Vol. 19, No. 3
July 2014

Reactive Attachment Disorder

Reactive attachment disorder (RAD) is a disruptive disorder believed to be caused by chronic and severe neglect in early childhood. RAD was first added to the Diagnostic and Statistical Manual of Mental Disorders (DSM) in the 1980s. Researchers and practitioners have been wrestling to clearly identify and treat it ever since.

RAD Has Been Redefined
Until recently there were two types of RAD: emotionally withdrawn/inhibited and indiscriminately social/disinhibited. Now the DSM-V, which appeared in 2013, classifies these disorders as separate diagnoses: RAD, which involves emotionally withdrawn and inhibited behaviors, and disinhibited social engagement disorder (DSED) which involves indiscriminately social and disinhibited behaviors.

RAD's new narrower, more targeted definition is now characterized by a child who is inhibited and withdrawn from adult caregivers, rarely seeks or responds to comfort when they are upset, and has persistent social and emotional disturbances, such as minimal responsiveness to others, minimal positive emotions, and irritability, sadness, or fear during non-threatening social interactions.

One of the reasons the DSM-V separates RAD and DSED are their different progressions. After children have been placed in a stable environment, research shows that signs of RAD disappear over time and become quite rare. Symptoms of DSED take much longer to resolve (Zeanah, et al., 2004).

Diagnosis Can Be Difficult
RAD is generally diagnosed in children between the ages of 9 months and 5 years. Assessments of RAD past school age can be quite difficult; by this age early attachment experiences are just one of many factors that determine emotion and behavior (Mercer, 2006). The American Academy of Child and Adolescent Psychiatry (Boris, et al., 2005) does not recommend diagnosing RAD in children over age 5.

Diagnosing RAD can also be difficult because it shares traits with disorders such as autism spectrum disorder, intellectual disability, oppositional defiance disorder, conduct disorder, social phobia, and PTSD. Diagnosis is further complicated by the fact that compared to other children, children with RAD experience higher rates of general behavior problems, social problems, somatic complaints, anxiety/depression, thought and attention problems, delinquent or aggressive behavior, and/or a lack of empathy (Buckner, et al., 2008).

It should also be noted note that fetal alcohol exposure is quite common among children in foster care (Ospina & Dennett, 2013). Caregivers who see their child as having a Fetal Alcohol Spectrum Disorder (FASD) may be much more understanding of the child's behavior, since this is a neurological problem, not psychiatric. A more positive attitude by caregivers, in turn, may enhance attachment security and promote healthy development for the child (Potter, 2014).

RAD Is Rare
The DSM-V estimates that RAD is very uncommon, occurring in less than 10% of severely neglected children. A study in the United Kingdom looked at all children aged 6-8 in a low-income area and found RAD's prevalence rate to be 1.4% (Minnis, et al., 2013).

If You Think RAD's a Possibility
Child welfare professionals who see troubling behavior or are concerned about RAD due to the child's history should ensure the child is assessed by a skilled practitioner familiar with diagnosing and treating RAD. A thorough psychosocial history of the child should be gathered to help with the differential diagnosis. Additionally, because serious, chronic, social neglect is inherent in a RAD diagnosis, child welfare workers should assess the child's living situation carefully to ensure the child is receiving attentive and appropriate care (Hornor, 2007).

Treatment
At present we do not have effective interventions specifically for RAD. Efforts are being made to develop them, however. For example, the latest NIMH grant for Attachment and Biobehavioral Catch-Up (ABC) is for treatment of RAD. The Bucharest Early Intervention Project, which began in fall 2000, is also designed specifically for the treatment of RAD.
In the meantime, other treatments aimed at attachment disorders in general have led to improvement for children with RAD. Programs such as Parent-Child Interaction Therapy, Behavior Management Training, and the Incredible Years may provide a place to start therapy. In time these programs may build the evidence base for effective RAD treatment (Buckner, et al., 2008).

Treatment for RAD should involve work with caregivers as well as the child, assuming caregivers are psychologically healthy enough to participate (Boris, et al., 2005). It may also be beneficial for the caregiver--whether foster, adoptive, or biological--to engage in their own therapy. Children with RAD often respond to caregivers in difficult ways. Therapy can help caregivers process their own reactions and learn to respond in a therapeutic manner (Lyons, 2007).

References for this and other articles in this issue