Reactive Attachment Disorder - Foothills Behavioral Health Partners

Reactive Attachment Disorder - Foothills Behavioral Health Partners

Reactive Attachment Disorder (RAD) Clinical Guidelines
Developed in collaboration with the mental health centers associated with NBHP and FBHP
DSM-IV-TR Diagnostic Code: 313.89
Diagnostic Considerations:
1. Ensure diagnostic accuracy. RAD is a rare diagnosis (< 1%), and behaviors may be better accounted for
with other diagnoses. Research demonstrates that in reasonably responsive caregiving environments,
children generally develop at least one healthy attachment. RAD has never been reported in the absence of
serious neglect. Diagnosis requires the following: 1) disturbed and developmentally inappropriate social
relationships before age 5; 2) failure of the child to respond to or initiate social interactions, or inappropriate
friendliness with strangers; and 3) failure of early caregivers to meet emotional needs for comfort and
affection, attend to the child’s physical needs, or repeated changes in primary caregiver (pathogenic care
before age 5). Some children have signs and symptoms of one type, many children have both.
Two subtypes include:
 Inhibited: 1) resisting affection and comfort from caregivers; 2) avoiding both physical and eye
contact; 3) preferring to play alone; and 4) appearing to be on guard or wary.
 Disinhibited: may demonstrate inappropriate and indiscriminant attachment behavior to virtually
everyone, including strangers. Symptoms vary according to age and developmental stage and may
include: 1) readily going to strangers, rather than showing stranger anxiety; 2) exaggerating needs for
help doing tasks; 3) inappropriately childish behavior; and 4) appearing anxious or unable to focus.
2. Thorough clinical assessment by an experienced evaluator includes observation of child and caregiver
interactions in numerous contexts, review of attachment behaviors with caregivers, careful developmental
history (including placement and legal history), and observations of the child’s behavior with unfamiliar
adults. An assessment of abuse and/or neglect or maltreatment should be conducted. In addition to broad
behavioral measures, such as the Child Behavior Checklist (CBCL) or Behavioral Assessment Scale for
Children (BASC), the following semi-structured interviews may be useful: Disturbances of Attachment
Interview (DAI) for young children under 5; Child Attachment Interview (CAI) for middle childhood and
adolescence; Adult Attachment Interview (AAI) for older adolescents and adults; and the Preschool Age
Psychiatric Assessment (PAPA).
3. Healthy attachment occurs when, between birth and three years old, a child is consistently responded to in
a caring, sensitive, and attentive way. The child develops a sense of safety and security knowing that others
are available and supportive. Children with healthy attachments learn they are worthy of love, have positive
expectations about relationships, demonstrate reciprocity in relationships, display a range of emotions and
appropriate levels of eye contact and comfort seeking behaviors. Attachment is a spectrum. While some
children might display mild, or even moderate, attachment problems, this does not mean that full criteria for
a RAD diagnosis is met.
4. Review medical history and current health status. Children who experience extreme neglect may show
signs of growth delay, physical abuse, malnutrition, vitamin deficiencies, or infectious diseases. Encourage
annual visits with primary care provider, and coordinate care as appropriate.
5. Differential diagnosis should include mental retardation, autistic disorder and other pervasive
developmental disorders, language disorders, and posttraumatic stress disorder. There are a range of
disruptions in attachment that do not necessarily lead to developing RAD, though maltreatment, relational
trauma, or loss of an attachment figure increase the risk of developing other mental health disorders, such as
PTSD, disruptive behavior disorders, depressive and anxiety disorders. These can also co-occur with RAD.
6. Risk factors and protective factors. Secure attachment (children seeking closeness and contact from
caregiver when distressed and finding comfort in such contact) serves a protective function whereas
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disorganized attachment (mixture of approach and avoidance with caregiver, unable to be comforted) is a
risk factor, though insufficient in itself for diagnosis of RAD. Severe neglect during early childhood, and
long term institutional care are risk factors. Even in these extreme situations, however, the rates of RAD for
children raised in institutional settings and/or with severe neglect, is only 15%. The presence of one or more
consistent, responsive caregiver is protective, even in institutional settings or frequently disrupted foster
care placements. Little is known about the long term course of RAD. Prognosis is variable based on level of
environmental support. However, even with the development of attachments later in life, indiscriminate
sociability may persist.
