Reactive Attachment Disorder A Guide to the Symptoms, Risk Factors, and Treatment

Reactive Attachment
A Guide to the Symptoms,
Risk Factors, and Treatment
of RAD
What is Reactive Attachment
Disorder (RAD)?
„ Reactive attachment disorder is a rare but serious mental health
condition in which infants and young children don’t establish
healthy bonds to parents or caregivers.
Children with reactive attachment disorder typically were
neglected or abused in infancy, passed through many foster
homes, or lived in orphanages where their emotional needs
weren’t well met.
Reactive Attachment Disorder
What is Reactive Attachment
Disorder (RAD)?
„ Because their basic needs for comfort, affection, nurturing and
stimulation weren’t met, these infants and children didn’t learn
how to create loving and caring attachments with other people.
They can’t give or receive affection.
„ Attachment disorders can limit a child’s ability to be emotionally
present, flexible and able to communicate in ways that build
satisfying and meaningful relationships.
Reactive Attachment Disorder
What is Reactive Attachment
Disorder (RAD)?
„ Reactive attachment disorder is often enmeshed in controversy.
• Both its diagnosis and treatment are difficult, and parents
and caregivers are commonly distressed as they try to cope
with the disorder and a seemingly uncaring child.
• Some nonconventional treatment methods have been
associated with the deaths of several children, escalating the
• Despite the challenges, a commitment to proven psychiatric
treatment may help these children enjoy a better quality of
life and develop more stable relationships.
Reactive Attachment Disorder
Recognizing RAD: Symptoms
„ Reactive attachment disorder is broken into two types:
• Inhibited, and
• Disinhibited.
„ While some children have signs and symptoms of just one type,
many children have both.
Reactive Attachment Disorder
Recognizing RAD: Symptoms
™ Inhibited type
In inhibited reactive attachment disorder,
children shun relationships and attachments
to virtually everyone. This may happen
when a baby never has the chance to
develop an attachment to any caregiver.
Signs and symptoms of the inhibited type may include:
• Avoiding eye contact
• Appearing to seek contact
but then turning away
• Avoiding physical contact
• Difficulty being comforted
• Preferring to play alone
Reactive Attachment Disorder
• Resisting affection from parents or
• Failing to initiate contact with
• Appearing to be on guard or wary
• Engaging in self-soothing
Recognizing RAD: Symptoms
™ Disinhibited type
In disinhibited reactive attachment disorder, children form
inappropriate and shallow attachments to virtually everyone,
including strangers. This may happen when a baby has multiple
caregivers or frequent changes in caregivers.
Signs and symptoms of the disinhibited type may include:
• Readily going to strangers, rather than showing stranger
• Seeking comfort from strangers
• Exaggerating needs for help doing tasks
• Inappropriately childish behavior
• Appearing anxious
Reactive Attachment Disorder
Recognizing RAD: Symptoms
„ Other symptoms of an attachment disorder may include:
low self-esteem; needy, clingy or pseudo-independent behavior;
inability to deal with stress and adversity; depression; apathy; whining;
susceptibility to chronic illness; obsession with food - hordes, gorges,
refuses to eat, eats strange things, hides food; bed-wetting
lack of self-control or impulse control; inability to develop and maintain
friendships; alienation from caregivers or authority figures; aggression
or violence; self-destructive behaviors; inappropriate sexual conduct;
manipulating; difficulty with genuine trust & affection; lack of empathy
or remorse; hopeless, pessimistic view of self, family and society
behavioral problems at school; speech and language problems;
incessant chatter and questions; difficulty learning
„ Because attachment affects all aspects of development,
symptoms of RAD may mirror – and be partly responsible for –
developmental problems including ADHD and autism.
Reactive Attachment Disorder
Recognizing RAD: Diagnosis
„ RAD usually presents by age 5, but a parent, caregiver or
physician may notice that a child has problems with emotional
attachment by their first birthday.
„ Often, a parent brings an infant or very young child to the doctor
with one or more of the following concerns:
severe colic and/or feeding difficulties
failure to gain weight
detached and unresponsive behavior
difficulty being comforted
preoccupied and/or defiant behavior
inhibition or hesitancy in social interactions
disinhibition or inappropriate familiarity or closeness with strangers
Reactive Attachment Disorder
Recognizing RAD: Diagnosis
„ A thorough medical and psychological evaluation is necessary
when it’s thought that a baby or child may have reactive
attachment disorder.
„ The disorder can be similar to other disorders, including autism,
developmental disorders, social phobia, conduct disorders and
attention-deficit/hyperactivity disorder.
In fact, a child with reactive attachment disorder may also have
other disorders as well.
