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com

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 Interventions
for children with
reactive
attachment BY HEATHER VEGA, ASN, RN, CNOR, RNFA;
KIMBERLY COLE, ASN, RN; AND

disorder KENNETH HILL, ASN, RN

Abstract: Characterized by aggressive or violent

behaviors, reactive attachment disorder (RAD)
affects children who have been repeatedly exposed
to traumatic experiences. This article discusses the
underlying causes of RAD and provides insight on
therapies and interventions.
Keywords: aggression, behavioral therapy,
developmental trauma disorder, early childhood
development, foster care, foster children, pediatrics,
reactive attachment disorder, trauma, trust-based
relational intervention

REACTIVE ATTACHMENT DISORDER (RAD) is a

serious condition in which infants or young chil-
dren do not establish healthy attachments with a
primary caregiver and their basic needs for com-
fort, affection, and nurturing are not met.1 It is a
developing issue in psychology and healthcare,
affecting children between ages 6 months and 2
years who have experienced disrupted attachment
and lacked individual attention during fundamen-
tal periods of development. RAD is commonly
seen in foster children who have been repeatedly
exposed to traumatic experiences, including
neglect; physical, sexual, and/or emotional abuse;
or other maltreatment.2
Children with RAD are more likely to develop
behavioral health disorders, social disorders,
CHRISTOPHER BERNARD / ISTOCK

substance abuse disorders, and other attachment

disorders such as disinhibited social engagement
disorder.3 Additionally, foster children diagnosed
with RAD or developmental trauma disorder
(DTD), which is characterized by symptoms that
overlap with but extend beyond those of posttrau-
matic stress disorder (PTSD) due to interpersonal
trauma during development, are at increased risk

