Kid Confidential: What Reactive Attachment Disorder Looks Like

July11

 

Over the last few years, I have become aware of an increase in the number of referrals to assess children diagnosed with Reactive Attachment Disorder. Whether this is a coincidence or an indication of statistical increase in incidence of RAD, I cannot say.  What I can tell you is how clinically interesting and extremely frustrating these cases can be.

What is RAD?  According to Nancy Thomas, author of “When Love is Not Enough: A Guide to Parenting Children with RAD-Reactive Attachment Disorder,” RAD,  originally termed “attachment disorder” prior to 1979, is defined as a condition where an individual has difficulty forming lasting relationships and lacks the ability to be genuinely affectionate toward others.  In addition, persons with RAD do not learn to trust others and do not appear to develop a conscience.  This is believed to be caused by abuse or separation (physical or emotional) from one’s primary caregiver during the first three years of life which translates to an internally suppressed rage.  If untreated, children with RAD grow up to be adults who cannot truly ever feel love.  It is suggested that many of these adults will eventually be labeled as sociopaths or psychopaths.

According to Thomas, the following are a list of some signs that put infants at high risk for RAD in the first year of life:

  • Constant crying or a weak crying response
  • Tactile defensiveness (after 8 weeks, flinching or startling)
  • Poor clinging or holding on
  • Resistant to cuddles (may seem “stiff as a board”)
  • Lacks strong sucking response
  • Lacks eye contact and tracking skills
  • Demonstrates developmental delays
  • Does not exhibit a reciprocal smile
  • Doe not demonstrate “stranger anxiety”; appears to be indifferent to strangers
  • Will exhibit self abusive behaviors (head banging, etc.)

 

What can parents do to facilitate bonding with their infant?  Thomas makes several suggestions in her book.  Here are just a few of them:

  • Breastfeed if at all possible; hold bottle, never prop it up
  • Use a sling or carrier to carry the infant front facing toward the child’s mother for 4-6 hours daily
  • Baby massage, 20 mins/daily while smiling and using a high voice
  • Rock and hold infant with good eye contact while singing and taking using “motherese”
  • Sleep with or near parents at night
  • Nap skin to skin on dad’s chest

As these infants may be referred to speech-language pathologists due to feeding problems, we may be the first professionals to see these children.  So I believe it is important for us as professionals and parents to learn the warning signs and make the appropriate referrals as needed.

The following are signs and symptoms of RAD in children found in Thomas’ book:

  • Child is superficially engaging and charming
  • Lacks eye contact on parents’ terms
  • Demonstrates affection with strangers indiscriminately
  • Not affectionate on parents’ terms (no cuddling, etc.)
  • Appears “accident prone” in that the child is destructive to self, others and objects
  • Exhibits cruelty to animals
  • Steals
  • Lies about obvious things (outlandish lies)
  • Lacks impulse control; hyperactive frequently
  • Developmental delays (“learning lags”) due to being in a state of anger and frustration affecting ability to learn
  • Lacks cause and effect thinking
  • Lacks conscience
  • Exhibits abnormal eating patterns (not eating and/or gorging)
  • Has poor peer relationships
  • Seems to be preoccupied with fire, blood/gore, violence
  • Persistent nonsense chattering and questioning
  • Very demanding or inappropriately clingy
  • Exhibits abnormal speech patterns for the purpose of controlling situation
  • Attempts to triangulate adults against each other
  • Tells of false allegations of abuse
  • Feel entitled
  • Parents appear angry/hostile

 

What type of therapy works for children with RAD?  According to Thomas’ attachment therapy is a must. A good attachment therapist will work with the parents and child to create an attachment.  He/she will NOT allow the child to manipulate and triangulate them against their parents.  Additional therapies that can be of use in conjunction with attachment therapy are:  holding therapy, Neurofeedback or EEG biofeedback, EMDR (eye movement desensitization and reprocessing), Theraplay, Therapeutic horseback riding, specialized art therapy, music and sound therapy (Tomatis, Somonis), massage, nutritional supplements, and Psychodrama.

