Reactive Attachment Disorder: Recognition, Action, and Considerations for School Social Workers Steven R. Shaw and Doris Pdez

School social workers are increasingly faced with students who have attachment issues, those who have been diagnosed with reactive attachment disorder (RAD), as well as the families affected by this disorder. In this article, key features of the RAD diagnosis are presented. Other psychiatric disorders associated and confused with RAD are also discussed. The often ignored family and systemic focus of RAD and its effective treatment are emphasized. Recommendations for social work practice in this area are described. KEY WORDS: attachment; clinical diagnosis; reactive attachment disorder

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any educators report that there is a new subset of children in the schools (Green, 2003). These children are disrespectful, argumentative toward authority figures, appear to have no empathy, lack academic motivation, have severe attention problems, have violent emotional outbursts, do not bond with teachers or form close attachments with friends, typically do not respond well to counseling, and have behaviors that seem resistant to the best behavior management programs. In addition, educators often quietly express concern over the quality of parenting or foster care. Prenatal crack cocaine exposure was once thought to be the cause of this set of behaviors (Rodning, Beckwith, & Howard, 1991), but more tightly controlled studies have not supported this simple explanation (Richardson & Day, 1994) .Yet the problem remains and is very real. Educators, and specifically school social workers, require a reasonable explanation for this behavior set and suggestions for addressing these behaviors. One area of consideration comes from the psychiatric and developmental psychology literature. These troublesome behaviors now besetting schools are wholly consistent with disordered attachment (Kay Hall & Geher, 2003). Attachment is a behavior control system that maintains the safety and security of infants and children through the care and nurturance

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of a caregiver (Bowlby, 1988). Secure attachment is a protective factor providing a degree of predictability and control for young children. Thus, secure attachments increase motivation to explore the physical and social environment with confidence. As children reach preschool and school age, psychological availability in addition to care and nurturance become increasingly important (Ainsworth, Blehar, Waters, & Wall, 1978). Without feelings of safety and security, exploration ofthe physical and social environment becomes impaired (Bowlby, 1979). Insecure attachments are so often associated with parenting issues (that is, abuse and neglect) that "parent blaming" is a common theme in the literature (Chaffm et al., 2006). Certainly, caregiver behavior is a major issue. Parents who are critical, rejecting, and abusive often have difficulty developing secure attachments with their children (Zeanah et al.,2004).Also,parents who are unresponsive to their children because of drug and alcohol abuse, personal stressors, or depression may cause insecure attachments (Das Eiden & Leonard, 1996). However, attachment is an interaction between parent and child. Children who are difficult to calm, irritable, or unresponsive because of temperament, prematurity, or chronic illness or who have a developmental disability (for example, autism or attention deficit/hyperactivity disorder [ADHD]) are

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also at risk of attachment problems (Goldberg, Gotowiec,& Simmons, 1995).Moreover,the environment also affects parent—child attachment. Domestic violence, community violence, recent immigration, adoption, poverty, and war can have strong effects on parent—child attachment (Lyons-Ruth, Zeanah, & Benoit, 1996). The most severe form of attachment problem is known as reactive attachment disorder of infancy and early childhood (American Psychiatric Association [APA], 2000). However, less severe forms of attachment problems also have a major effect on children's behavior. One way to approach disordered attachment is to consider that the child has not developed a basic trusting relationship in his or her first relationship (that is, mother-child). Quite often there is a lack of trust in all relationships thereafter. RECOGNITION AND DIAGNOSIS T h e Diagnostic and Statistical Manual of Mental

