Reactive Attachment Disorder (RAD): What is it and how can it be treated?

Jason Brien.

     Reactive attachment disorder (RAD) is a condition whereby an infant or young child was not provided the opportunity to form healthy and secure attachments with their primary care givers (i.e., mothers, fathers, grandparents, pre-school teachers, etc). This inopportunity may have resulted from neglect and abuse, caregiver drug use, caregiver mental health issues, caregivers compelled to work long hours, post-partum depression or a variety of other reasons. Children diagnosed with this condition will often have difficulty forming and maintaining relationships with others and they will most likely have difficulty regulating and managing their emotions. Furthermore, children diagnosed with RAD typically won’t seek out comfort, love and care from their caregivers as this vital need was never learnt during their most vulnerable time of development. This disorder is recognised by the Diagnostic and Statistical Manual of Mental Disorders Edition 5 (DSM-5) and the diagnostic criteria for RAD includes:

• A consistent pattern of emotionally withdrawn behavior toward caregivers, shown by rarely seeking or not responding to comfort when distressed
• Persistent social and emotional problems that include minimal responsiveness to others, no positive response to interactions, or unexplained irritability, sadness or fearfulness during interactions with caregivers
• Persistent lack of having emotional needs for comfort, stimulation and affection met by caregivers, or repeated changes of primary caregivers that limit opportunities to form stable attachments, or care in a setting that severely limits opportunities to form attachments (such as an institution)
• No diagnosis of autism spectrum disorder (Reactive attachment disorder can present diagnostically similar to Autism Spectrum Disorder (ASD) which is why ASD must be ruled out first).

     Most professionals believe that children diagnosed with RAD maintain the capacity to form attachments however the ability to do so was impaired due to their early life experiences and lack of healthy bonding opportunities. If treatment approaches are enacted before the onset of adulthood, whilst the brain is still malleable and the child has not become overly rigid in their ways, intervention will most likely lead to improved outcomes.  Whilst there is no one prescribed method for treating RAD, the most common treatment goals seek to provide a child with consistent, safe and reliable living conditions and assist the child to develop positive interactions with parents, guardians, caregivers, etc, which, over time, will hopefully lead to strong and secure attachments. Treatment strategies which may help achieve these goals may include;

• Fostering the child's development through nurturance, responsiveness, validation and caring
• ensuring consistent and stable caregivers to help establish a stable attachment for the child,
• providing a stimulus rich and positive environment for the child,
• meeting the child's medical, safety, housing, schooling, social and religious/cultural needs,
• family and individual counselling/psychotherapy.

Resources

Giltaij, H. P., Sterkenburg, P. S., & Schuengel, C. (2017). Convergence between observations and interviews in clinical diagnosis of reactive attachment disorder and disinhibited social engagement disorder. Clinical Child Psychology and Psychiatry, 22(4), 603–619. https://doi.org/10.1177/1359104517709049 

Humphreys, K. L., Nelson, C. A., Fox, N. A., & Zeanah, C. H. (2017). Signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years: Effects of institutional care history and high-quality foster care. Development and psychopathology, 29(2), 675–684. https://doi.org/10.1017/S0954579417000256 

Lehmann, S., Monette, S., Egger, H., Breivik, K., Young, D., Davidson, C., & Minnis, H. (2020). Development and Examination of the Reactive Attachment Disorder and Disinhibited Social Engagement Disorder Assessment Interview. Assessment, 27(4), 749–765. https://doi.org/10.1177/1073191118797422 

Nelson, R., Chadwick, G., Bruce, M., Young-Southward, G., & Minnis, H. (2020). Can reactive attachment disorder persist in nurturing placements? A systematic review and clinical case series. Developmental Child Welfare, 2(2), 110–131. https://doi.org/10.1177/2516103220940326