Reactive Attachment

Disorder
How to recognize, manage & treat
effectively
Brian Kadinger, MS, LMFT
Manager, Clinical Services
Importance of Reactive Attachment
Disorder (RAD)
 “New” disorder-diagnosis created in 1980
 Increase in prevalence
– Divorce rate
– Studies in Trauma
– Single parent households have doubled since
1970 & continue to increase
 Inherited quickly
 Definitions
 Clinical DSM-IV-R
– Based upon Attachment Theory
– Markedly disturbed and developmentally
inappropriate social relatedness in most contexts,
beginning before age 5 years, as evidenced by either:
 Persistent failure to initiate or respond in a
developmentally appropriate fashion to most social
interactions, as manifest by excessively inhibited,
hypervigilant, or highly ambivalent and contradictory
responses (cold, withdrawn, odd approaches,
avoidance) OR
 Diffuse attachments as manifest by indiscriminate
sociability with marked inability to exhibit appropriate
selective attachments (overly familiar with new folks,
too social)
 DSM-IV-R (continued)
 The disturbance is not accounted for solely by
developmental delay (as in Mental Retardation)
and does not meet criteria for a Pervasive
Developmental Disorder
 Pathogenic care as evidenced by at least one of
the following: 
(1) persistent disregard of the child's basic
emotional needs for comfort, stimulation, and
affection 
(2) persistent disregard of the child's basic
physical needs 
(3) repeated changes of primary caregiver that
prevent formation of stable attachments (e.g.,
frequent changes in foster care) 
 DSM-IV-R (continued)
 There is a presumption that the care is
responsible for the disturbed behavior
(e.g., the disturbances began following
the pathogenic care). 
 Specify type: 
– Inhibited Type: if Criterion 1 predominates in
the clinical presentation 
Disinhibited Type: if Criterion 2 predominates
in the clinical presentation
 Real world symptoms
 Abandonment, abuse & neglect
 Bounced from place to place, never had a
connection or lost connection (death, divorce,
prison)
 Inability to learn from mistakes (poor cause-and-
effect thinking)
 Learning problems or delays in learning (not
related to MR/DD issues)
 Impulsive behavior
 Destructive or cruel behavior
 Attempts to “launch” early
– Heavy sexual interaction, long periods from home
 Inhibited vs. Disinhibited
 Armor & Naked-two sides of the same coin
– Armor (Inhibited)-withdrawn, extremely guarded,
expecting others to “screw” or leave them
 Set self up for others to leave them due to this mistrust
– Self fulfilling prophecies
 Pick friends to “bond” to that will betray
 Test others & push them away-expecting them to leave
– Naked (Disinhibited)-clingy, overly attracted to folks
 Emotional vomit-tell entire life story to complete stranger
 Jump from partner to partner, friend to friend
 “Fake”-overly excited with folks, seem extremely attached
quickly
 Goal for both is the same-hide vulnerabilities and
reduce chance for hurt
 World View of the RAD
 Logic of children-blame self, low self
esteem
– “Once you eliminate the impossible, whatever
remains, no matter how improbable, must be
the truth.”
 Imbalance of locus of control
– Take responsibility for things they don’t
control, and give away responsibility for
things they do control
 Pattern of objectification in relationships
 Neurological Effects of Trauma
 Children who suffer trauma have smaller
brains overall
 Deficits in frontal lobe that affect judgment &
planning
 Anterior cingulate gyrus-The “gear shifter” of
the brain
– Gets stuck-obsesses, holds grudges, inflexible
– lower levels of chemicals that affect rapid decision
making, reward anticipation, empathy & neuron
health
 Micro-expression understanding & emotional
recognition
 Co-Morbidity
 Mood & Anxiety Disorders
 Attention Deficit Hyperactive Disorder
 Substance Abuse & Dependence
 Acute and Post Traumatic Stress Disorders
 Conduct Disorder & Oppositional Defiant
Disorder
 Personality Disorders
 Family Structure & RAD
 Generational impact
– How many generations in a family
experienced these issues?
– Homeostasis issues and dysfunction
 Inconsistency in rules and follow through
– Enabling and manipulation
 Enmeshment & detachment
 Poor regulation of emotions
 Family Structure & RAD
 Parentified children & Adolescentified
parents
 Usually DCS or CPS involvement
 Biological family contact may be limited or
gone
 “Pedestal” view of abuser/abandoner that
makes no sense to you
 Conceptualizing for Interventions
 Maslow’s Hierarchy of Needs
 If you don’t achieve one, you get stuck
– Physiological-Food, water, shelter
– Safety-Personal, financial, employment, safety against
accidents/illness
– Social-Friends & family-belonging
– Esteem-Sense of contribution (is this for the client or
us?)
– Self Actualization-living up to full potential
 Strange behaviors fill the need
 Conceptualizing for Interventions
 Grief Model
– What did they lose?
