CHAPTER 1

The Reality of RAD

Some of us know children who deliberately break or ruin things.We know children who do not seem to feel guilt for their actions.In other words, some children do not seem to have a conscience.We know children who are involved in very dangerous activitieswhile ignoring the possibility of getting hurt. How about otherchildren who may act very innocently when caught in the actof doing something very bad? We know some adults that areconsidered to be villain without any apparent conscience. Theseare a few of the realities of Reactive Attachment Disorder.

Keep in mind that not all children with reactive attachmentdisorder exhibit all of these behaviors, but they may exhibitbehaviors that do not seem to make sense to the rest of us.There is hope! It is my sincere expectation that this book mayoffer suggestions and methods for parents in taking care of theirchild or children with some of these behaviors.

This foundational chapter may seem dry to some readers;however, this chapter is needed to help establish what theprofessionals in the field know, when they know it, and whatthey currently think about reactive attachment disorders. Inthis chapter I will briefly address some definitions, theories andcharacteristics surrounding reactive attachment disorder.

Definition

I am using the Diagnostic and Statistical Manual of MentalDisorders-Fourth Edition (DSM-IV) definition in this section.DSM-IV is a professional "book" that provides classification ofknown mental disorders. DSM-IV provides appropriate categoriesand criteria for diagnosing these disorders and it is to be used byprofessionals with appropriate training. In other words, DSM-IV isthe "go-to book" with high credibility for all known disorders.

Diagnostic and Statistical Manual of Mental Disorders-FourthEdition (DSM-IV) uses four diagnostic criteria to explain reactiveattachment disorder of infancy or early childhood. These criteriaare: A) Markedly disturbed and developmentally inappropriatesocial relatedness in most contexts, beginning before age 5years, as evidenced by either: (1) persistent failure to initiate orrespond in a developmentally appropriate fashion to most socialinteractions, as manifest by excessive inhibited, hypervigilant,or highly ambivalent and contradictory responses or (2) diffuseattachments as manifest by indiscriminate sociability withmarked inability to exhibit appropriate selective attachments.B) The disturbance in criterion A is not accounted for solely bydevelopmental delay and does not meet criteria for a PervasiveDevelopmental Disorder; C) Pathogenic care as evidenced by atleast one of the following: (1) persistent disregard of the child'sbasic emotional needs for comfort, stimulation, and affection,(2) persistent disregard of the child's basic physical needs, (3)repeated changes of primary caregiver that prevent formation ofstable attachments. D) There is a presumption that the care incriterion C is responsible for the disturbed behavior in criterion A.

DSM-IV has the following two specific types of RAD: InhibitedType and Disinhibited Type. Inhibited Type is when criterion A1predominates in the clinical presentation. Disinhibited Type iswhen criterion A2 predominates in the clinical presentation.

Reactive Attachment Disorder is a serious disorder that affectschildren as early as infancy. Reactive attachment disorder canhave lasting, damaging effects reaching into other relationships ifappropriate, consistent, and ongoing interventions are insufficientor lacking. It is vital that infants and young children develop asecure form of attachment and trusting relationship with theirparents or primary caregivers. However, when this attachment islacking during or after infancy and not intervened effectively, thechild may carry this lack of attachment (mistrust) into adulthood,which interferes with other social relationships.

Theories

The term reactive attachment disorder was coined throughstudying the behavior of young children in orphanages and lowerincome lifestyles with poor family relationships. Professionalsconcluded that an insecure relationship with a primary caretakeris detrimental to the emotional development of a child. This wasfurther clarified that the child's principal attachment-figure can befilled by others than the natural mother or father for that matter.The child must feel secure in having his/her needs met throughcreating a relationship with another person at an early age tocognitively, socially, and emotionally develop properly.

Attachment theory, described above is the most commontheory used by professionals when writing about or providingtreatment for reactive attachment disorder. The attachmenttheory hypothesizes that, beginning in infancy; children formhighly affective relationships or attachments with their primarycaregivers that are based on the infant's need for protection,comfort, and nurturance. There are three types of attachments:secure, insecure, and disorganized.

Children with secure attachments feel that their caregivers arephysically and emotionally available to them and generallyhave better developmental outcomes and lower rates ofpsychopathology than children with insecure or disorganizedattachments. Secure attachments provide a "secure base" withthe caregiver that fosters safe exploration and learning.

Insecure attachment results from an infant's or child's attempt tomaintain proximity to a caregiver who is emotionally unavailableor only intermittently responsive. This insecure attachment wouldmanifest in children in the form of "anxious avoidant", which meanavoiding a caregiver because they are apprehensive and do notknow how the caregiver would respond to them. In other childreninsecure attachment would manifest in "anxious resistant", whichmean that these children worry about the caregiver's response.Either way, insecure attachment creates in children an abnormalform of attachment.

