Parenting Children with Reactive Attachment Disorder
Reactive Attachment Disorder (RAD)—

Reactive attachment disorder (RAD) is the broad term used to describe the severe and relatively uncommon
disorders of attachment characterized by markedly disturbed and developmentally inappropriate ways of relating
socially in most contexts, beginning  before the age of five. It can either take the form of a persistent failure to initiate
most social interactions or respond to them in a developmentally appropriate way, or present as indiscriminate
sociability, such as excessive familiarity with relative strangers.

Reactive attachment disorder is a disturbance of social interaction caused by neglect of a child's basic physical and
emotional needs, particularly during infancy. Babies placed in orphanages at birth and raised by multiple caretakers
without primary parent-figures can also develop this disorder, even if physical care was adequate.

RAD arises from a failure to form normal attachments to primary caregiving figures in early childhood. Such a failure
would result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages
of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's
communicative efforts. Not all, or even a majority of such experiences result in the disorder.

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.

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.

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 non-conventional treatment methods have been associated with the deaths of several children,
escalating the controversy. Despite the challenges, a commitment to proven psychiatric treatment may help these
children enjoy a better quality of life and develop more stable relationships.

Attachment Styles—

There are four attachment 'styles' known as secure, anxious-ambivalent, anxious-avoidant, (all organized) and
disorganized. The latter three are characterized as insecure.

A securely attached toddler will explore freely while the caregiver is present, engage with strangers, be visibly upset
when the caregiver departs, and happy to see the caregiver return.

The anxious-ambivalent toddler is anxious of exploration, extremely distressed when the caregiver departs but
ambivalent when the caregiver returns.

The anxious avoidant toddler will not explore much, avoid or ignore the parent - showing little emotion when the
parent departs or returns - and treat strangers much the same as caregivers with little emotional range shown.

The disorganized/disoriented toddler shows a lack of a coherent style or pattern for coping. Evidence suggests this
occurs when the care-giving figure is frightening thus putting the child in an irresolvable situation regarding
approach and avoidance. On reunion with the caregiver children can look dazed or frightened, freezing in place,
backing toward the caregiver or approaching with head sharply averted, or showing other behaviors that seem to
imply fearfulness of the person who is being sought. It is thought to represent a breakdown of an inchoate
attachment strategy and it appears to affect the capacity to regulate emotions.

Signs and symptoms—

Child:

· Avoids caregiver
· Avoids physical contact
· Difficult to comfort
· Indiscriminate sociability with strangers
· Resists social interaction
· Seeks isolation

Caregiver:

· Disregard for child's basic emotional needs for comfort, stimulation,
and affection

· Disregard for child's basic physical needs like food, toileting, and play

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.

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:

·        Appearing to be on guard or wary
·        Appearing to seek contact but then turning away
·        Avoiding eye contact
·        Avoiding physical contact
·        Difficulty being comforted
·        Engaging in self-soothing behavior
·        Failing to initiate contact with others
·        Preferring to play alone
·        Resisting affection from parents or caregivers

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:

·    Appearing anxious
·    Exaggerating needs for help doing tasks
·    Inappropriately childish behavior
·    Readily going to strangers, rather than showing stranger anxiety
·    Seeking comfort from strangers

Causes—

Although increasing numbers of childhood mental health problems are being attributed to genetic defects, reactive
attachment disorder is almost by definition based on a problematic history of care and social relationships. However,
reactive attachment disorder may resemble many other emotional disorders with an etiology in which a
predisposition or constitutional weakness is affected by an environmental stressor. It has been suggested that types
of temperament, or constitutional response to the environment, may make some individuals susceptible to the stress
of unpredictable or hostile relationships with caregivers in the early years. In the absence of available and
responsive caregivers it appears that some children are particularly vulnerable to developing attachment disorders.

Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. Abuse is
associated with developed, albeit disorganized attachment. This style is a risk factor for a range of psychological
disorders although it is not in itself considered an  attachment disorder under the current classification.

There is as yet no explanation for why similar abnormal parenting produces two distinct forms of the disorder. The
issue of temperament and its influence on the development of attachment disorders has yet to be resolved. RAD
has never been reported in the absence of serious environmental adversity yet outcomes for children raised in the
same environment vary widely.

Reactive attachment disorder is caused by neglect of an infant's needs for physical safety, food, touching, and
emotional bonds with a primary and/or secondary caretaker.

The risk of neglect to the infant or child is increased with parental isolation, lack of parenting skills, teen parents, or
a caregiver who is mentally retarded. A frequent change in caregivers (for example, orphanages or foster care) is
another cause of reactive attachment disorder.

Children adopted from foreign orphanages are commonly affected, particularly if they were removed from their birth
parents during the first weeks of life.

