RAD Reactive Attachment Disorder Introduction

RAD

Reactive Attachment Disorder

Introduction / Argument

There are many pertinent questions in the minds of researchers looking into the causes of Reactive Attachment Disorder (RAD). These questions will be addressed in this paper as forthrightly as possible. For example, is RAD caused for the most part by "grossly pathological child care" as the National Library of Medicine (NLM) asserts? What are the other explanations for the cause of RAD that rebut NLM? And moreover, a) is RAD identified more closely with internationally adopted children or with nationally adopted children? And b) why are there so many different explanations for RAD and such a plethora of alleged solutions? Does anyone really understand RAD or know how to deal with it? Why are so many supposed response solutions in the literature? Are there other ailments and medical issues linked to young children that are misdiagnosed as RAD?

Thesis: Given the seemingly endless confusion vis-a-vis the causes of -- and potential solutions for -- RAD, the medical research community and healthcare providers should be embarrassed at the lack of clarity.

Presentation of Contradictory Literature

The NLM (a division of the National Institutes of Health in Washington D.C.) flatly states that RAD "begins before age 5" and is "associated with grossly pathological childcare" (www.nlm.nih.gov). The NLM explanation goes on to state, as other definitions do, that the inhibited child may "persistently fail to initiate and respond to social interactions in a developmentally appropriate way." Alternatively, the NLM says the "disinhibited type" of child may show a "pattern of diffuse attachment with nondiscriminate sociability" (www.nlm.nih.gov).

Meantime Dr. Mark Lerner, a psychologist with International Adoption Center (www.adoptiondoctors.com) explains that RAD can be caused by: exposure to substances; birth trauma; "inconsistent or inadequate day care"; separation issues; abuse and neglect. Any of all of these can be "precipitating factors" that may lead to RAD. Dr. Lerner goes on to suggest that "internationally adopted children" exhibit this kind of serious childhood disorder "at a significantly higher rate than the general population" (www.adoptiondoctors.com).

The American Academy of Child & Adolescent Psychiatry (www.aacap.org) lists several possible causes for RAD and then, surprisingly admits that, "…The exact cause of Reactive Attachment Disorder is not known." Of course because this is a psychiatric organization the recommendation is for parents to "…seek a comprehensive psychiatric evaluation" for a troubled child because RAD is a "serious clinical condition" and it is a challenging "complex child psychiatric disorder" (AACAP). The bad news from AACAP is that there are no "simple solutions or magic answers" -- but the good news, "…it is relatively rare."

The Brown University Child and Adolescent Behavior Letter (Boekamp, 2008) describes the troubled life of a 4-year-old Asian-American boy (named Joseph) who displayed anger, hit other children, seemed uninterested in or "non-compliant with basic daily routines." This child had been living in an environment where there was frequent domestic violence and had been removed from that home and placed in a "group home." After a year in the group home, he was placed in a foster care family home and "within a month" he began to behave normally. He "responded to social initiatives, started to chat…began to seek comfort when distressed from the most readily available adult" (Boekamp, p. 6).

Certainly Joseph's behavior is "consistent with the core features" of RAD, Boekamp writes, but the author doesn't explain why Joseph so quickly turned around and became a responsive normal boy. Some descriptions of RAD-like behavior in other literature indicate that the RAD child doesn't exhibit normal child behaviors for a long period of time after being removed from a disturbing home environment. Boekamp asserts that the "criteria" for the diagnosis of RAD in a child is firmly in place: the child's "markedly disturbed social relatedness must be present across situation and relationships, and start before age 5" (p. 6). In addition, to be a verified RAD child, Boekamp goes on, the child must have been a product of a "grossly neglectful care…in severe deprivation."

But wait, later in his article Boekamp asserts there are "very few empirical studies on RAD"; he states that the "prevalence of RAD is unknown"; and there is "almost no data on the course of RAD beyond early childhood" (Boekamp, 2008). Boekamp insisted initially that Joseph's case was consistent with RAD-type behavior; but on page 7 he admits, "no empirically supported protocol for assessing RAD exists."

