Diagnosing and Treating Reactive Attachment Disorder

Jamie M. Washington
Wake Forest University, Department of Counseling
ABSTRACT
Diagnosis of Reactive Attachment Disorder of Infancy, or Early Childhood (RAD) appears to be very
uncommon (American Psychiatric Association, 2000, p. 129). Children in early infancy need to be
nurtured in various, yet specific ways in order for their brains to make the connections necessary for
them to form healthy, secure attachments with their caregivers. Forming healthy attachments for
children is needed in order for them to be able to thrive in their environments; is a part of basic
human survival instincts; and central to lifespan development. In cases of severe neglect, children
are at a greater risk of forming insecure, unhealthy attachments which compromises their ability to
establish and maintain relationships later on in life. The overall impact on peoples lives can be
damaging, and is only made worse when the disorder is not properly diagnosed and goes untreated.
Mental health clinicians are faced with the dilemma of how to effectively diagnose the disorder, and
provide the best treatment so that favorable outcomes can be achieved. In order for clinicians to
address this dilemma RAD must first be distinguished from developmental disorders as well as
anxiety disorders. This literature review will; (a) provide additional background information about
RAD; (b) include a discussion about the disorders significance; ( c) reveal strategies used to find
the most current literature on the disorder; (d) identify potential gaps in the current research; and ( e)
provide recommendations for future research and study. Additionally, this review will explore the
prevalence of RAD, and attempt to uncover threads of epidemiological data that might help to
improve upon past limitations in diagnosis and treatment. RAD remains one of the least evidence
based areas of DSM and ICD nosology (Kay & Green, 2012, p. 115). Case studies of children
diagnosed with RAD will be briefly examined to help pinpoint potential evidenced-based
approaches that might be useful in treating the disorder. In conclusion, a standard evidenced-based
approach to treating RAD has not been identified. Providing clinicians and caregivers with the
proper psycho-educational tools is imperative, and will likely be the best approach to treating this
disorder.

Diagnosing RAD:
Diagnosis of Reactive Attachment Disorder
of Infancy, or Early Childhood (RAD)
appears to be very uncommon (American
Psychiatric Association, 2000, p. 129).
According to the American Psychiatric
Association (2000), the essential feature of
Reactive Attachment Disorder (RAD) is
markedly disturbed and developmentally
inappropriate social relatedness in most
contexts that begins before age 5 years and is
associated with grossly pathological care
(Criterion A) (p. 127).
RAD is broken down into two different
subtypes, Inhibited Type and Disinhibited
Type.
According to the American Psychiatric
Association (2000), the inhibited subtype is
used to describe a childs failure to respond
to a majority of social interactions in a
developmentally appropriate way. In the
disinhibited subtype children are
indiscriminate in their sociability and
demonstrate a lack of selectivity when it
comes to attachment (American Psychiatric
Association, 2000). This is commonly
experienced as inappropriate friendliness
(Swain, Leckman, Volkmar, 2005, p. 55).

INTRODUCTION
An unborn child starts to form attachments to their mother in utero, and after birth an infant displays an
innate biological need to build on this relationship by receiving comfort when frightened, and
nourishment when hungry (Stinehart, Scott, & Barfield, 2012; Page, 2011). Infants attend to
human voices, recognize human faces, and gaze into parents eyes when being fed (Hardy, 2007, p.
27). Infants do this because they rely solely on adult caregivers for all of their basic needs. The
quality of the interactions between caregiver(s) and infant is motivated specifically by the childs
need for safety and protection, both of which are central to lifespan development (Page, 2011, p.
31). According to the American Psychiatric Association (2000), the essential feature of Reactive
Attachment Disorder (RAD) is markedly disturbed and developmentally inappropriate social
relatedness in most contexts that begins before age 5 years and is associated with grossly
pathological care (Criterion A) (p. 127). The instrument used to measure and examine RAD is
attachment theory. Attachment theory suggests that infants are evolutionarily primed to form a
close, enduring, dependent bond on a primary caregiver beginning in the first moments of life
(Hardy, 2007, p. 27). Hardy (2007) further points out that infants look to their caregivers for cues
when faced with novel stimuli.
The best approaches to treating RAD appear to be; (1) support and education of a consistent caregiver;
(2) corrective social experiences for children; and (3) social skills training for children (Swain,
Leckman, Volkmar, 2005). Additional approaches that have proven effective in the treatment of
RAD include dyadic developmental therapy, family therapy, and integrative play therapy
(Stinehart, Scott, & Barfield, 2012, p. 357). The increasing popularity of international adoption of
older children has only added to the interest in RAD in recent years (Stinehart, Scott, & Barfield,
2012). It may be beneficial to parents considering adoption to learn more about RAD in order to be
able to make the best treatment decisions for their children, should they find themselves dealing with
a child with the disorder. In a mixed methods study consisting of qualitative focus groups and
whole population survey, Ferguson et al. (2011) concluded that Child and Adolescent Mental
Health Services (CAMHS) staff and residential workers may need more specialized training on
RAD to be able to recognize behaviors suggestive of the disorder (p. 101). Glowinski (2011) offers
that clinicians should consider the conditions endured by orphanage children and that, RAD
diagnoses must be made with parsimony, never reflexively, in adopted and/or fostered patients
exposed to deprivation (Glowinski, 2011, p. 211). Educating primary and secondary caregivers on
how to deal with children diagnosed with RAD is of the utmost importance. If the problems with
properly diagnosing and treating RAD persist, we run the risk of remaining at an epidemiological
stalemate; further complicating matters.