Most children are naturally resilient, and even those who have been neglected, have lived in orphanages or have
had multiple caregivers develop healthy relationships and strong bonds. It's not known what causes some babies
and children to develop reactive attachment disorder. But a variety of theories about attachment may help explain
some of the emotional processes that give rise to the disorder.

Traditional attachment theory says that to feel safe and develop trust, infants and young children need a stable,
nurturing environment. Their basic emotional and physical needs must be consistently met. In addition, interactions
with babies must be caring and positive, not harsh or negative. For instance, when a baby cries, his or her need for
a meal or a diaper must be met promptly with a shared emotional exchange that may include eye contact, smiling
and caressing.

A child whose bottle is propped up on his or her chest to self-feed or whose diaper is changed roughly without kind
words and warm facial expressions may feel rejected and insecure. When this happens repeatedly, the baby learns
that he or she can't rely on adults for nurture and love. The baby becomes distrustful and unattached. Babies 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.

Some 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 that 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.

Risk factors—

Reactive attachment disorder is considered uncommon. 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.

Factors that may increase the chance of developing reactive attachment disorder include:

·   Extreme poverty
·   Forced removal from a neglectful or abusive home
·   Frequent changes in foster care or caregivers
·   Inexperienced parents
·   Institutional care
·   Living in an orphanage
·   Parents who have a mental illness, anger management problems, or drug or alcohol abuse
·   Physical, sexual or emotional abuse
·   Postpartum depression in the baby's mother
·   Prolonged hospitalization
·   Significant family trauma, such as death or divorce

When to seek medical advice—

This disorder is usually identified when a parent (or prospective parent) is identified as being at high risk for neglect
or when an adoptive parent has difficulty coping with a newly adopted child.

If you have recently adopted a child from a foreign orphanage or another situation where neglect may have
occurred and your child exhibits these symptoms, see your health care provider.

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.

Consider getting an evaluation if your baby or child:

·        Avoids you
·        Doesn't seek out physical contact
·        Prefers not to be held
·        Seems uninterested in you
·        Usually likes to play alone
·        Will readily go to strangers

Screening and diagnosis—

RAD is one of the least researched and most poorly-understood disorders in the DSM. There is little systematically
gathered epidemiologic information on RAD, its course is not well established and it appears difficult to diagnose
accurately. Several other  disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders,
post traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused
with RAD leading to over and under diagnosis.

RAD can also be confused with neuropsychiatric disorders such as autism spectrum disorders, pervasive
developmental disorder, childhood schizophrenia and some genetic syndromes. Some children simply have very
different temperamental dispositions. Because of these diagnostic complexities, careful diagnostic evaluation by a
trained mental health expert with particular expertise in differential diagnosis is considered essential.

While RAD is likely to occur in relation to neglectful and abusive childcare, automatic diagnoses on this basis alone
cannot be made as children can form stable attachments and social relationships despite marked abuse and neglect.

A thorough medical and psychological evaluation is in order 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.

A complete and thorough evaluation should include:

·   Examples of behavior in a variety of situations
·   Parenting and caregiver styles and abilities
·   The baby's or child's pattern of behavior over time
·   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

To be diagnosed with reactive attachment disorder, a baby or child must meet criteria spelled out 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 and by insurance companies to reimburse for
treatment.

The main criteria for the diagnosis of reactive attachment disorder include:

·   Disturbed and developmentally inappropriate social relationships beginning before age 5
·   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
·   Failure to respond to or initiate social interactions, or being inappropriately friendly and familiar with strangers

Consider getting a second opinion if you have questions or concerns about the diagnosis or treatment plan.

Complications—

Without treatment for reactive attachment disorder, a child's social and emotional development may be permanently
affected.

Complications and related conditions may include:

·        Academic problems
·        Aggression
·        Anxiety
·        Bullying or being bullied
·        Depression
·        Developmental delays
·        Drug and alcohol addiction
·        Eating problems
·        Growth delays
·        Inappropriate sexual behavior
·        Lack of empathy
·        Malnutrition
·        Relationship problems in adulthood
·        Temper or anger problems
·        Trouble relating to classmates or peers
·        Unemployment or frequent job changes

Treatment—

All mainstream prevention programs and treatment approaches for attachment disorder for infants and younger
children are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the
caregiver, or if that is not possible, placing the child with a different caregiver. These approaches are mostly in the
process of being evaluated. The programs invariably include a detailed assessment of the attachment status or
caregiving responses of the adult caregiver as attachment is a two-way process involving attachment behavior and
caregiver response.