www.Nursing2019.com June l Nursing2019 l 51

Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

for criminal behavior and incarcera-
tion as adults.4,5 Increasing awareness
and implementing early interventions
is necessary to gain a complete under-
standing of these children and increase
their chances of success as adults. This
article examines the role of healthy
attachments in early childhood devel-
opment and discusses how nurses can
intervene to mitigate RAD and other
trauma-related disorders.
Early childhood development
John Bowlby outlined attachment
theory in the 1960s, proposing that
early caregiver interactions are a reli-
able predictor of future interpersonal
relationships.6 The concept relies on
the theory that an infant’s primary
instinct is to form a close bond of
comfort and security with a primary
caregiver in the first year of life.7
Infants rely on caregivers to recog-
nize their physical and psychological
needs during growth and develop-
ment. Those who do not form bonds
with caregivers in infancy are at an
increased risk for developing future
behavioral problems, such as with-
drawal, aggression, impulsiveness,
and other socially inappropriate be-
havior. Inconsistent care, continual
neglect of basic and emotional needs,
and the inability to form a secure,
stable attachment make up the clini-
cal criteria for diagnosing RAD.1
The impact of complex develop-
mental trauma at a young age may
also lead to the development of RAD.
Many of these children have experi-
enced neglect, physical and/or sexual
abuse, and emotional trauma at vul-
nerable stages.2 Additionally, scientific
research has demonstrated that
chronic child maltreatment perma-
nently alters brain maturation, forma-
tion, structure, and function,
resulting in an inability to regulate
cognition, emotion, and behavior.
Cumulative childhood adversities
combined with the subsequent
chronic stimulation of the neuroen-
52 l Nursing2019 l Volume 49, Number 6
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Children with RAD are
more likely to develop
behavioral health
disorders, social disorders,
substance abuse
disorders, and other
attachment disorders.
docrine system and inflammatory
pathways may also impair brain
development.8
Stimulation of a developing brain
encourages neural activity and
prompts the formation of synaptic
connections. In neglected and abused
children, these neural connections fail
and the neurons die. The prefrontal
cortex is responsible for personality
expression, decision-making, impulse
control, and social behavior. These
functions are compromised in chil-
dren with RAD.8
RAD was first recognized by the
American Psychiatric Association in
1987 in the Diagnostic and Statistical
Manual of Mental Disorders, third
edition. Neglect is a core factor, and
symptoms typically manifest by age 5.1
Due to limited research, the diagnos-
tic criteria are controversial, and the
disorder has been misunderstood
and underdiagnosed since its intro-
duction.9
Children with RAD typically ex-
hibit aggressive or violent behaviors,
which can negatively impact their
lives and place in society without
proper intervention and support
from those responsible for their care.
They are often described as with-
drawn, with unexplained fear, sad-
ness, or irritability. These children
do not seek or show any response to
comfort, and they cannot maintain
significant relationships. Addition-
ally, they demonstrate a need to con-
trol their environment and others
around them.1,10
Disrupted attachment, the under-
lying cause of RAD, can stem from
various circumstances. These include
living in an orphanage or foster care,
prolonged hospitalization, abuse or
neglect by primary caregivers, mul-
tiple out-of-home placements, and
the prolonged separation from or
death of a primary caregiver. Trauma-
based disruptions alter childhood
development and produce children
who are impulsive; rage-filled; un-
able to give or receive love; and
lacking in conscience, remorse, and
empathy. These impairments can
have lifelong consequences.10
Factors related to foster care
Attachment disorders are typically
associated with and diagnosed in (but
not limited to) foster children.10 As of
2017, over 430,000 children in the
US were in the foster care system.11
Of these, 61% were removed from
their homes due to neglect.12
According to a 2012 statistic,
approximately 80% of US prison
inmates have been in foster care.13
Data show that men placed in foster
care as children are 23% more likely
to have an arrest, conviction, and in-
carceration than those who remained
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at home.14,15 Similarly, a 2014 study
found that 55% of young men be-
tween ages 19 and 31 who aged out of
foster care were involved in criminal
activity since leaving the system.14
A review of the literature yielded
limited evidence regarding the preva-
lence, diagnosis, treatment, and out-
comes for RAD. According to the
International Child and Youth Care
Network, 800,000 children with se-
vere attachment disorders have been
brought to the attention of child wel-
fare services, but the actual number
may be up to 16 times higher than
the given statistics.16 One US study
of foster children ranging from ages
10 to 47 months identified RAD in
38% of participants.17 Another com-
parable study identified RAD in 19%
of foster children between ages 6 and
12 years.17 These figures indicate a
significant prevalence of RAD in the
foster care population.
RAD management
Traditional parenting styles and be-