Reactive Attachment Disorder
Recognizing RAD: Diagnosis
„ A complete and thorough evaluation should include:
• The baby’s or child’s pattern of behavior over time
• Examples of behavior in a variety of situations
• The baby’s or child’s relationship with parents or caregivers
as well as others, including other family members, peers,
teachers and child care providers
• The home and living situation
• Parenting and caregiver styles and abilities
Reactive Attachment Disorder
Recognizing RAD: Diagnosis
„ To be diagnosed with reactive attachment disorder, a baby or
child must meet criteria outlined 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.
Only a trained physician or psychologist
can accurately diagnose RAD.
If you have concerns for your child, you
should consult a physician immediately.
Reactive Attachment Disorder
Recognizing RAD: Diagnosis
• The main criteria for the diagnosis of reactive attachment
disorder include:
Disturbed and developmentally inappropriate social
relationships beginning before age 5
Failure to respond to or initiate social interactions, or
being inappropriately friendly and familiar with strangers
Failure of early care to meet the baby’s or child’s
emotional needs for comfort and affection, failure of early
care to attend to the child’s physical needs, or repeated
changes in the primary caregiver
• Consider getting a second opinion if you have questions or
concerns about the diagnosis or treatment plan.
Reactive Attachment Disorder
Possible Causes of RAD
„ Among the basic needs of
a human being are safety,
security, and trust.
An attachment disorder is formed
when these needs are not only
not met, but also ignored.
„ If healthy attachments aren’t formed in infancy and early
childhood, a child won’t have the experiences they need to grow
up feeling confident in themselves or trusting of others.
Reactive Attachment Disorder
Possible Causes of RAD
„ Children who lack proper care and attention in the first few years
of life have a high level of stress hormones. This affects the way
important elements of the nervous system and the brain system
This may lead to attachment
disorders. These disorders may be
reflected in learning problems,
social problems, mental problems
and failed personal and
interpersonal relationships.
Reactive Attachment Disorder
Possible Causes of RAD
„ It’s not known what causes some babies and children to develop
reactive attachment disorder, and what causes others to be
But a variety of theories about attachment may help explain
some of the emotional processes that give rise to the disorder.
Reactive Attachment Disorder
Possible Causes of RAD
™ Traditional attachment
theory says that to feel
safe and develop trust,
infants and young children
need a stable, nurturing
Their basic emotional and
physical needs must be
consistently met. In
addition, interactions with
babies must be caring and
positive, not harsh or
Reactive Attachment Disorder
Possible Causes of RAD
™ Traditional attachment theory (cont’d)
• For example, when a child seeks out assistance from a parent,
it should be met promptly with a shared emotional exchange
that includes eye contact, smiling and comfort.
• In contrast, a child who is left to self-care or handled roughly
without kind words and warm facial expressions may feel
rejected and insecure.
• When those negative interactions happen repeatedly, the child
learns that he/she can’t rely on adults for nurture and love. The
child becomes distrustful and unattached.
• Children who seek comfort from a caregiver but are met with
hostility or abuse become confused and conflicted — wanting
closeness but turning away from it for fear of rejection or harm.
Reactive Attachment Disorder
Possible Causes of RAD
The cycle of attachment:
Reactive Attachment Disorder
Possible Causes of RAD
™ Other attachment theories suggest that emotional interactions
between babies and caregivers actually shape neurological
development in the brain.
• They say that interactions cause the formation of neural
networks within the brain, which ultimately influence a baby’s
personality and relationships throughout life.
• In babies whose needs aren’t met with caring and love,
these neural networks don’t form properly, creating
attachment problems.
Reactive Attachment Disorder
Risk Factors for RAD
„ Reactive attachment disorder is considered rare.
However, there are no accurate statistics on how many babies
and children have the condition.
„ It can affect children of any race or either sex.
„ By definition, reactive attachment disorder begins before age 5,
although its roots start in infancy.
Reactive Attachment Disorder
Risk Factors for RAD
„ Factors that may increase the chance of developing reactive
attachment disorder include:
Physical, sexual or emotional abuse or neglect
Separation from a primary caregiver
Living in an orphanage or group home
Frequent changes in foster care or caregivers
Inexperienced parents
Institutional care
Prolonged hospitalization
Extreme poverty
Forced removal from a neglectful or abusive home
Significant family trauma, such as death or divorce
Other traumatic experiences, such as natural disaster
Postpartum depression in the baby’s mother
Parents who have a mental illness, anger management problems, or drug
or alcohol abuse
Reactive Attachment Disorder
I suspect my child may have RAD …
what now?
If you think your baby or child may have reactive attachment
disorder or you feel that a strong bond isn’t developing,
consider seeking a medical or psychological evaluation.
Professionals to seek out:
See your physician or pediatrician.
