Reactive Attachment Disorder (RAD)

1. Reactive Attachment Disorder(RAD) Knowledge is the Key to Understanding Abby Gould abgould@hotmail.com

2. Learning Objectives • Understand a working definition of attachment • Distinguish between two subtypes of Reactive Attachment Disorder (RAD) • Recognize four common symptoms of RAD • Identify three possible strategies teachers can implement in the classroom to help students with RAD

3. What is Reactive Attachment Disorder? • RAD is a complex psychiatric disorder in which individuals have difficulty forming lasting, loving and intimate relationships. • Markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before the age of five and is associated with grossly pathological care. (DSM-IV-TR, 2000)

4. Glossary • Psychiatric disorder - occurs in an individual and is usually associated with distress or disability that is not expected as part of normal development or culture (http://en.wikipedia.org, 2007) • Markedly disturbed - showing extreme symptoms of emotional illness or mental disorder (http://medical.merriam-webster.com, 2007) • Social relatedness - a person’s ability to associate and interact with society and its members (e.g. A child with RAD does not possess appropriate social relatedness as seen in excessive familiarity with strangers.) (http://en.wikipedia.org, 2007)

5. Grossly Pathological Care: Grossly pathological care is defined by: • A persistent disregard for the child’s emotional needs for comfort, stimulation, and affection • Persistent disregard for the child’s physical needs • Repeated changes of primary caregivers (Schwartz & Davis, 2006)

6. Medical Conditions Associated with Grossly Pathological Care and RAD: Include: malnutrition, growth delay, evidence of physical abuse, vitamin deficiencies, or infectious diseases. (DSM-IV-TR, 2000)

7. Two Subtypes of RAD • Inhibited • Refers to children who continually fail to • initiate and respond to social interactions in a • developmentally appropriate way • Interactions are often met with a variety of • approaches, avoidance and resisting to com- • forting, often hypervigilant or highly • ambivalent Example: A child or infant that does not seek comfort from a parent or caregiver during times of threat, alarm or distress.

8. Two Subtypes of RAD • Disinhibited - Refers to a child who has an inability to display appropriate selective attachments(DSM-IV-TR, 2000) - More enduring over time than the inhibited type Example: A child who displays excessive familiarity with strangers.

9. Why is Attachment important? Attachment is essential for the formation of a healthy personality which includes: • Development of a conscience • Ability to become self-reliant • Ability to think logically • Ability to cope with frustration and stress • Ability to handle fear or a threat to self • Development of relationships

10. Symptoms displayed by individuals with RAD • Lack of self-control / impulsive • Speech and language delays • Lack of conscience / shows no remorse • Indiscriminately affectionate with strangers • Avoids physical contact • Hyperactive

11. Symptoms of RAD, Cont’d • Aggressive • Destructive towards self, property and others • Food issues: hordes, gorges, refuses to eat, hides food • Often on guard, anxious, wary • Prefers to play alone • Inhibition or hesitancy in social interactions

12. Severe Warning Signs in Infants • Severe Colic • Poor eye contact, difficulty tracking • No reciprocal smile response • Delayed gross motor skill development (sitting, crawling, etc.) • Difficulty being comforted (extreme crying, constant whining) • Resists affection and cuddling from caregiver/parent • Appear stiff, display tactile defensiveness • Poor sucking response when eating

13. Potential Causes of RAD • Frequent changes in primary caregiver • Extended separation from the parent/primary caregiver • Frequent moves and/or placements in foster care or institutions • Traumatic experiences • Undiagnosed, painful illness such as cholic, ear infections, etc. • Young or inexperienced mother with poor parenting skills • Neglect • Abuse

14. I’m a foster / adoptive parent . . . Should I be concerned? Be sure to learn about the environment of the orphanage, institution, or foster home • High numbers of children and limited staff in the environment in which the child is being cared for can hinder the development of a healthy bond between caregiver and child.

15. Prevalence The prevalence of RAD has been estimated at 1% of all children under the age of five. Children orphaned at a young age have an increased likelihood of this disorder. However, since the onset can be detected as early as two months of age, considerable improvement or remission is possible if the child experiences an appropriately supportive environment. (DSM-IV-TR, 2000)

16. Effective Treatments • Family therapy - helps the parents or caregivers and other children in the family understand symptoms of the disorder and effective interventions. • Individual therapy - helps the child directly with monitoring emotions and behavior • Play therapy - helps the child learn appropriate skills for interacting with peers and other social situations

17. Other possible treatment options • Medication- for symptoms of the disorder (for example, anxiety and hyperactivity) • Special education services within the child’s school (including a Individualized Education Plan (IEP)) - specifically designed programs that can help the child learn skills required for academic and social success, while addressing behavioral and emotional difficulties.