havior modifications have not proven
successful for disruptive behaviors.
These include verbal criticism, time-
outs, harsh punishments or threats,
and guilting or ignoring the child.
These methods can have negative
effects and are not productive or con-
ducive to change.18,19 Psychotherapy
is crucial in managing delayed devel-
opment, but evidence-based studies
are lacking in the treatment of RAD.
Since the 1980s, many treatments
have been implemented (see Devel-
opmental disorders and therapies).
These include:20-22
• trauma-focused cognitive behavioral
therapy, which targets “inaccurate or
negative thinking”20 to help patients
manage challenging circumstances
and “includes education, relaxation
exercises, coping skills training,
stress management, or assertiveness
training.”21
• dialectical behavioral therapy,
which incorporates “skills training,
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Developmental disorders and therapies
Cognitive A form of psychotherapy that targets inaccurate or negative
behavioral therapy thinking to help patients manage challenging circumstances20
Developmental A relatively new diagnosis that describes “the biopsychosocial
trauma disorder sequelae of exposure to interpersonal victimization in
childhood that extend beyond the symptoms of PTSD”5
Dialectical An empirically supported therapy approach to manage
behavioral therapy complex mental health problems32
Eye movement An evidence-based but controversial psychotherapy
desensitization approach in which bilateral movements are used to help
and reprocessing manage PTSD33
therapy
Reactive A serious condition in which infants or young children do
attachment not establish healthy attachments with a primary caregiver
disorder and their basic needs for comfort, affection, and nurturing
are not met1,34
Trust-based A holistic intervention developed for childhood victims of
relational “maltreatment, abuse, neglect, multiple home placements,
intervention and violence” who may have developed behavioral disorders.26
mindful practice, and close monitor- of attachment. Proposed by Schore,
ing of and intervention in crises” for regulation theory explores how early
patients who have difficulty regulat- parent-child interactions have a large
ing their emotions.21 impact on an infant’s regulatory ca-
• eye movement desensitization and pacities.9
reprocessing therapy, which utilizes TBRIs have the potential to im-
bilateral stimulation to help patients pact the lives of children who have
focus on and reduce the emotions experienced complex developmen-
related to past trauma.22 tal trauma such as RAD.24 A 2013
Medication therapies have been study supported the effectiveness of
used successfully as well, including TBRIs in decreasing maladaptive and
psychopharmacologic agents to violent behaviors and promoting
address the associated behavioral healthy attachment relationships.24
symptoms such as “explosive anger, TBRI is designed to connect and
hyperactivity, and difficulty in focus- build a relationship with children
ing or sleeping.”8 Rather than the of all ages and follows three princi-
traditional behavioral methods, how- ples to encourage healthy attach-
ever, effective treatments seem to ment: empowerment, connection,
have focused on attachment-based correction.18,24-26
therapies, which have proven Empowerment focuses on the eco-
successful in promoting positive logic and physiologic concerns of the
healing and recovery in children child, with emphasis on a safe and
with RAD.3,18,23 structured environment, sensory
needs, and nutrition to encourage
Understanding TBRI trust in traumatized children. Trauma-
Trust-based relational intervention tized children often have sensory pro-
(TBRI) is an attachment-based thera- cessing deficits, which may negatively
py focused on safety, human connec- affect behavior, social and motor skills,
tion, and regulation.24 Regulation and academic performance. Sensory
refers to the neurobiological aspects stimulation improves physiological,
June l Nursing2019 l 53
mental, and emotional health. Proper
nutrition is important for healthy
children, and those with prenatal
exposure to drugs and/or alcohol
may experience fluctuations in blood
glucose that affect behavior. Proper
hydration and a nutritious snack every
2 hours stabilizes blood glucose levels,
improves mood, and optimizes
cognitive functioning.18,24
Connection focuses on observa-
tional awareness, self-awareness,
attachment skills, playful engagement,
and attunement. Observational
awareness helps caregivers recognize
anxiety and allows them to respond
appropriately. Many traumatized
children cannot verbalize their
needs. TBRI helps caregivers be-
come aware of nonverbal cues,
such as dilated pupils, increased
heart and respiratory rates, and
muscle tension.18,24
Self-awareness is also important, as
caregivers must always be emotionally
available to promote healing. Similarly,
attachment skills are also modeled
under the connection principle of
trust-based relational intervention.
TBRI teaches caregivers to give the
child a voice, allowing children to be
heard and promoting connection. Play-
ful engagement and interactions pro-
mote warmth and trust to enhance
attachment, socialization, and language.
Attunement refers to verbal and
nonverbal communication of the care-
giver and child, including appropriate
tone of voice, eye contact, and body
position, as well as matching, in which
the child mimics the caregiver.18,24
Correction modifies behavioral