Disorganized children or infants are caught between cravingproximity and fearing to approach the caregiver. They oftenexhibit disorganized or contradictory behavior, such as freezing,stilling, or apprehension toward their attachment figures. Ofall three types of attachments described above, disorganizedchildren tend to be at the highest risk for later behavioral andemotional difficulties.

Although attachment theory makes it clear that early relationshipsare important to development, this knowledge does notextrapolate directly to understanding attachment disorders.

Attachments vary across secure, insecure, and disorganizedpresentations, and each carries a different degree of risk.DSM-IV, however, does not recognize variations in attachmentsor severity of attachment difficulties as part of the reactiveattachment disorder diagnosis. None of the types of attachmentsdelineated in attachment theory directly corresponds withattachment disorders in DSM-IV.

Broaden the Definitions

The attachment theory described above; however, left out alarge group of children with reactive attachment disorder. Somechildren born to two parents who are in middle to upper incomebrackets have reactive attachment disorders as well. Hearing howchildren turn on their parents, etc, in the news media today makesone wonder when the disconnection happened within that family.To give us a clearer understanding of what reactive attachmentdisorder is, we need to broaden the definition. Broadendefinition: Children with reactive attachment disorder are thosewhose basic needs to develop a secure form of attachment andtrusting relationship were not met by their parents or caregivers,regardless of race, gender, culture, linguistic backgrounds,religion, and socio-economic status. This definition is broad andinclusive and clear.

It is easy to see how children in the orphanage and foster caresystem, and those from low socio-economic status, do nothave their basic needs met. But how about children from stabletwo-parent homes' or children from stable middle to upper classhomes? This broadened definition looks beyond what parentscan physically provide for their children to what children needpsychologically. Parents from stable middle to upper classhomes may be providing what they think their children need,but if their children's perceptions of their needs differ from whatthese parents think they need, a gap in the relationship startsto form. As children grow and the perceptions of their needsdiffer significantly from what their parents provide, they start todetach from their parents emotionally. Attachment disorder is avery complex one and it affects children differently, even if thesechildren have similar backgrounds.

In response to this mismatch between DSM-IV and the clinicalpopulation, some clinicians and theoreticians have suggestedthat the diagnostic criteria for reactive attachment disorder beexpanded to include those children who have "secure basedistortions." Secure base distortions refer to children who havea selective but highly disturbed relationship with caretakers. Sucha conception focuses on the way the child interacts with and usesthat caregiver.

Let us look at these basic needs and secured base distortionsfor a minute. All babies need to be loved, fed, held, changed,played with, etc. Let's assume for a second that all children from"stable" homes get all this attention plus more. How could theyhave reactive attachment disorder? Every child has a differentpersonality and different perception of the world around them.As they grow from infant to toddler to pre-school, they startto show who they truly are and what they perceive their needsto be. If children's perceptions of their needs differ from whattheir parents think they need, a gap in the relationship starts toform. As children grow and the perceptions of their needs differsignificantly from what their parents provide, they start to detachfrom their parents emotionally. Caution: This does not meanthat all children who rebel in one way or another have reactiveattachment disorder! Some children use rebellion as one of theways to test the boundaries to see how far they can go.

We know that most children with reactive attachment disorder areundiagnosed since the concept of attachment disorder is new.Reactive attachment disorder was mentioned for the first time inDSM-III, and most professionals associated reactive attachmentdisorder with children in orphanages and the foster care system.However, we know that reactive attachment disorder does not"discriminate", and children from two parent homes and thosefrom middle to upper class homes could have reactive attachmentdisorder as well. The best way to look at reactive attachmentdisorder is when there is disconnect between what parentsthink is best for their children and what those children truly needor when there is disconnect because what parents think theirchildren needs are differ from what children perceived their needsto be. Does that mean that all children who do not agree withtheir parents have reactive attachment disorder? Absolutely not!It is possible that two children born to the same parents may havedifferent needs; one may have reactive attachment disorder andthe other may not have it.

Most children with undiagnosed and untreated reactiveattachment disorder end up with criminal behaviors, starting fromteenage years into adulthood. Their crimes tend to be in the areathat "put them in power." They yearn to have control of their livesand their environments. These children (or adults) may targetthose they see (symbolically) as having taken the control awayfrom them.

