Best practice guidelines for treatment of reactive attachment disorder MAIN MESSAGES OVERVIEW

Best practice guidelines for treatment of reactive attachment disorder
• Reactive attachment disorder
(RAD) is thought to develop in
children demonstrating a
disorganized style of
attachment with their
caregiver and is related to the
development of
psychopathology later in life.
Reactive attachment disorder (RAD) is diagnosed in children who
demonstrate disturbed or developmentally inappropriate social
relationships and have a history of pathogenic care. RAD is thought to be
linked with the disorganized style of attachment and related to the
development of psychopathology later in life.
• An important practice in the
treatment of RAD is to improve
the relationship between the
child and parent or caregiver.
• Recommended practice
parameters in assessing and
treating RAD include ensuring
that direct observation of the
child with the primary
caregiver is structured, so that
patterns in child behaviour can
be observed.
Interventions exclusively targeting RAD are limited. There are, however,
some well-supported interventions that do not specifically focus on RAD
but do centre on improving the child-parent relationship – a best practice
treatment recommendation. Common themes for treatment include
focusing on improving the child’s understanding of emotions and social
cues, working on behaviour management and recognizing culture as an
important consideration, especially in the case of international
placement or adoption.
In 2005, the American Academy of Child and Adolescent Psychiatry
published practice parameters on the assessment and treatment of RAD.
Practice recommendations include ensuring that assessment involves
direct observation of the child with the primary caregiver, as well as
unfamiliar adults and other adults who may be able to attest to the
child’s early relationship with the caregiver (pediatrician, case worker,
school employee and others). Initial observations should be relatively
structured, so that patterns in behaviour with multiple adults can be
observed. It is important also to gather a history of the child’s
attachment behaviour.
Evidence In-Sight is a free service that responds to practice-related questions from Ontario child and youth mental health agencies. Evidence-In-Brief summarizes
those answers to provide a snapshot of available knowledge on a particular topic. The information is not exhaustive, and is intended to support – rather than
direct – evidence-informed decision making. The Ontario Centre of Excellence for Child and Youth Mental Health is pleased to offer these products as part of our
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Reactive attachment disorder continued
Assessing the caregiver’s attitude toward, and perception about, the child is important for treatment selection.
Parents may react with anger or anxiety because of their child’s maladaptive attachment behaviour, which
may affect their style of discipline and further escalate the problematic relationship. After ensuring the child is
in a stable and safe environment, treatment should focus on creating positive interactions with caregivers.
There are three options for intervening to improve interactions between the child and caregiver: working with
the caregiver alone; working with the child-caregiver dyad; or working with the child alone.
Since RAD may result from pathogenic care, the child could be at risk for other conditions such as
developmental disorders, untreated medical conditions, or speech and language difficulties. Referral to other
professions for medical examination is a recommended practice. Children who display aggressive or defiant
behaviour may require adjunctive treatment. Parent education or even multi-systemic therapy used for the
treatment of aggression in oppositional defiant disorder may be useful.
For the full Evidence In-Sight report on treating reactive attachment disorder, please contact Valerie Repta.
See the full list of Evidence In-Sight reports available on our website.
Reactive attachment disorder, best practice, treatment guidelines, attachment disorders, treatment for
attachment disorders, RAD