Talk with an educational consultant to help you find the
right program for your child and help with the child’s school
Consult with a therapist or counselor. Your child’s
physician or pediatrician will be able to refer you for help, if
Reactive Attachment Disorder
I suspect my child may have RAD …
what now?
Treatment of reactive attachment disorder often involves a mix
of psychotherapy, medications and education about the
It may involve a team of medical and mental health providers
with expertise in attachment disorders. Treatment usually
includes behavior modification for both the baby/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
Reactive Attachment Disorder
I suspect my child may have RAD …
what now?
Treatment of this complex disorder involves BOTH the child
and the family.
Therapists focus on understanding and strengthening the
relationship between a child and his or her primary caregivers.
Reactive Attachment Disorder
I suspect my child may have RAD …
what now?
There’s no standard treatment for reactive attachment
disorder. However, it often includes:
Individual psychotherapy
Recreation/Play therapy
Family therapy
Education of parents and caregivers about the condition
Parenting skills classes
Medication for other conditions that may be present, such as
depression, anxiety or hyperactivity
Residential or inpatient treatment for children with more serious
problems or who put themselves or others at risk of harm
Special education services
Reactive Attachment Disorder
I suspect my child may have RAD …
what now?
Without treatment for reactive attachment disorder, a child’s
social and emotional development may be permanently
Complications and related conditions may include:
9 Developmental delays
9 Malnutrition
9 Eating problems
9 Growth delays
9 Relationship problems in
9 Drug and alcohol addiction
9 Depression
9 Anxiety
Reactive Attachment Disorder
9 Academic problems
9 Aggression
9 Inappropriate sexual
9 Lack of empathy
9 Temper or anger problems
9 Bullying or being bullied
9 Trouble relating to
classmates or peers
Reducing the Risk of RAD
While it’s not known if reactive attachment disorder can be
prevented with certainty, there may be ways to reduce the risk of its
If your baby or child has a background that includes
orphanages or foster care, educate yourself about attachment
and develop specific skills to help your child bond.
If you lack experience or skill with babies or children, take
classes or volunteer with children so that you can learn how to
interact in a nurturing manner.
Be actively engaged with babies and children in your care by
playing with them – for example, talking to them, making eye
contact or smiling at them.
Reactive Attachment Disorder
Reducing the Risk of RAD
Learn to interpret your baby’s cues, such as different types of
cries, so that you can meet his or her needs quickly and
Don’t miss opportunities to provide
warm, nurturing interaction with
your baby or child, such as during
feeding, bathing or diapering.
Teach children how to express
feelings and emotions with words.
Lead by example, and offer both verbal and nonverbal
responses to the child’s feelings through touch, facial
expressions and tone of voice.
Reactive Attachment Disorder
Repairing Attachments
in Youth with RAD
Recent studies show that it’s never
too late to create positive change
in a child’s life, or in an adult’s,
for that matter.
The learning that accompanies
new experiences can alter neural
connections in the brain.
Relationships with relatives, teachers and childcare providers can
supply an important source of connection and strength for the
child’s developing mind.
[Taken from (2007):
Gina Kemp, M.A., Jaelline Jaffe, Ph.D., Jeanne Segal, Ph.D., & Sheila Hutman]
Reactive Attachment Disorder
Repairing Attachments
in Youth with RAD
Taken from (2007):
Gina Kemp, M.A.,
Jaelline Jaffe, Ph.D.,
Jeanne Segal, Ph.D.,
& Sheila Hutman
In attempts to repair attachments with children, here are some
things to consider:
Attachment is an interactive process.
It is an evolutionary fact that our brains are structured to
connect to one another. The attachment process alters the
brains of both parent and child.
But what makes attachment so unique is that the stronger,
older, more experienced parent attunes and follows the lead of
the younger, less experienced, more vulnerable child.
However, following a child’s lead does not mean that that the
child makes all the decisions. It does mean that the caretaker
follows and responds to the child’s emotional needs when
Reactive Attachment Disorder
Repairing Attachments
in Youth with RAD
Taken from (2007):
Gina Kemp, M.A.,
Jaelline Jaffe, Ph.D.,
Jeanne Segal, Ph.D.,
& Sheila Hutman
Attachment is a nonverbal process.
Attachment takes place many months and even years before
speech and thought develop. Communication is accomplished
through wordless means that rely on several things to convey
interest, understanding and caring:
Visual – eye contact; facial expression;
posture ; gesture & body movement.
Auditory – tone of voice; speech rhythm
and rate; timing, intensity and voice
Reactive Attachment Disorder
Repairing Attachments
in Youth with RAD
Taken from (2007):
Gina Kemp, M.A.,
Jaelline Jaffe, Ph.D.,
Jeanne Segal, Ph.D.,
& Sheila Hutman
Children vary in what they find soothing.
