Treatment and Diagnosis of Reactive Attachment Disorder

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Reactive attachment disorder (RAD) occurs when a person does not form a healthy attachment with their primary caregiver during childhood. It is a rare but serious disease that can affect people well into adulthood.

RAD can occur as a result of childhood abuse, trauma, or neglect. Children with the disorder can I have difficulty forming relationships and feeling threatened by physical or emotional closeness.

Treatment for RAD involves creating a safe and secure environment and then treating the condition with psychotherapy. There are different types of therapies that can help.

Read on to learn more about RAD treatment.

In psychology, the term “attachment” refers to the bonds that people form with each other. According to attachment theory, the bonds that children form with their primary caregivers early in life influence their mental health and future relationships.

Usually, the primary caregivers are the parents, but they can also be grandparents, foster parents, or other people responsible for the care of the child.

When adults respond with love and affection most of the time, children form healthy or secure bonds with them. It is important for their development. The Challenges of Attachment may occur due to:

  • a lack of love and affection
  • separation of caregivers
  • early trauma

the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) specifically links RAD to neglect or abuse. When children don’t get the care and love they need, they don’t learn to form healthy attachments. They may find affection threatening.

In the general population, RAD is rare. In Canada, for example, the prevalence is about 1%. However, for children who have been abused or placed in an institution, the rate can be as high as 40%.

RAD is a serious disease, but it responds to treatment. The treatment of the disease involves several key elements:

Establish a healthy and safe environment

People cannot begin to recover from trauma until they feel safe. For this reason, a central part of RAD treatment is to provide a safe and healthy environment.

For children, this may mean addressing the behavior of family members, parenting training or family counseling. If the home environment is unlikely to become safe, they can stay with another caregiver.

For adults, establishing a healthy environment can mean ending harmful relationships, finding a safe place to live, or having a good support network of friends or family members.

Compassionate Care

If the person with RAD is a child or adolescent, their current caregivers should treat them with compassion during their treatment.

Children with RAD do not act on purpose. Instead, the behavior stems from intense emotional distress, fears of abandonment, and difficulty feeling secure in relationships. Punishing them for their behavior will not help.

Instead, caregivers can learn positive or non-punitive techniques for dealing with difficult behaviors. This helps reduce disturbances without punishing the child.

Caregivers can also benefit from learning other techniques, including:

  • how to identify triggers, which are events that trigger intense or overwhelming emotions
  • how to avoid triggers or how to soothe the child when they occur
  • how to understand and respond to non-verbal communication

Similarly, for adults with RAD, friends, family, or colleagues can provide support by learning about the disorder and its impact. They can offer emotional support or, if a person feels more comfortable, practical help. For example, they could accompany the person to appointments.

Therapy

Therapy, especially trauma-informed therapy, is the next step in RAD treatment.

There is no standardized approach to therapy for RAD, and researchers are still learning what works best. A person may benefit from trauma therapy to deal with the impact of traumatic memories. Attachment therapy is also an option. This is specifically aimed at helping people with attachment security.

Some may find it helpful to try different approaches or combine several. However, it is important to note that some once popular interventions for RAD are very harmful and do not work. In fact, they can intensify symptoms or lead to serious consequences. These include:

  • physical restraint or coercion, such as “therapeutic attire”
  • attempt to “rework” the trauma via “rebirth therapy” or similar approaches
  • regression therapy to promote “attachment”

RAD is a clinical diagnosis. This means that doctors diagnose the condition based on symptoms rather than physical tests.

For this reason, it can be difficult to diagnose RAD, as the symptoms can be similar to other conditions. For example, people with autism may have difficulty in social situations and those with conduct disorder exhibit dysregulated behaviors.

In addition, parenting practices vary by culture. For example, in Hawaii, parts of Africa, and India, children often refer to people outside their family by family terms, such as “aunt.” To a stranger, this may make the child seem too familiar when in fact they are typical.

