Reactive Attachment Disorder 101, a Review

Reactive Attachment Disorder 101
By Esther Bernstein
This book recently came out in 2121 as a short handbook introducing parents to the realities of Reactive Attachment Disorder (RAD) and some suggestions for seeking professional help. Written by a mother whose biological child suffered from RAD after a period of ill-health following the child’s birth, causing her to be separated from him for several months, this book illustrates the point that RAD does not only happen to adoptive or foster families. Any period of neglect or frequently changing caregivers can cause RAD in a child, especially if this occurs during infancy; but, only a small percentage of children who experience neglect end up with a RAD diagnosis. 

This is because many factors make up characteristics of resilience in each individual. One thing this book provides, which is probably the most unique, is quite a few real stories of families who have lived with RAD. Most of them are disturbing but necessarily honest. Not all of them have a happy ending. The author makes it known that she has tried to provide as many hopeful stories, where the child is doing well following therapy, as possible. She is attempting to provide hope and to emphasize the value of early diagnosis and intervention. What I felt was missing, was more description of the actual interventions that worked. I think the author may have left those descriptions out in order to not provide medical treatment advice without proper credentials. However, many of her pearls of wisdom may be helpful to parents in the trenches. I will include a few of those I thought were likely to be helpful. I apologize in advance to the author, as I will likely not be able to convey everything in the way that she would. These include the following:

1. Parents should attempt to see things from the child’s point of view. Children with RAD live in a state of fear. Having an emotional connection to a caregiver or sometimes a sibling is a fearful thing. Therefore, they do things to repel the caregiver. The caregiver is the “nurturing enemy.”
2. Those outside the home, and sometimes the father who is often gone to work are less of a threat and therefore behavior in front of them can be normal, which can seem manipulative.
3. A healing environment for a child with RAD is one where consequences are always predictable and the caregiver or household do not react in an emotionally charged way or allow the child to visibly alter the family’s plans. The child acts out in order to create chaos, get a negative response, and provoke a harsh reaction in a way they feel they have control over, because they were able to provoke it. The caregiver can counteract this by not showing how frustrated they are and providing consequences that are predictable but do not alter the caregiver’s plans.
4. Parents should practice keeping their facial expressions neutral in response to negative behaviors, and walk away to calm down when that is not possible. Parents of children with RAD have to become outwardly thick-skinned.
5. The child sees connection as something to be feared. The parent can help by reducing the amount of nurturing connection they try to provide the child. The parent should think of themselves as a “caregiver” rather than a parent for a period of time and withdraw from trying to force emotional bonding. The child must feel safe and that the home is predictable for a long time, possibly years, before they will then be ready to allow the parent to be a parent and display emotional connection. The parent can provide connection such as eye contact or touches at levels that they can tolerate or with permission.
6. Children with RAD usually need constant supervision. “Time outs” are a reward. “Time ins” are not desired and therefore may work as a consequence. But whether they are in trouble or not, a child with RAD should not be left unsupervised for any period of time. This gives them an opportunity to create chaos or misbehave in ways that push their caregiver away. They often need cameras and alarms on doors to monitor them at night as well.
7. Children with RAD lack an understanding of how their behaviors affect others. As a result, they may target siblings for physical or sexual abuse. This is another reason they need constant supervision.
8. The home environment should be as structured and supportive of the caregiver as possible. However, letting the child know what the schedule or plans are, gives them an opportunity to sabotage the plans.
9. Children with RAD often have a hard time with special plans or events such as holidays, birthdays, or vacations. They often sabotage special times. They may do this because they feel all good things end up bad, and they want to control the timing of the bad outcome. Or, they may do this when they can tell their caregiver or siblings care about something, as a way of pushing them away and creating chaos.
10. Parents should document daily activities, behaviors, and consequences as much as possible. This allows patterns to be seen by themselves and therapists, or other care team members, and used in the treatment plan. It also provides documentation if the child makes false accusations of abuse against the parent, which is common.
11. Parents should seek knowledgeable physicians, therapists, psychologists and other providers to create a treatment team. They should be prepared to help educate those who work with their child at school and family members and friends about RAD.
12. When a child poses a danger to other members of the family, they may have to receive out of home care for a period of time. Structured environments work best. Those that take RAD into account would be even better. instituteforattachment.org  in Colorado is one such place. 
13. Part of treatment usually involves relating consequences of the child’s actions to negative effects to them personally. They are not affected by general consequences or consequences to others. Negative consequences must relate to something they personally care about. Teaching them to make restitution can be helpful, meaning they have to repay those they have wronged with actions rather than just words. They may have to pay for something they broke, do chores to earn money to pay, write a letter of apology, clean up a mess, or some other action.
14. Small victories should be celebrated, but in a mild, non-threatening way. Children with RAD only understand and value tangible rewards, but they may easily use reward systems as an opportunity to manipulate, so behavioral intervention plans should be created with the help of a RAD informed therapist or psychologist. 
15. Marriages and family units are often strained by RAD. Caregivers often develop PTSD, anxiety/depression, or insomnia due to the physical and psychological targeting of the child toward the primary caregiver. The spouse often does not see these behaviors and struggles to deal with the aftermath of the effects on their spouse and family.
16. The caregiver and child can be supported by a good source of respite care. The respite caregiver should be consistently the same, be aware of RAD and the caregiver’s expectations for the child’s behavior, and ideally can provide respite at regular intervals in a predictable way.
17. Schools often struggle to work with children with RAD. The child could behave perfectly in school and only display negative behaviors at home. They could struggle academically due to the effects of neglect or prenatal substance exposure on the brain, but without a labeled disability, it may be hard to gain accommodations. Behaviors may also be explosive at school. Frequently, due to conflicts at school, parents will attempt to homeschool. This can create a downward spiral as this is forcing the child to be with the person who triggers their feelings of fear all the time and does not give the caregiver a break from constant structure, supervision, and negative behaviors either.
18. Early recognition, diagnosis, and development of a care plan can be vital to producing positive outcomes in the lives of children with RAD. As children are still developing, the sooner interventions can be made, the longer their brain will have to develop in positive ways.

In reading this book, I was hoping for a few more behavioral interventions or behavior management strategies. So, if that is what you are looking for, this may not be the resource which provides that. I feel it was helpful in providing a framework, or outline, of things to take into consideration for a parent of a child who is newly diagnosed with RAD, or suspects their child may have RAD. It provides a few websites and access to support groups related to RAD, as well. Unfortunately, this diagnosis does not have a large amount of evidence-based information available about it. Parents have had to form groups and nonprofits to support each other and pool collective knowledge. Some of these resources are out there, such as RADadvocates.org, and hopefully we can share this knowledge with parents who need it, and cannot wait for the science to catch up. 

Laura Shamblin MD