REACTIVE ATTACHMENT DISORDER

New Hanover County Mental Health Trainers

Diagnostic Criteria

• A. markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 years and is associated with gross pathological care.

• B. The disturbance in Criterion A is not accounted for solely by developmental delay and does not meet criteria for a Pervasive Developmental Disorder.

• C. Pathogenic care: disregard of the child’s basic emotional needs & physical needs; repeated changes of primary caregiver

Benefits of Attachment

PHYSICAL

EMOTIONAL

SOCIAL

MENTAL

SPIRITUAL

ATTACHMENT CYCLE

• Interactions necessary to develop a bond:o Eye contacto Skin to skino Rockingo Providing foodo Suckingo Vocalizations

Secure Attachment

In Children:1. Able to separate

from parent.2. Seeks comfort from

parents.3. Return of parents

met with positive emotions.

4. Prefers parents to strangers.

In Adults:1. Have trusting

relationships.2. Positive self-esteem.3. Shares feelings with

others.4. Will seek support

when needed.

Symptoms of Attachment Impairment

In Children• Avoids parents.• Does not seek much

comfort or contact from parents.

• Shows little or no preference between parent & strangers.

In Adults• Reluctant to become

close to others.• Worry that their

partner does not love them.

• Become very distraught when a relationship ends.

Symptoms of Attachment Impairment

In Children:

1. May be wary of strangers.

2. Become greatly distressed when the parent leaves.

3. Do not appear to be comforted by parent.

In Adults:

1. Problems with intimacy.

2. Very little emotional investment in relationships.

3. Unable or unwilling to share feelings.

Therapeutic Interventions

• Theraplay: play therapy which has the intention of helping parents and children build relationship through games that focus on; engagement, challenge, structure and nurture.

• Dyadic Developmental Psychotherapy: verbal therapy which creates a safe setting in which the client can begin to explore, resolve, and integrate a wide range of memories, emotions, and current experiences. Safety is created by insuring that this exploration occurs with nonverbal attunement, reflective, non-judgmental dialogue, along with empathy and reassurance.

SITUATIONS /EXPERIENCES THAT PLACE CHILDREN AT HIGH RISK

PARENT CHILD ENVIRONMENT-Abuse/Neglect -Difficult temperament -Poverty-Ineffective Care -Premature birth -Violence; victim/witness-Depression/Bipolar -Medical conditions -Lack of

support/services-Postpartum Depression -Hospitalizations -Out of home

placements-Severe psychological -Failure to thrive -High stress/chaos in disturbances -Congenital and/or bilogical family and community-Teenage Parenting problems -Lack of Stimulation-Substance Abuse -Genetic Factors: family-Intergenerational history of mental illness,attachment difficulties depression, aggression-Prolonged absence (prison,hospital, desertion)

CHARACTERISTICS OF RAD

Impairment in capacity to attachRage, hurt and hatredPoor impulse controlLack of spontaneityLack of self-identityAggressionTemper TantrumsHoarding

Layers of Emotions

ANXIETY

ANGER

RAGE

SHAME

SADNESS/GRIEF

RAD IN SCHOOL

Learning disabilitiesBelow average IQLanguage delaysSuperficial eye contactLack of cause / effect thinkingDo not sequence verbal instructionsDevelop sophisticated behavior to defend

themselves against the worldDifficulty adapting to change

Sammy Student• Problems with regulation of energy or activity level; Fast-paced,

slow paced, or fast/slow combination, impulsive or hyperactive• Strong and interfering negative views toward self, school and life• Overly focused on something that is suppose to happen• Gorges or hoards food• Is oppositional, argumentative, defiant• Is manipulative or controlling• Has frequent or intense angry outbursts• Destructive to self, others, and property• Steals• Has poor peer relationships

STRATEGIES AT SCHOOL

Do better with one teacher that knows them well Good parent/teacher communication – united

front Consistent rules and expectations between

home and school Natural and immediate consequences Use “time in” vs. “time out” Utilize Non-Verbal Cues Stimulated activity followed by low activity Same rules across the board – in ALL settings

MORE SCHOOL TIPS

• Utilize Peer Buddy• Have daily meeting – 30 minutes/during lunch – to talk or

not to talk• Minimize downtime which increases structure• Provide for place for eating vs. cafeteria• Be confrontational about feelings (yours and his/her)• Provide list of privileges vs. rights• Teach how to and provide opportunities for play• Social stories to teach relationship skills• Teach and label emotions other than anger

SUGGESTIONS

• Utilize written directions with verbal• Teach organizational skills• Teach time management skills• Avoid power struggles• Let them know that total fairness is impossible• Utilize restitution whenever possible• Accountability papers • Give choice between two options (A or B)

Relationship Building

• Provide physical and emotional closeness• Children with RAD will tend to sabotage • Utilize matter of fact tone that is free of

emotional edge• Love/kindness viewed as a weakness and

used against those who offer it• It is important to ignore irritating behaviors

whenever possible (whatever you pay attention to you will see more of!)

CHILDREN WITH RAD DEEPLY BELIEVE THAT THEIR VERY SURVIVAL DEPENDS ON THEIR BEING IN CONTROL OF EVERYONE ELSE, IN EVERY SITUATION, ALL OF THE TIME.

“YOU ARE NOT REQUIRED TO DO IT ALL. THAT WOULD BE PERFECTION. DO WHAT YOU CAN DO. THAT OFTEN TURNS OUT TO BE QUITE A BIT.”

Rudolf Dreikurs

Resources

• http://psychology.about.com• www.attachmentdisordermaryland.com• www.crosscountryeducation.com• www.radkids.org• Why Is Johnny So Detached? Thomas M. Ottavi, Ph.D.• Karen Wheeler, LCSW, RPT-S Integrated Therapy Ass.• Suzanne Rilling, M.Ed., CHt.• Elizabeth Uzcategui, P-LCSW, MSW• Kristine Hancock, IBS Teacher