Updated March 2024
Autism spectrum disorder, fetal alcohol spectrum disorder, why not reactive attachment spectrum disorder? Although the name is not likely to change anytime soon, viewing reactive attachment disorder (RAD) as a spectrum can be immensely helpful.
When we adopted from foster care, I associated reactive attachment disorder with children who didn’t want to be touched (our son wanted hugs on his terms) and were violent. Viewing reactive attachment disorder in such rigid terms made me blind to it for years—years that could have been spent getting the right help.
Our family, and many like ours, have struggled immensely from the poorly defined and overlooked disorder that stems from early trauma.
The Impact of Trauma Determines Appropriate Treatment of Reactive Attachment Disorder
Like any other affliction—from an injured arm to cancer—it is critical to determine the severity of a child’s reactive attachment disorder to decide on appropriate care. “Just as a band-aid isn’t enough to heal a gaping head wound, interventions such as attachment-focused therapy aren’t appropriate for moderate to severe reactive attachment disorder,” says RAD Advocates President Amy VanTine. “In fact, such treatments can make matters worse and waste a family’s valuable and often scarce resources of time and funding.”
Influential Factors with Trauma
Forrest Lien, LCSW, spent the last three decades of his career working with children with developmental trauma and their families. He'll be presenting “Why Am I Feeling Crazy?: The Life of RAD Parenting” at the Navigating RAD event, to be held next on April 19-21, 2024 in San Antonio. It is difficult enough to raise a child with reactive attachment disorder, but all the more difficult if the disorder isn't properly recognized.
An assessment was developed by one of Lien’s colleagues to rate the severity of reactive attachment disorder. He says a number of things play into the severity of reactive attachment disorder and the resulting behaviors. Influential factors include the severity of the abuse and neglect prior to the age of 3, genetic predispositions to mental illness, and the child’s unhealthy attachment style: ambivalent/preoccupied, dismissive/avoidant or fearful/disorganized.
While siblings may have similar genetics and life experiences, it’s common to see one who is more ambivalent/preoccupied and obvious with their behaviors, while the other is avoidant and therefore viewed as less of a problem.
“Aggressive, pushback angry behaviors are typical of the ambivalent subtype,” Lien explains. “If they’re asked to do anything, it would trigger that response. What they learn is that if I get angry, no one is going to expect anything from me, so I’ll continue to be angry.”
Influential Factors with Treatment
One of the reasons severity is important to consider is that children in the moderate-severe range often can’t be treated successfully at home. If the parents have a trauma history themselves and are highly triggered, it makes it doubly difficult to treat the child in the home.
“These kids typically need to be outside the home for treatment because everyone in the home is suffering,” Lien says. “A lot of clinicians will push the attachment relationship with the mom rather than looking at the whole breakdown of the family system.”
Our son was passive-aggressive versus physically aggressive. Lien says this is a more covert way of exerting control. Because children who experienced early abuse and neglect couldn’t trust their caregivers, they want to be in control at all times.
“The smarter a kid is with this disorder, the better they are at taking in the cues of the environment for control,” Lien says. Children with reactive attachment disorder are experts at triangulation, which is part of how they control the adults around them. “In therapy, we work with kids to let their healthy parents be healthy parents. To do so, they need to give up control and allow their parents to guide and direct them,” Lien explains. “That’s like saying to these kids ‘Give up all your survival tools and trust me.’ To them that feels scary because controlling their environment is how they survived their early trauma.”
The parents themselves, no matter their own histories, also need support to take part in attachment work. “Parents are often guarded as well after having lived with the child’s troublesome behaviors for so long,” says VanTine. “To force attachment onto two people who feel scared isn’t helpful. Everyone needs to feel safe first.”
That’s why kids in the moderate-severe range need intense treatment in a safe environment with experienced clinicians.
While almost all kids who come out of foster care or a similarly traumatic background have some trust and attachment issues, those on the lower end of the spectrum can be treated in the home with the correct approach. “With the mild disordered kids, you can typically get to the core issues with the right strategies in an outpatient setting,” Lien says.
Reactive Attachment Disorder Behaviors Across the Spectrum
Behaviors for a child with reactive attachment disorder stem from their reaction to the trauma itself, along with how the trauma stymied their brain development during early childhood. While most RAD behaviors negatively impact the child and their family, those behaviors vary depending on the specific child, the severity of their illness and their particular family.
The need for control, triangulation, plus lying and stealing are typical across the reactive attachment disorder spectrum. “Toddlers lie and steal because they don’t know it’s wrong,” Lien says. “With attachment-challenged kids, their brains are stuck in that developmental phase. All they know is ‘I see it, I take it, and it’s mine.’ And because they are not attached to their caregivers, they aren’t worried about pleasing them like attached children are with their healthy parents.”
Other behaviors, including violence to oneself or others, may or may not occur depending on the severity of the child's disorder. We spoke with four moms dealing with reactive attachment disorder about the concept of reactive attachment disorder as a spectrum and where their own children fall on that spectrum.