 

As SLPs, we may have children who have been or have yet to be diagnosed with RAD referred to us due to the “abnormal speech patterns” they tend to use.  The difficulty is in determining the true communication abilities of these children.  According to Thomas, little research supports effectiveness of speech services for children with RAD as communication is often times not truly affected.  Therefore, our role becomes more of a referral source either to a child psychologist for diagnostic purposes or to an attachment therapist for possible treatment.

 

Case Study, “Johnny”, 3 years old, seen in early childhood special education classroom setting:

 

Speaking from personal experience, I too was duped with the first child I ever suspected to have RAD.  Although, he was not diagnosed prior to my evaluation, I had come believe RAD was a strong possibility after many, many hours of collaboration and consultation with his early childhood special educator.

 

For confidentiality purposes let’s call this child, Johnny.  Johnny was reported to be a “difficult” child at home, requiring his mother’s constant attention, exhibiting extreme anger during typical play and sharing situations, highly impulsive, and very much enjoyed using language for the purpose of interrupting the classroom and manipulating adults.  As I was not familiar with this child prior to the evaluation, the only information I had were parent complaints of behavior at home.  When speaking to his mother, I was surprised to see that as Johnny tried to snuggle up to his mom in front of me, she would roll her eyes and push him away.  I didn’t understand then, that this reaction was because she knew he was attempting to manipulate me, showing me he was the loving child and his mother was the “bad guy.”  I didn’t know then, that his mother had spent years with little to no sleep because he insisted on sleeping on a cot at the bottom of his parents’ bed at night and woke up every night pretending to sleep walk.  I didn’t know then that Johnny would use a very high pitch and what I can only describe as “baby talk” when he wanted to seem sweet and affectionate all while trying to get something he wanted from someone.  I didn’t know then that this child would demonstrate the most rage and anger I had ever seen in a 3-year-old.  I didn’t know then, that the language he was using during my evaluation was his way of manipulating me.

 

After a few months, it became quite clear that the expressive language deficits Johnny exhibited during the initial assessment were not an accurate view of his true abilities.  In fact, although considered typically developing, he appeared to have higher receptive language skills than he portrayed during testing as well.  Academically, when Johnny would slip up a bit and show us what he really knew, he demonstrated good rote counting skills, early identification of some letters, and understood concepts of sorting and patterning with ease.  However, he had significant difficulties with peer interactions.  At this time, I attempted to change my strategies and help with his social skills by focusing on verbal expression of feelings of anger/frustration and using cognitive problem solving skills to determine appropriate behaviors during peer interactions in order to reduce hitting, grabbing, and physical contact with peers.

 

Yet, it wasn’t until the day, during a school assembly, Johnny picked his nose so long that he was gushing blood, did I realize he did not seem to register pain like you and I do.  As his teacher was unable to leave the rest of the classroom in the assembly without her, I took Johnny back to the classroom bathroom to clean up. Of course this was a day the school nurse was not in so I was on my own.  As he approached the bathroom, I watched as he stood up on the stool, looked in to the mirror and proceeded to smear his blood all over his face and arms while smiling in the mirror.  He did not see me watching him.  I’ve never seen a 3-year-old act like this.  It was in that moment, I became a true believer that he could very well be a child with RAD.

 

Unfortunately, Johnny and his family moved out of state prior to ever getting an outside evaluation to determine or rule out RAD.  And as you can imagine, the therapy strategies I attempted failed to carryover to functional play situations, although in the therapy room, he seemed to say all the right things (incidentally another sign that he might have had RAD).

 

I share this story with you because I know how easily one can be mislead and manipulated by a child.  Although I know I cannot diagnose RAD but based on the above signs and symptoms, Johnny exhibited 15 out of 22 of them and in my humble opinion, RAD was a very good possibility.

 

As they say, hind sight is 20/20, and I feel I am still learning long after Johnny is no longer on my caseload.  If I could turn back the clock there are two things I would have done differently.  Firstly, once I knew Johnny and saw him for who he truly was, I would have told his mother with sincerity that I believed her when she was telling me about his behavior problems at home.  Secondly, I would have pushed harder for her to follow through with a psychological evaluation prior to their move out of state.

