The DSM-IV indicates that Reactive Attachment Disorder (RAD) may arises from the “repeated changes of primary caregiver that prevent formation of stable attachments (e.g. frequent change in foster care.)”
Treating Reactive Attachment Disorder (RAD)
More than with any other mental disorder, the healing for Reactive Attachment Disorder (RAD) takes place in the home. The main job of the therapist is to structure significant connecting with others, especially family members.
In the days of the cold war, when east and west were walled off, a man made daily trips across the border into the east zone with wheelbarrows full of fruit packed in straw. Although the fruit was legitimate, the border guards were certain that the man was a smuggler. For weeks, they checked everything, searched the straw, broke open the fruit, tested wood splinters and pieces of straw for contraband chemicals. One day, the man told them it was his last trip. The guards outdid themselves in checking, but to no avail.
Once the man was safely across the border, they asked him if he would reveal what he was smuggling. “We can’t sleep at night not knowing.” “Of course,” the man replied. “I’m smuggling wheelbarrows.”
Don’t miss the obvious. RAD is not amenable to cognitive behavioral therapy, crisis intervention, nor even to behavior modification. Bonding cannot be forced, but occurs naturally when the stage is set and the time is right. Attachments and bonding happen, not in offices, but out there in the everyday world.
Broken relationships are a major cause of RAD. They lead to hesitance in re-connecting and indifference. The cure involves beginning to trust and learning to share important events over time in daily life, such as eating, sleeping, going places, and playing together.
Meaningful and vital relationships do not take place in artificial environments. They happen in that wonderful mix of emotional entanglements within the family. Five obvious factors should constitute the basis of RAD therapy.
A Permanent Home: The bonding therapist's first job is to make sure the child has a permanent home. Bonding takes place between specific persons. To facilitate bonding with a person likely to disappear is dangerous. Losing a loved one hurts badly. The loss may cause the child to reconsider the risk of future attachments and vote to “opt out.” Repeated loss entrenches RAD.
Every child has the right to a permanent home. One might even argue that “permanent” is one of the hidden assumptions built into the idea of “home.” The therapist’s first job is a social work task: to do everything possible working with the welfare department to further permanence. Help the child remain with the birth parents if possible. Arrange for in-home services. If the child must be removed, work to shorten the time in limbo. Foster care is, or should be, temporary. Help evaluate available kin. Promote concurrent planning to minimize multiple moves. Try to approach every placement away from the birth home as if it could be the last one. Find adoptive parents.
A good therapist realizes that foster parents face a serious dilemma. On the one hand, foster parents are likely to attach, even “fall in love” with the children in their care. On the other hand, if the child trusts and loves them in return and then is moved, trauma results. To anticipate this dilemma, the therapist should do everything possible to prevent or minimize multiple moves, and to shorten the time in temporary care. Bonding therapy should not be attempted in a temporary setting.
Structure Connecting: As soon as a permanent home is established, facilitate the avenues of attachment. Bonding occurs naturally and so should the treatment of RAD. Parents should be counseled to notice at least two extra things about their child each day. The therapist should remind them to smile at their child, and touch, and ask questions. Read or make up bedtime stories. Consider getting a pet to love and be loved by.
Parents of an RAD child should avoid grounding and time-outs as discipline since these procedures tend to isolate and further alienate the child. Instead, keep the child nearby so he or she can interact. Should the child become angry and shout, this is a personal reaction and may actually be a step forward from the detachment of RAD.
Peers are critical partners, perhaps even more than parents. The therapist will advise parents to encourage participation in groups such as 4-H, school clubs and sports, summer baseball, soccer, or the swim team. Be there and cheer them on even if they are not stars. Welcome sleepovers and two-person games on the computer. Parents should be urged to do what they can to provide possibilities for contact with peers, even when that contact involves arguing and disagreements. Bonding has positive and negative aspects, but it cannot happen without the opportunity to interact.
Model Emotions and Compassion: Emotions are personal. Reasoning and logic are not. The therapist should encourage parents to let their own feelings show. Children need to learn that their parents have feelings too. Foster/adopt parents should feel free to laugh with their child. Some things are very funny. It is all right for foster/adopt parents to show their anger too, as long as it does not degenerate into physical violence or personal demeaning.
Crying is okay. I remember when my mother phoned to tell me my father had two major heart attacks and was not expected to live. I dropped the phone, began to cry, and raced around the house frantically to prepare for a quick trip to Chicago. My children were amazed. They had never seen me cry. They responded immediately to my requests for cards to give grandpa. (He recovered.) My relationship with my children deepened.
Therapists can teach parents to use “I” messages. For example: “I am upset with what you have done. I want you to come here and sit next to me for five minutes.” Putting parental emotions into words can help the RAD child recognize his or her own feelings. Parents should avoid starting sentences with “you,” as this suggests that the parent knows what is going on inside the child. Further, it implies an accusation which the child will probably deny.
Accentuate the Positive: Parents will get more of whatever they pay attention to. Every teacher, parent, and supervisor knows this. People are known to say: “I don’t know what’s the matter with her. The more I get after her, the worse she gets….She’s just doing it to get attention.” Of course she is. Attention, whether positive or negative, is a payoff.
The therapist needs to teach parents to brainstorm with each other about times when their child relates personally with others. This is an important way to share awareness about incidents worthy of notice. Pick any event when the child interacts with a companion. When he or she joins a club, has a friend over, or plays with a pet. Especially be aware of incidents such as; getting into an argument or a fight, joining in the family in conversation or action. Then, reward these moments with a comment or a touch; “I’m glad to see you and Nicole together….”I am glad you came with us…..” Parents need to encourage these breakthroughs with attention.
Expect Misbehavior: Misbehavior may be problematic but it is, nevertheless, a relationship. Misbehaving is a step forward, away from being a loner, and into the real world of other people. On the road back to normalcy, the RAD child may be disrespectful, lie, fight, steal, break things, and do much else to irritate the parent. They may try a parent’s patience to its limit.
The therapist needs to support and encourage parents as they deal with an unruly child. The therapist can teach how to correct these behaviors without squelching the child. Avoid long lectures. Lectures give too much attention to misbehavior and rarely work. The therapist can suggest more appropriate ways to discipline than isolating the RAD child. Instead, focus directly on the lying and stealing and other uncivil behaviors. If the child lies, the discipline might be to refuse to accept his word from then on. If he steals, search his room, pat him down before leaving for school, make him pay back what is pilfered. The goal is to skip the lecture, ignore the bad behavior itself, and accomplish the desired outcome. The lies are stopped because the parents seek other sources for the truth. The stealing is handled because the parents take practical measures to uncover the theft.
While misbehavior may be wearisome to the parents, the therapist can remind them that, for the RAD child, it may represent progress. Parents might even be somewhat pleased that the child is testing them out. The therapist should encourage them to respond personally and directly, without pushing the child away. Failure to attach is the predecessor of psychopathy, the lack of empathy or feeling for others. This is true moral retardation, far more serious than the more common misbehaviors of childhood.
To truly help a child, the parent must go where the child “lives,” to the child’s personal world view. Giving moralistic admonitions to an RAD child is like trying to provide directions to a location without knowing where the potential traveler is starting out. To get a traveler where he needs to be, one must start where he is. With RAD, the starting point is a lack of empathy or emotion. To heal this, the therapist must help the parent to understand the emotional hurt and resultant anger that underlies the fear to love.
In summary, the therapist might say to the parent: “Open your eyes to the obvious. Accept the real issues that circumscribe RAD. Then be patient. Don’t force things. Pass the tests. And most simply of all, just be there.”