RESEARCH POSTER PRESENTATION DESIGN 2012

www.PosterPresentations.com

CONCLUSION

R E S U LTS
Treating RAD:
The best approaches to treating RAD
appear to be support and education of a
consistent caregiver; corrective social
experiences for children; and social skills
training for children (Swain, Leckman,
Volkmar, 2005).
Additional approaches that have proven
effective in the treatment of RAD include
dyadic developmental therapy, family
therapy, and integrative play therapy
(Stinehart, Scott, & Barfield, 2012, p. 357).
Weir (2011) suggests play therapy for
clinicians who are seeking an attachment
based model of treatment for RAD.
Treatment for children with attachment
disorders must be developmentally
appropriate. In that vein, superheroes are
ideal vehicles for treating RAD because as
Wenger (2007) suggests, they appeal to
the limbic system due to their strong visual
and emotional stimulus value (p. 195).
Wenger (2007) posits that it is the limbic
system that appraises facial expression,
posture, tone of voice, and tempo of
movement. Superheroes are rich in all these
cues (p. 195). Wenger (2007) further
states:
In addition to the power of the superhero
fantasy to contribute to the corrective
experience, the dramatic self-presentation
inherent in the superheros costume functions
much like the mothers face. In this context,
the costume is associated with positive
feelings as well as the promise of hope,
rescue, safety, and trust. Equally important,
the superheros visual impact arouses strong
emotion, which can evoke affect and
contribute to self-regulation (p. 195).

Integrative play-therapy has been identified by some clinicians as the

most beneficial form of therapy for treating children with RAD, and
has been noted as being particularly successful with adoptive and
foster families (Steinhart, Scott, & Barfield, 2012, p. 357; photo
courtesy of howstuffworks.com).

METHOD

Play therapy appears to be emerging as the best treatment for children diagnosed with RAD. One of
the main limitations of current research on RAD, however, is that researchers have still not
identified a standard evidenced-based treatment for the disorder. Steinhart et al. (2012) suggest that
counselors use therapies that have been successful in treating disorders with similar symptoms.
Follan et al. (2011) offer that, clinical diagnosis of RAD can be made reliably by clinicians,
especially when focusing on eight core RAD symptoms. Clear discrimination can be made between
children with RAD and children with ADHD (p. 520).
Finally, a lot of effort has been put into pointing out the shortcomings of secondary caregivers who
support children suffering from RAD. While this may be useful in uncovering current issues with
the quality of care, it provides no useful information about the number of incorrect diagnoses
children receive or improve the quality of treatment. Additionally, attachment theory appears to be
the only instrument used in research on RAD. Attachment theory provides a reasonable explanation
for why neglected and maltreated children are at a greater risk of developing RAD, however, it
provides little information about why a majority of maltreated and neglected children never develop
the disorder. Perhaps a closer look at this will lead to more clues about effective evidenced-based
treatment for RAD.

