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Running head: REACTIVE ATTACHMENT DISORDER

Reactive Attachment Disorder in Adopted Children and Treatment Implications

Elizabeth Cuttle

Wake Forest University

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Abstract

Reactive attachment disorder (RAD) is a childhood disorder that results from maltreatment,

abuse, or neglect from a young age. Because of the inability to form attachments to abusive or

absent caregivers, some children develop RAD symptomology. Children with a RAD diagnosis

display little to no positive affect, do not seek or respond to comfort from caregivers, and

experience unprovoked episodes of extreme anger, hostility, or sadness. The findings on the

prevalence of RAD are inconsistent, but it is more likely to develop in children who are

institutionalized and who are placed in adoptive families at a later age. RAD not only affects the

child experiencing symptoms, but it also affects the family as a whole. The majority of adoptive

families of children with RAD describe their experience as stressful, socially isolating, and

uncontrollable, but they are nonetheless supportive of their children. Treatments for RAD

include attachment therapy, which involves activities such as holding and parental education

about abuse. Play therapy and behavior management training (BMT) are additional modes of

treatment. All in all, RAD is a highly misunderstood childhood disorder, and little is known

about the effectiveness of the various treatment modalities, which warrants further empirical

research on the subject.

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Reactive Attachment Disorder in Adopted Children and Treatment Implications

From birth, children rely on a caregiver to provide them with basic needs, such as love,

food, shelter, attention, and care. When children are abused, neglected, or maltreated from an

early age, devastating effects can follow them persistently throughout their lives, even when

secure attachments are later formed (Stinehart et al., 2012). Reactive attachment disorder (RAD)

is one disorder that can emerge as a result of inadequate caregiving of a child. RAD is especially

prevalent in children placed in institutionalized care, and adoptive families often struggle to

relate to their RAD-diagnosed children (Shaw & Páez, 2007). Children with a RAD diagnosis

display little to no positive affect, do not seek or respond to comfort from caregivers, and

experience unprovoked episodes of extreme anger, hostility, or sadness (American Psychiatric

Association, 2013). Shaw and Paez (2007) disclose that “even in the most loving and stable

homes or settings, we have seen children urinating on furniture, harming family pets, engaging in

self-harm, destroying household objects, hitting and kicking adoptive or foster parents, and

running away” (p. 73).

RAD clearly poses significant challenges to both the child and the family, and it is

important to understand the implications of the disorder. This literature review reports the

findings of the current literature on RAD risk factors, RAD prevalence in adoptive and foster

children, challenges faced by adoptive families of children with RAD diagnoses, and a

discussion of various treatment options. Although reactive attachment disorder is not very well

understood, this review points out strengths and gaps in the current literature in hopes of both

lowering the risk for RAD development and improving the lives of children diagnosed with RAD

and their families.

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Method

To find articles pertaining to reactive attachment disorder, I searched the PsycInfo, ERIC,

and PubMed databases. I set the search parameters for peer-reviewed journal articles published

in the years 2007 to 2020. For my initial search on PsycInfo, I typed the key words “reactive

attachment disorder” to get a general idea of the current literature of the topic as a whole. This

yielded 383 results, so it was clear that I had to narrow the search. Next, I searched “reactive

attachment disorder” AND “adopt* OR foster.” The truncation of “adopt*” allowed for the

database to search for all related terms (i.e. adopted, adoption, adoptive). This technique yielded

100 articles, which still proved to be quite a broad range. I further narrowed this search to 15

articles by changing the search field to include the key words in the title only. Moreover, to find

articles based on treatment options for reactive attachment disorder, I searched “reactive

attachment disorder” AND “treatment OR intervention OR therapy,” which provided me with

eight journal articles. Throughout my search process, I excluded articles discussing solely

“attachment” or “attachment styles” rather than “reactive attachment disorder.” Although they

are related topics, the prior topics are not specific to reactive attachment disorder. Finally, I

repeated the above search processes for the ERIC and PubMed databases, but PsycInfo yielded

the most useful results.

Results

According to the DSM-5, a diagnosis of reactive attachment is suggested if the following

criteria are met:

A. “A consistent pattern of inhibited, emotionally withdrawn behavior toward adult

caregivers, manifested by both of the following:

1. The child rarely or minimally seeks comfort when distressed.

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2. The child rarely or minimally responds to comfort when distressed.