Tina, Charlotte and Sophia*
Tina and her husband had five biological children, ages 5 through 16, when they decided to adopt two non-related teens from a Russian orphanage. Charlotte was 16 at the time and has cerebral palsy. Sophia was 13 and has spina bifida. They are now 16 and 19. (*Names have been changed to protect identities.)
Both girls were violent from the moment they arrived. While Tina had learned about reactive attachment disorder in adoption training, she thought their behaviors were fear-based or learned from the orphanage at first. After all, they were suddenly brought to a new country, in a new home, with a new language. “It’s such a tied-up mess that it’s hard to unravel,” she says.
The orphanage/adoption agency withheld information about the girls’ behaviors and issues. Tina was slow to recognize reactive attachment disorder, and with a lack of educated professionals in their area, the experts were slow to see it as well. However, Charlotte and Sophia demonstrate many common reactive attachment disorder behaviors.
“Lying, deceit and manipulation is their native tongue,” she says.
This has led to false accusations. And like most kids with reactive attachment disorder, both girls go to extremes to get their way and fight against limits. Charlotte self-harms and soils herself. She also has breaks with reality and claimed the devil possessed her and wanted her to kill Tina.
“We were so afraid she was going to kill herself or one of our other kids,” Tina says.
Both girls were diagnosed with psychiatric conditions after placement. Finding resources was difficult. Two years ago, they accepted a bed in a group home for Charlotte but still stay in touch and visit.
“Just as a band-aid isn’t enough to heal a gaping head wound, interventions such as attachment-focused therapy aren’t appropriate for moderate to severe RAD,” says RAD Advocates President Amy VanTine. “In fact, such treatments can make matters worse and waste a family’s valuable and often scarce resources of time and funding.”
Meanwhile, Sophia would corner her younger siblings with her wheelchair and beat up on them. She stabbed one of her siblings with a pen and was also violent toward Tina and the pets. Like Charlotte, she also self-harms and exhibited other extreme behaviors like squeezing her blood into the family’s food and trying to cause car accidents. She suffered a cancer scare but couldn’t complete all treatments due to her extreme behaviors.
Eventually, it was discovered that Sophia was intentionally burning herself, which progressed to her turning the stove on at night and trying to kill the family. The police became involved, and it was recommended she be sent to an acute psychiatric facility, but finding one that could work with her other disabilities was challenging. She went in and out of facilities, insurance wanted to stop paying, and the family had to go to court to keep her in treatment.
The experts agree that Sophia is not safe to return home. Now Sophia lives in a group home with other girls suffering from reactive attachment disorder. The staff had received training from RAD Advocates and recommended the group to Tina.
Tina appreciates finding other people who “get it” and hopes one day her girls will want to change, grow and receive the help they so desperately need. Needless to say, both girls are on the severe side of the reactive attachment disorder spectrum.
Heather, Layla and Austin
Heather was raising two biological children when she decided to pursue becoming a foster parent. She adopted her foster son Austin when he was 10, then two years later her ex-husband’s granddaughter Layla moved in. At the time, Austin was 12 and Layla was 9. Both have a reactive attachment disorder diagnosis. Layla spent time with Heather when she was younger. Later, Heather and her current husband adopted a sibling set of girls who do not have reactive attachment disorder.
At placement, Austin was so heavily medicated that she didn’t see how severe his reactive attachment disorder was. Layla is level 1 on the autism spectrum, and Heather categorizes her reactive attachment disorder as mild-moderate.
While most RAD behaviors negatively impact the child and their family, those behaviors vary depending on the specific child, the severity of their illness and their particular family.
“Layla is 12 now, but many of her behaviors are very toddler-like,” Heather says. “I have a lock on my linen closet because she dumps all products down the drain or makes potions. The obsession with screens is disturbing. No rewards of or consequences work her.”
Other behaviors include constant lying, destruction of property and “accidentally” hurting others, though not severely.
“With Austin he does all that. He’s very angry and much more volatile and violent. His stealing moved to the neighbor’s house. His behaviors really escalated. He’s assaulted me twice. He’s at a residential treatment facility for the second time.” She found out about RAD Advocates through social media, and they have helped her navigate Austin’s treatment.
“Reactive attachment disorder is like autism, it’s a spectrum,” Heather says. “It’s a symptom of trauma and neglect. How traumatized and neglected was this child? This will often be an indicator of how difficult a time they’ll have dealing with the world. Austin was abused in every way possible. His reactive attachment disorder is severe. Layla witnessed domestic violence—sometimes directed at her but more often not. Hers is not as severe.”
Getting the reactive attachment disorder diagnosis helped put in perspective what she was dealing with. And Heather’s seen progress in Layla that she finds hopeful.
Carly, Brandon and Laurie
Altogether, Carly and her husband have 13 kids—eight biological and five adopted children. While their children adopted from foster care each have various struggles, two have severe reactive attachment disorder.
