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Reactive Attachment Disorder, RAD, and Attachment

Abstract: Attachment disorder is the inability to create and maintain intimate relationships due to pathological care during infancy.

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Reactive Attachment Disorder, RAD, and Attachment

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Written by: Hanna Molander, psychology student at Linköping university
First version: 22 Jul 2008.
Latest revision: 31 Jul 2008.

What is Attachment Disorder?


Reactive Attachment Disorder (RAD), also known as Attachment Disorder (AD) is a relatively new diagnosis. Because of that, it is quite unknown and it is has often been misdiagnosed.

What is attachment? Attachment is the result of the bonding process that occurs between a child and a caregiver during the first couple years of the child's life. When the infant has a need, s/he expresses the need through crying. Ideally, the caretaker is able to recognize and satisfy the need. Through this interaction, the child learns that the world is a safe place and trust develops. Attachment is a reciprocal process and an emotional connection forms between the child and the caretaker. This connection allows the child to feel safe in his or her environment. This basic safety works as a secure base from which the child can confidently explore the world. Attachment is essential for optimal brain development and emotional health, and its effects are felt physiologically, emotionally, cognitively and socially.

When this initial attachment is lacking, the children don’t develop the ability to form and maintain intimate relationships. They grow up with an impaired ability to trust that the world is a safe place and that others will take good care of them. Children with an attachment disorder are hyper vigilant in order to look after their own safety. This means they don’t allow others to take care of, love and nurture them and they become extremely demanding and controlling in response to fear. Emotionally they believe that if they don’t control their world they will die. Because these experiences happen so early in life the children have learned these lessons at a preverbal stage, and at a biochemical level in the brain. They also have an unusually high level of stress hormones, which has an effect on the way the brain and body develops.

Having attachment difficulties is not the same as having an attachment disorder. Many adoptive and foster families deal with attachment and bonding issues but that does not mean the child has an attachment disorder. Neglect and pathological care don’t always result in attachment disorder and the disorder seems to be uncommon. According to DSM- IV, for a child to be diagnosed as having RAD the child’s behaviour has to be markedly disturbed and developmentally inappropriate social relatedness in most contexts beginning before the age of 5 and associated with grossly pathological care. There are two types of attachment disorder: the inhibited and the disinhibited.

A distinguished characteristic of the inhibited type is that the child persistently fails to initiate and to respond in a developmentally appropriate fashion to most social interactions. The child shows a pattern of excessively restrained, hyper vigilant, or highly ambivalent and contradictory responses (e.g. the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness).

The disinhibited type is characterized by a pattern of diffuse attachments manifested by indiscriminate sociability and an inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures).

Children diagnosed with Reactive Attachment Disorder are responding to events in their early life that may include neglect or abuse. In addition, the early exposures to such stressors make these children highly sensitive to other stressors during later life. All children have both risk and protective factors. Protective factors include the child’s temperament, intelligence and the quality of the child’s relationships, along with good schools, safe neighbourhoods and regulatory activities. Protective factors might decrease the problem, disrupt the chain of events that cause the problem or block the effect of the problem. Risk factors include both enduring and transient factors. Risk factors that last over time are generally biological in origin, such as a child with a difficult temperament, or a physical abnormality. An insecure attachment is, of course, a risk factor but with a safe and structured environment, a lot of love and patience and the right help you can break the chain. Because of the pre-verbal nature of these experiences, children with this disorder require a different type of therapy. In attachment therapy you try to work with both the parents and the child. The goal is to help the child bond to the parents and to resolve the fear of loving and being loved. If the parents are adoptive or foster parents, they also need the education and understanding that the child's behaviour is not caused from their parenting, but from past traumas. From this base then, new parenting strategies can be designed to fit to a child with special needs.

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