Reactive Attachment Disorder
In the media, in court cases, on the Internet, and in child welfare agencies, there is much confusion about Reactive Attachment Disorder (RAD) and an unrecognized, fad diagnosis with a similar name that often poses as RAD.
Reactive Attachment Disorder (RAD)
RAD is a recognized diagnosis which is defined in the Diagnostic and Statistical Manual (DSM-IV-Tr) of the American Psychiatric Association (it is essentially unchanged in the DSM-V). RAD is considered an "uncommon" disorder (code 313.89) which follows children's experiences of extreme neglect or abuse and which is expressed in one of two ways in while children react to extreme neglect and/or abuse in one of two ways:
Markedly disturbed and developmentally inappropriate social relatedness in most contexts, as evidenced by either of two behaviors:
Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses...
Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers).
In other words, children with RAD have experienced extreme social and emotional conditions and have become either very withdrawn and clingy or more friendly with unfamiliar people than we would expect of children their age. While there is no validated therapy specifically for RAD, many experts recommend gentle, patient, consistent and responsive parenting for these children, as for all children with special emotional needs. This disorder can be diagnosed while the child is five years of age or younger; as children get older, their behavior matures and changes in ways that make attachment problems much less evident.
“Attachment Disorder” (AD) — An Over-Reaching Diagnosis & Grounds for DHS Investigation
Foster Cline, MD, the Colorado psychiatrist who popularized Attachment Therapy, is also credited with inventing AD, the unrecognized diagnosis used nearly exclusively by Attachment Therapists. Decades of vigorous marketing of this fad diagnosis to parents and child welfare agencies has positioned it as a dreaded disorder of adopted and foster children, as well as a path to eligibility for "special needs" subsidies.
Proponents of the AD diagnosis frequently refer to it as "RAD," leading to public confusion about the two, but the two are conceptually very different. There is suspicion that Attachment Therapists who treat problems they have diagnosed as AD will charge insurance companies for treating RAD; because AD is not a legitimate diagnosis, its treatment would not be reimbursed by public or private insurers.
Rather than meeting the criteria for behaviors that would receive the RAD diagnosis, the AD diagnosis is characterized by a laundry list of behaviors, making it a typical catch-all "diagnosis" of the sort commonly identified with quack practices. Many of the so-called "symptoms" are extremely violent behaviors; some are normal for certain age groups; and even good behavior can be interpreted and reframed as a child "stalking his prey." The AD diagnosis contains a number of internal contradictions, as when children are said to lack empathy but yet they are believed able to understand people well enough to be clever manipulators and triangulate adults. Likewise both eye contact, or lack of it, are considered problematic AD signs.
Practitioners using the AD model warn parents and prospective parents that if a child does not exhibit all the signs associated with AD he is likely to develop them in the future if not treated with Attachment Therapy/Parenting. Lists of AD signs have been called “wildly inclusive” and commonly include the following.
Signs of “Attachment Disorder”
- Superficially engaging and charming
- Lack of eye contact on parent's terms
- Eye contact when lying or angry
- A darkness behind the eyes when raging
- Indiscriminately affectionate with strangers
- Good behavior [interpreted as the child “stalking his prey”]
- Views relationships as threatening, or not worth the effort
- May be a workaholic, as a way of avoiding relationships
- Not affectionate on parent's terms
- Resists comforting
- Resists being held
- Destructive to self, others, and material things
- Accident prone
- Cruelty to animals
- Cruelty to young children
- Lying about the obvious or "crazy lying"
- No impulse controls
- Intolerant of rules and authority
- Shallow and vain
- Grandiose or unrealistic fantasies
- Feelings of being unique
- Feels unappreciated
- Feels unwanted
- Attitude of entitlement
- Lacks morals, values, and spiritual faith
- Identifies with Satan
- Oversensitive to rejection, easily gives in to jealousy
- Temper tantrums
- Hyperactive, yet lazy in performance of tasks
- Prone to depression
- Developmental lags
- Failure to gain weight
- Delayed responsiveness to stimuli
- Appears listless
- Failure to smile
- Learning lags
- Exceptionally bright, but act "dumb"
- Lack of cause and effect thinking
- Compulsive caregiving
- Overly critical of self and others
- Lack of conscience
- Lack of empathy and remorse
- Abnormal eating patterns, e.g. hoarding and gorging
- Refuses to eat
- Eats strange things
- Poor peer relationships
- Victimized by others
- Perceives others as unsafe, dangerous
- Perceives self as victim
- Preoccupation with fire
- Preoccupation with blood and gore
- Persistent nonsense questions and chatter
- Inappropriately demanding and clingy
- Abnormal speech patterns
- Triangulation of adults
- Controlling and manipulative
- Sees others as being difficult to understand
- Unable to understand the concept of altruism
- Extreme emotions
- Never get sick
- Can’t float in water
- Can’t feel physical pain
- False allegations of abuse
- Sneaks things without permission even if he could have them by asking
- Child 'forgets' parental instructions or directives
- Presumptive entitlement issues
- Parents appear hostile and angry
- Parents feel used
- Parents are wary of the child's motives if affection is expressed
- Frequently hyperactive
- Targets the adoptive mother for abuse
- Narcissistic behavior
- Enuresis and encopresis
- “I hate you” attitude
- “You can’t make me” attitude
- Abrupt change in personality
- Attempted suicide or threats of suicide
- ADHD and Conduct Disorder
- Blames others for mistakes or behaviors
- Presenting as calmer when alone
- Uncontrollable anger
- Inappropriate emotional responses
- Distant or aloof behavior, resentful
- Easily misled
- Lazy, lacks motivation
- Risky behavior
- Runs away
- Sexually active
- Smoking or other tobacco use
- Calm when left alone
Only two of these signs ("indiscriminately affectionate with strangers" and "inappropriately demanding and clinging") are consistent with the description of RAD in DSM-IV.