Disorders (fourth ed., text revision, or DSM-IVTR; APA, 2000) defines two types of reactive attachment disorder (RAD): inhibited, disorganized, hypervigilant, and sometimes highly ambivalent and contradictory responses (fdr example, the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting or may exhibit frozen watchfulness) or diffuse attachments as shown by indiscriminate sociability with inability to show appropriately selective attachments. Either children do not form productive and secure attachments with anyone or children form attachments with anyone they see.These are both equally problematic. The second part ofthe definition is that RAD

developmental disorder (for example, autism). This is because many children with autism or mental retardation have difficulty forming appropriate attachment solely due to their disabling condition. Although the criteria for RAD appear clear, differential diagnosis for child and adolescent cases is difficult for many reasons (APA, 2002). First, behaviors overlap with many other mental health issues. Second, there are no laboratory tests for most psychiatric diagnoses; rather, diagnosis is based on a report of symptoms (child or caregiver), observable behaviors, family history, and clinical course ofthe disorder. For children and adolescents, diagnosis is particularly complex because there may be several reporters and observers ofbehaviors (sometimes with conflicting views), a complete family history may or may not be available or accurate, behaviors may be part of a normal developmental progression, and childspecific criteria have not been established for some psychiatric disorders (for example, mood and personality disorders; Byrne, 2003).

persistent disregard ofthe child's basic emotional needs for comfort, stimulation, and affection; persistent disregard of the child's basic physical needs; or repeated changes of primary caregiver that prevent formation of stable attachments (for example, frequent changes in foster care).This definition of RAD places the direct cause ofthe behavior issues on parenting. The third part ofthe definition is that problematic attachment cannot be due solely to a diagnosis of mental retardation or pervasive

Clearly, children with disordered attachment show many characteristics of other psychiatric disorders. However, the obvious difference is the inability to form healthy, consistent patterns of attachment and a history of pathological care.To some degree, the link between substance abuse and RAD may be partially accurate. Although there is no evidence that use of specific illicit drugs (for example, crack cocaine) or alcohol by a caregiver results in poorly attached children, the lifestyle of a parent who is addicted to alcohol or illicit drugs does not lead to close attachments with infants (Rodning et al., 1991). In cases in which children are removed from these homes, serial foster placements may have taken place. When children are shuttled across foster care settings, there is little time to develop attachment. The problem frequently becomes worse rather than better after the child is removed from the home. A diagnosis of RAD is difficult to make and carries much emotional baggage. Some clinicians see every child with social skills problems as having RAD and make the diagnosis frequently (Green, 2003). Some clinicians never make the diagnosis (APA, 2002). Of course.

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is caused by pathogenic care, which is described as

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the truth lies somewhere in between. Many clinicians in this area have described numerous behaviors that indicate the presence of RAD, such as superficial charm, severe tantrums, low intelligence, intentional destruction of property, age-inappropriate sexual acting out, physical aggression toward adults, profanity, difficulty adjusting to change, running away, sociopathic tendencies, toileting accidents, and others (Kay Hall & Geher, 2003; Zeanah, 1996). We have seen some children with these behaviors who do not meet criteria for RAD and others who do. A complicating issue is that there are often significant cultural differences in the parenting and foundation for the development of parent-child attachment (Vargas & Beatson,2004). Despite some significant weaknesses (Chaffin et al., 2006), DSM-IV-TR remains the gold standard for diagnostic criteria. Clinicians should remember that a RAD diagnosis is an explicit condemnation of the parents, the foster care system, or both, and makes working directly with parents or the foster care system difficult. Often such a diagnosis is made immediately before or after reporting the family to the state or provincial child protective services agency (Coleman, 2003).Therefore, the burden of proof for this diagnosis is extremely high. Furthermore, beyond the diagnosis, thoughtful analysis of the basis for the child's behaviors is necessary for planning interventions,particularly the reactions of significant adults to the child. How adults conceptualize RAD (that is, as a learned behavior response or an underlying disturbance of attachment) should be child or family specific and suggests different treatment approaches (Byrne, 2003; Hanson & Spratt, 2000). In our experience, nearly all children with disordered attachment or RAD have been given the diagnosis of ADHD at some time. Oppositional defiant disorder or the more severe conduct disorder are also common diagnoses (Green, 2003). Among other diagnoses given to children with disordered attachment are mental retardation, learning disabilities, anxiety disorders, adjustment disorders, posttraumatic stress disorder, eating disorders, and depressive disorders (Chaffin et al., 2006).