Some of these treatment or prevention programs are specifically aimed at foster carers rather than parents, as the
attachment behaviors of infants or children with attachment difficulties often do not elicit appropriate caregiver
responses. Approaches include 'Watch, wait and wonder,' manipulation of sensitive responsiveness, modified  
'Interaction Guidance,' 'Preschool Parent Psychotherapy,' 'Circle of Security', Attachment and Biobehavioral Catch-
up (ABC), the New Orleans Intervention, and Parent-Child psychotherapy. Other treatment methods include
Developmental, Individual-difference, and Relationship-based therapy (DIR, also referred to as Floor Time) by
Stanley Greenspan, although DIR is primarily directed to treatment of  pervasive developmental disorders.

The relevance of these approaches to intervention with fostered and adopted children with RAD or older children
with significant histories of maltreatment is unclear.

In 2005 the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W.Boris and
C.H.Zeanah) based on its published parameters for the diagnosis and treatment of RAD. Recommendations in the
guidelines include the following:

1.        "Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child,
assessing the caregiver's attitudes toward and perceptions about the child is important for treatment selection."

2.        "Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional
behavior require adjunctive (additional) treatments."

3.        "Children with reactive attachment disorder are presumed to have grossly disturbed internal models for
relating to others. After ensuring that the child is in a safe and stable placement, effective attachment treatment
must focus on creating positive interactions with caregivers."

4.        "The most important intervention for young children diagnosed with reactive attachment disorder and who
lack an attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an
emotionally available attachment figure."

Treatment is twofold. The first priority is to make sure the child is currently in a safe environment where emotional
and physical needs are met.

Once that has been established, the next step is to alter the relationship between the caregiver and the child, if the
caregiver has caused the problem. Parenting skills classes can help with this. These skills give the caregiver an
ability to meet the child's needs and help them bond with their child.

The caregiver should also undergo counseling to work on any current problems, such as drug abuse or family
violence. Social Services should follow the family to make sure the child remains in a safe, stable environment.

Parents who adopt babies or young children from foreign orphanages should be aware that this condition may occur
and be sensitive to the needs of the child for consistency, physical affection, and love.

These children may be frightened of people and find physical affection overwhelming at first, and parents should try
not to see this as rejection. It is a normal response in someone who has been maltreated to avoid contact. Hugs
should be offered frequently, but not forced.

Treatment of reactive attachment disorder often involves a mix of psychotherapy, medications and education about
the disorder. It may involve a team of medical and mental health providers with expertise in attachment disorders.
Treatment usually includes both the baby or 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
relationships.

There's no standard treatment for reactive attachment disorder.

However, treatment often includes:

·   Education of parents and caregivers about the condition
·   Family therapy
·   Individual psychotherapy
·   Medication for other conditions that may be present, such as depression, anxiety or hyperactivity
·   Parenting skills classes
·   Recreation therapy or occupational therapy
·   Residential or inpatient treatment for children with more serious problems or who put themselves or others at risk
of harm
·   Special education services

Because symptoms of reactive attachment disorder can last for years, treatment may be long term. 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.

Nonconventional treatments:

Some forms of treatment of reactive attachment disorder remain highly controversial, and this has heightened in the
last several years after the deaths of several children were attributed to these methods. Some of these methods are
sometimes called re-parenting, re-birthing, and compression or holding treatment, and they often involve physical
restraint. However, not all of these methods are used the same way by all practitioners.

The American Academy of Child and Adolescent Psychiatry, the American Psychiatric Association, and the American
Professional Society on the Abuse of Children have all denounced as dangerous and unproven any practices that
involve tightly wrapping, binding or holding children while forcing eye contact, intentionally triggering a rage, or
ignoring pleas about breathing difficulties.

Prevention—

Early recognition is very important for the child. Once a parent is identified as being at high risk for neglect,
parenting skills should be taught. The patient should be followed by either a social worker or doctor to make sure
the child's needs are being met.

While it's not known if reactive attachment disorder can be prevented with certainty, there may be ways to reduce
the risk of its development:

·        Be actively engaged with babies and children in your care by playing with them, talking to them, making eye
contact or smiling at them, for example.

·        Don't miss opportunities to provide warm, nurturing interaction with your baby or child, such as during feeding,
bathing or diapering.

·        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.

·        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're an adult with attachment problems, it's not too late to get professional help. Getting help may prevent
you from having attachment problems with your children, who otherwise may also be at risk.

·        Learn to interpret your baby's cues, such as different types of cries, so that you can meet his or her needs
quickly and effectively.

·        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.

Coping skills—

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.

You may find it helpful to:

·   Acknowledge that the strong or ambivalent feelings you may have about your child are natural
·   Be willing to call for emergency help if your child becomes violent
·   Continue friendships and social engagements
·   Find respite care so that you can periodically have downtime if caring for your child is particularly troublesome
·   If your child was adopted, reach out to your adoption agency for attachment resources
·   Join a support group to connect with others facing the same issues
·   Practice stress management skills
·   Take time for yourself through hobbies or exercise

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