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Before I became a full-time stay-at-home dad/homeschool instructor/blogger, I was a licensed mental health counselor doing face-to-face counseling sessions with adults, kids, families, couples, and groups over the course of 10 years. With all of that experience, you would think that I had seen and heard it all, and that is pretty much the case, with one notable exception: Reactive Attachment Disorder or RAD. To learn about RAD, I simply had to adopt two children from foster care, and live with them everyday 24/7 for the past 3-5 years, respectively. Raising kids with RAD is a lot of things, but one thing it is for sure is a Master class in finding out how little you really know about anything, despite years of academic and clinical training.
The bad news is, I wasn't the only one who lacked experience with RAD symptoms and behaviors, and the effects these have on families and communities. One would be hard-pressed to find many counselors, therapists, social workers, etc. that can say they are familiar with the diagnosis at all, let alone feel proficient in diagnosing and treating clients who present with it. Why is this the case? Upon reflection, I think I can boil it down to three main problems.
1. RAD is really rare. Mental health counselors deal with people who are on the margins of society all the time. Even the most commonly diagnosed disorder among children ages 4-17 (ADHD) is estimated at only 11 percent in the US, per the CDC. Compared to those prevalence rates, RAD is almost nonexistent, and hard numbers are difficult to find. One UK-based study found RAD traits in 22 children out of 1,600, about 1.5%. So, part of the issue is that there are relatively few children with RAD walking around in the world, and of course, even fewer are presenting at counseling offices for help. The trick here is understanding that prevalence rates vary among different populations. For example, a European study that focused on children in foster care found a RAD prevalence rate of 20 percent. That is a huge jump. Some studies have estimated RAD symptoms in 35-40% of children raised in the infamous Romanian orphanages in the 1990s. Of course, RAD occurs in populations besides orphans and foster children as well. Some cases involve major medical issues which require long inpatient hospitalizations, right from birth. Attachment opportunities can be missed while these life-saving procedures are taking place. Also, mothers who experience Postpartum Depression are sometimes unable to provide basic emotional and physical bonding opportunities.
Because it is so rare, a therapist should not suspect RAD with every client that walks into the office. How can a therapist diagnosis RAD correctly? By knowing the child's early developmental history of trauma (abuse, neglect) and whether or not the child was adopted, in foster care or some other institutional setting, including long-term hospitalizations. These are major red flags that should alert a careful clinician to consider RAD as a diagnosis, if all the other criteria are present, of course. Again, just because it's unlikely, doesn't mean it won't happen, especially when it comes to the world of mental illness.
2. RAD looks a lot like other things. Kids with RAD share only one thing in common: the inability to effectively "attach" to their primary caregiver, due to abuse, neglect, and inadequate, inconsistent care during the child's first year of life. The effects of this trauma are permanent and will not improve over time without intervention, and, most importantly, result in a huge variety of behavioral, psychological, emotional, social and educational problems. No two RAD kids look the same. A child who presents with irritable mood, sleep disturbance, lack of social interactions, and rarely smiles can look a lot like a child with depression, but could easily fit the description of a child with RAD. Similarly, a child who loses his temper frequently, questions authority figures, bullies peers and actively defies rules probably meets the criteria for Oppositional Defiant Disorder, but could easily describe traits of many RAD children as well. Because of the lack of interest in social interactions that young kids with RAD often display, they could easily be mistaken for a child with a Pervasive Developmental Disorder or Autism Spectrum Disorder. One clinician that has extensive experience with RAD children noted that these kids are so good at observing and assessing adults' expectations of them, that they will "act as crazy as people think they are." The bottom line is, without doing a careful developmental history, obtaining relevant medical records, and interviewing a parent (or two), there is no way to diagnose RAD correctly. So much of what goes on in a therapy office has to do with the here and now. It would seem foolish if a clinician asked about parental care during infancy when the child in question is a 12 year old who is getting into fights at school or setting fires at home. Yet, if untreated and undiagnosed, the effect of early childhood trauma could explain quite a lot about what is going on, 11 years later.
Some experts have proposed a view of RAD as a form of PTSD. This is a useful idea, since PTSD has some very specific and very effective treatment approaches, and most counselors have experience working with PTSD clients. While broadening the definition of PTSD to include RAD is a step toward making the condition more visible and treatable, RAD is a different breed of traumatic stress. Someone with PTSD usually wants help. A child with RAD resists help at all costs. So, while a PTSD diagnosis is a closer fit than, say, ADHD or ODD, it still does not result in effective interventions for a family struggling with RAD behaviors. RAD is unique, and it requires a unique treatment approach which we will examine in the next section.