Indeed, children with RAD are typically noticed in schools because of significant antisocial or violent behaviors (Green, 2003). Understanding of the literature on violent children will therefore be extremely helpful to school personnel as they proceed with their assessments and school-based interventions. The basis for violent behaviors noted in children include lack of empathy; negative self-school image (that is, a realization that they cannot succeed in school through academic means, thus success is being acknowledged for antisocial acts); inability to learn from mistakes; deficits in social information processing or poor reality testing (for example, misperceptions of others' actions and motives, oversimplification of issues, and survival—threat reactions); stunted moral development; need for immediate gratification; and inability to selfsoothe or self-calm (Hayes, 1997). KEY POINTS FOR SCHOOL-BASED SOCIAL WORKERS

The school social worker must be prepared to address the specific manifestations of RAD and the related issues, including discipline, behavior management, communicating with teachers, counseling approach, motivation training, social skills training, liaison with foster parents, and educating parents and colleagues.The following recommendations are offered for school-based social work practice with children and adolescents diagnosed with RAD. Focus on Total System of the Child Unlike many disorders that are proven or presumed to have a genetic, biochemical, or other internal basis, RAD, by definition, is caused by the environment. As a result, there is little evidence that child-focused therapies, including psychotropic medications and counseling, have a major effect (Marvin &Whalen,2003).However, such therapies reduce some problematic cooccurring symptoms such as anxious symptoms, depressive symptoms, conduct problems, and social skills difficulties.The most effective strategy to date is for children to live in stable, safe, and supportive environments over an extended period of time (Chaffin et al., 2006; Marvin & Whalen). However, caution and modulation of

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expectations are warranted as the literature suggests that enhancing the caregiver environment may have more of an effect on those children who are emotionally withdrawn and may be less effective with the indiscriminate pattern of RAD (Zeanah, 2000). Nonetheless, a systems approach appears to be the most effective. Effective service plans for children with RAD are also conceptualized and conducted as family services plans, as opposed to individualized child services plans. These plans should also be conceptualized as having phases with measurable goals. For example, the initial phase of a plan may include the foUowing: ensuring the child's safety; increasing feelings of trust for the child and family; stabilizing immediate crises as they arise (for example, child's violent behavior, parental rehabilitation setbacks); establishing and maintaining boundaries; cohesive home-school actions and reactions; providing caregiver education and practice with behavior management; and building school and community supports. Working to stabilize school, family, and community environments is extraordinarily challenging, yet it provides improved lives for all students, especially those with attachment problems. Addressing only one part of the system or targeting only one person in the system is not likely to lead to enduring change or benefit.

are available to listen to concerns, assess progress in caregiving skills, and provide respite. Beware of "Experts" There is a large industry of self-proclaimed experts in the diagnosis and treatment of RAD popping up across communities and on the Internet. The problems are that they tend to see attachment disorders in nearly all children, and they tend to overstate the efficacy of their treatments (APA, 2002).To date, no widely effective therapeutic techniques are described in the literature, although there are some promising ideas with modest support (APA; ChafFin et al., 2006).The field of attachment disorders seems to bring out a variety of bizarre therapies of questionable utility, past-life regression therapy and rebirthing therapy among them (ChafFm et al.). Recall that therapists who were described as experts in attachment disorders were convicted of suffocating 10-year-old Candace Newmaker during an attempted rebirthing therapy session (Mercer, Sarner, & Rosa, 2003). Ineffective therapies are one thing, but dangerous and ineffective therapies are completely unacceptable (American Academy of Child and Adolescent Psychiatry, 2003). Be cautious to whom you refer families where attachment disorders are suspected. Some success has been noted with cognitive—behavior therapy targeting symptoms of fear, anxiety, and posttraumatic stress (Deblinger, Steer, & Lippman, 1999). In this approach, a child's perceptions about and habitual reactions to situations are addressed simultaneously. Although cognitive—behavior therapy has promise, its effectiveness is limited by young children's language abilities and level of cognitive development.

