Usually likes to play alone
3. Doesn't seek out physical contact
4. Avoids you
5. Will readily go to strangers
6. Seems uninterested in you

Causes
To feel safe and develop trust, infants and young children need a stable, caring environment. Their basic emotional and physical needs must be consistently met. For instance, when a baby cries, his or her need for a meal or a diaper must be met with a shared emotional exchange that may include eye contact, smiling and caressing.

A child whose needs are ignored or met with emotionally or physically abusive responses from caregivers comes to expect rejection or hostility. The child then becomes distrustful and learns to avoid social contact. Emotional interactions between babies and caregivers may affect development in the brain, leading to attachment problems and affecting personality and relationships throughout life.

Most children are naturally resilient, and even those who've been neglected, lived in orphanages or had multiple caregivers can develop healthy relationships and strong bonds. It's not clear why some babies and children to develop reactive attachment disorder and others don't.

Risk factors
Reactive attachment disorder is rare. However, there are no accurate statistics on how many babies and children have the condition. It can affect boys or girls. Reactive attachment disorder begins before age 5, usually starting in infancy.

Factors that may increase the chance of developing reactive attachment disorder include:

1. Living in an orphanage
2. Institutional care
3. Frequent changes in foster care or caregivers
4. Inexperienced parents
5. Prolonged hospitalization
6. Extreme poverty
7. Physical, sexual or emotional abuse
8. Forced removal from a neglectful or abusive home
9. Significant family trauma, such as death or divorce
10. Postpartum depression in the baby's mother
11. Parents who have a mental illness, anger management problems, or drug or alcohol abuse

Complications
Complications of reactive attachment disorder can continue into adulthood and can include:

1. Delayed learning or physical growth
2. Poor self-esteem
3. Delinquent or antisocial behavior
4. Relationship problems
5. Temper or anger problems
6. Eating problems, which can lead to malnutrition in severe cases
7. Depression
8. Anxiety
9. Academic problems
10. Drug and alcohol addiction
11. Unemployment or frequent job changes
12. Inappropriate sexual behavior

Tests and diagnosis
To be diagnosed with reactive attachment disorder, a baby or child must meet criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM). This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

The main criteria for the diagnosis of reactive attachment disorder must include:

1. Disturbed and developmentally inappropriate social relationships beginning before age 5, not due to developmental delay (mental retardation)
2. Failure to respond to or initiate social interactions, or being inappropriately friendly and familiar with strangers
3. Failure of early caregivers to meet the baby's or child's emotional needs for comfort and affection, failure of early caregivers to attend to the child's physical needs, or repeated changes in the child's primary caregiver

Psychiatric evaluation
A thorough, in-depth examination by a psychiatrist is necessary to correctly diagnose reactive attachment disorder. This type of evaluation can take 90 minutes or longer.

A thorough evaluation may include:

1. Direct observation of the baby's or child's interaction with his or her parents or caregivers
2. Details about the baby's or child's pattern of behavior over time
3. Examples of the baby's or child's behavior in a variety of situations
4. Information about how the baby or child interacts with parents or caregivers as well as others, including other family members, peers and teachers
5. An evaluation of the baby's or child's home and living situation since birth
6. An evaluation of parenting and caregiver styles and abilities

Your child's doctor will also want to rule out other possible causes of behavior problems or emotional issues. Signs and symptoms of reactive attachment disorder may resemble those related to other disorders, such as:

1. Post-traumatic stress disorder (PTSD)
2. Anxiety disorders
3. Adjustment disorder
4. Autism spectrum disorders
5. Social phobia
6. Conduct disorder
7. Attention-deficit/hyperactivity disorder (ADHD)

Disagreement over diagnosis methods
Not all experts agree on the signs and symptoms of reactive attachment disorder, or which tests should be used to diagnose the condition. Some therapists use checklists with numerous signs and symptoms that go beyond the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders. Be cautious when trying to interpret checklists that include such signs and 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 can be signs and symptoms of a number of mental health conditions.

Treatments and drugs
Treatment of reactive attachment disorder often involves a mix of psychological counseling, medications and education about the disorder. It may involve a team of medical and mental health providers with expertise in attachment disorders. Treatment usually includes both the baby or child and the parents or caregivers.

Goals of treatment are to help ensure that the baby or child has a safe and stable living situation and that he or she develops positive interactions with parents and caregivers. Treatment can also boost self-esteem and improve peer relationships.

There's no standard treatment for reactive attachment disorder. However, it often includes:

1. Individual psychological counseling
2. Education of parents and caregivers about the condition
3. Parenting skills classes
4. Family therapy
5. Medication for other conditions that may be present, such as depression, anxiety or hyperactivity
6. Special education services
7. Residential or inpatient treatment for children with more-serious problems or who put themselves or others at risk of harm

Other treatments for reactive attachment disorder that may be helpful include:

1. Development of attachment between the child and the child's therapist
2. Close, comforting physical contact

Managing reactive attachment disorder is a long-term challenge and can be quite demanding for parents and caregivers. You may want to consider seeking psychological counseling yourself or taking other steps to learn how to cope with the stress of having a child with reactive attachment disorder.