 Individuals
 Answers to “givens”
– Moms and dads love their kids
 Safety & Security
 Trust and understanding
– Exponential grief-what other grief issues from
the past may be going on with this?
 Conceptualizing for Interventions

 Grief Model-Kubler-Ross
– Denial-not going to affect me. “I’m fine”
– Anger-mad @ lots of people, things (may feed
guilt)
– Bargaining-the fuel for Anger and Depression
depending upon thought process
– Depression/Sadness-self explanatory (looks
like anger in adolescents & young adults)
– Acceptance-not happy, but can deal with it
 Attachment Theory
 Basis for Reactive Attachment work
 Humans are “pack” animals-attach to
caregiver for security, comfort, pleasure
 Experiments
– Home port, rhesus monkeys
 When lost, person feels unsafe and fearful
of exploration
 Develops into mistrust of world
 Conceptualizing for Interventions
 Homeostasis and Family Preservation
– Every behavior is designed to keep us
“balanced”
– Context of “normal” life after this
– How do you get to “normal” after something
like this? Is it possible?
– What happens when askew becomes
“normal”?
 Developing Interventions
 Based upon the conceptualization you
choose
 May be mixed at times depending upon
the client’s needs, understanding and skill
set
 Not about the why, focus on the what
 Address impact on here and now
 Goals for Interventions
 Create a safe, secure environment to grow,
learn and thrive
 Create the opportunity to learn to connect with
others and work in society appropriately
 Challenge the understanding of their impact on
self and others, and how they can lower the
costs of their behaviors to gain their goals
 Ensure interventions do not re-traumatize
those involved
 What not to do!
 “Trust me”-think used car salesman
 “It’s not that bad. Others have gone through . . .”
 “I promise”
 Be wishy-washy-confidence is vital to success
 “You need to,” “You should,” “You have to,”
 Make yourself the savior-”You’re the only one . . .”
 Upping the ante on consequences again and again
 Intentional dishonesty
 Logic them-it doesn’t work
 Medications
 Focus on the co-morbid diagnosis
– Anti-depressants or mood stabilizers
– ADHD
 Sleep/anti-anxiety medications helpful as
well
– Dependence issues
 May use old school blood pressure medications
 Watch for interactions-meds for physical
ailments vs. psychological
 Maslow & Grief Models
 Identify with the stage the client thinks
they are in
 Work to build upon safety for Maslow’s
Hierarchy by developing structure and
social connection
 Identify problem areas which may trigger
negative reactions and implement safety
plans
 Attachment Theory
 Trauma Informed Care
– Systems (Team) approach
 Works best with younger clients and very
involved/invested families
 “Family is the change agent”-clear delineation of
power structure is vital to success
 “If they connected once, they can do it again.”
 Focuses on developing the safety and connection
the child missed or lost
 Therapeutic interactions occur in home & office
 Build from family’s identified strengths
 Limited outside “interference”-can be tough if
family isn’t supportive of probation and
expectations
 Homeostasis
 Every behavior is a way to balance
someone in the family and themselves
 Encourage family therapy and challenge
family to deal with their stuff instead of
putting it all on kid
 Look for the Personality Disorder Drama
– Hero/Victim/Villain (persecutor)
– Roles balance one another and avoid
responsibility of change-”Hot Potato!”
 Call out the roles, and return the focus of
attention on the client instead of
defending or explaining
 Specifics for all cases
 New Golden Rule-Focus on Self
– If you focus on others, a power struggle
occurs immediately-”Make” someone is a bad
call
 Provide choices, but decide the choices for
them-this goes for consequences as well
 Space to move vs. lording over-Spare the
rod . . .
 Guard rails, not slot cars
 Fun ways to create change
 Use the resistance to your advantage
– Reframes current situation and gives new solutions-
“I think you want to be placed in detention-it’s safe
and away from others. We can do that, but you must
tell me to do it with more than your actions.”
– “Don’t trust me, don’t trust anyone”-normalize
distrust
– Balance Locus of Control-can’t be all on one side or
the other
– Could there be a benefit to this still affecting them?
 Dexter approach
– How can they use their mistrust as an advantage to
self?
 Fun ways to create change
 Tell them to do the symptom
– Give control to the client-sets up for a win/win
 Out “catastrophize” them
– The “yeah, but . . “s of the world
 Randomize the symptoms-coin flip
 Plan for life being awful
– Agree with them that they have no control and their life
will be terrible
– Takes away the “battle” and power struggle-they usually
switch sides & argue why their life can be better
– They can either fight you or accept the help and plan to
“cope” with it-win/win situation
– Roll dice or play “odd/even” to decide the next steps and
recommendations
 Things to remember
 Focus on self-not controlling them and what
you will “make” them do
 Avoid getting wrapped up in drama
(hero/victim/persecutor) by keeping
boundaries
 It’s good to be blunt without being “abusive”-
remember the resilience
 Take the unconventional approach-they know
the old patterns-give something new