RAD, PTSD, ODD, ADHD, BP, BPD, SPD…who cares? Children from hard places come with a veritable alphabet soup of labels and diagnosis. The one thing these kids have in common is trauma. It’s tough for them. It’s tough for us. It’s tough all the way around. So my question is simple. Why do we care so much about Reactive Attachment Disorder? Why should we care about RAD?
Way back in the early 1900s B. F. Skinner, a behaviorist, was studying human behavior. He placed an infant known as “Baby Albert” in a small empty room. Then he put in a little white rat. At first, the baby delighted in the soft fascinating creature. Then, Skinner began to pair the entrance of the rat with a loud, frightening noise. Pretty soon, Baby Albert was terrified of the rat even without any paired noise. He was also afraid of other white creatures, such as a bunny, even when there was no longer any sound. Skinner called this fear of other similar objects, “stimulus generalization.” The child was afraid of things that had not been part of the initial traumatizing experience.
I’m simplifying it, of course, but my point remains. When you teach a child to fear something, or that something is unpleasant and uncomfortable, they will believe it. Kids coming from scary caregiver situations will soon generalize this fear to other caregivers. It takes a long time for the fear to go away. Therapists describe attachment challenges as falling into categories. There are some estimates that place about 80% of kids coming into foster care as having what is referred to as “disorganized attachment.” This basically means that the child has no consistent response to caregivers. they may react with fear and/or avoidance when presented with a caregiver. they may become distraught and afraid when that caregiver leaves. I’ve often heard of it referred to as sort of a “push-pull” situation where the child pushes the caregiver away but then desperately tries to pull them back in.
Kids in the foster care system are also more likely than a returning US war veteran to experience symptoms of PTSD. Think about it. Just being ripped from their biological family and everything they know is traumatizing. They are grieving a huge loss. Add to that any neglect or abuse and it is no wonder they are experiencing distress.
What does this all have to do with the DSM-V label of “Reactive Attachment Disorder?” Well, the diagnosis for this has changed. It used to be listed under “disinhibited” and “inhibited” types. Now it seems that only inhibited type is in the manual, and the disinhibited type moved into another disorder known as “Disinhibited Social Engagement Disorder” which may or may not have any prior caregiver-related trauma. The following are the criteria listed for an official diagnosis of RAD:
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
- The child rarely or minimally seeks comfort when distressed.
- The child rarely or minimally responds to comfort when distressed.
B. A persistent social or emotional disturbance characterized by at least two of the following:
- Minimal social and emotional responsiveness to others
- Limited positive affect
- Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults
- Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios)
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder.
F. The disturbance is evident before age 5 years.
G. The child has a developmental age of at least nine months.
Specify if Persistent: The disorder has been present for more than 12 months.
Specify current severity: Reactive Attachment Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.
Sometimes older children sort of move on from the RAD diagnosis into Borderline Personality Disorder. It can all get very tricky in terms of diagnosing the conditions that kids from hard places present with. Parents of these children need diagnosis for several reasons. The first major reason is for insurance purposes in order to get necessary treatments. The second is to just have someone else recognize that you need assistance and your child’s struggles are not just “typical kid behavior” that they might “grow out of.”
I think some people have very negative feelings about the RAD label, because it sparked some highly questionable treatment methods in the 80s and 90s. There was a scary “rage reduction” techniques practiced under “Attachment Therapy.” Children were humiliated, abused, and frightened. It looks horrible and it must feel horrible. This practice is not the same as the actual disorder. In fact, it isn’t even the same as therapy today involving building attachments. The negative connotation of these dangerous practices has unfortunately permeated the very diagnosis and led many to deny the very existence of attachment challenges in children from hard places.
This all comes back to the question of, “Who cares?” I will tell you who cares about RAD. I do. Other parents fighting to bond and build trust with their children care, too. Parents who are fighting a war against their child’s past experiences. Parents who are fighting a war against their child’s past trauma. Parents who are fighting a war against attachment challenges.
The label doesn’t really matter as much as the child does. The child is clearly in distress and in need of love and safety. It sin’t surprising to me that children would have problems trusting or bonding with new caregivers. It’s surprising to me that others would deny this could be a problem.
Regardless of the diagnosis, we should all try and empathize with families and children dealing with trauma and loss. We should all try to be understanding. This is a hard road to walk and it doesn’t need to be walked alone. The label doesn’t define the child or the caregivers. We are all soldiers here.
**Want more Information of RAD and attachment challenges? Please visit
–This website has many resources:
–This post has a great analogy about kids with RAD and attachment:
–Another blogger from the trenches!