For these reasons, children can only be diagnosed with RAD if they have a known history of trauma or neglect, and another condition does not better explain the symptoms.

Diagnostic criteria

the DSM-5 states that for a person to be diagnosed with RAD, they must:

  • being withdrawn and strongly inhibited, and having trouble finding comfort when distressed
  • have a history of abuse, neglect, mistreatment or deprivation
  • have at least two of the following symptoms:
  • be at least 9 months old, with symptoms appearing before age 5
  • not qualify for an autism diagnosis

Part of this process involves a child or adult talking to a doctor about the history of the trauma. It can be difficult. In some cases, there may be abuse that the child’s caregivers are unaware of, such as from a grandparent or foster parent.

Finding out if abuse has taken place can be difficult and, in some cases, may not be possible. If a person has the symptoms of RAD, but the cause is unclear, they should not try to diagnose themselves.

Only a medical professional can diagnose RAD, and self-diagnosis can mean a person doesn’t get the care they need if it’s incorrect.

If possible, speak to a medical professional with a background in attachment disorders or who works with traumatized children for help and expert advice.

It is important to find a mental health professional who specifically understands RAD and attachment theory. A therapist with more general training may not have the right skills to treat it.

Try asking for a referral or recommendation at:

  • child care agencies or authorities
  • a doctor or pediatrician
  • other therapists

Building a positive relationship with a therapist is an important part of psychotherapy. However, since attachment is difficult for people with RAD, it can be a difficult process. A person with RAD may feel like they don’t get along well with their therapist.

One indicator that the therapist is well adjusted despite this is the progress the person makes during treatment. If they don’t progress over time, they may benefit from switching to another.

Treatment for RAD may involve exploring the root causes and experiences that led to attachment disturbances. As RAD has strong ties to neglect and abuse, it can be a difficult process.

Sometimes neglect occurs when caregivers are unavailable to care for the child or when strong pressures prevent them from doing so. These pressures include:

  • poverty
  • difficulty accessing childcare
  • substance addiction
  • mental health problems
  • incarceration

Institutions, foster homes and group homes can also be problematic. In overcrowded settings, it is not always possible for children to get the care and attention they need.

It may be common in some orphanages to leave babies in cribs and not hold them too much. Isolation and lack of contact with loving caregivers can increase the risk of RAD.

A 2019 study found a lower rate of RAD among children living with their families in a community setting than children living in foster care or clinical settings, such as a psychiatric hospital.

Here are other examples of situations in which RAD can develop:

  • Instability: Children may have an attachment to a caregiver, but then experience a disruption in the relationship. For example, authorities may move a child through multiple foster homes during infancy, preventing him from forming deep attachments.
  • Forced separation: Conscription, imprisonment and other events can forcibly separate caregivers from children. An example of this is the United States government separating parents and children trying to enter the country.
  • Mourning: The death of a parent or primary caregiver can increase the risk of RAD if there is no other loving caregiver who can raise the child.

People concerned about their mental health or the well-being of a child can ask for help at any time.

For a child or teen who may have RAD, speak with a child psychologist or other mental health professional for an evaluation. It is especially important to do this if the person:

  • has a history of trauma or abuse and is not currently receiving support
  • has difficulty forming relationships with others
  • experiences severe distress disproportionate to the situation in which he finds himself
  • engages in antisocial or high-risk behavior, such as substance abuse or crime

Adults who think they may have RAD can also speak with a therapist. Family therapy or couples counseling can also be helpful because they can help people who love the person understand their attachment issues.

Reactive Attachment Disorder (RAD) occurs when a child experiences severe abuse or disruptions in their attachment to a primary caregiver. While the effects tend to be most apparent in childhood, they can have consequences for the rest of a person’s life.

It is impossible to change the circumstances that led to RAD, and it is a very serious condition with many long-term ramifications. A loving environment alone cannot cure it. However, with compassionate support, a safe environment, and psychotherapy, a person may be able to develop a healthier attachment style.

Learn more about the symptoms, impact and complications of RAD here.

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