 

At the end of the day, for the few months that I worked with Johnny, I learned to question everything I thought I knew about child development and language acquisition.  I learned to keep looking, consulting, collaborating and never give up trying to find the source of the problem.  Even if clarity came to us as a multidisciplinary team too late, I find that I will always be grateful to Johnny for the lessons he taught me and how he has personally made me a better diagnostician, therapist, collaborator and yes, even a better parent to my own son.

 

RAD can be a very confusing and trying disorder to understand.  We as professionals can work with a child for a very long time before we realize all the signs and symptoms are really pointing to something other than communication deficits.  However, as long as we never give up trying to help, as long as we continue to consult, collaborate, and research we may just be able to help these children by referring them to the correct professional.

 

 

Maria Del Duca, M.S. CCC-SLP, is a pediatric speech-language pathologist in southern, Arizona.  She owns a private practice, Communication Station: Speech Therapy, PLLC, and has a speech and language blog under the same name.  Maria received her master’s degree from Bloomsburg University of Pennsylvania.  She has been practicing as an ASHA certified member since 2003 and is an affiliate of Special Interest Group 16, School-Based Issues.  She has experience in various settings such as private practice, hospital and school environments and has practiced speech pathology in NJ, MD, KS and now AZ.  Maria has a passion for early childhood, autism spectrum disorders, rare syndromes, and childhood Apraxia of speech.  For more information, visit her blog or find her on Facebook.

Comments

  1. Maria,
    Thank you so much for your timely and relevant post. From what I have seen working in a psychiatric setting is that RAD continues very much to be a disorder of considerable controversy among many related professionals because its signs often overlap with a number of other psychiatric diagnoses including childhood bipolar disorder, Oppositional Defiant Disorder, Autistic Spectrum Disorders, and so on. I think identification of RAD is a bit easier with certain at risk populations such as domestically and internationally adopted post institutionalized children as well as children from high risk environments (given a documented history of parental substance addition as well as child abuse and neglect). I have also noticed a certain reluctance in the psychiatric community to diagnose RAD in children who reside with biological parents because as one physician had aptly put it, it is interpreted by parents as an accusatory diagnosis since to them it looks as though it is the mother’s fault that the child has the disorder.
    Once again thank you so much for bringing up this topic. We SLPs definitely need to be mindful of this disorder (both confirmed and suspected cases) since children with this diagnosis often present with pretty ‘unique’ linguistic challenges especially because one of its hallmark characteristics is the impairment in the domain of social pragmatic interaction.

  2. Tatyana, I completely agree with the messiness of these comorbid diagnoses. The implications of social skills deficits are apparent. I think as professionals we should take advantage of our psychologists and work collaboratively with them to determine the best course of action. Over time I would like to think we will have better dianostic tools as well as more evidence of efficacious treatment strategies for these children who seem to straddle the boundaries of various disorders. Thanks for your feedback. Its an interesting discussion to say the least.

  3. J.Keller says:

    This has been exhibited by some elementary students through my years of classroom teaching. Five of the students had parents in the prison system. Three of the children were brothers and died as teenagers from guns, drugs and prison life. Two little girls (cousins) had fathers also in prison. Precious children, but hard to reach.

    • I think the biggest thing I always have to remind myself when working with my clients is how their family life and early life experiences do shape them. For my more challenging cases, I try very hard to at the very least be that person of encouragement and hope for my clients. However, sometimes no matter how hard we work with our students, their lives may not become what we hope and dream for them. And in those cases, it is very very tough to do our jobs effectively, especially when it seems no matter what we do, we can’t seem to reach that particular child. I am very sorry to hear of your struggles when working with some students, but I hope at the end of the day, your success stories out number these tragedies by far! Keep it up because every child needs you and you do make a difference! Thanks so much for your comment J. Keller!

  4. Lisa Butler says:

    Nancy Thomas has no formal training in psychotherapy and no academic credentials. Please do research with due diligence regarding attachment therapy and Reactive Attachment Disorder.