Julia D. Buckner (Yale School of Medicine) and three colleagues write in the journal Child Maltreatment that "few examinations of empirically informed treatments" have been performed (Buckner, 2008). Buckner (290) explains that RAD children display behavioral problems, aggressive behavior, lack of empathy, emotional "liability," impulsivity, hyperactivity and "stealing, lying" among other bad traits. But how can a clinical researcher 100% certain the child given the RAD label isn't in fact behaving badly because he or she has Fetal Alcohol Spectrum Disorder (FASD)? The Centers for Disease Control and Prevention (CDC) states that children with FASD display "hyperactive behavior" and "learning disabilities," problems with daily living, "poor reasoning and judgment skills"; and FASD sufferers display "psychiatric problems" and "criminal behavior" (www.cdc.gov). Aren't those exactly the same as RAD behaviors? How can researchers be so seemingly certain when there are few empirical studies? Not only is there confusion as to whether a child really has RAD or not, or the origins of the malady, the vagueness thus far regarding interventions is troubling.

In response to Buckner's research, Mark Chaffin of the University of Oklahoma writes in the journal Child Maltreatment (Chaffin 2008) that the "behavioral parent training" may be "too simple and too limited in focus." Chaffin (p. 313) writes that when a child experiences "seriously pathogenic early care" (like trauma, neglect, etc.) it is "fashionable" to come to the conclusion that they "…are damaged goods whoa re extremely difficult to redeem" (p. 313). Because regular treatments don't seem to work, researchers launch "radical, risky, and coercive" treatments that are unconventional, untested, and lack "scientific support." These radical approaches produce "negative results" (p. 314) according to Chaffin, who lines up with many other scholars in admitting that a) diagnosing RAD is problematic; and b) interventions are experimental and unproven for the most part (p. 314).

Another research article, this one in the Journal of Child and Adolescent Psychiatric Nursing (Cornell, et al., 2008), restates the fact that "…there are few studies addressing therapeutic interventions for attachment disorder" (Cornell p. 35). In this paper the authors are actually providing what available information there is regarding interventions for psychiatric nurse practitioners. As to the etiology (the causation) of RAD, Cornell (p. 37) admits the "exact prevalence or incidence of RAD is unknown." As to how to tell if a child is truly a RAD child: The authors allude to the Randolph Attachment Disorders Questionnaire (RADQ) (a 30-question screen test for adults living with a child for 3 or more months) which "only identifies a child as attachment disordered" if he or she meets several criteria. Conduct Disorder and Oppositional Defiant Disorder, along with DSM-IV, are included among those criteria. All these criteria are confusing and overlapping, and again, how does a parent or doctor know for certain that the child doesn't have a bipolar condition or attention deficit hyperactivity problem? Much of the research in the literature seems less than exact.

Medline Plus (www.nlm.nih.gov) explains that children who are adopted from foreign orphanages are "commonly affected" -- especially if they were taken form their birth parents "during the first weeks of life." And while other research suggests there are no known workable interventions, Medline Plus (National Institutes of Health) flatly asserts that treatment "…has two parts." One put the child in a "safe environment" and meet his or her emotional and physical needs. And two, change the relationship between the "caregiver and the child." Both those interventions seem starkly simplistic -- and yet, since the point has been made that reliable clinical interventions are scarce (or not existent) the federal health agencies put out what basic information they have.

One potentially appropriate treatment for children with "disorders of attachment" and children with Post Traumatic Stress Disorder (PTSD) is Dyadic Developmental Psychotherapy (DDP), reviewed and analyzed in the journal Child and Family Social Work (Becker-Weidman, 2008). The article uses a lot of fancy terms but comes down to the basic fact that DDP emphasizes "non-verbal" interventions for the troubled child: offering warmth; taking it slow in establishing secure physical environments; generating an attitude of empathy; squeezing the child's hand; being playful and positive. The summary insists that DDP has "strong empirical evidence" of success (Becker-Weidman, p. 335). The problem is that RAD is not specifically integrated into the intervention strategies, but rather is applied in a general way to persons suffering from "depression, anxiety disorders, trauma and marital problems" (Becker-Weidman p. 335). This is not to say DDP is not a valuable intervention for RAD, but more research needs to be done.