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Vol. 20 no. 2
culturally inappropriate, overly familiar behavior with relative
strangers.”
8
These behaviors include having no emotional/
psychological filters when approaching unfamiliar adults,
excessive people pleasing and affirmation seeking behaviors,
indiscriminate emotional and verbal sharing, and being overly
affectionate with others.
Attachment, Prevalence and Course
One of the biggest misunderstandings with these two disor-
ders is the confusion with attachment theory. Though a child
with RAD most likely has an insecure attachment style, not all
children with insecure attachment styles have RAD. In fact,
a child could have a secure attachment to a primary caregiver
and still be diagnosed with disinhibited social engagement
disorder.
Prevalence rates of both disorders are unknown, but rare
in clinical settings. Even in the most severe cases of child
neglect, prevalence rates are less than 10% for RAD and 20%
for disinhibited social engagement disorder.
9
The diagnosis,
then, for RAD, in particular, is rare, and most often left for
the most extreme cases of harmful insecure attachments.
10
A
diagnosis of either disorder should not be given prior to nine
months of age to account for the ability of a child to develop
selective attachment. Also, since it is unknown whether RAD
manifests in older children, the
DSM-5
warns clinicians to use
caution when making this diagnosis for those older than five
years of age.
On the other hand, disinhibited social engagement
disorder does manifest itself through older childhood and into
adolescence. However, there is no evidence of this disorder
developing in children whose neglect begins after two years
of age. This underscores the relation to the child’s perhaps
anxious attachment style, which is developed in the first two
years of life by a caregiver who showed ambivalence toward
the child.
Interventions and Treatment Protocols
Since very few empirically-based protocols for RAD exist,
treatment consists of interventions found to be effective in
addressing disorders with similar symptomology.
11
One of
the most controversial interventions is known as “holding
therapy.” The only reason I mention it here is because it is
also referred to as “attachment therapy,” and should not be
confused with other forms of empirically valid attachment-
based treatments. This form of therapy has shown detrimental
results in literature, including children death, and has thus
been outlawed by some states.
Empirically valid forms of therapy for RAD and disin-
hibited social engagement disorder include attachment-based
family therapy,
12
trauma-focused cognitive behavioral
therapy,
13
integrative play therapy,
14
and behavioral manage-
ment therapy,
15
which utilizes the implementation of 20
minutes of command free time per day between the child and
safe attachment figures.
✠
Joshua Straub, Ph.D.,
is a speaker, author,
counselor, and professor. He is the coauthor of
God
Attachment: Why You Believe, Act and Feel the Way
You Do About God
and
The Quick-Reference Guide
to Counseling Teenagers
. Dr. Straub specializes in
attachment and relationship research, the Millennial
generation, crisis and trauma, marriage and family, and spiritual formation.
He is married to his favorite Canadian, Christi, and together they are the
proud parents of Landon Andrew.
Endnotes
1
U.S. Department of Health and Human Services (2009).
The AFCARS
Report: Preliminary FY 2011 Estimates as of July 2012
(19). Retrieved
May 31, 2013, from acf.hhs.gov/sites/default/files/cb/afcarsreport19.pdf.
2
Bureau of Consular Affairs (2011). FY 2011
Annual Report on
Intercountry Adoption
. United States Department of State. Retrieved
May 31, 2013, from adoption.state.gov/content/pdf/fy2011_annual_
report.pdf.
3
Millward, R.R., Kennedy, E.E., Towlson, K.K. & Minnis, H.H. (2006).
Reactive Attachment Disorder in Looked-after Children.
Emotional &
Behavioural Difficulties
, 11, 273-279.
4
Potter, D., Chevy, C., Amaya-Jackson, L., O’Donnell, K. & Murphy,
R. (2009). Reactive Attachment Disorder (RAD): Appropriate and
Inappropriate Application of the Reactive Attachment Disorder
Diagnosis on an Age Continuum from Birth through Age 18.
Clinical
Guideline Series
. p. 10.
5
Boris, N. & Zeanah, C. (2005). Practice Parameter for the Assessment
and Treatment of Children and Adolescents with Reactive Attachment
Disorder of Infancy and Early Childhood.
American Academy of Child
and Adolescent Psychiatry
. 44:11: pp.1,206-1,219.
6
American Psychiatric Association. (2013).
Diagnostic and Statistical
Manual of Mental Disorders
(5th ed.). Washington, D.C. p. 266.
7
Ibid.
8
Ibid. p. 269.
9
Ibid. p. 266.
10
Tobin, D., Wardi-Zonna, K. & Yezzi-Shareef, A.M. (2007). Early
Recollections of Children and Adolescents Diagnosed with Reactive
Attachment Disorder.
Journal of Individual Psychology
, 63, 86-95.
11
Buckner, J.D., Lopez, C., Dunkel, S. & Joiner, J.E. (2008). Behavior
Management Training for the Treatment of Reactive Attachment
Disorder.
Child Maltreatment
, 13, 289-297.
12
Levy, S.A., Diamond, G.S. & Creed, T. (in press). Repairing
Relationships. In P. Rhodes & A. Wallis (Eds.),
Working with Families: A
Practical Guide
. Australia: IP Communications.
13
Cohen, J., Mannarino, A. & Murray, L. (2011). Trauma-focused CBT for
Youth who Experience Ongoing Traumas.
Child Abuse and Neglect
.
35. pp. 637-646.
14
Weir, K.N. (2007). Using Integrative Play Therapy with Adoptive Families
to Treat Reactive Attachment Disorder: A Case Example.
Journal of
Family Psychotherapy
, 18, 1-16.
15
Buckner, J.D., Lopez, C., Dunkel, S. & Joiner, J.E. (2008). Behavior
Management Training for the Treatment of Reactive Attachment
Disorder.
Child Maltreatmen
t, 13, 289-297.