    • Lisa, thank you so much for your feedback. I can feel your passion for this topic and I love it! For continual education purposes, I did participate in an undergraduate family studies course at a state university 3 years ago that spent 1/2 the semester on RAD. And yes, information was presented by many researchers in the field as well as information from Nancy Thomas. The reason I chose to reference this particular book was because it was the most parent friendly book I have in my collection at this time and did not appear to go against any previously learned information from my class. Other than the distinctions made between Nancy’s claim of children forming “no attachment” vs. what researchers actually believe more often occurs is in fact an “insecure attachment”, I was completely unaware of the controversy her books have fostered in the field prior to your comment. I did know she was not licensed which is why she has no title of course, but her experience as a foster mother of children with RAD was given adequate support within my classroom setting and therefore, I felt her information was adequate for the basics of this topic. I suppose I trusted the professor of my course as I deferred to her as more of an expert than of course myself, who I feel will forever be a student in the field of Speech Pathology. Thank you so much for bringing this to controversy to light. As always, I encourage people to perform their own research, take into account their own clinical experiences and in conjunction with client priorities and goals, make their own clinical decisions. Thank you again for your passion and feedback.

  5. Kathreen Ryan says:

    My son, Seth, who we adopted when he was 4 years old, is now in 7th grade. He was diagnosed as a RAD kid by his first therapist his first year with us and I have battled with classroom teachers every year. They just won’t believe me. He does have an IEP for behavior but most of the time they won’t follow it. I always begin the school year by giving Nancy Thomas’ “Letter to the Teacher” to his teachers. So far, only one teacher, one of his 6th grade teachers, read it and discussed it with me. The school year is a nightmare for us. Please, Please, Please, listen to the parent. Work with the parent. We only have our child’s best interest. You can destroy the healing process if you don’t.

    • Kathreen,
      Thank you so much for being the voice of parents! It’s so important for professionals to work together with families especially in cases such as yours. You are absolutely right when you talk about the healing process being affected when families don’t get the appropriate support outside of the home environment. I am very saddened to hear of your experiences with your son’s school staff. I very much hope this school year will be much better for you both! Never give up fighting for your son! Best wishes to you and your family!!!

  6. I am a 17 year old who had RAD. After reading this article i see that my parents have done everything to support and help me through what i am dealing with. But i think you should hear from a child who has rad what it is like. When you think about a girl you like and you ask her out because you feel she will make all the difference in the world, and then you get her, you lose because you are not happy. In fact you become depressed. Your siblings don’t trust you, your parents don’t trust you and you don’t trust yourself. People who don’t know you like you the moment they meet you, thinking your a good kid and you wouldn’t hurt people but when they get too close you find yourself hurting them mentally to push them away. There is no real attachment just a surface.

    • Annanyonous,
      Thank you so much for your reply! Sharing your personal experience with us here today is not only brave but also extremely helpful for those of us trying to provide the best possible service for our clients/students. No one on the outside of RAD can really truly understand it. So hearing from someone living with RAD is so invaluable and I am grateful you were willing to share with us today. Hopefully you are following this conversation so you can answer this question for us. In your opinion, what would be the most helpful thing that we can do as adults/professionals working with children (very young or older, such as yourself) to help children with RAD? Is there anything we should not do in your opinion?

      Thank you again for your reply to this thread. I’d love to hear more from you!
      Maria

  7. I worked at a residential and day treatment facility for 4 years right after my CFY and remember distinctly a younf first or second grader who had been diagnosed with RAD and how I thought she had a severe expressive language delay. Three years I worked with her before I finally “saw” the RAD. Definitely hard diagnosis to work with !

    • I completely agree with you Jesse! How difficult it truly is to work with children with RAD and to fully know their capabilities!! Thank you for sharing your experience with us here!!!

  8. Hi, I am a 16 year old Chinese girl. I am sure I have RAD. I was adopted at the age of 4 1/2. I am a scared, private, critical, and shy person. At the orphanage I was scared, sad, and lonely. When I came to the U.S, I was scared of the new surroundings and also afraid I would be taken back to the orphanage. I know my family loves me but I can’t seem to say “I love you” to them meaningfully. I do not like to be touch, kissed, and hugged by anyone. I am a critical person; I criticize my family and myself. At home I more comfortable but when I am in public I am shy. I can’t look into peoples’ eyes often…When I was younger, I would always play by myself. I am somewhat independent. I find it hard to trust people..even myself.