Controversial and coercive techniques
The American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, and the American Professional Society on the Abuse of Children have all criticized dangerous and unproven treatment techniques for reactive attachment disorder. Controversial practices can be psychologically and physically damaging and have led to accidental deaths.

Some unproven treatments for reactive attachment disorder include:

1. Re-parenting, rebirthing
2. Tightly wrapping, binding or holding children
3. Withholding food or water
4. Forcing a child to eat or drink
5. Yelling, tickling or pulling limbs, triggering anger that finally leads to submission

Beware of mental health providers who promote these methods. Some offer research as evidence to support their techniques, but none has been published in reputable medical or mental health journals.

If you're considering any kind of unconventional treatment, talk to your child's psychiatrist first to make sure it's legitimate and not harmful.

Coping and support
If you're a parent or caregiver whose baby or child has reactive attachment disorder, it's easy to become angry, frustrated and distressed. You may feel like your child doesn't love you — or that it's hard to like your child sometimes.

You may find it helpful to:

1. Join a support group to connect with others who have children facing the same issues. You may find a support group in your local community or on the Internet.
2. Check with social service agencies to see what resources are available in your community.
3. Find someone who can give you a break from time to time. It can be exhausting caring for a child with attachment disorder. You'll start to get burnt out if you don't periodically have downtime.
4. Be prepared to call for emergency help if your child becomes violent.
5. Practice stress management skills, such as yoga or meditation, to help you relax and not get overwhelmed.
6. Make time for yourself. Maintain your hobbies, social engagements and exercise routine.
7. Acknowledge it's OK to feel frustrated or angry at times, and that the strong feelings you may have about your child are natural.

Prevention
While it's not known if reactive attachment disorder can be prevented with certainty, there may be ways to reduce the risk of its development.

1. Educate yourself about attachment issues if your baby or child has a background that includes orphanages or foster care. This can help develop specific skills to help your child bond. Resources include books, pamphlets, Internet sites and support groups. You may want to check with an adoption agency to identify educational materials and other resources.
2. Take classes or volunteer with children if you lack experience or skill with babies or children. This will help you learn how to interact in a nurturing manner.
3. Be actively engaged with your child in your care by playing, talking to him or her, making eye contact or smiling often, for example.
4. Learn to interpret your baby's cues, such as different types of cries, so that you can meet his or her needs quickly and effectively.
5. Provide warm, nurturing interaction with your baby or child, such as during feeding, bathing or changing diapers.
6. Teach children how to express feelings and emotions with words rather than by acting out. Lead by example.
7. Offer both verbal and nonverbal responses to the child's feelings through touch, facial expressions and tone of voice.
8. If you're an adult with attachment problems, get help — it's not too late. Seeing a mental health provider not only may help you, but also may prevent you from having attachment problems with your children.

References

• Reactive attachment disorder of infancy or early childhood. In: Diagnostic and Statistical Manual of Mental Disorders DSM-IV-TR. 4th ed. Arlington, Va.: American Psychiatric Association; 2000. PsychiatryOnline - Home Accessed June 23, 2009.
• Reactive attachment disorder. In: Moore DP, et al.: Handbook of Medical Psychiatry. 2nd ed. Philadelphia, Pa.: Mosby; 2004. MDConsult.com Accessed June 23, 2009.
• Newman L, et al. Recent advances in the theories of and interventions with attachment disorders. Current Opinion in Psychiatry. 2007;20:343.
• Haugaard JJ, et al. Recognizing and treating uncommon emotional disorders in children and adolescents who have been severely maltreated: Reactive attachment disorder. Child Maltreatment. 2004;9:154.
• Cornell T, et al. Clinical interventions for children with attachment problems. Journal of Child and Adolescent Psychiatric Nursing. 2008;21:35.
• Hanson RF, et al. Reactive attachment disorder: What we know about the disorder and implications for treatment. Child Maltreatment. 2000;5:137.
• Report of the American Professional Society on the Abuse of Children Task Force on Attachment Therapy, RAD and Attachment Problems. American Psychiatric Association. RAD and Attachment Problems Accessed July 1, 2009.
• Coercive interventions for reactive attachment disorder. Association for Treatment and Training in the Attachment of Children. Attachment Disorder information and support at ATTACh.org Accessed July 1, 2009.
• Child Abuse and Neglect Committee. American Academy of Child & Adolescent Psychiatry. Coercive Interventions for Reactive Attachment Disorder | American Academy of Child & Adolescent Psychiatry Accessed June 29, 2009.

 

[Banned]

I've done an extensive amount of reading on RAD and how it affects both children and adults. Children with RAD are frequently referred to as RADishes.

There have been some tragic outcomes to treatment methods with children with RAD, such as the case of Candace Newmaker, who suffocated and died during a rebirthing session. Her story, and the story of several others, is here:

ACT - Victims of AT

(Note that all of these children were subjected to highly unethical and dangerous "treatment" methods. These stories may be triggering or disturbing to some.)