Currently Reactive Attachment Disorder (RAD) is the diagnosis associated with attachment impairment. There is little research available as to the prevalence of this disorder, but there are thousands of children who have been impacted by trauma and exhibit many of the symptoms that are part of the RAD definition . Some children are diagnosed with PTSD or other conditions instead of (or in addition to) RAD. It is often used as a catch-all term for children who are struggling due to problems in their past.
Reactive Attachment Disorder (RAD) – This is the condition which occurs when a child has experienced significant abuse and/or neglect as an infant or very young child. These adverse childhood experiences cause the child never to form an attachment with the caregiver. As a result, it becomes difficult for the child to form a secure attachment to anyone. RAD is at the extreme end of the spectrum of attachment challenges. Parenting a child with RAD can be overwhelming for the parents.
Attachment Disorders – Attachment disorders are a spectrum, and not every child who has experienced trauma falls at the extreme end. A child, for the same reasons stated above or because of other trauma and/or neglect, can develop problems attaching with a caregiver, but these problems are not as pervasive or as severe as a child diagnosed with RAD.
PDD or Pervasive Developmental Trauma – These are both terms to describe how a child reacts to previous trauma. While we normally think of PTSD as related to trauma associated with war, it can also describe what happens to a child in an abusive or neglectful situation. Some therapists and doctors prefer to use the term Pervasive Developmental Trauma to describe the global effects that trauma has on a growing brain, but due to its lack of inclusion in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders published by the American Psychiatric Association), it is not a term used universally or as an official diagnosis.
There is significant overlap in cause and effect between these three categories, and this can cause confusion. All three come with a hefty dose of fear, anger, and a lack of trust.
While there is nothing clear or simple about any of the effects of trauma, remember that there is a broad spectrum of attachment and related disorders. The term “RAD,” while frequently applied to a wide range of behaviors, actually applies only to the most serious extreme of this spectrum.
Attachment Disorders
The types of problems that adoptive parents see in their children are most likely the result of breaks in attachment that occur within the first three years or through multiple placements over long term. They are problems that impair, and even cripple, a child’s ability to trust and bond – or attach – to other human beings.
These issues with attachment are the ones that cause the greatest problems in adopting a child with special needs. As adoptive parents attempt to attach to a child whose attachment ability is impaired by developmental delays, the attachment will either be nonexistent, distorted, or focused around negative behaviors.
Children who have suffered abuse or neglect severe enough to bring them into the foster care/adoption system may meet the diagnostic criteria for Reactive Attachment Disorder. This clinical diagnosis identifies children who have not been able to attach appropriately to a caregiver in a meaningful way.
For therapy to be effective, it must be directly related to the problems that the family and the child are experiencing. Specific problems warrant specific solutions, and boilerplate methods serve no purpose. In most cases, finding the right therapist to point out the right path is the first step toward family harmony.
We continue to hear complaints from adoptive parents that many mental health professionals blame them for their child’s current problems. It is an unfortunate fact that many of those who attempt to provide treatment to adoptive parents with disturbed children know very little about issues related to adoption. This is particularly alarming when we realize that they not only fail to provide effective therapy, but also solidify the child’s existing pathology and complicate subsequent therapeutic efforts. It is not unusual for us to work with families who have seen four to six other mental health professionals without results.
Since many children who have experienced neglect, abuse, and abandonment have not yet developed an internalized set of values by which they judge themselves and others, they are not able to receive and experience empathy, nor can they develop insight. They project blame onto others and onto objects. They blame their adoptive parents for causing their anger, and they blame toys for breaking. They blame things that could not possibly be responsible for anything!
Most often, children or adolescents who engage in projecting blame are those who have not yet developed a conscience. These same children are adept at engaging others in a superficial manner, thus therapists, teachers, and outsiders to the family feel that these children are easy to be around, and that they are truly misunderstood by those who should know them best — their parents.
“Unfreezing” Development
Developmental change occurs within the context of intense interpersonal relationships.