REFERENCES
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., Text Revision).
Washington, DC: Author.
Ferguson, L., Follan, M., Macinnes, M., Furnivall, J., Minnis, H.,. (2011). Residential childcare workers' knowledge of reactive
attachment disorder. Child and Adolescent Mental Health, Vol 16(2), 101-109. doi: 10.1111/j.1475-3588.2010.00575.x.
Follan, M. & Minnis, H. (2010). Forty-four juvenile thieves revisited: From Bowlby to reactive attachment disorder. Child:
Care, Health and Development, Vol 36(5),, 639-645. doi:10.1111/j.1365-2214.2009.01048.x.
Follan, M., Anderson, S., Huline-Dickens, S., Lidstone, E., Young, D., Brown, G., Minnis, H. (2011). Discrimination between
attention deficit hyperactivity disorder and reactive attachment disorder in school aged children. Research in Developmental
Disabilities, Vol 32(2), 520-526. doi: 10.1016/j.ridd.2010.12.031.
Gleason, M.M., Fox, N. A., Drury, S., Smyke, A., Egger, H.L., Nelson, C.A., III; Gregas, M.C.; Zeanah, C.H. (2011). Validity of
evidence-derived criteria for reactive attachment disorder: Indiscriminately social/disinhibited and emotionally
withdrawn/inhibited types. Journal of the American Academy of Child and Adolescent Psychiatry v50 n3, 16.
Glowinski, A. (2011). Reactive attachment disorder: An evolving entity. Journal of the American Academy of Child and
Adolescent Psychiatry, Vol 50(3), 210-212. doi: 10.1016/j.jaac.2010.12.013.
Hardy, L. (2007). Attachment theory and reactive attachment disorder: Theoretical perspectives and treatment implications.
Journal of Child and Adolescent Psychiatric Nursing, Vol 20(1), 27-39. doi: 10.1111/j.1744-6171.2007.00077.x.
Haugaard, J.J. & Hazan, C. (2004). Recognizing and treating uncommon behavioral and emotional disorders in children and
adolescents who have been severly maltreated: Reactive attachment disorder. Child Maltreatment, Vol 9(2), 154-160. doi:
10.1177/1077559504264316.
Kay, C. & Green, J. (2012). Reactive attachment disorder following early maltreatment: Systematic evidence beyond the
institution. Journal of Abnormal Psychology, doi: 10.1007/s10802-012-9705-9.
Minnis, H., Green, J., O'Connor T.G., Liew, A., Glaser, D., Taylor, E., Follan, M., Young, D., Barnes, J., Gillberg, C., Pelosi, A.,
Arthur, J., Burston, A., Connolly, B., & Sadiq, F.A. (2009). An exploratory study of the association between reactive
attachment disorder and attachment narratives in early school-age children. Journal of Child Psychology and Psychiatry,
931-942. doi:10.1111/j.1469-7610.2009.02075.x.
Page, T. (2011). Attachment theory and social work treatment. In F. Turner, Social work treatment: interlocking theoretical
approaches (5th ed.) (pp. 30-47). New York, NY: Oxford University Press.
Stinehart, M. A., Scott, D. A., & Barfield, H. G. (2012). Reactive attachment disorder in adopted and foster care children:
Implications for mental health professionals. The Family Journal, Vol 20(4), 355-360. doi 10.1177/1066480712451229.
Swain, J.E., Leckman, J.F., Volkmar, F.R. (2005). The wolf boy: Reactive attachment disorder in an adolescent boy. Psychiatry,
Vol 2(11), 55-61.
Weir, K. (2011). Playing for Keeps: Integrating Family and Play Therapy to Treat Reactive Attachment Disorder. In A. B.
Drewes, Integrative Play Therapy (pp. 243-264. doi: 10.1002/9781118094792.ch14). Hoboken, NJ: John Wiley & Sons Inc,
xv, 399.
Wenger, C. (2007). Superheroes in play therapy with an attachment disordered child. In L. Rubin, Using Superheroes in
Counseling and Play Therapy (pp. 193-211). New York, NY: Springer Publishing Co. xxxiii.

Photo courtesy of wallsave.com

Relevant sources found in:

PsycINFO
PubMed

Parameters of search:
Sources published between the years 20002013.
Printed in English

Keyword search included:

Reactive Attachment Disorder
Diagnosing RAD
Treating RAD
Prevalence of RAD

Results of Search:
PsycINFO was the database that provided the
best results.
PsycINFO was the most user-friendly.
Literature addressed the issue of diagnosis and
treatment.

RECOMMENDATIONS FOR FUTURE RESEARCH

There is still a lot of ground to cover when it comes to finding the best evidenced-based approaches to
treating RAD. With RADs increased popularity in recent years it is necessary for the mental health
and education communities to direct more attention to the disorder. A great deal of the research on
RAD is done on adopted children and children living in foster care. While this demographic might
provide a great deal of information about the disorder as a whole, more needs to be done to include
the accounts of other maltreated children living in poverty across the globe. I understand that the
prevailing assumption is that a majority of maltreated children are either living in foster care or as a
part of adopted families. What is missing in current research are the narratives of the children who
may seek mental health treatment, but who receive inaccurate diagnoses because of the similarities
of the symptoms of developmental or anxiety disorders.