Reactive Attachment Disorder

Reactive Attachment Disorder (RAD) is a clinically recognized form of severe insecure attachment.

Reactive Attachment Disorder (RAD) is a clinically recognized form of severe insecure attachment. Children with RAD are so neurologically disrupted that they cannot attach to a primary caregiver or go through the normal developmental processes. These children cannot establish positive relationships with other people. Many of these children may have been incorrectly diagnosed as having severe emotional and behavioral disturbances ranging from attention-deficit hyperactivity disorder (ADHD) to bipolar disorder to depression. In response to these diagnoses, they may have received various combinations of unnecessary psychotropic mediation.

There are two major subtypes of Reactive Attachment Disorder: the inhibited type, characterized by the persistent failure to initiate and to respond to most social interactions in a developmentally appropriate way; and the disinhibited type, characterized by an indiscriminate sociability or a lack of selectivity in the choice of attachment figures.

Reactive Attachment Disorder is different from Severe Mental Retardation, or from a Pervasive Developmental Disorder such as Autistic Disorder. A child with Reactive Attachment Disorder has the capacity to comprehend social relationships, but does not function appropriately, while a child with Severe Mental Retardation or a Pervasive Developmental Disorder suffers from a neurologically based disability that impedes expected development in social relationships.

The cause of Reactive Attachment Disorder is not known. Most children with this disorder have had severe problems or disruptions in their early relationships. Many have been physically or emotionally abused or neglected. Some have experienced inadequate care in an institutional setting or other out-of-home placement (for example a hospital, residential program, foster care or orphanage). Others have had multiple or traumatic losses or changes in their primary caregiver.

The physical and emotional milestones of children with Reactive Attachment Disorder deviate from expected developmental norms. Many of the children appear significantly malnourished. They may show a pattern of inhibited, hypervigilant or ambivalent reactions (e.g., frozen watchfulness, resistance to comfort, or a mixture of approach and avoidance). Dullness, listlessness or apathy with a lack of spontaneous activity and reciprocity with the caregiver are often seen. Some children look sad, unhappy, joyless or miserable. Older infants show minimal curiosity about their surroundings and little exploratory behavior. They may show delayed responsiveness to a stimulus that might elicit fright or withdrawal in other children. Some may shrink from contact; others may exhibit indiscriminate attachments.

The severity and the course of the disorder vary, depending on individual factors in the child and the caregiver, the degree of the associated psychosocial deprivation, the length of time spent in the deprived environment, the nature and adequacy of the intervention, and the age of the child at the time of intervention. Considerable improvement or remission may occur if a disorder follows a continuous course. Possible interventions include, but are not limited to, the following:

Psychosocial support services, which can include providing homemakers, assessing the capacity of the caretakers, improving the physical condition of the home or obtaining more adequate housing, improving the financial status of the family, and decreasing the isolation of the family;
Psychotherapeutic intervention, which can include family or marital counseling and medications for associated difficulties. Treatment should target the symptoms, not just the attachment problems.
Educational/counseling services, which can include mother/infant groups and education to increase awareness and understanding of the child's needs and improve parenting skills;
Provisions for close monitoring of the progression of the infant's physical and emotional well-being;
Placement with relatives, foster care, or adoption may become alternatives should these interventions be unfeasible.

Reactive Attachment Disorder is a serious clinical condition. Fortunately, it is relatively rare. Evaluating and treating children with complex child psychiatric disorders such as Reactive Attachment Disorder is challenging. There are no simple solutions or magic answers. However, close and ongoing collaboration between the child's family and the treatment team will increase the likelihood of a successful outcome.

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