The relationships forged in the birth family – although locked in faulty thinking and ultimately causing developmental arrest – were intense. As a result, a strong connection developed between the abused child and the abusing parent. It is important to remember this dynamic, and to understand that our positive relationships must be equally intense if they are to counteract and compete with the abusive relationships that initiated and solidified the child’s pathology.
Therapy with hurt children needs to include: high energy, intense focus, close physical proximity, frequent touch, confrontation, movement, much nurturing and love, almost constant eye contact, and fast-moving verbal exchanges. One goal of therapy, then, is to approximate what occurs in the healthy attachment cycle, thus reworking the process that was so traumatically interrupted early in the child’s life. Therapy that is detached, non-directive, and passive is seldom received by the child as it is intended by the therapist. It is most often viewed as cold, uncaring, uninvolved, boring, and useless.
Holding Therapy
Close physical proximity heightens the therapeutic process and the interpersonal contact. Holding the child or adolescent results in an intensity that cannot be duplicated in any other therapeutic format. We have found that therapeutic holdings – not restraint – mobilize development. Clearly, this is an intended outcome of therapy with those who have developmental delays.
Holding the child or adolescent is accomplished by having him lie across the laps of two therapists and/or his parents. His right arm is behind the back of the lead therapist, who is sitting closest to the child’s head. His left arm, is free, or may be restrained if he uses it to try to hit the therapist or to engage in self-stimulation such as scratching or fidgeting. ‘Such self-stimulating activities may increase during holding as the child attempts to deflect contact with the therapist and to maintain awareness of self by avoiding others. This behavior is discouraged, since the goal is to heighten the child’s contact with others.
The lead therapist is responsible for guiding the session. Eye contact is critical, and is enforced nearly all the time. The child is responsible for maintaining eye contact with the person with whom he is talking. When he doesn’t, the therapist uses either verbal or physical cues – such as turning the child’s head – to help him establish the connection he needs. Most of the professionals who advocate holding therapy are in agreement about the following elements:
- Emotional contact between the child and the therapist/holder is heightened.
- Holding produces emotional responses that are unlikely to occur in any other kind of therapeutic intervention.
- Corrective emotional experiences may occur during, and as a result of, holding.
- Holding enhances the child’s capacity to attach.
- Holding increases the child’s attachment to the therapist /holder; and facilitates the transfer of this connection to the parents
- Holding provides physical containment, which is reassuring to the child whose feelings often frighten him
- Therapists who do holding are more aware of this child’s nonverbal experiences – than they would be if they sat across from him with no physical contact.
Some people refer to holding therapy as rage reduction therapy. We think that the term “rage reduction” is a limited description of what holding encompasses. Of course reducing the child’s rage is a desirable and necessary outcome. However, most of the time spent in therapy is not focused on the provocative rage work that is often featured in television coverage of holding therapy. Rather, a variety of interventions and strategies are utilized.
Holding is a process that often reactivates delayed development. It is a vehicle that allows an intense, interpersonal relationship to develop, and consequently promotes, nurtures, and supports growth. Holding therapy does not result in a “quick fix,” but rather in a “jump start.” The child and therapist can access feelings that would not be available through ta1k therapy alone.
When treating rage-filled children and adolescents, holding promotes heightened emotional release. Not all children who have attachment issues operate out of a rage state. But for those who do, the releasing process helps to clear away the rubble so they can begin to experience other feelings. Emotions that they often attempt to ignore – sadness, hurt, and fear – can surface within a safe context, with safe people.
Most therapy attempts to correct past insults. While no therapy can change what has already happened, perceptions can be altered. Reframing one’s circumstances and responses can help an individual gain mastery over his greatest fears and his most serious losses.
Therapy for a hurt child should provide corrective emotional experiences. Holding enhances the likelihood that this will happen, since it accesses, the child’s feelings and prior experiences almost immediately. A disturbed child’s feelings related to early negative experiences are not usually managed well. He may have been avoiding them for years, and/or projecting them onto his adoptive parents.
Source: Greg Keck, Coalition 2007 Workshop Presentation. Reprinted from Adopting the Hurt Child by Gregory C. Keck, PhD, and Regina Kupecky, LSW. Used by permission of Pinon Press. All rights reserved.