Understanding Reactive Attachment Disorder -- An Overview of One
of the More Misunderstood Conditions Affecting Child Welfare
A few years ago, I spent a good bit
of my time crisscrossing the country lecturing on the topic of Reactive
Attachment Disorder (RAD) -- a mental health disorder common among children who
were subject to severe abuse and neglect during critical stages of brain
development in infancy.
I argued then that the misdiagnosing
and subsequent counterproductive treatment of the disorder was the single
biggest issue confounding the child welfare system.
I still think that’s true. I don’t
see any evidence that the situation is improving. In fact, it’s reached a crisis
point and we need to make this issue more a part of our national dialogue.
Reactive Attachment Disorder is
caused when an infant doesn’t bond properly to its primary caregiver. This
basic loss results in ongoing feelings of rage, shame, lack of trust, a morbid
fear of attaching to anyone, an inability to understand cause and effect
thinking and a compulsive need to control everyone and every situation.
Extreme cases are typically caused by
chronic neglect in early infancy followed by years of instability -- an
all-too-common formula for children in foster care.
Without proper intervention, these
children have little chance of meaningful relationships. In foster care, they
often bounce from foster home to foster home as one well-meaning foster parent
after another gives up because of the severity of the child’s behavior
problems; each move exacerbates the condition. Children with RAD are masterful
at rejecting caregivers and burning bridges.
They get labeled “unadoptable” and
frequently spend their entire childhoods in foster care, a system designed to
be temporary. The far end of the continuum includes children who are violent,
destructive, unmanageable, dangerous and sociopathic.
Experiences early in life have a
tremendously important impact on the developing brain. We recognize now that it
doesn’t take a fist or a blunt object to cause brain damage.
In the cerebral cortex (where
language, emotion and logic are developed), for example, trauma or lack of
stimulation during infancy leads to the underdevelopment of neurotransmitters
in that region. Consequently, this section of the brain is actually smaller in
abused, neglected children than in healthy children. Traumatized infants
secrete abnormally high amounts of stress hormones which have myriad adverse and
long-term effects, as well. So, when a child with RAD seems incapable of trust
or empathy or remorse, there’s good reason to believe that its etiology is
neurological in nature and not just willful disobedience.
The good news is that with proper
treatment, RAD children rehabilitate and function well in families and society.
There’s even reason to be optimistic that damaged areas of the brain can be
repaired. In the hands of a skilled Attachment Therapist along with the
commitment of an invested caregiver, children with RAD typically show signs of
marked improvement in a matter of months.
insight-oriented, relationship-based, cognitive/behavioral therapies are
ineffective in treating the disorder, and in some ways counterproductive. As are
typical parenting methods. Without proper treatment, children with compromised
attachment continue to struggle in virtually all settings: home, school,
residential treatment programs, etc. That’s the big problem: only a small
percentage of the children who need specialized treatment for the disorder are
receiving it. We insist on putting square pegs in round holes and shaking our
heads at its futility.
When I was on the road, everywhere I
went, workshop participants complained about lack of resources for these
children. We need more clinicians trained in an attachment model; we need more
accurate diagnosing. These children are frequently misdiagnosed because their
symptoms can look like a lot of different disorders, Bipolar Disorder and ADHD,
for example. We waste a lot of precious time going down the wrong path with
these kids. Key players system-wide need a better understanding of the nuances
of the disorder including social workers, judges, pediatricians, children’s
attorneys and advocates, not just mental health workers.
Caregivers need special training to
be effective. Behavior management strategies such as positive reinforcement,
time out, token economies and other standard parenting techniques just don’t
work with these children. Too often, foster and adoptive parents lose faith in
the mental health and social service systems. They feel helpless and hopeless
regarding any positive outcome and they give up. Who can blame them?
And, there’s no escaping politics.
Especially in child welfare, treatment often comes down to a battle among the
state, the courts and insurance companies over who’s responsible for payment --
particularly in communities where specialized treatment isn’t readily available
and the only option is sending the child out-of-state for expensive treatment.
Too often, the child doesn’t get the help he or she needs.
Instead he wastes time in the office
of an ill-equipped therapist. We then blame the child for not making progress.
To me, it’s analogous to prescribing Tylenol for a child with diabetes who
needs insulin to survive, and then absolving yourself of responsibility once
you do. It’s unconscionable, but it’s what I see a lot of communities doing.
It is estimated that RAD affects 3-6%
of the overall population. But it is rampant within the child welfare system, I
think. There’s no way to know for sure how many of the approximately 600,000
foster children in the US are suffering from RAD, but I’m positive the disorder
is flying under the radar and contributing significantly to the chaotic state
of our foster care system. I personally know dozens of children who’ve been in
ten, fifteen, even 30 different foster homes. Again, I attribute much of
problem to undiagnosed and untreated RAD.
The prognosis is poor for children
with RAD who don’t get the help they need as they reach adulthood and are
released from protective care. Approximately 20,000 foster children age out of
the system each year, often with no familial connections and nowhere to go. Too
often they end up homeless, incarcerated, institutionalized and dead. And,
they’re raising the next generation of attachment-compromised children.
Inadequate mental health care is one of the primary reasons for such dismal
If the State is going to be so bold
as to remove a child from his parents because they’re incapable of parenting
properly, then it has a responsibility to provide the highest quality of
services for that child. The child is already at a tremendous disadvantage. The
State, acting in loco parentis, should expect and demand the same high
level of medical, mental health and educational services as any good parent
would for their child. Unfortunately, that doesn’t always happen.
The consequences for society are more
far-reaching than one might realize. We already know that a vast majority of
habitual felons were abused as children. I don’t think it takes much to
extrapolate that a large percentage of them are adults with undiagnosed and
untreated RAD. Our prisons are filled with RAD kids grown up, I believe.
It makes sense when you consider that
children with RAD typically lack self-control, have antisocial attitudes and
behavior, are aggressive and violent and lack empathy, compassion and remorse.
Isn’t that exactly the same set of adjectives we use to describe hardened criminals?
Like most disorders, prevention and
early intervention are the best solutions. I recommend learning more about RAD
by visiting the website for the Association for Treatment and Training of Attachment of Children
(ATTACh), where you’ll also be able to locate registered attachment
therapists and clinics in your area.
It comes down to priorities. We know
what the problem is and what the solution is. What’s left to be seen is whether
the powers that be will actually devote the energy and resources the disorder
warrants and children and families affected by it deserve.