3. RAD is not amenable to the most commonly used therapy techniques and strategies. The majority of therapists are trained to do individual, person-centered talk therapy. Most will utilize more structured techniques as well, such as cognitive behavior therapy. Family therapists focus on forces that exist around each family member which are causing disruptions to family functioning (systems). They identify ways to break up communication/behavioral patterns that make the problems worse. Child therapists tend to employ play therapy techniques with children, often a very productive and powerful technique for that population. You can guess how well any of these techniques work for RAD kids. In fact, you could argue that individual therapy with RAD kids could make things worse. Play therapy in particular is less than effective.
Finding a therapist who is knowledgeable about RAD and competent and comfortable with treating RAD kids is hard. As we discussed in a previous post, the most vital step for getting help is to get a valid diagnosis from a certified developmental pediatrician, as early in the child's life as possible. That way, the therapist can focus on developing rapport and tailoring a treatment plan specific to the child's needs, rather than gathering developmental history. Children with RAD experience developmental delays in many cases, and so a clinician working with these children needs to be familiar with developmental norms for young children. It means considering that, emotionally, a 6 year-old client is functioning more like a 2-year old, so treatment approaches should be tailored with that delay in mind.
So, what does work? The key is parental participation, for three reasons.
The child's self-reported information and responses to the therapist's questions are not going to be factual, and in fact, may be manipulations. So the parent's job is to fact-check the child's responses to the therapist and be the therapists' eyes and ears at home. There is no better resource for the child's developmental history than the parent who was there to see it, (or as close to it as possible in the case of adoption and foster care.)
The parent needs a witness to confirm that the child's behaviors are real and significant, something that a parent of RAD kids questions at times. One of the greatest tools a therapist has is normalizing. Telling a parent that it is perfectly understandable for a RAD parent to have the desire to throw their child out the window can mean the world to that individual. The person-centered, supportive, unconditional regard that therapists use with individual clients? That is reserved for the parent during sessions, not the child with RAD.
A biological mother of a child with RAD can be extra sensitive and harbor enormous feelings of guilt and regret. In many cases, mothers who experience Postpartum Depression never intentionally hurt or neglect their child; but the lack of emotional bonding with the infant can result in RAD-like behaviors over time. A wise clinician can gently discuss these circumstances in a way that avoids judgment and offers an atmosphere of support and understanding instead. In many ways, it is the mother of a RAD client who benefits from the therapy.
The therapeutic approach with the RAD child is more confrontational, unconventional and frequently involves more sensory input than any approach that is typically used with children. Advanced trauma techniques, such as EMDR, can be used with RAD clients as well, especially for those who are experiencing flashbacks or panic attacks and want help with that. The therapist and parents (as well as any siblings in the home) form an alliance to hold the child accountable, eventually joining with the client, as the child seeks out help and support (the RAD trait of not seeking help is a major obstacle to doing therapy with RAD kids.) A team approach is essential.
Those are fairly standard treatment goals, which most therapists will feel comfortable working on, the major difference is the presence of the parents and/or other family members in every session. In the absence of a therapist who can do all of that, a parent may want to focus therapy work on the child's anxiety or PTSD-like symptoms in therapy, if the child is also seeking help and willing to do the work. Still always make sure the parent is present, and if a therapist has an issue with this, seek help elsewhere.
The course of therapy with RAD kids is a long, bumpy one and has very little chance of success, in general. One therapist we know considered it a success if a RAD child makes a healthy attachment with one other person, by the time the child reaches adulthood. If anything, the therapist's role might be as another trustworthy, consistent authority figure in the RAD child's life; someone who cares and shows that concern genuinely. They can also provide support and documentation that may be needed at one point in time or another to protect your family, as they will know you've done all you can to help your child on a consistent basis.
RAD children need help, even though they resist it. Parents of RAD children need advocates. Therapists can play a major role in improving the daily functioning of a family that is afflicted with RAD. It takes a little extra study and preparation, and willingness to try some unconventional approaches to counseling, but the efforts can profoundly affect many lives for the better, for years to come.
A quick note about "attachment therapy": there are some very controversial therapy techniques that are being promoted on the internet by so called "attachment" therapists. These are usually easy to identify. Attachment therapists are rarely licensed, certified professionals. They don't even have counseling degrees in some cases. These folks implement harsh, punitive techniques that have little therapeutic value, and can do more damage. Rebirthing is a famous example of an "attachment" technique that has no empirical support. These therapists also refer to a generalized attachment disorder, rather than Reactive Attachment Disorder, as defined in DSM-V and other medical references. Avoid therapists that recommend any techniques described above and make sure to check the credentials of any therapist you may be considering for your RAD child.
Fore more information and support when dealing with Reactive Attachment Disorder, check out the following posts.
About the Author:
Disclaimer: Any advice or suggestions that Jason writes here CANNOT be considered therapy or professional consultation, due to counseling ethics standards. It is not really practical or possible to do counseling with someone he has never met. What we hope to offer IS our personal experience as as parents and foster parents of special needs children, plus things Jason has learned as a professional counselor. Take any advice that fits, leave aside what doesn't fit.
I am learning so much from you Renae! Thank you for brave enough to share.
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