Reactive Attachment Disorder

April 6, 2018

National Association of School Psychologists. Communique

Working with Students with Reactive Attachment Disorder

By Lee, Rachel L.; Eschenbrenner, Charlotte R.

It is not uncommon for school districts to serve children who have been removed from their homes or families due to issues of abuse or neglect, children who have been in multiple foster homes, or children who have been adopted at an older age. Within this population of students, it is likely that a school district may be asked to serve a student diagnosed with reactive attachment disorder (RAD). Consequently, it is important for school psychologists to understand and receive training regarding RAD, in order to best meet the needs of the students with this diagnosis. Public schools are increasingly being asked to provide mental health services, and graduate students in school psychology have opportunities to receive training to understand psychological disorders and their impact on educational performance. Graduate students also receive training on the design and implementation of interventions addressing psychological and academic needs. School psychologists are not only expected to be mental health experts, but within the public school setting, they are among the most highly trained staff members in the assessment and treatment of mental health issues (Ysseldyke et al., 2006).

WHAT IS REACTIVE ATTACHMENT DISORDER?

According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; American Psychiatric Association [APA], 2013), RAD is characterized by a disturbed and developmentally inappropriate social relatedness in a majority of situations, beginning before age 5. Although this characterization could describe other mental health issues as well, it is important to remember that a key component to a RAD diagnosis is extreme disregard for the child's basic needs by the caregiver. This "pathological care" could include a persistent lack of stimulation, comfort, or basic physical needs; or frequent changes in the primary caregiver, thus preventing a stable attachment.

Whereas two subtypes of RAD (inhibited and disinhibited) existed in the DSM-IVTR (APA, 2000), the DSM-5 (APA, 2013) divided RAD into two separate conditions: reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED). In the DSM-IV-TR inhibited subtype were included children who might not initiate or respond to social situations in a way that is expected (House, 2002). For example, they might seem withdrawn, unresponsive, or reluctant to participate or engage in age-appropriate social exchanges (APA, 2002). These children are now diagnosed as having RAD in the DSM-5 (APA, 2013). On the other hand, children who would have been diagnosed with the DSM-IV-TR disinhibited subtype of RAD were seen as unable to discriminate appropriate sociability (House, 2002). In other words, these children were seen as overly social and inappropriate with both familiar and unfamiliar people, even strangers (APA, 2002). Under the DSM-5, these children now receive a diagnosis of DSED.

WHY IS IT IMPORTANT TO UNDERSTAND REACTIVE ATTACHMENT DISORDER?

Although some students with RAD may have received the diagnosis from a community case worker or mental health service provider prior to attending school, school psychologists should be aware of RAD and be able to recognize its symptoms. Symptoms of RAD can often be mistaken for other disorders, such as attention deficit hyperactivity disorder, anxiety, or autism (APA, 2000). Interventions designed for students with these alternate disorders may not have an effect on a student with RAD. Additionally, diagnoses do not directly translate to an educational classification in the school, and school psychologists capable of recognizing the symptoms of RAD will be better able to determine the supports necessary for students with this disorder. It is imperative that school psychologists obtain an accurate family history when consulting about a student, as the key indicator of RAD is the neglect by a caregiver. A school psychologist must know which questions to ask to find out whether a student has been exposed to extreme disregard at home.

Reactive Attachment Disorder or RAD for short is becoming increasingly present in our schools today. Children who have faced trauma or neglect in their early developmental years do not develop an attachment to either parents or their caregiver. The longer this goes on the harder it will be for the individual child to change their pattern of behavior an form an attachment or bond with either immediate family members or their caregivers. 

This occurs frequently with children have spent much of their early lives out of their biological home. They many times do not know or even realize what their actions incur. If they never address the bonding issues they may not have meaningful relationships with anyone in the future. This may include a spouse or children of their own. The cycle then continues to the next generation because it is likely their parents may have had attachment issues themselves.

Children with RAD state that they may have feelings of unworthiness or feel strange when a bonding moment may present itself. Many times when this occurs they react in the opposite direction and display behaviors designed to push those who may be getting too close away. 

The only real way for a child with RAD to heal is to have intensive therapy with a licensed mental health practitioner who has been trained extensively in Reactive Attachment Disorder. This may include deliberate brain stimulation patterns in therapy sessions. Some children may have to go back and crawl like an infant, lay on their stomach, or be held in someone’s arms because they may have missed that when they were very young.

The implications for schools are that RAD may be disguised as severe behavioral problems like defiance, disobedience, theft of unimportant items, refusal to comply with requests, etc… Students may also display their passive aggression with poor personal hygiene. They many times crave the attention they get, good or bad with their behavior. Students with RAD may make untrue statements to get attention or fulfill their needs as well.

The consequence for the school is that children with RAD take inordinate amounts of time away from administration or teachers with no real improvement. It becomes a vicious cycle of violation of school rules and consequences. Sometimes what is thought to be the proper disciplinary procedure with a normal student, the opposite may be best for a RAD student. 

One thing is clear, as time goes on, more and more children with RAD will be entering schools and most likely will go undiagnosed. The disruption and the inability to  demonstrate improvement will create disruptions in the learning environment and consume time that could be better spent somewhere else.

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