needs and focuses on building social
competence. This is achieved after
empowerment and connection have
been established and focuses on pro-
active and responsive behavioral
strategies. Proactive behavioral
strategies use preventive teaching
methods, such as role-playing, verbal
reminders or demonstrations,
rehearsals, and life value terms, to
54 l Nursing2019 l Volume 49, Number 6
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
Facilitating the use of
TBRI techniques in
schools and healthcare
settings can support
children with RAD.
demonstrate problem behaviors. Life
value terms create a culture of mutual
respect by using words instead of
negative behaviors, accepting “no,”
accepting consequences, and making
eye contact. Responsive behavioral
strategies are used when children
exhibit more challenging behaviors
and guide them to the appropriate
behavior and response to assist with
self-regulation.18,24
Assessment and treatment
To individualize treatment plans for
children at risk for RAD, a compre-
hensive psychiatric assessment by a
behavioral health professional is need-
ed. The American Academy of Pediat-
rics recommends that children receive
a full behavioral health evaluation,
including assessments for trauma and
suicide risk, by a trauma-informed
pediatric behavioral health profes-
sional within weeks of their place-
ment in foster care.27 An initial health
screening is recommended within 72
hours. Additionally, children in foster
care should be seen by a pediatrician
monthly during their first 6 months of
life, every 3 months until age 24
months, and a minimum of every 6
months thereafter.27
Children with RAD may benefit
from individual, group, and family
psychological counseling.28 For
guardians, parenting skills classes may
also be beneficial. The treatment goals
focus on providing a safe and stable
living situation for children at risk for
or diagnosed with RAD, and encour-
aging positive interactions between
primary caregivers and children. A
2014 study demonstrated potential
for maltreated children to develop
secure attachments to foster parents in
adolescence even without appropriate
attachment to a biological parent.29
Safety and support
The impulsive and unpredictable
behaviors of children with RAD can
put them at risk, as well as others.8
Children with RAD are at risk for
self-destructive behaviors, and their
caregivers are at risk for violence sec-
ondary to aggression, manipulation,
and triangulation, in which a child
disrupts communication between
three parties for control.8,9 Caregivers
may also need support and reassur-
ance when caring for these children.
As such, routine safety assessments
should be conducted to ensure that
these children and families are not
at risk. Additionally, healthcare pro-
fessionals should advocate for and
provide access to the appropriate
behavioral health services.8,9,30
Parental influence is a key factor in
healing and attachment, but nurses,
mental health professionals, and soci-
etal awareness may also encourage
growth in children with RAD.24 Nurses
and those knowledgeable in TBRIs
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may have a better understanding of
how best to care for these populations.
Educating clinical professionals and
caregivers about complex trauma from
events with a long-term impact on
development, expanding insight on
TBRIs, and facilitating the use of this
technique in schools and healthcare
settings can support healing in chil-
dren with RAD.31 It can also help par-
ents and other caregivers develop
healthy attachments with their chil-
dren. Additionally, healthcare profes-
sionals and educators can help to
promote awareness with training
and education on healing and brain
development.7
Future directions
Early interactions and relationships
with caregivers are key to establish-
ing healthy infant and child develop-
ment. Children who have been
abused or neglected become fearful
and develop hostility toward attach-
ment figures, potentially becoming
disconnected from society without
the appropriate intervention. Stable,
consistent, loving relationships are
necessary to establish a secure rela-
tionship, build trust, and strengthen
child-caregiver connections.
The key to success is for health-
care professionals, teachers, families,
communities, and society to have
awareness, proper education, and
training on childhood development
for children with RAD and DTD. An
overall awareness of developmental
issues, early interventions, and spe-
cific therapies can facilitate healthy
development and minimize the risk
of criminal behavior in adulthood.
Increasing awareness and imple-
menting strategies and therapeutic
interventions benefit not only chil-
dren diagnosed with RAD, but also
society as a whole. The earlier an
intervention is implemented, the
more likely a child diagnosed with
RAD will become a successful and
productive adult. ■
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Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
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At Methodist Le Bonheur Healthcare in Memphis, Tenn.,
Heather Vega is a nurse in the surgical ICU and Kenneth
Hill is a nurse in the medical-surgical ICU. Kimberly
Cole is a nurse in the postanesthesia care unit at
West Tennessee Healthcare in Jackson, Tenn. All of
the authors are also BSN students at the University
of Tennessee at Martin.
The authors have disclosed no financial relationships
related to this article.
DOI-10.1097/01.NURSE.0000554615.92598.b2
June l Nursing2019 l 55