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How Common is Reactive Attachment Disorder (RAD)?

June 28, 2013

Last September, my colleague Suzette Lamb, LPC-S and I sat at the Irving Convention Center in Irving, TX listening to Daniel Siegel, MD, a pioneer in the field of Interpersonal Neurobiology. Dr. Siegel’s work has been instrumental in my understanding and conceptualization of attachment – as well as trauma, memory integration, and affect regulation. To say that Suzette and I were excited to be in Irving would be a gross understatement! I took copious amounts of notes, typing as fast as I could. At one point in the lecture, Suzette and I stopped and turned to each other. She tilted her legal pad in my direction and used her pen to point to the exact same phrase I had also just typed out. “Reactive Attachment Disorder is extremely rare.”

Why does the Diagnosis Matter?

One of the primary purposes of assessment and diagnosis is to inform clinical treatment. The treatment for depression is different than the treatment for schizophrenia. The treatment for anxiety is different than the treatment for ADHD. Proper diagnosis assists the clinician in determining the appropriate course of treatment. Keeping this in mind, it is much more helpful to assess a child’s attachment patterns while concurrently considering the impact of early trauma as opposed to labeling a child with Reactive Attachment Disorder. These two pieces of information- attachment patterns and the impact of early trauma- are more powerful pieces of information than a label of Reactive Attachment Disorder when determining how to help a child heal. (Heal trauma, heal attachment, heal trauma, heal attachment…repeat).

Reactive Attachment Disorder could not exist without early relationship trauma. Unfortunately, when a child is diagnosed with RAD, it is easy to lose sight of the child’s tragic beginnings, focusing instead on the current maladaptive behaviors that led to the diagnosis. Reactive Attachment Disorder has become a description of the child. It has come to be synonymous with “hopeless,” “unable to attach,” and even “sociopathic.” It is talked about as if the child merely chooses not to attach. Although I doubt this was the intention when RAD first made its way into the DSM, it is the unfortunate outcome. RAD has become a diagnosis that is all-too-quickly suggested for any child with a history of attachment trauma. The most serious negative impact of this diagnosis that I have seen is how it shifts a parent and professional’s view of the child away from the trauma.

Disorganized Attachment Pattern

Attachment patterns develop between a child and their caregiver. The ideal attachment pattern is a secure attachment. There are three types of insecure attachment: anxious/ambivalent, avoidant, and disorganized. The child with a disorganized attachment pattern is stuck in the unsolvable dilemma of being terrified of their attachment figure. One part of their nervous system protects them from danger and screams “RUN!! GO AWAY!” while simultaneously another part of their nervous system compels them to seek safety and proximity from their primary attachment figure. The disorganized child cannot solve this contradiction- to be compelled both toward and away from the same person- and the result is a disorganized attachment; there is no solution or adaptation possible for the child.

Rather than asking yourself “Does my child have Reactive Attachment Disorder” it is more helpful to ask yourself what style of attachment your child demonstrates. If your child experienced abuse or neglect, he likely has a disorganized pattern (85% of children who experience abuse or neglect develop a disorganized attachment pattern) (Dan Siegel, MD).

Impact of Trauma

The second thing to consider when doing assessment and treatment planning for a child with early developmental trauma is “How was my child’s brain and nervous system impacted by trauma?” “What current behavioral problems are the result of early trauma being triggered?” “What is the PURPOSE of my child’s behaviors when I consider how that behavior served them during the trauma?”

Reframing the child’s behaviors helps us find our empathy. Understanding the origins of their behavior helps us know where to begin with trauma resolution, linking up those implicit and explicit memories. These ‘stuck’ memories and a dysregulated nervous system (due to trauma and neglect) are what is contributing to the behaviors commonly associated with RAD. Instead of asking ourselves WHY our children cannot let go of these maladaptive behaviors, we should ask ourselves when this behavior was adaptive.

I agree with Dr. Siegel that RAD is extremely rare, much more rare than is currently diagnosed. Regardless of the accuracy of the diagnosis, consider your child’s attachment pattern (is it disorganized?) along with their history of early trauma. You may find that this is more helpful information to consider than a diagnosis of Reactive Attachment Disorder.

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Robyn Gobbel, LCSW is a child and family therapist in Austin, Texas specializing in adoption, trauma, and attachment counseling. She is the founder of the Central Texas Attachment & Trauma Center.

