Understanding Reactive Attachment Disorder
Preface: I fully realize that the current Diagnostic Statistical Manual of Mental Disorders (DSM) lists Reactive Attachment Disorder (RAD) as Disinhibited Social Engagement Disorder but since I believe that they have made it more obscure and less understood, I will continue to use the acronym RAD. At times I might say, “RAD child”; this in no way means I don’t understand that it is a child with RAD traits (usually some not all), but for simplicity it is easier to just say RAD kids.
Throughout this chapter, I reference studies that can be found in a wonderful resource - The Neurobiology of Attachment-Focused Therapy by Jonathan Baylin and Daniel A. Hughes.
This chapter contains a few case studies of children with Reactive Attachment Disorder (RAD), which include descriptions of aggressive behaviors and trauma that may be distressing to some readers. These examples are meant to help the reader understand RAD traits.
Like Autism, I think RAD is a spectrum. I have seen some children who have just a few of the many traits and several at the other end who almost border on sociopathy. In my opinion, RAD is, without intervention, a straight path to the personality disorders such as Borderline Personality Disorder, Narcissistic Personality Disorder, Antisocial Personality Disorder and Avoidant Personality Disorder. While these are generally not diagnosed until the age of 18, I have seen some foster children who exhibit RAD traits even if they have come straight to a loving adoptive home. Some studies have shown that their brains may function differently, and this can come from the steps that led them to these traits after birth or actions taken, or not taken, by the mother and/or family members affecting the child in utero.
My favorite explanation of RAD was made by a foster parent. Take a baby whose only way of communication is to cry when they are hungry, wet, tired, agitated, or lonely. Ideally a parent swoops in and feeds them, rocks and hugs them, changes them - all comforting responses to them. These babies develop a trust with the world, even imagining that they are the masters of their universe. They whimper and someone comes and loves them. In some cases, babies are left to cry and cry and nothing wonderful happens for them. Either the parent is distracted by something else or just doesn’t have the skills required to fulfill their needs. It doesn’t take long for the baby to either not develop trust or, if trust is developed by one caregiver, it may be disrupted by another. There also seems to be at least anecdotal evidence that we instinctively crave the mother’s love and there may be a disconnect when, in the first couple of months, it is not the mother who is doing the caregiving.
There are other routes to RAD including too many moves among family members or foster homes in early childhood, abuse, or mother’s absence. In one example, I have observed that colic may lead to RAD traits, but there's certainly no proof that this will happen other than occasionally.
So, what are these RAD traits? I’ve seen very few children have them all and many have only a few. These are listed in no particular order, but the first couple are the ones I see most. Also, no matter where they are on the spectrum, it is always (a word I almost never use, which is another word I try not to use) about control. They didn’t have control when they should have as babies, so it is imperative that they have it now. After all, if the people who were supposed to take care of them didn’t, they learned they must take care of themselves.
Manipulative
Presents well to others
Attacks the mother figure more than the others
Attention seeking
Attracts drama
Makes friends easily but is unable to keep them
Lying— more in terms of manipulation
Stealing—not for gain, but for control
High thresholds of pain
Collects funny objects—turn out their pockets and there will be bits of plastic, rocks, etc.
Black and white thinking
Victim mentality
Poor, if non-existent, boundaries
More times than I can count, I have sat with stepmoms, foster moms, and adoptive moms who have thought they were going crazy because no one else has witnessed the abuse they are suffering at the hands of the child. I have seen marriages going south because the father has come to the erroneous conclusion that the mother simply doesn’t respond appropriately to the child and blames the mom. In one case, the stay-at-home parent was the dad, and he was actually the one targeted. The mother ended up thinking they were the problem because they don’t love the child as they deserve.
It is counterproductive to put RAD kids in counseling if the disorder is not understood. They want to look so good that even the most well-meaning counselor will believe that the child is extraordinary and saddled with really mean, abusive parents. As a guideline, I do not see a RAD child without seeing at least one caregiver to truly understand the family dynamic accurately.
One of the traits, as you read above, is a very high threshold of pain and I have witnessed this firsthand.
I was seated next to a foster child when blood gushed from her ear without her noticing. When I started walking her to the bathroom to get a towel another foster child accidentally brushed her arm and you would have thought she’d broken it.
I’d also like to say here that lots of children have some of the traits—especially attention seeking. Once at an amusement park, a little girl broke away from holding the foster mother’s hand to tell a complete stranger she had to go to the bathroom and would he please take her. They may sit on men’s laps and can be enchanting and tend to be promiscuous when entering puberty. This is purely anecdotal but since they have very few boundaries, they skew towards attention-seeking behaviors and tend to seek it from male figures because their relationship with female nurturers can remain compromised by their biological mothers not always being in their lives.
