Diagnosis of Reactive Attachment Disorder (RAD)

In order to make a diagnosis of Reactive Attachment Disorder (RAD) one needs an assessment by a competent professional. That means an assessment by a professional with substantial experience evaluating and treating adopted and foster children, preferably one who is a member of the Association for the Treatment and Training in the Attachment of Children, ATTACH (www.Attach.org). The assessment must include a thorough review and past history and be comprehensive in its scope. The following elements should be considered. First, there should be a detailed review of the child's first three years of life and prenatal history. Second, all pertinent documents, including protective service reports, court summaries, and prior evaluations must be reviewed. Third, there should be a compete review with the parents of the child's behavior and symptoms and of the child's responses to several "sentinel" events. Sentinel events include the child's response to need and pain, how the child responds to affection on the parent's terms, and the child's need to control and be in control. Fourth, there should be an individual evaluative meeting with the child. I usually have the child compete the House-Tree-Person projective test, sometimes the Child Apperception Test and the MAPI, and we conduct a detailed interview with the child. Fifth, the parents complete several questionnaires such as the Randolph Attachment Disorder Questionnaire. Sixth, there should be a meeting with the parents to review the assessment and treatment plan. It is vital that the evaluation consider such possible co-morbid conditions as Bipolar I Disorder and Sensory-Integration Disorders. A good evaluation should result in a differential diagnosis and comprehensive treatment plan.

There are several different sub-types of RAD. The ambivalent sub-type can be described as an "in-your-face" child. This is the child who is angry, oppositional, and who can be violent. The anxious sub-type is clingy, anxious, shows separation anxieties, among other symptoms. The avoidant sub-type is often overlooked. This child is very compliant, agreeable, and superficially engaging. This child often has a lack of depth to his emotions and functions as an "as-if" child; meaning that he tries to do and say what you want, but is not genuine, authentic, or real in emotional engagement. Finally, there is the disorganized subtype. This child often presents with bizarre symptoms.

In order to make a diagnosis of RAD the child must not only have the symptoms, the child MUST have a history of physical, sexual abuse, or neglect before the age of five years. The history must be significant and will usually encompass the first two or more years of life...the longer the worse. Emotional neglect or a chronic painful long illness is other causes. Many children a history of multiple placements, failed potential adoptions, etc., present with similar types of problems you are describing. Reactive Attachment Disorder and less severe attachment disorders are caused by histories of neglect and/or abuse in the first few years, often exacerbated by multiple placements. Such children develop a worldview in which they experience the world as unpredictable, hurtful, and bleak. They experience adults as not caring for them, hurtful, and sources of pain. These children have very limited capacity of authentically connect emotionally with family. They often recreate relationships that mirror their past abusive or neglectful relationships. These children fundamentally believe they are bad, defective, and unlovable. You can get more information on my website: www.Center4FamilyDevelop.com

A professional assessment is necessary to determine whether or not a child has an Attachment disorder. At the Center we use several tests as part of a comprehensive assessment to determine what attachment issues are causing problems and what will be the most effective treatment plan. We work very closely with the parents to develop a plan to help remdiate attachment problems. This checklist can help you identify areas of potential problem. This checklist is not meant to substitute for a professional assessment and treatment plan.

Circle the items if they are frequently or often true.

1. My child acts cute or charms others to get others to do what my child wants.
2. My child often does not make eye contact when adults want to make eye contract with my child.
3. My child is overly friendly with strangers.
4. My child pushes me away or becomes stiff when I try to hug, unless my child wants something from me.
5. My child argues for long periods of time, often about ridiculous things.
6. My child has a tremendous need to have control over everything, becoming very upset if things don't go my child's way.
7. My child acts amazingly innocent, or pretends that things aren't that bad when caught doing something wrong.
8. My child does very dangerous things, ignoring that my child may be hurt.
9. My child deliberately breaks or ruins things.
10. My child doesn't seem to feel age-appropriate guilt when my child does something wrong.
11. My child teases, hurts, or is cruel to other children.
12. My child seems unable to stop from doing things on impulse.
13. My child steals, or shows up with things that belong to others with unusual or suspicious reasons for how my child got these things.
14. My child demands things, instead of asking for them.
15. My child doesn't seem to learn from mistakes and misbehavior (no matter what the consequence, the child continues the behavior).
16. My child tries to get sympathy from others by telling them that I abuse, don't feed, or don't provide the basic life necessities.
17. My child "shakes off" pain when hurt, refusing to let anyone provide comfort.
18. My child likes to sneak things without permission, even though my child could have had these things if my child had asked.
19. My child lies, often about obvious or ridiculous things, or when it would have been easier to tell the truth.
20. My child is very bossy with other children and adults.
21. My child hoards or sneaks food, or has other unusual eating habits (eats paper, raw flour, package mixes, baker's chocolate, etc.)
22. My child can't keep friends for more than a week.
23. My child throws temper tantrums that last for hours.
24. My child chatters non-stop, asks repeated questions about things that make no sense, mutters, or is hard to understand when talking.
25. My child is accident-prone (gets hurt a lot), or complains a lot about every little ache and pain (needs constant band aids).
26. My child teases, hurts, or is cruel to animals.
27. My child doesn't do as well in school as my child could with even a little more effort.
28. My child has set fires, or is preoccupied with fire.
29. My child prefers to watch violent cartoons and/or TV shows or horror movie (regardless of whether or not you allow your child to do this).
30. My child was abused/neglected during the first year of life, or had several changes of primary caretaker during the first several years of life.
31. My child was in an orphanage for more than the first year of life.
32. My child was adopted after the age of eighteen months.

If you find that more than a few items (more than five or so) have been circled, your child may be experiencing difficulties that require professional assistance. If, in addition to several items being marked, any of the last three items is check, your child may be experiencing attachment related problems.

Traditional parenting does not work with attachment-disordered children. Sticker charts, behavioral programs, and such don't work. Why? Because all these approaches, including play therapy and traditional talk therapies, require a relationship. Charts work with children when the child is attached to a caregiver and desires to please the caregiver; the child feels good when the child makes the parent happy. Your child probably has not such relationships; hence charts won't work.

So, what does work? A combination of parenting that recreates the environment of a toddler (remember while your child's body may be 10 years old, she is probably psychologically and developmentally only 2). The parenting must be VERY structured and VERY nurturing. Natural consequences, not lectures, words, or charts, work best. If the child does not want to eat and you've put a meal in front of her; she doesn't have to eat. If she complains and begins to ruin the mealtime...remove her from the table. The key is to not let such a child make everyone feel like she does. Such children are very good at externalizing their feelings and getting everyone else to feel as miserable as the child does. While that might make the child feel a bit better in the short run, it is not healing in the long run. You have to bring the child up to your level.

I suggest three books to learn about the parenting required:

1. Parenting with Love and Logic by Fay and Cline

2. Building the Bonds of Attachment by Daniel Hughes, Ph.D.

3. When Love is not Enough by Nancy Thomas.

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