    • I’m so sorry to read about your experience! I can’t possibly understand all of the things you have gone through but it does make sense when you write it in this way. I think you have a very good sense of yourself and how your personal history has affected your emotional development. I’m so grateful you are sharing your story with us. I think it’s easy to “miss” some of the signs when a child is quiet or shy and it does make me wonder how many children do remain undiagnosed or misdiagnosed for this reason. Thank you so much for your much needed insight into RAD and your personal experience with it. Best of luck to you!

      • attachment therapy methods have a gross violation of the UN Convention on the Rights of the Child. AT was condemned by a number of professional associations of paediatricians and psychologists in the United States, as fanatical, unscientific and has no relation to the evidence of psychology and medicine theory and practice.

        • Thank you for sharing this information. I am aware that the use of holding therapy is unscinentific and considered detrimental and I wonder if these are the tactics to which you are referring. I am not a psychologist so my understanding of treatment options in this area are limited however I think you hit the nail on the head here. With the difficulty accurately diagnosing this population and lack of effective treatment measures, this population remains somewhat of a puzzle, particularly for those of us who are not specialists in this area. Thank you so much for sharing your information and expertise.

  9. Maria, my husband and I became foster parents two years ago. We wanted to adopt a child who was legally free for adoption. We were told about an 8 year old boy who had been removed from his home at the age of 7. He was with one other foster family prior to living with us. We had no honeymoon period when he came to live with us. His tantrums started on day 1 and the only place he enjoyed was school. My husband and I thought that his behaviors would evtually subside, but they just got worse. Once we finally had a diagnosis of RAD, we did not receive the help he needed to address this. After a year, CPS removed him from our home when we were not prepared to sign adoption papers. We still think of him often and wonder how he is doing. He has not contacted us, even though he had memorized our phone numbers. We are wiser from the experience and still looking to adopt. I hope we will have a child or siblings placed with us this year. More information needs to be provided to foster parents and teachers about attachment disorders.

    • Michelle,
      I’m so sorry to hear about your experience. How heartbreaking for you and your husband! I completely agree with you regarding the need for providing information in this area to educators and parents who are looking to foster and/or adopt (both domestically and internationally). What are the red flags? What can we do if/when we see these red flags? Sharon Glennan Ph.D., CCC-SLP, Professor Department of Audiology, Speech Language Pathology & Deaf Studies at Towson University, provides parents with a number of pre-adoption questions regarding all areas of development that can be asked prior to adoption (http://pages.towson.edu/sglennen/PreAdoptionQuestions.htm). This is a start but I agree with you more education and training in this area is much needed. Again, I’m so sorry to hear your story. Thank you so much for sharing your experience. I know it will be of much help to all who read these comments. Best of luck to you and your family!

      • Thanks, Maria. Unfortunately our son was labeled as basic level of care. It wasn’t until he was placed with us that he started to get the medical and psychological help that he needed. Unfortunately, he will probably be in a lpng care foster home until he ages out because I don’t think there are many adoptive parents who would be willing to deal with such challenging behaviors. Helping kids from hard places is diificult, but even moreso when the child feels no genuine joy, remorse, or willingness to change. It is a sad situation for all parties involved.

  10. Our son came to us at 19 months. His mother was a drug user and our son experienced extreme neglect. He was very independent from the start but he wouldn’t let me hold him or comfort him. My husband and I continued to believe we could help him to trust and to come to love us. We were wrong. He is now 16 and is abusing drugs, acting out violently and terrorizing our family. He was recently hospitalized and was diagnosed with RAD. We are looking at placing him in a facility that can help him because we no longer can. It’s been a heart-breaking ride and I’ve come to realize that love isn’t always enough. We hope to reunite someday because we love him and don’t want to give up on him, but it’s extremely difficult.

    • Oh Zelda, my heart breaks reading your story! I think you say it all when you say “…I’ve come to realize that love isn’t always enough.” Oh if we could find a way to identify, accurately diagnose and effectively treat this population early, what a difference we could make in the lives of so many! I cannot imagine the pain, frustration, and disappointment you have felt over the years as a parent. I’m sure you’ve questioned yourself and your parenting techniques thousands of times. However, I hope you find comfort in knowing that your son’s difficulties were and are still beyond your control. They are deeper than anything we as mothers, educators, or clinicians can truly understand or imagine. I will think of you and all the parents who have commented in this thread often and hope that one day you will get the reunion you so desperately long for!