18. What can I do as a parent ? • Get information on attachment and helping your child form a healthy bond. (references that follow include helpful websites) • If you don’t have much experience in caring for an infant or small child, take classes or try to volunteer with young children to increase your knowledge. • Be active with your child through play, making eye contact, talking with, smiling at, reading with, sharing mealtimes.

19. School Implications • Children with reactive attachment disorder have difficulties self-regulating emotions and behaviors. • These children struggle to form typical, reciprocal relationships with peers and adults. • Self-regulatory and social skills are important prerequisites for school readiness and academic success.

20. The unique school challenge for children with RAD • While the school setting is meant to educate, children with RAD are primarily concerned with internal feelings of safety, security and trust. • Greater degree of dependency on the teacher due to past disruptions in attachment.

21. How can teachers help a child with RAD reach academic success? • Be consistent, predictable, and repetitive • Set clear, concise expectations • Set a classroom routine • Model and teach appropriate social behaviors • Maintain realistic expectations • Ignore “junk” behaviors - that is behaviors that are not harmful to the child, others or property

22. More classroom techniques for teachers • Be patient with the child (and yourself) • Understand behaviors before punishing • Utilize other resources (school counselor/psychologist, internet, etc.) to gain needed information to understand the effects of Reactive Attachment disorder on the child’s behavior and emotions • Help the child learn how to regulate his or her feelings and actions

23. How do parents help to ensure school assistance with behaviors? Children with the diagnosis of RAD are eligible to receive PA Code Chapter 14 services, which require teachers and school districts to follow a individual student plan.

24. Pennsylvania Code Chapter 14 The state regulation that implements the federal Individuals with Disabilities Education Act and explains how children with disabilities who need special education can get help from their school districts. (Education Law Center, 2006)

25. PA Code Chapter 14 cont’d • Children with RAD are eligible for the services outlined in Chapter 14 due to speech and language delays, as well as, various other learning delays. Through this law, children are provided with specially designed instruction and other related services after a comprehensive evaluation is completed by the school district. • Although children with RAD can be diagnosed at a young age, they are still eligible for specialized instruction in their district pre-schools, kindergartens, DART programs and early intervention programs. • Parents are involved, along with the teacher and school district representative, in deciding the special instruction and related services that the child will receive. (Education Law Center, 2006)

26. For more information on Chapter 14. . . Contact the Education Law Center at: (412) 391-5225 (Pittsburgh) (215) 238-6970 (Philadelphia) www.elc-pa.org

27. There is hope . . . • Keep in mind Reactive Attachment Disorder is quite rare even in children involved in the foster system. • RAD can be treated and children often experience remission, especially if recognized at an early age. • Support systems and information are available through various institutions including school districts, adoption agencies, foster care agencies and treatment centers.

28. References • American academy of child and adolescent psychiatry. (2007). http://www.aacap.org/page.ww?name=Reactive+Attachment+Disorder&section=Facts+ for+Family. • American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.) Text revision. Washington, DC: Author. • Association for treatment and training in the attachment of children. (2007). http://www.attach.org. • Attachment & trauma network: hope & healing for traumatized children and their families. (2006). http://www.attachmenttraumanetwork.org • Attachment disorder site. (2007). http://www.attachmentdisorder.net. • Education law center. (2006). http://www.elc-pa.org

29. References cont’d • Helpguide: a trusted non-profit resource. (2001-2007). http://www.helpguide.org/mental/parenting_bonding_reactive_attachment_disord • Merriam-Webster. (2007). http://medical.merriam-webster.com • Reactive attachment disorder and detachment issues. (2007). http://www.radkid.org • Schwartz, E., and Davis, A. (2006). Reactive Attachment disorder: Implications for school readiness and school functioning. Psychology in Schools, 43, 471-479. • Stoller, J.L. (2006). Parenting other people’s children: understanding and repairing reactive attachment disorder. Vintage Press. • Thomas, N. L. (2005). When love is not enough: a guide to parenting children with RAD. Colorado: Families by Design. • Three rivers adoption council. (2007). http://www.3riversadopt.org • Wikipedia. (2007). http://en.wikipedia.org

30. Contact Information Abby Gould abgould@hotmail.com