Reactive Attachment Disorder

This is the episode where we talk about the thing that we’ve all been waiting for, and the thing that people like to pretend is baby BPD. Reactive Attachment Disorder (RAD for short, but I’m pretty sure rad is the one thing it isn’t).

What is Reactive Attachment Disorder?

First of all let me tell you what Reactive Attachment Disorder is not. It is not the child form of Borderline Personality Disorder. It is a thing that is entirely its own. That being said RAD is:

Reactive Attachment Disorder is a severe disorder in children beginning before the age of 5 that is characterized by exceptionally disturbed and developmentally inappropriate ways of relating socially (in most contexts).  There are two “types”.

1. Inhibited Form  
2. Disinhibited Form

RAD is caused by the failure to form normal healthy attachments to primary caregivers early in childhood. This failure is the result of severe early experiences such as neglect, abuse, abrupt separation from caregivers (usually during the 6 month to 3 year age period), frequent changes in caregivers (like in an orphaned foster home scenario), or a lack of caregiver responsiveness to a child’s efforts to communicate. 

“Children with RAD are presumed to have grossly disturbed internal working models of relationships which may lead to interpersonal and behavioral difficulties in later life.” … This is where people tend to jump to the conclusion that the adult result must be BPD. I’m not saying that this is never the case. Certainly it’s feasible that the abuse and neglect that creates RAD could continue to evolve into BPD, but it’s also not necessarily a direct correlation. For instance, if you ask my parents, I was a very content (slightly anxious) child, but I didn’t have any real behavior problems until a little later on in life. I would never have been diagnosed with RAD.

It’s also important to note that while RAD is most likely to occur in relation to neglect and abuse, it’s in no way a guarantee (just like BPD is not guaranteed to develop in cases of abuse and neglect). Some children grow up just fine and are able to form stable attachments and social relationships despite early childhood problems. Unlike many disorders that are marked by genetic components, RAD is specifically based on problematic care and relationship history. This is a disorder entirely created by a child’s environment.

As previously mentioned the core features are severely inappropriate social relating in children.

Disinhibited Form - Indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers (older children and adolescents may also aim attempts at peers).

Inhibited Form  - Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed. [12]

There hasn’t been any conclusive research on why one form arises above the other. There does seem to be a temperament/constitution quality that gives certain children a greater sensitivity to unpredictable and hostile relationships in their environment that makes them more susceptible (just like with BPD and PTSD).  Some kids are more sensitive, some are more robust. When you’re more sensitive you are potentially more susceptible to disturbances in affect regulation.

So what criteria qualify a child for have Reactive Attachment Disorder?

• Markedly disturbed and developmentally inappropriate social relatedness in most contexts (e.g., the child is avoidant or unresponsive to care when offered by caregivers or is indiscriminately affectionate with strangers)
• The disturbance is not accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder;
• Onset before five years of age (there is no age specified before five years of age at which RAD cannot be diagnosed)
• A history of significant neglect;
• An implicit lack of identifiable, preferred attachment figure.

ICD-10 also includes some things that the DSM-IV doesn’t

• Abuse, (psychological or physical), in addition to neglect;
• Associated emotional disturbance;
• Poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases (inhibited form only);
• Evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness in interactions with appropriately responsive, non-deviant adults (disinhibited form only).

 Other things that may contribute to the development of RAD are:

• A baby cries and no one responds or offers comfort.
• A baby is hungry or wet, and they aren’t attended to for hours.
• No one looks at, talks to, or smiles at the baby, so the baby feels alone.
• A young child gets attention only by acting out or displaying other extreme behaviors.
• A young child or baby is mistreated or abused.
• Sometimes the child’s needs are met and sometimes they aren’t. The child never knows what to expect.
• The infant or young child is hospitalized or separated from his or her parents.
• A baby or young child is moved from one caregiver to another (can be the result of adoption, foster care, or the loss of a parent).
• The parent is emotionally unavailable because of depression, an illness, or a substance abuse problem.

Sometimes the circumstances that cause the attachment problems are unavoidable, but the child is too young to understand what has happened and why. To a young child, it just feels like no one cares and they lose trust in others and the world becomes an unsafe place.

So to sum up:

(A) A child must display behavior disturbances of either the Inhibited or Disinhibited Forms of RAD.

(B) That disturbance should not be accounted for soley because of developmental delay (like mental retardation).

(C) Pathogenic care as evidenced by at least one of the following:

1. persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection 
2. persistent disregard of the child's basic physical needs 
3. repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)

 (D) The presumption is that this pathogenic care is responsible for the disturbance of Criteria A.

To be fair to people that like to jump to the conclusion that RAD leads to BPD, they do both have foundations in affect dysregulation, and they’re both marked by relationship attachment problems. The reasons for those problems can even be from similar environments. But BPD also has a clear bio-genetic component and is not necessarily the result of only neglect or abuse (though obviously it can be). Regardless, as with BPD, therapy and learning ways to attach properly are possible. Though usually with RAD the therapy and skill learning focus is on the caregiver not just for the child. Then again, it’s often helpful for our partners to take a therapy session or two to help them understand us and our needs better as well. After all, relationships take two.