B. A persistent social and emotional disturbance characterized by at least two of the

following:

1. Minimal social and emotional responsiveness to others.

2. Limited positive affect.

3. Episodes of unexplained irritability, sadness, or fearfulness that are evident

even during nonthreatening interactions with adult caregivers” (American

Psychiatric Association, 2013, Reactive Attachment Disorder section).

Moreover, to meet the criteria for a diagnosis, the child must experience symptoms as a

result of extreme insufficient care. This can be in the form of social neglect or deprivation,

frequent changes in caregivers, or rearing in unusual settings, such as institutions with high

child-to-caregiver ratios (American Pediatric Association, 2013). These are all situations that

limit the opportunities for a child to form secure, selective attachments and have their emotional

needs met by caregivers. Lastly, the child must be at least nine months old and the symptoms

must be evident before the age of five (American Psychiatric Association, 2013).

RAD Risk Factors

The current literature reveals several main risk factors for children developing reactive

attachment disorder. Guyon-Harris et al. (2009) found that the longer children were in

institutional care, the more RAD symptoms they tended to display. Moreover, children placed

into families at later ages tended to have more severe RAD symptoms (Guyon et al., 2009).

Foster care (as opposed to institutional care) led to greater reductions in RAD symptoms (Guyon

et al., 2009). Similarly, Smyke et al. (2012) found that institutionalized children with RAD that

were placed in foster homes before age 24 months showed a greater decrease in symptoms than
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children placed in foster homes after 24 months of age. Furthermore, Hornor (2008) declared that

RAD, by definition, is caused by maltreatment, abuse, or neglect in early childhood. Conditions

that may contribute to the onset of RAD include physical abuse, sexual abuse, neglect, parental

alcoholism or drug use, parental mental illness, or absence of a consistent primary caregiver

(child institutionalized, in foster care, parental incarceration, or parental abandonment) (Hornor,

2008). In another study, Minnis et al. (2009) found that attachment style and reactive attachment

disorder were not mutually exclusive; that is, 30% of the children with RAD were rated as

securely attached. Also, children with RAD who experienced a history of abuse or neglect were

more likely to display an insecure-disorganized attachment style than those without a clear

history of abuse or neglect (Minnis et al., 2009).

Prevalence of RAD Among Adopted and Foster Children

The research on the prevalence of reactive attachment disorder is limited. In a study with

young children placed in child protective services, Bruce et al. (2018) found that 5% of the

sample met the criteria for a RAD diagnosis when first placed in foster care. After about one year

in improved foster care conditions, the number was reduced to 2.1%. Further, Hornor (2008)

reports that although RAD only affects about 1% of the general population, the prevalence is

much higher in high-risk populations (i.e. maltreated toddlers and children placed in foster care

as a result of abuse or neglect). Shi (2014) relays that up to 35-45% of abused or neglected foster

children display symptoms of RAD. More research is warranted on this topic to fully grasp the

scale of reactive attachment disorder.

Challenges for Adoptive and Foster Parents

Reactive attachment disorder not only affects the child, but it also affects the family as a

whole. In a recent research study, Follan and McNamara (2014) interviewed eight adoptive
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parents of children with RAD. The parents disclosed they were highly unprepared for the

situation and felt insecure about their parenting skills. They described their relationships as

exhausting, fragile, uncontrollable, and strange. Although the child-parent relationships were met

with continual destabilization, the parents remained strongly committed to advocating for their

adopted children (Follan & McNamara, 2014). In another study, Vasquez and Stensland (2016)

performed multi-staged semi-structured interviews with five adoptive families of children with a

RAD diagnosis. Several prominent themes emerged, including being continually stressed,

socially isolated, and unable to obtain needed services (Vasquez & Stensland, 2016).

Effective Treatments

Although there is much left to learn about the treatments and therapy for reactive

attachment disorder, current studies shed some light on several effective methods. Wimmer,

Vonk, and Bordnick (2009) studied the effectiveness of attachment therapy on a group of 24

adopted children with RAD. The therapy involved educating both the parents and children about

their history of abuse, addressing problem behaviors, parental skills training, emotional catharsis,

psychodrama, and holding (the parent caresses the child in a nurturing manner). The children

who received therapy showed statistically significant improvement on the Randolph Attachment

Disorder Questionnaire (RADQ) and on the Child and Adolescent Functional Assessment Scale

(CAFAS) (Wimmer, Vonk, & Bordnick, 2009). In a related study by Wimmer, Vonk, and

Reeves (2009), mothers were interviewed about the effectiveness of the attachment therapy they

received (outlined above). The parents thought the attachment therapy was “consistently

supportive,” “emotionally painful,” “physically safe,” as well as having the quality of

“preserving the family structure” (Wimmer, Vonk, & Reeves, 2009, p. 124).
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Shi (2014) described a similar course of therapy for a child diagnosed with RAD. Stage

one (treatment sessions one through three) consisted of providing a safe haven for the child. The

sessions were held in a large play therapy room, and the child could play with any of the various

play therapy toys, as long as he helped clean up the toys at the end of each session (Shi, 2014).

