Reactive Attachment Disorder: Concepts, Treatment, and Research

Abstract

Reactive Attachment Disorder (RAD) is a disorder characterized by controversy, both with respect to its definition and its treatment. By definition, the RAD diagnosis attempts to characterize and explain the origin of certain troubling behaviors in children. The RAD diagnosis presumes that "pathogenic care" of a young child can result in an array of markedly disturbed behaviors in social interactions and poor attachments to caregivers and others. (See full definition in the body of this report). The RAD diagnosis derives from the attachment theories of John Bowlby and Mary Ainsworth. Several authors question whether RAD is a valid diagnostic category, citing the overlap of symptoms with Pervasive Developmental Disorder and other disorders, the inconsistent connection to attachment theory, and the lack of empirical validation.

Assessment and diagnosis of RAD is complicated and difficult for several reasons. First, children are not always referred for mental health services for attachment problems per se, but because of a variety of behavioral that may co-exist with RAD. Second, in the abuse and neglect population, there may be over-reporting because of a predeliction to view these children as having attachment disorders stemming from early abuse experiences. Third, differential diagnosis can be problematic because RAD symptoms can overlap or be confused with symptoms of Post Traumatic Stress Disorder, Pervasive Developmental Disorder, depression, anxiety, and other conditions. The Association for the Treatment and Training in the Attachment of Children (ATTACh), as well as other authors, recommend a multi-dimensional assessment including systematic observations, extensive history, school and family reports, and individual and family assessment. The review of the literature uncovered one assessment instrument that has been sufficiently researched and can aid in the assessment process: the Randolph Attachment Disorder Questionnaire (RADQ).

The controversy about treatment of children with RAD centers on the practice of "holding therapy," especially when the child is held against his/her will and struggles to resist. Although proponents argue that this experiential method is necessary for the child to establish a bond, or attachment, with a caregiver, critics decry that the experience can be traumatizing, and that any apparent behavioral gains could be the result of trauma bonds, not healthy attachment relations. While ATTACh and other authors attempt to distinguish between coercive and non-coercive holding, the difference between "therapeutic" or "nurturing" holding and coercive traumatizing holding remains a fine line and a matter of interpretation. In addition, there is very little empirical evidence to support the practice of holding therapy, on either an inpatient or outpatient basis. For these reasons, holding therapies should be avoided in favor of less intrusive methods, including trauma-based, family-centered, and community-based interventions.