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
- 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.