Brandon was adopted at 20 months and is now almost 18. While he was angry from the beginning, his behaviors began to escalate around 6, acting out and raging. He would follow Carly around screaming obscenities at her. He’s also been violent. His first hospitalization was at age 10, and they were rapid-fire after that. “It was pretty much hospital hell for the last eight years,” Carly says.
Brandon has been in a residential treatment facility for the past two years. Meanwhile, Laurie was the oldest of three siblings adopted as toddlers. She is now 15.5 and also suffers from reactive attachment disorder.
With both children, Carly asked Child Protective Services for help. Unlike what many families experience, the department did everything they could to help their family. “There’s no way I could have kept them in the house without their help,” she says.
The university where the kids underwent trauma assessments had completed training with RAD Advocates and actually understood Carly’s struggle.
In addition to self-harming and other high-risk behaviors, it was discovered that Laurie was plotting to kill the family. She went in and out of treatment. Today, she’s at home and doing okay. Carly and Laurie attend therapy together. Like many homes where children with reactive attachment disorder live, theirs is full of locks and cameras.
Carly wants other families dealing with reactive attachment disorder to know that even kids who aren’t violent take their toll: “Emotional abuse is just as bad and kills us in different ways. It makes us question our parenting. It makes us question our core. Just because someone isn’t trying to kill you doesn’t mean they aren’t severe.”
Lisa, Kaylee and Adam
Lisa and her husband adopted biological siblings Kaylee and Adam when they were 1.5 and 3. Kaylee is the oldest, and they are now 18 and almost 19. They didn’t receive a reactive attachment disorder diagnosis until middle school, and from the beginning the disorder manifested itself differently in each child.
As is too often the case, the chaos of reactive attachment disorder took a toll on Lisa’s marriage, and after 25 years they divorced four years ago. Lisa is now a single mom to Adam, who is a junior in high school. Kaylee graduated a year ago and is trying to “adult” but has a hard time. Like many kids with reactive attachment disorder, they act younger than their biological age.
Lisa categorizes Adam as having moderate-level reactive attachment disorder and Kaylee as mild-moderate. Both kids target her, triangulate, have issues with peer relationships and hygiene, and also suffer from anxiety and depression. Adam is impulsive, has damaged the house, stolen from her, been in trouble with the law, can’t abide by boundaries, vapes and smokes pot, is verbally abusive to Lisa, and has also been violent. Even when in trouble with the law, he shows no remorse. Her home is equipped with cameras and locks. Kaylee has severe social anxiety, has made false accusations and has food issues. At 18, she stopped therapy and medications. Until recently, Lisa had trouble finding appropriate treatment.
“I tried to teach them about reactive attachment disorder a little bit,” Lisa says. “Two months ago, Adam started with a reactive attachment disorder therapist. If they go into adulthood with it, reactive attachment disorder will affect them for the rest of their life. The more that they understand and know about it, they can then learn to deal with things in a different way. Even the sessions he’s had so far with this reactive attachment disorder therapist have been really good.”
Carly wants other families dealing with reactive attachment disorder to know that even kids who aren’t violent take their toll: “Emotional abuse is just as bad and kills us in different ways. It makes us question our parenting. It makes us question our core.
Lisa says looking at reactive attachment disorder as a spectrum helps her understand why she’s had to parent her two kids so differently. “It’s an ongoing thing to learn parenting techniques,” she says. “Understanding the ends of the spectrum is helpful for that. They’re not in the same place.”
She utilized RAD Advocates for some coaching sessions for Kaylee.
“What’s nice about RAD Advocates is they look at your situation and make their help very customized to your family,” Lisa says. “I think they’re a very good resource for families going through this.”
Bringing Real RAD Life to Light
The stigma of reactive attachment disorder is strong and interferes with equipping families with effective treatment. To appropriately define and recognize the disorder is a good start. RAD Advocates is an organization founded by parents who advocate for other parents. They are not clinicians and do not claim to have answers for treatment. Rather, they’re bringing the reality of the disorder and what’s missing to light so communities can work toward solutions.
“To deny that these realities exist does not make them go away. How I wish that were the case,” says VanTine. “Healthy and stable families are the single most important part of the healing solution for these kiddos. But families can’t survive if we keep dismissing RAD struggles as theirs alone. This is our collective responsibility as a society and to our children and families. We must keep moving forward as a community, speak the truth and support these remarkable and very human families. They need and deserve real help. Although challenging, solutions are entirely possible when we work together.”
About the Author:
Micaela Myers and her husband adopted a pair of siblings from foster care in 2015, when the children were 9 and 13. Since then, she has become an advocate for foster care reform and the support and education of adoptive parents. She was a member and is a supporter of RAD Advocates. Micaela earned her MFA in writing from Vermont College of Fine Arts and works as a professional writer and editor in Wyoming.