7. Consider cultural factors during assessment that may influence behavioral norms such as acceptable
amount of eye contact, interpersonal space, parenting values, etc. For children adopted cross culturally, also
consider adaptive challenges when coming from orphanages in other countries, and how behaviors that
appear dysfunctional may have served an adaptive function in that environment.
Treatment Guidelines:
1. Treatment providers should have adequate training for the treatment of RAD, in particular child
development. Seek supervision, consultation, or additional training if needed before beginning treatment. Be
aware of community supports and additional resources or referrals to support the client and family.
2. The primary goal of treatment is to strengthen the relationship between the child and primary caregivers.
Working with families to develop or maintain a safe and stable living environment in which the child can
explore trusting relationships is key. In foster care or adoptive placements, collaborate with social services
and advocate for an emotionally available attachment figure. Support caregivers in providing a stable
environment.
3. Parenting skills can facilitate developing attachment. Work with the primary caregiver by educating about
distinguishing typical child development from symptoms of RAD. Help parents read the verbal and nonverbal cues of the child and attune to the child’s needs (physical and emotional) even when expressed
indirectly. Processing trauma and feeling intimacy creates fear responses from children with RAD, and fear
responses can look like aggressive behaviors, hoarding food and objects, or running away. The caregiver’s
messages of unconditional love allow the child to feel safe enough to process trauma and feel intimacy. Key
parenting tasks include teaching children how to identify emotions, develop empathy, and consistency in
support, caring, and reinforcement patterns. Discussion around how caregivers can effectively handle
rejection from the child (common in children with RAD) is helpful in maintaining stable placements.
4. Family therapy, that involves the child and caregiver working together to create positive interactions, is
one of the most important factors for treatment success. Two models of effective dyadic interactive therapy
for young children, which have been effective in cases of disturbed attachment, are Infant-Parent
psychotherapy and Interaction Guidance. Evidence suggests the most effective interventions include similar
components to effective child interventions in general, including: focused, goal-directed, behavioral
approaches targeted at increasing sensitive parental behaviors and including fathers as well as mothers in the
intervention. Parent Child Interaction Therapy is an evidence-based behavioral management intervention.
Family treatment approaches include: The Beyond Consequences Model and Bruce Perry’s Neurosequential Model (see resource list).
5. Individual psychotherapy for the child is considered adjunctive to working with the family. It can be
helpful to work with children at their developmental level on skills such as: understanding emotions, social
cues, understanding and responding effectively in interpersonal situations.
6. Ongoing collaboration with parents/caregivers, social services, teachers and medical providers is essential.
The clinician needs to provide support and education about RAD to the primary caregivers and providers
and help to create consistency between environments. Provide information about the persistent nature of
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RAD and its effect on learning, behavior, social skills and family functioning. Educate caregivers about how
children with RAD may respond and relate differently than other children in the home. There is often a need
for ongoing intervention, focused either on RAD or secondary conditions.
7. Support for parents/caregivers is important to the success of treatment. This may include individual
therapy and/or couples therapy to manage feelings of frustration, anxiety or anger. Support groups, such as
parenting support groups, can be helpful to connect with other families, to mutually learn coping skills, and
to help normalize their experiences. Recommend respite for parents to take breaks when needed.
8. Adjunctive treatments for families of children who also display aggressive and oppositional behavior may
benefit from EBP’s such as parent effectiveness training, multisystemic therapy and teaching caregivers
about redirecting behaviors and utilizing natural consequences. Trauma focused therapies, such as Trauma
Focused Cognitive Behavioral Therapy (TF-CBT), may also be helpful if indicated.
9. Alternative treatments, intended to provide “corrective attachment experiences” such as holding therapies,
"rebirthing" techniques, or forced eye-contact have been denounced by research and there is no scientific
evidence to support the effectiveness of such interventions. The use of such techniques has been associated
with serious injury and even death, and at the very least can lead to humiliation and fear. Be wary of
treatment approaches using the term “Attachment therapy” as this is a broad, vague term that sometimes
includes non-evidence based approaches.
10. Medication: There is no medication to treat RAD itself. However, medications may be used to treat
associated symptoms.