Next, sessions four through nine focused on facilitating mother-child interaction. This included

holding and playing together (Shi, 2014). Sessions 10 through 16 aimed to strengthen the

mother-child relationship. Although there were many setbacks throughout the nine-month course

of therapy, the child “began to show more positive affect, was responsive, and was much more

comfortable with physical contact” (Shi, 2014, pp. 9-10). Three years after therapy, the mother

reported that her child was still “much better in every aspect” (Shi, 2014, p. 10).

Furthermore, play therapy has been documented in the literature as an effective treatment.

Weir (2007) described a detailed account of a case study. The study outlined the effectiveness of

integrative play therapy in an adopted child with a RAD diagnosis. The child was previously

physically abused by his biological mother, and in his adoptive family, he often showed extreme

aggression and hatred toward his adoptive parents. Weir (2007) outlined specific examples of

play therapy techniques to use with children diagnosed with RAD and their families, including

feeding a snack to one another, balloon volleyball, snake-on-the-grass tag, and assigning ‘special

time’ homework. The family reported significant reduction or elimination of RAD symptoms

and improved relationships (Weir, 2007).

Another potential therapy for children diagnosed with reactive attachment disorder is

behavior management training (BMT). Bucker et al. (2008) discussed the case study of one child

with RAD treated with BMT. The treatment consisted of 10 steps, and in each of the 12 sessions,

a new step was introduced. The therapist taught the caregivers techniques, or steps, which
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included noticing and commenting on the child’s good behavior, giving effective commands,

implementing a home point system, and disciplinary methods used for punishment (such as

taking away points or time-out). After the course of therapy, the caregivers reported an increase

in compliance, increase in play with peers, and improved behaviors (Buckner et al., 2008).

However, this is only based on one case study, and there are conflicting reports. In Hardy’s

(2007) one-subject case study, the child with RAD did not respond to the behavior management

techniques implemented at the residential treatment home. In fact, his behaviors became

increasingly difficult to manage, despite the implementation of a point-earning system for

positive behaviors. The support for BMT as a treatment for RAD is therefore limited and

conflicting.

Discussion

By definition, reactive attachment disorder results from the mistreatment, abuse, or

neglect of young children. RAD is not very well understood, and although scientists know the

root of the disorder, less is known about why some maltreated children develop it and some do

not. Despite a subgroup of maltreated children displaying RAD symptomology, many other

children “have been shown to be resilient in spite of their early history of institutional neglect”

(Pignotti, 2011, p. 30). More research is warranted to delve into why some children are more

susceptible to developing RAD symptoms, while other children remain resilient, despite similar

experiences in early childhood.

The treatments for RAD have not been studied extensively. Many of the journal articles

in the current literature report on case studies based off of only one child, thus, causing

conflicting reports. For example, in Hardy’s (2007) one-subject case study, the implementation

of behavior management training proved unsuccessful. This conflicts with the study by Buckner
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et al. (2008) that outlines the successful implementation of behavior management training (see

Results section above). While this is certainly useful information and provides the scientific

community with invaluable therapeutic techniques, more empirical research is warranted to

compare the effectiveness of various treatment modalities. An experimental research design

would be potentially useful, including a ‘treatment-as-usual’ control group and an intervention

group receiving a particular type of therapy (i.e. play therapy).

Moreover, the challenges faced by adoptive families of children with reactive attachment

disorder are significant. Many parents reported feelings of isolation, stress, unpreparedness, and

frustration about inability to access services. These findings warrant a need for implementation

of parental support programs for adoptive parents of children with RAD symptomology. Shaw

and Páez (2007) suggest the utilization of school social workers to “provide multisystem

interventions focusing on family, school, and community collaboration” in order to “create a

stable, safe, and supportive environment so that trusting relationships between child and

caregivers can be formed” (p. 73). All in all, more research should be dedicated toward

understanding and treating reactive attachment disorder in order to help the children and families

that must deal with the consequences of inadequate child rearing on a daily basis.
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