Some do well at school, some do better at home but in general, they have difficulty holding it together in all environments. RAD kids are much like typical kids but intensified.
The most extreme cases I’ve seen have worked hard to hurt others or get others in trouble. Names and identifying information have been changed to protect their identities.
Johnny came into an extremely brilliant foster home just after he turned five. Three weeks earlier he was living with his disabled grandfather, an older and younger brother, and many pets. He asked his grandfather to cook him some sausage and when the grandfather failed to do so immediately, Johnny went upstairs and lit his mattress on fire. All humans were able to get out before the house burned down, but the grandfather eventually died. When asked about it later, Johnny’s reply was simply, “He should have made me my sausages.” At school and in his kindergarten class, the teacher and secretary thought he was adorable and “wished they could take him home” because they didn’t think the foster parents were loving enough. In reality, they were handling things correctly, but even after I told the teacher not to, they kept a little baggy of tokens pinned to Johnny’s desk so they could reward him whenever he did the littlest thing right. Until the day he didn’t get a token when he thought he should; his classmates heard words and saw a reaction they likely haven’t forgotten yet.
James was a child I had in two different homes from the ages of nine to eleven. He did well for a while, but then began grooming a birth child in the first home. He went to another excellent home where he loosened screws on the ceiling fan because he believed it would decapitate someone when turned on. Not long after, he kicked the family dog to death, mocking it while it lay dying. The foster mother handled him with the exact strategies I had taught her, and he began to make many improvements. We had hope…until the state was given permanent custody. A new worker came with a videographer for adoption, and he was able to tell his lies to a new audience and convince them he was still a victim in the foster home. In the end, he was institutionalized; they did so much damage by believing him that it was too late to save the foster placement or even seek an adoptive home.
Jenny was so angry that she spent all her time trying to get her brothers into trouble. She stole from one and hid it in the other’s chest of drawers so he would get in trouble. She smeared feces if she didn’t get her way; she went into her brother’s locker to rip up his papers on her way to the bathroom. After visiting her aunt and uncle, the aunt noticed her engagement ring was missing. When Jenny was questioned, she told her mom that she took it and gave it to a friend. When she couldn't produce the friend's name, she said she flushed it down the toilet. Several weeks later, the aunt found it in a box where Jenny said she put it for safekeeping but didn't tell anyone, causing weeks of grief for the aunt.
In spite of these things, children with attachment issues have my respect. They are bright and beautiful, and not only have they survived what I doubt I could survive; they spend a great deal of time working out how to manipulate to get what they want. What is truly hardest is no matter how much they receive both in love and material possessions, they can be “black holes”; parents can be left feeling what is given is often not enough for them, so parents feel unappreciated and unable to fill them up. Despite the negatives, the strengths of these children can often be strong. They are wonderful helpers and are often very good with younger children. When understood, true love can be fostered with the techniques we've been using.
Understanding RAD is understanding a lot of complex emotions and behaviors. There were things I understood well because of the foster parents I was blessed to learn from and work with, but I also learned much from my clients and their families and from a gem of a book, The Neurobiology of Attachment Focused Therapy by Daniel Hughes and Jonathan Baylin.
I knew that CAT scans of children with RAD’s brains were different than healthily attached brains, but there were still mysteries like how a child can go straight from the hospital into a loving, adoptive home and still have RAD traits later. It might be explained if the birth mother consumed alcohol or drugs during pregnancy, but that isn’t always the case.
One possibility is that when the baby doesn’t hear the birth mother’s voice, the voice they’ve heard in utero, the amygdala goes into overdrive in a flight or fight scenario and the message is “you are not safe.” This means that the baby may not feel safe if they are not hearing the voice that ensures that everything is fine.
Another thing I never understood is the very high threshold of pain that many of them are able to withstand, like the child with the burst ear drum. Their brains, in some cases, release opioids when they are hurt or traumatized which can account for their being able to handle pain differently than other children can. In the end, RAD kids are the same as other children in many ways, but more intense and more reactive than kids who were properly cared for from birth.
They frequently do well during a special event like a party or a trip to the zoo, but then there is payback later that night or the next day. They almost seem angry that they have had a good time. I’ve thought a lot about this, and I think it boils down to them not truly feeling worthy of having or doing anything good. They may feel If they aren’t good enough for their own parents to love them then they really must not be good enough for anything or anyone.
This is the challenge - how to love a child who feels they are unlovable.
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