Families Can Be Saved A diagnosis of RAD necessarily means that some aspect of parenting is lacking. Sometimes the assumption is that the only hope for the child's success is to remove the child from the "pathogenic" family. However, helping parents receive mental health or addiction recovery treatments can be a major component of treating the family and child (Coleman, 2003). Continuing training in parenting skills can contribute to creating healthy families. Caregivers should be taught the difference between bonding (that is, adult-caregiver feeling toward the child) and attachment (that is, child's feeling toward the adult—caregiver) (Hanson & Spratt, 2000) .There is also a need to recruit stable adults who can serve as adjunct caregivers.These individuals support the child's curreht caregivers and

Relationships Take Time and Patience A common mistake made by professionals working with children and adolescents with RAD is believing prematurely that a relationship has formed. The core requirements for working with children and adolescents with RAD are the needs for a long-term commitment and for the intervention to take the individual along a path from feeling secure to self-awareness (Zeanah,

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1996). Along that path there are several intervening steps.The individual must gain a sense of belonging and be able to trust. From trust, the person can form relationships. From these relationships, the person can achieve self-awareness. In the school setting, beginning this relationship could take the form of having lunch with the child and his or her class, sharing activities, and coteaching. As noted previously, the difference between attachment and bonding must also be considered and periodically assessed. Prepare for the Worst We have been involved in many cases of adoption and foster placements in which the children with attachment problems engaged in the most severe testing behaviors at home and at school. To address such behaviors, the behaviors or behavioral style of key adults need to be assessed and addressed. Cohen and Mannarino (2004) suggested that when working with families, caregivers, and school personnel responsible for the child with BJVD, several adult characteristics needed to be considered, including stress management skills, affective regulation (that is, how they express their own feelings),problem-solving skills, communication skills, self-confidence, and interpersonal trust. Even in the most loving and stable homes or settings, we have seen children urinating on furniture, harming family pets, engaging in selfharm, destroying household objects, hitting and kicking adoptive or foster parents, and running away. Some of these adoptive and foster parents ended up revoking their status as parents and "returning" the children.Thus, one more rejection leads to the reinforcement of attachment problems. When asked why he behaved in such a manner, one young man said, "They said they loved me and said I will live with them no matter what. I guess I wanted to see if that was true." This child's adoptive parents were emotionally prepared for these extreme behaviors. Over the course of 18 months, these behaviors faded. Although there is still evidence of trust and relationship issues in his words, during an interview two years later he said, "They talked the talk and walked the walk. I admire them for keeping their promises. They must love me

because I was a pretty bad kid. And...well...I guess I like them too." Similarly, all significant adults interacting with the child during a school day must be briefed on beneficial and nonbeneficial reactions to a child's behaviors. Plans should be generated proactively to address antisocial behaviors. For example, having an adult asking a child to calm down, the reason for his or her behavior, to identify the related moral issue, or to "feel" something is likely not to be helpful unless steps have been taken to build trust and directly teach prosocial behaviors. CONCLUSIONS

RAD is a complex disorder ofthe ability to form effective relationships because of pathogenic parenting.The recognition and diagnosis of this disorder is difficult.Treatment strategies are even more difficult to implement. However, school social workers are in an excellent position to provide multisystem interventions focusing on family, school, and community collaboration. The goal of this collaboration is to create a stable, safe, and supportive environment so that trusting relationships between child and caregivers can be formed. S REFERENCES Ainsworth, M.D.S., Blehar, M. C.,Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Lawrence Erlbaum. American Academy of Child and Adolescent Psychiatry. (2003). Policy statement: Coercive interventions for reactive attachmentrfi'sorrfer.Washington,DC:Author. American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author. American Psychiatric Association. (2002). Reactive attachment disorder: Position i(a(emen(.Washington, DC: Author. Bowlby,J. (1979). The making and breaking ofaffectional bonds. London:Tavistock. Bowlby,J. (1988). A secure base: Clinical applications of attachment theory. NewYoric: Basic Books. Byrne, J. G. (2003). Referral biases and diagnostic dilemmas. Attachment & Human Development, 5, 249—252. Chaffin, M., Hanson, R., Saunders, B. E., Nichols.T, Barnett, D , Zeanah, C , Berliner, L., Egeland, B., Newman,E., Lyon,T., Letourneau, E., & Miller-Perrin, C. (2006). Report ofthe APSAC task force on attachment therapy, reactive attachment disorder and attachment problems. Child Maltreatment, 11,76—89. Cohen,J. A., & Mannarino, A. P. (2004). Trauma-focused cognitive behavioral therapy. Retrieved on January 15,2006, from http://modelprograms.samhsa. gov/pdfs/Details/TFCBT.pdf Coleman, P. K. (2003). Reactive attachment disorder in the context of the family: A review and call for