Whether the professionals in the field agree with the typesand diagnostic criteria or not, there are two most dangerouschallenges relating to reactive attachment disorder: First, reactiveattachment disorder is grossly under-diagnosed because someof its characteristics overlap with other disorders, which makes itdifficult to differentiate. As stated earlier, many of the children withundiagnosed reactive attachment disorder may end up leadinglives of criminal behaviors. This sadly makes sense since mostof them do not know right from wrong. For these children, right iswhat they want to do and wrong is what they do not want to do.The second challenge is discipline. One of the things that childrenwith reactive attachment disorder need is consistent disciplinein love, but most of them may not have experienced love. Thechallenging question in this case is how do we teach thesechildren to differentiate between discipline in love and rejection?

Characteristics

DSM-IV lists diagnostic characteristics criteria when assessingchildren for Reactive Attachment Disorder (RAD) with twosubtypes: Inhibited and Disinhibited. An individual must exhibitnoticeably troubled and developmentally inappropriate socialbehaviors. Inhibited behavior is marked by a failure to initiate and/or respond to social interaction in a way that is developmentallyappropriate. Disinhibited behavior is evidenced by an inability todisplay and form appropriate attachments to others. Another partof the diagnostic criteria is that the inappropriate social behaviorcannot be linked to a developmental delay or a pervasivedevelopmental disorder. The final element in the diagnosticcriterion is that there must be evidence of parental/guardiandisregard for the child's emotional and/or physical needs.Furthermore, there may be repeated adjustments to the child'sprimary caregiver resulting in unstable attachments. There mustalso be evidence that these things are causing the inappropriatesocial behavior (Floyd, Hester, Griffin, Golden, & Canter, 2008).

According to Sheperis, Renfro-Michel, and Doggett (2003),reactive attachment disorder characteristics include, lowself-esteem, lack of self-control, anti-social attitudes andbehaviors, aggression and violence, and among other things,a lack of ability to trust, show affection, or develop intimacy.Children who are characterized as having reactive attachmentdisorder may also struggle with cause and effect thinking. Thisdifficulty is also seen in children who have Attention DeficitHyperactivity Disorder. It is sometimes difficult to accuratelydiagnose reactive attachment disorder due to the similarities incharacteristics between reactive attachment disorder and otherdisorders. Reactive attachment disorder can go undiagnosedbecause it can appear to be childhood or adolescent depression.It is essential that evaluators perform careful assessments andobservations of specific characteristics when diagnosing childrenwith reactive attachment disorder.

One question that both parents and professionals ask is, "Whendo I ask for an evaluation of the child for possible reactiveattachment disorder?" The evaluation process for reactiveattachment disorder does not do any damage to the child;therefore, when in doubt, ask a psychiatrist who treats childrenand adolescents with reactive attachment disorder for theirprofessional views. If your child exhibits some of the behaviorslisted earlier, such as stealing, lying, damaging property,smearing feces, sabotaging situations, embarrassing/humiliatingtheir caregivers, harassment, self abusive behaviors, etc. then itmight be appropriate to ask for an evaluation.

Behaviors

Children who have Reactive Attachment Disorder displayspecific behaviors. These behaviors can range from mild tosevere depending on each individual child. Some childrencan be self-destructive, suicidal, self-defeating, and engage inself-mutilation. Children with reactive attachment disorder may bepathological liars who are highly capable of manipulating others.Engaging in stealing is also a behavior that may be present inchildren with reactive attachment disorder. There are many casesof children with reactive attachment disorder who have beensexually abused in some way. If this is the case, the child maydisplay voracious behaviors like sexualized attitudes and play,as well as excessive masturbation. Educators should be awarethat children may or may not display these sexual behaviors.Educators should also be cognizant of the fact that children withreactive attachment disorder may feel that they are victims evenas they display victimizing behaviors to others.

Children with reactive attachment disorder tend to have difficultyregulating their own behaviors. This may be displayed in failedattempts to regulate impulses, behaviors, and emotions. It isessential for parents/caregivers and educators to understand thisinability to self-regulate because it is very important to teach andin some cases model self-soothing and self-regulatory behaviors.Children with reactive attachment disorder may have difficultyunderstanding social boundaries. This difficulty may result inbehaviors such as invading another individual's private space,rejecting appropriate displays of affection and/or engaging inovert displays of affection with the aim of receiving a reaction.It is essential for parents/caregivers and educators to constantlymodel appropriate social boundaries and to address anypossible inappropriate social interactions. Children with reactiveattachment disorder have tremendous challenges in the area ofdeveloping trust and intimacy. Intimacy is generally threatening toa child with reactive attachment disorder. The inability for childrenwith reactive attachment disorder to gain positive feelings fromsocial relationships can lead to depression.