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Reactive Attachment Disorder
Basic Trust vs. Mistrust (Erikson)
Infants are totally helpless and
dependent on
If needs are met consistently,
the child learns to trust others,
and the foundation for a
secure attachment is laid.
If needs are not met
consistently, the child
becomes fearful and learns not
to rely on others.
The Attachment Cycle: First Year
The Attachment Cycle: 2nd Year
The 2nd year attachment
cycle cannot be started
until the first year secure
attachment cycle has
been met.
Children with insecure
attachment do not
progress to this 2nd year
Unhealthy Attachment & the Brain
Dr. Allan N. Schore’s 2001
article detailing the effects of
traumatic attachment on the
development of the right
hemisphere changed the way
RAD is conceptualized and
Traumatic attachment results
in periods of “hyperarousal and
dissociation,” which interferes
with the developing autonomic
nervous system & limbic
system of the right brain.
The structural changes in the
brain lead to ineffective stress
coping mechanisms in the
What results is PTSD
Early intervention with
neurofeedback programs is
crucial to altering the process.
RAD as a diagnosis
First talked about in 1980 as part of DSM- III
Considered a controversial diagnosis at the time
Some disagreement as to whether it is separate
from Ainsworth’s disorganized attachment or
basically the same thing.
Current thinking is that it is a subcategory of
disorganized attachment
Disorganized attachment is also considered a
risk factor for RAD.
Changes from DSM IV to DSM 5
DSM-IV listed RAD as having two
--Emotionally withdrawn/inhibited
--Indiscriminately social/disinhibited
DSM 5 turned the two subtypes into
separate disorders:
--Reactive Attachment Disorder (RAD)
--Disinhibited Social Engagement Disorder (DSED)
Category placement of RAD/DSED
DSM 5 places both disorders in the
general category of trauma & stressrelated disorders.
Included in this group (besides RAD and
DSED) are
Adjustment disorders
Acute stress disorder
Same etiological pathway for both
RAD has dampened positive affect (depressive symptoms) and is
more internalized; equivalent to a lack of or improperly formed
attachment to caregivers.
DSED resembles ADHD more closely. Marked by externalized
behavior and disinhibition.
Social neglect during childhood is a diagnostic requirement for both
conditions, but a child with DSED may have secure attachments.
Diagnoses differ in correlates, causes, and responses to
intervention and are therefore considered separate disorders in
DSM 5.
DSM 5 criteria for RAD
A. Consistent pattern of inhibited, emotionally withdrawn
behavior toward adult caregivers, manifested by both of
the following:
--Rarely/minimally seeks out comfort when distressed
--Rarely/minimally responds to comfort when distressed
B. A persistent social & emotional disturbance
characterized by at least 2 of the following:
--Minimal social & emotional responsiveness to others
--Limited positive affect
--Episodes of unexplained irritability, sadness, or fearfulness that are
evident even during nonthreatening interactions with caregivers
DSM Criteria (cont.)
C. The child has experienced a pattern of extremes of insufficient
care as evidenced by at least 1 of the following:
1. Social neglect or deprivation in the form of persistent lack of
having basic emotional needs for comfort, stimulation, and
affection by caregiving adults.
2. Repeated changes of primary caregivers that limit
opportunities to form stable attachments (e.g., frequent changes
in foster care).
3. Rearing in unusual settings that severely limit opportunities to
form selective attachments (e.g., institutions with high child-tocaregiver ratios).
DSM criteria (cont.)
D. The care in Criterion C is presumed to be responsible
for the disturbed behavior in Criterion A (e.g., the
disturbances in Criterion A began following the lack of
adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder.
F. The disturbance is evident before age 5.
G. The child has a developmental age of at least 9
Specify if:
Persistent: The disorder has been present
for more than 12 months.
Specify current severity:
RAD is specified as severe when a child
exhibits all symptoms of the disorder, with
each symptom manifesting at relatively high
Key Diagnostic Features
Absent or extremely underdeveloped attachments
between the child and caregiving adults.
No comfort-seeking behavior or responses to comfort
when child is distressed.
Diminished or absent positive emotions when interacting
with caregivers
Evidence that emotional regulation is compromised;
negative emotions of fear, sadness, and irritability that
are not easily explained.
Older vs. Young Children
It is unclear whether older children show
the same symptoms as younger children
do or if the disorder even presents in older
Diagnosis should be made with caution in
children older than age 5.
Signs and Symptoms of RAD
In Infants
Withdrawn, sad, listless
Failure to smile
Failure to follow others with
No interest in interactive
games (peek-a-boo) or toys
Won’t hold out arms to be
picked up
Self-soothing behavior
Calm when left alone
In Toddlers & Children
Withdrawing from others
Aggressive behavior
Avoiding or dismissing comfort
Watching others closely but
not getting involved
Obvious & consistent
awkwardness or discomfort
Failing to ask for assistance
Masking feelings of anger or
Treatment of RAD
No standard treatment
Individual and family
counseling is typical.
Behavior therapy is
sometimes used.
No pharmacological
treatment exists.
Neurofeedback is a
promising new research
& treatment area.
Three Crucial
Ingredients by
Beware of “Attachment Therapy”
Based on the idea that the child must release pent-up rage in order
to become emotionally healthy
“Rebirthing”—has been linked to several deaths
Holding therapy
“Strong sitting”
Forced eye contact
Craniosacral therapy
Some attachment therapists are quick to diagnose RAD based on
vague symptoms; they do not follow the DSM’s diagnostic criteria
and charge thousands of dollars for their “therapy.”
BethThomas—original RAD kid (1989) HBO documentary
Child of Rage.