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further research. Emotional & Behavioural Difficulties, 8, 205-216. Das Eiden, R., & Leonard, K. E. (1996). Paternal alcohol use and the mother-infant relationship. Development and Psychopathology, 8, 307-324. Deblinger, E., Steer, R., & Lippman, J. (1999).Two-year follow-up study of cognitive behavioral therapy for sexually abused children suffering from post-traumatic stress symptoms. Child Abuse & Neglect, 23, 1371-1378. Goldberg, S., Gotowiec,A., & Simmons, R. (1995). Infant—mother attachment and behavior problems in healthy and chronically ill preschoolers. Development and Psychopathology, 1, 267—282. Green, J. (2003). Are attachment disorders best seen as social impairment syndromes? Attachment & Human Development, 5, 259-264. Hanson, R. E, & Spratt, E. G. (2000). Reactive attachment disorder: What we know about the disorder and implications for treatment. Child Maltreatment, 5, 137-146. Hayes, S. H. (1997). Reactive attachment disorder: Recommendations for school counselors. School Counselor, 44, 353-361. Kay Hall, S. E., & Geher, G. (2003). Behavioral and personality characteristics of children with reactive attachment disorder. Jowraa/ of Psychology: Interdisciplinary and Applied, 137,145-162. Lyons-Ruth, K., Zeanah, C. H., & Benoit, D. (1996). Disorders and risk for disorders during infancy and toddlerhood. In E. J. Mash & R. Barkley (Eds.), Child psychopathology (pp. 457—491). New York: Guilford Press. Marvin, R. S., &Whalen,W. E (2003). Disordered attachments:Toward evidence-based clinicai practice. Attachment & Human Development, 5, 283—288. Mercer, j . , Sarner, L., & Rosa, L. (2003). Attachment therapy on trial.The torture and death of Candace Newmafecr. Westport, CT: Praeger. Richardson, G.A., & Day, N. L. (1994). Detrimental effects of prenatal cocaine exposure: Illusion or reality?JoMmii/ of the American Academy of Child & Adolescent Psychiatry, 33, 28-34. Rodning, C , Beckwith, L., & Howard, J. (1991). Quality of attachment and home environments in children prenatally exposed to PCP and cocaine. Development and Psychopathology, 3,351—366. Vargas, C. M., & Beatson,J. (2004). Cultural competence in differential diagnosis: Posttraumatic stress disorder and reactive attachment disorder. Mahwah, NJ: Erlbaum. Zeanah, C. H. (1996). Beyond insecurity: A reconceptualization of attachment disorders in infancy. Jowraa/ of Consulting and Clinical Psychology, 64, 42—52. Zeanah, C. H. (2000). Disturbances of attachment in young children adopted from institutions.Jowraa/ of Developmental and Behavioral Pediatrics, 21, 230—236. Zeanah, C. H., Scheeringa, M., Boris, N . W , Heller, S. S., Smyke, A., &Trapani,J. (2004). Reactive attachment disorder in maltreated toddlers. Child Abuse & Neglect, 28, 877-888.

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Steven R. Shaw, PhD, is assistant professor. Department of Educational and Counselling Psychology, McGill University, 3700 McTavish, Montreal, Quebec H3A 1Y2 Canada; e-mail:[email protected]. Doris Pdez, PhD, is director. Metropolitan Studies Institute, University of South CarolinaUpstate, Spartanburg. Accepted May 30, 2006

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