Attachment Therapists also claim children diagnosed with AD are capable of being sexual predators, with the potential to become serial killers as adults. AD has been referred to as "Ted Bundy Disease."
Because of the possible role of this belief in promoting child abuse, it is most disturbing to see among characteristics attributed to children diagnosed with AD the supposed inability to feel pain (while being overly sensitive to light touch).
A discussion of AD and RAD is included in the 2006 Report on Attachment Therapy by the American Professional Society on the Abuse of Children (APSAC). The task force that authored this report remarked on the tendency to over-diagnosis a “rare” condition such as RAD, plus the problem of the highly inclusive lists of AD criteria:
Clearly, these lists of nonspecific problems extend far beyond the diagnostic criteria for RAD and beyond attachment relationship problems in general. These types of lists are so nonspecific that high rates of false-positive diagnoses are virtually certain. Posting these types of lists on Web sites that also serve as marketing tools may lead many parents or others to conclude inaccurately that their children have attachment disorders.
It is easy to see that any child is likely to be labeled as AD when concerned parents consult with an Attachment Therapist. AD is considered a common condition by its proponents. The diagnosis clearly demonizes adopted and foster children, making parents fearful and suspicious of even normal child behaviors. It sets up a situation where harsh parenting is perceived as justified to head off a child's disastrous future.
Attachment Therapists claim that AD is foundational for a number of other disorders, and that AD must therefore be treated first, and by a practitioner who is committed to the AD concept. They may diagnose AD with the use of any of several unvalidated checklists, such as the Randolph Attachment Disorder Questionnaire (RADQ) , the Attachment Disorder Symptom Checklist, Walter Buenning’s Infant and Child Symptom Checklists, and the Evergreen Consultants Check List.
Some parents charged with criminal child abuse have tried to convince juries that their children had AD. As Jean Mercer, PhD — leading critic of Attachment Therapy — commented, "The RAD defense is regrettably becoming more common as a way to extricate abusive, even homicidal, parents from legal difficulties." In a blame-the-child defense strategy, AD is portrayed as a disorder so severe that it would unhinge the most loving of parents.
Journalists don't help to clarify the situation for the public. They rarely question the AD diagnosis — or even consult the DSM — but rather parrot the portrayal of adopted children as "monsters at home."
NOTE: APSAC & the American Psychological Association’s Division on Child Maltreatment recommend that child welfare workers investigate where AD has been diagnosed.
- “Diagnostic criteria for 313.89 Reactive Attachment Disorder of Infancy or Early Childhood,” DSM-IV-TR.
- “F94.1 Reactive attachment disorder of childhood,” International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10), 2007, Geneva: World Health Organization.
- “Reactive attachment disorder: position statement,” 2002 June, American Psychiatric Association.
- “A Review of a Review of the RADQ,” by Jean Mercer, PhD, for Advocates for Children in Therapy.
- Attachment Therapy: a treatment without empirical support,” Jean Mercer, Scientific Review of Mental Health Practice, 2002 Winter;1(2).
- “Diagnosis and Attachment Disorder” in Attachment Therapy, Wikipedia.
- “Correlates of the Randolph Attachment Disorder Questionnaire (RADQ) in a Sample of Children in Foster Placement,” Cappelletty G, Brown M, Shumate S (February 2005), Child and Adolescent Social Work Journal, 2005 Feb; 22 (1): 71–84. [DOI]
- “Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems,” Chaffin M, et al, Child Maltreatment, 2006 Feb; 11(1):76-89.
- “Self-Test for Reactive Attachment Disorder: How can you know if your RAD teenager needs to be placed in a residential treatment program?” Apr 2012, Parenting Children & Teens with Reactive Attachment Disorder website.