References and Resources for Clinicians
American Academy of Child & Adolescent Psychiatry (2005). Practice parameter for the assessment and
treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. 44
(24), NGC:004221. http://www.aacap.org/galleries/PracticeParameters/rad.pdf
American Psychiatric Association (2010). Reactive attachment disorder: A review for DSM-V.
http://www.dsm5.org/Proposed%20Revision%20Attachments/APA%20DSM5%20Reactive%20Attachment%20Disorder%20Review.pdf
Parent Child Interactional Training: Online Manual for clinicians
http://pcit.phhp.ufl.edu/Presentations/PCIT%20Integrity%20Checklists%20and%20Materials%204-13-06.pdf
Beyond Consequences Institute (bci) “Parenting Beyond Consequences, Logic, and Control: Towards a New
Alternative to Behavior Modification and Understanding why Consequences are Ineffective”
http://www.beyondconsequences.com/freearticle.pdf
Child Trauma Academy
http://www.childtrauma.org/index.php/articles/cta-neurosequential-model
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Reactive Attachment Disorder: Tips for families
Developed in collaboration with the mental health centers of NBHP and FBHP & the Client and Family Advisory Board
1. Be an active part of your child’s treatment. Family therapy, including the caregiver(s) and child, is
central to overall success. Be actively involved in setting treatment goals and educating yourself about
RAD. Let your teachers and daycare providers know about the diagnosis and any interventions you are
using. Ask for written materials and additional information from your providers (see attached resources.)
2. Ask questions. RAD is a very rare disorder (less than 1% of the population). Be sure your child has
been diagnosed by an experienced evaluator. Your therapist should be open to answering questions you
have about the treatment of RAD. You may want to ask about your therapist’s experience working with
other children with RAD, what treatment approach they use, and how they involve the family in therapy.
Feel free to seek a second opinion if you have questions or concerns about the treatment plan. Avoid
therapies not based in research such as therapies that include terms such as “holding,” “re-birthing,”
“reattachment.” The primary goal of therapy should be to support you and your child in developing and
enhancing a trusting and positive relationship that meets your child’s specific emotional needs.
3. Care about yourself. It is important that you take care of yourself in order to care for your child.
Establish a healthy lifestyle of regular exercise, good eating habits, adequate rest and participating in
activities with others that you enjoy.
4. Interact with your child through activities that your child enjoys (singing, playing games, shopping,
etc.) and encourage your child to participate. Quality time builds relationships. Practice activities that
promote trust. Work with your child’s therapist to assist you in choosing these activities. Your child
needs your help to learn how to trust.
5. Develop a routine. Consistency and structure are essential to your child’s success. This includes
mealtime, homework time, bedtime, and setting times for privileged activities such as TV, games and
computer. Regular schedules, planning for transitions and routines will help your child feel safe and
cared for. Ensure that structure is as consistent as possible between home and school. Disruptions in
routine can sometimes cause emotional and behavioral outbursts. Develop and practice skills for coping
with unexpected changes in plans.
6. Pay attention to your relationships. Caring for a child with RAD can be challenging and stressful. It
is important that you support others in your family, especially other children, and provide them with
information about the nature of RAD, and keep your family relationships and friendships strong. Create
a support network that includes support groups. Ask about respite care resources as well.
7. Consistency in responding to challenging behaviors is important and can be difficult. Be sure to discuss
the best ways to praise your child and discourage inappropriate behavior with your therapist. Children
with RAD may be more sensitive to physical methods of discipline, and these should be avoided.
Instead, use methods that involve logical and consistent consequences (see parenting resources).
8. Always listen when children are ready to share their thoughts and feelings. They may open up when
you least expect it.
9. Try to be hopeful. Many adoptive and foster parents feel frustrated and hopeless at times when building
a relationship with the child. It is normal for children with RAD to push others away in the beginning. It
may take time, but these relationships can improve with therapy and support. Supportive and consistent
environments improve outcomes.
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Resources for Clients
The Mayo Clinic: http://www.mayoclinic.com/health/reactive-attachment-disorder/DS00988
The American Academy of Child and Adolescent Psychiatry:
http://aacap.org/page.ww?name=Reactive+Attachment+Disorder&section=Facts+for+Families
Child Trauma Academy: Articles for caregivers
http://www.childtrauma.org/index.php/articles/articles-for-caregivers
Revised December 2012
Trastorno de vinculación reactiva: Consejos prácticos para familias
Desarrollado en Colaboración con los centros de salud mental de NBHP y FBHP & la Comisión Consultiva del
Consumidor y Familia
1. Tome una parte activa en el tratamiento de su hijo/a. La terapia familiar que incluye el niño y su(s)
cuidador(es) es fundamental para el éxito global. Participe activamente en el establecimiento de metas
para el tratamiento e infórmese sobre RAD (por sus siglas en inglés). Informe a los maestros y al
personal de la guardería sobre el diagnóstico y cualquier tipo de intervención que está usando. Pida
materiales por escrito e información adicional a sus proveedores (véase la lista de recursos adjunta.)