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12 Comments leave one →
  1. Laura Langston permalink
    June 28, 2013 8:59 am

    Robin- I have been following you on FB and reading your blog for awhile now. This article compels me to tell you how much I appreciate your work and how right on the money you are! This article is so important and absolutely accurate. Thank you. I am both the mother of a 16 year old foster-adopted child and an MFT. I fostered her at 4 and adopted at 6. She has had a RAD diagnoses for years and while she has the hx and the behaviors associated with it, to me it doesn’t matter because what matters is how I (we) respond to how she perceives herself and her life. As a professional, I have seen how we use diagnoses to determine our course of tx and I have resisted this with attachment kids because this is never a one size fits all deal. I see attachment on a spectrum and think a more accurate diagnoses (if we must label) is complex PTSD anyways. I really love what you said and completely agree that what we as parents and clinicians should be looking for is what is the purpose of the child’s behavior- that is where the clues of understanding are. As a therapeutic mom that is how I have best been able to serve my child and not go completely crazy or give up. You are so right in saying that this understanding is where empathy can be found. I love the work you are doing as a parent and a professional. Keep on keeping on! I appreciate you! Laura

  2. June 28, 2013 10:04 am

    Love this! Totally agree and sharing everywhere!!!

  3. lisa c permalink
    June 28, 2013 3:14 pm

    If I child has RAD does that mean the other sisters have it

    • July 3, 2013 12:45 pm

      Hi Lisa- No! I have seen bio siblings react much differently to attachment trauma, some doing very well, some demonstrating symptoms of RAD.

  4. July 3, 2013 9:17 am

    You say–“The disorganized child cannot solve this contradiction- to be compelled both toward and away from the same person- and the result is a disorganized attachment; there is no solution or adaptation possible for the child.”
    Did you mean that the child has no solution? but parents need to provide a solution?
    I am looking forward to your next posts, because yes there are a lot of RAD DX’s out there.

    • July 3, 2013 11:02 am

      Great question! When I’m describing disorganized attachment here, I’m describing the situation in which a disorganized attachment is formed. Most of my kids come from abusive/neglectful environments in which the disorganized attached was created, but certainly some children experience this paradox even in biological homes, particularly if there is mental illness, substance abuse, or a parent who has a really really hard time with emotional regulation and can look ‘scary’ to a child, even if there is no violence. The fact that there is no solution means that a child wants to go toward and away from the same person. In other attachment styles, children can find a solution or adaption…but not here. The tricky part is when a child has a disorganized attachment as a result of trauma in someone else’s home, and then brings that disorganization into your home! Hopefully a child is adopted by a parent or caregiver with a strong secure attachment. By having that good attachment base, concurrent with good trauma work, the child’s symptoms should begin to decline.

  5. March 18, 2016 10:50 am

    Has there been any research done on the genetic side of this disorder? Or any links between certain genes that would make one child more more at risk to develop RAD from trauma than another child that has experienced the same trauma?
    My 5 yo adopted daughter is finally beginning treatment for this. She comes from a sibling group of 10 with the same bio-parents for all 10. The interesting thing is that she only spent 6 months in the home before being removed by CPS for neglect.
    Her insecure attachment is believed to be a result of traumatic visits that went on 2 times a week for 3 years after. While this has caused a problem for her it seemed to be more beneficial for the other older siblings. Regardless of what good this may have done for any of the children there are still 8 out of the 10 that display significant signs of RAD in an extremely similar way.
    It seems very interesting to me that with this being such a rare disorder it has developed in so many children one sibling group.
    Any additional information would be greatly appreciated.
    Jacy

  6. Robert Hafetz permalink
    November 6, 2017 10:14 am

    RAD is poor way to understand attachment related problems. I will argue that it doesnt exist. What we see in adoption is trauma in the context of attachment but fundamentally a trauma response that must be mitigated. The problem with RAD is that it has no criteria regarding the parents dysfunction or inability to attach and blames the child for the problem. With proper training parents can be taught how to respond to attachment compromised children and build a secure attachment. That hardly ever happens and we must fault the adoption industry for that lack. When an adopted child displays behavior problems in attachment the parents role must be considered and their attachment history becomes a vital aspect of counseling.

  7. Robert Hafetz permalink
    November 11, 2017 10:35 am

    RAD is an ineffective way to understand attachment in adoption and foster children. Its criteria is so inadequate it should be removed until updated. Compromised attachment in adoption is the result of a trauma response. If we regard this as trauma in the context of attachment and treat the underlying trauma we will have more success. Further the RAD criteria places no value on the parents inability to attach. They may have their own attachment dysfunction, or little understanding of adoption related trauma and parenting. RAD places all the responsibility on the child when a family systems context must be applied. Sadly there is no diagnosis for adoption related trauma in the DSM 5. The closest match would be PTSD childhood onset but we need an adoption related preverbal trauma diagnosis.

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