There is no “one size fits all” for every child.
In determining what constitutes “just right” communication for a
particular child, it will be up to the adult to follow the nonverbal
cues of that child.
What soothes a parent may not
soothe a child. Thus, parents may
have to explore the best techniques
for soothing their child and
themselves in order to make
a connection.
Reactive Attachment Disorder
Repairing Attachments
in Youth with RAD
Taken from (2007):
Gina Kemp, M.A.,
Jaelline Jaffe, Ph.D.,
Jeanne Segal, Ph.D.,
& Sheila Hutman
Attachment can’t begin until both parties feel safe with
one another.
Attachment is akin to falling in love, but unless both adult and
child feel completely safe, it will not be successful.
When adults are anxious, mad, tuned out or overwhelmed,
they will not be able to make a connection with a child.
If a child is overwhelmed or inconsolable, he may not be
available for an emotional connection.
Sensory activities such as rocking, singing, moving, touching,
and feeding can sooth children, but remember that youngsters
vary in their sensory preferences.
Reactive Attachment Disorder
Repairing Attachments
in Youth with RAD
Taken from (2007):
Gina Kemp, M.A.,
Jaelline Jaffe, Ph.D.,
Jeanne Segal, Ph.D.,
& Sheila Hutman
Positive emotional experiences are as important to share
as negative.
The shared positive emotional experiences of joy are as
important to the attachment bond as the shared negative
emotional experiences of fear, sadness, anger and shame.
Some parents are very good at detecting a child’s distress and
responding appropriately to it. Other parents share joyous
moments but leave or space out in times of trouble and
A strong attachment bond includes the full range of shared
emotional experience – including joy.
Reactive Attachment Disorder
Repairing Attachments
in Youth with RAD
Taken from (2007):
Gina Kemp, M.A.,
Jaelline Jaffe, Ph.D.,
Jeanne Segal, Ph.D.,
& Sheila Hutman
No matter how much we love our children, there comes a
point where we are not in agreement with them – a point
when we have to set limits, and say “no.”
This conflict temporarily disrupts the relationship while the
child protests or lashes out. Such protest is to be expected.
The key to strengthening the attachment bond of trust is to be
available the minute the child is ready to reconnect.
Parents aren’t perfect. From time to time, parents are the
cause of the detachment, but your willingness to initiate repair
can strengthen the attachment bond.
Reactive Attachment Disorder
Coping Strategies for Caregivers
Reactive attachment disorder can be especially challenging for
parents, because children with RAD may have no interest in
pleasing their parents – they do not reward parents with the
cues of pleasure, appreciation and affection that motivate
parental investment in children.
In fact, a complete stranger may elicit the exact same
response from a child with RAD as does a loving and
protecting parent.
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.
Reactive Attachment Disorder
Coping Strategies for Caregivers
You may find it helpful to:
9 Join a support group to connect with others facing the same issues.
9 Find respite care so that you can periodically have downtime if
caring for your child is particularly troublesome.
9 Be willing to call for emergency help if your child becomes violent.
9 Continue friendships and social engagements.
9 Practice stress management skills.
9 Acknowledge that the strong or ambivalent feelings you may have
about your child are natural.
9 Take time for yourself through hobbies or exercise.
9 If your child is adopted or in foster care, reach out to your agency
for attachment resources.
Reactive Attachment Disorder
Coping Strategies for Caregivers
Parents and caregivers also may want to consider seeking
professional treatment or counseling for themselves or other
family members to help cope with the stress of having a child
with reactive attachment disorder.
Reactive Attachment Disorder
Coping Strategies for Caregivers
Reactive Attachment Disorder
Because symptoms of
reactive attachment disorder
can last for years, treatment
may be long term.
But, in time and with
patience, even severe
attachment disorders can be
Name: __________________________
Date: ________
Children with RAD typically have not had their emotional needs well met in infancy
or early childhood.
True False
Attachment disorders can limit a child’s ability to communicate and build relationships.
True False
If a child has RAD, he/she will always appear fearful of and withdrawn from others.
True False
Children with RAD often have other social disorders, such as autism or ADHD.
True False
RAD is a fairly common disorder, and effects children of all ages.
True False
Common risk factors for RAD include childhood abuse or frequent changes in caregivers. True False
Treatment for RAD is something the child goes through by him or herself.
True False
You can prevent RAD by expressing your care for your child through non-verbal cues
such as eye contact, touch, facial expression, and tone of voice.
True False
Creating new attachments with your child cannot begin until both of you
feel safe with one another.
True False
Because symptoms of RAD can last for years, treatment may be long term.
True False
Reactive Attachment Disorder