On the left are the situational factors that should be a red flag to alert you to the possibility of RAD presentation -most often you will see the first factor as the causal one – pathologic care, as severe and chronic neglect or abuse, but sometimes RAD can occur after hospitalized (of caregiver or child) during the critical attachment periods in the first years of life -it can also occur because of a severe postpartum depression – resulting in nonattachment during the first months or year of life. Even though after that point the mother’s depression may remit, there is an important window of time that the primary attachment occurs and if this isn’t met during that period, it can severely disrupt the bond that the infant develops. -on the right are comorbid symptoms – not differential diagnoses necessarily, but problems that commonly co-occur with RAD
Obviously some of these signs are also signs of other disorders and commonly results of child abuse, but still when one of these comes up, you should automatically think RAD as a rule-out diagnosis.
These subtypes are not defined in the DSM, but are fairly accepted classifications among literature
There is not yet a strict “best practices” method for treating RAD. In the past, something called “holding therapy,” in which they would physically restrain the child and provoke him to anger and then soothe the child – sound somewhat similar to how to establish learned helplessness and is rarely used. Little, if any support for it’s effectiveness and may be harmful. Right now, the agreed upon method basically entails training the parent on how to interact with the child to re-establish the bond. Perhaps more than in some other disorders of childhood, the parent has to be VERY involved in this therapy, as it is based primarily on interaction between the child and parent. If the parent is not yet ready emotionally to undergo this type of interaction or if she/he is at all distant, aloof, avoidant, etc. the therapy will be inappropriate and maybe even disruptive to the child.
Three S’s are really the goals of therapy:
Play therapy can be a good intervention and also an excellent way to monitor symptoms and progress. Telling the child to draw a picture of a “family doing something” is used commonly to assess the child’s opinions or emotions – this is a projective measure – of feelings toward family. Make sure you only state that instruction “draw your family doing something” and don’t use the word “together” and then see what the child comes up with. There is not an empirically validated method for scoring these, but fortunately in one study, non-professionals were quite accurate at deciding whether a drawing was done by a child with a disorganized caregiver attachment.
It’s good to keep these stages of attachment in mind when doing therapy. The child may have moved appropriately through some stages, but not others. Or, if the disruption in attachment was early, you may need to progress through each level with the parent and child.
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