2. Haga preguntas. RAD es un trastorno muy raro (menos de 1% de la población). Asegúrese que su hijo
ha sido diagnosticado por un evaluador con experiencia. Su terapeuta debe ser abierto cuando le
contesta las preguntas que usted tenga sobre el tratamiento de RAD. Quizás usted quiere enterarse de la
experiencia que tenga el terapeuta trabajando con otros niños padeciéndose de RAD, cuál estrategia
utiliza en cuanto al tratamiento, y de qué manera participa la familia en la terapia. No dude en buscar
una segunda opinión si tiene preguntas o preocupaciones sobre el plan para el tratamiento. Evite
terapias no basadas en estudios, por ejemplo terapias que incluyen términos como “abrazando”
“renaciendo,” “re-apego.” La meta principal de la terapia debe ser apoyar a usted y a su hijo en
desarrollar y realizar una relación positiva, una de confianza, que cumple con las necesidades
emocionales específicas de su hijo.
3. Cuídese a sí mismo. Es importante que usted se cuida para poder cuidar a su hijo. Establezca un estilo
de vida sano que incluye ejercicio regular, buenos hábitos de comer, descanso suficiente, y la
participación en actividades que usted disfruta con otras personas.
4. Relaciónese con su hijo a través de actividades que le agradan (cantando, jugando juegos, yéndose de
compras, etc.) y anime a su hijo a participar. Se desarrollan las relaciones pasando tiempo dedicado a la
otra persona. Practique las actividades que fomentan la confianza. Trabaje con el terapeuta de su hijo
para que le ayude a escoger tales actividades. Su hijo necesita su ayuda para aprender a tener confianza.
5. Establezca una rutina. La consistencia y la estructura son esenciales al éxito de su hijo. Esto incluye
horas para comer, para cumplir tarea, para acostarse, y para programar actividades que son privilegios
como mirar la televisión, jugar juegos y usar la computadora. Los horarios regulares, las rutinas y la
preparación para transiciones le ayudarán a su hijo a sentirse seguro y cuidado. Asegúrese que esa
estructura es tan consistente como sea posible entre el hogar y la escuela. Interrupciones en la rutina a
veces pueden resultar en arrebatos emocionales y de comportamiento. Desarrolle y practique destrezas
para manejar cambios inesperados a los planes.
6. Fíjese en sus relaciones personales. Cuidar a un niño con RAD puede ser desafiante y estresante. Es
importante que usted apoya a los miembros de su familia, más que nada los demás niños, y
proporcionarles información sobre el índole de RAD. Mantenga las relaciones fuertes con sus familiares
y sus amistades. Cree una red de apoyo que incluye grupos de apoyo. Pida información sobre el
cuidado de reposo (respite care) también.
7. La consistencia en reaccionar a comportamientos desafiantes es importante y puede ser difícil.
Asegúrese de hablar con su terapeuta sobre las mejores maneras de elogiar a su hijo y de disuadir los
comportamientos inapropiados. Los niños con RAD pueden ser más sensibles a los métodos de
disciplina físicos, y éstos se deben evitar. Mejor use métodos que conllevan consecuencias lógicas y
consistentes (véase recursos para padres de familia).
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8. Siempre escuche cuando los niños están listos para compartir sus pensamientos y sus sentimientos. Es
posible que se abran y se sinceren cuando menos lo espera.
9. Trate de guardar la esperanza. Muchos padres adoptivos y de acogida (foster) se sienten frustrados y
desesperados en ciertos momentos cuanto se están forjando una relación con el niño. Es normal para los
niños que padecen de RAD aislarse de los demás al principio. Puede ser que dure tiempo, pero estas
relaciones pueden mejorarse con la terapia y apoyo. Los ambientes consistentes y apoyadores mejoran
los resultados.
Recursos para los clientes
The Mayo Clinic: http://www.mayoclinic.com/health/reactive-attachment-disorder/DS00988
The American Academy of Child and Adolescent Psychiatry:
http://aacap.org/page.ww?name=Reactive+Attachment+Disorder&section=Facts+for+Families
Child Trauma Academy: Articles for caregivers
http://www.childtrauma.org/index.php/articles/articles-for-caregivers
Revised December 2012