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In-home treatment of reactive attachment disorder in a therapeutic foster care system: a case example. (Practice).
Publication Date: 01-JAN-03
Publication Title: Journal of Mental Health Counseling
Format: Online - approximately 5422 words
Author: Sheperis, Carl J. ; Renfro-Michel, Edina L. ; Doggett, R. Anthony


When trauma precedes a child's placement in the foster care system, it can lead to lasting mental health difficulties. Often, children who experience extreme, chronic trauma prior to age 5 develop Reactive Attachment Disorder (RAD). However, the diagnosis of RAD is often overlooked. This article discusses the characteristics of RAD as well as diagnostic criteria and possible etiology. We present the case example of an adolescent diagnosed with RAD as an example of treatment from an in-home perspective.


Nearly 1 million children enter the foster care system each year. If trauma places them there, it can create negative mental effects (Children in foster care have more SA/MH needs, 2001). Although children can overcome the results of abuse and neglect with an appropriate support system, supportive resources are not always available. What happens to children who never had a support system? How can they develop into productive adults? Often these children are perpetual clients in the mental health system, and they present with a multitude of symptoms and diagnoses (Milan & Pinderhughes, 2000). Some evidence suggests that children in foster care are more likely to receive behavioral health care services than any other group of Medicaid eligible children (Children in foster care). Often these services are related to the effects of pathogenic care resulting in a disruption of healthy attachment patterns.

Chronic disruption of early childhood attachment patterns may result in Reactive Attachment Disorder (RAD), a commonly misunderstood and under-diagnosed disorder. RAD begins in early childhood, and the symptoms can become pervasive throughout an individual's life (Doane & Diamond, 1994; Leick & Davidsen-Neilson, 1990; Levy & Orlans, 1998). We address issues related to the treatment of RAD from an in-home treatment approach within a therapeutic foster care (TFC) system. We examine the basic elements of RAD, and use a case example to further illustrate the concepts.


Our review of the literature produced more than 2,000 articles relating to attachment, encompassing many disciplines and describing attachment throughout the human lifespan. However, there is limited research regarding the treatment of adolescents with RAD. The majority of authors have focused on infants and young children or discussed attachment issues in the general population (Boris, Zeanah, Larrieu, Scheeringa, & Heller, 1998; Richters & Vilkmar, 1994; Zeanah, 1996; Zeanah et al., 2001). Few authors have empirically examined RAD, and fewer authors examined adolescents diagnosed with RAD. Thus, we review information related to the characteristics of RAD and the etiology of the disorder.

In order to understand RAD, it is important to discuss the nature and development of attachment in healthy human relationships. Bowlby (1969) posited that attachment is a four-stage evolutionary process that functions as an instinctual drive toward survival of the species. The attachment process begins with infants' communication of the need for proximity and physical contact through vocal and behavioral cues (e.g., crying, latching on, and grasping). Between 8 and 12 weeks of age, infants begin the second stage of the attachment process by establishing indicators of caregiver preference through behavioral cues such as reaching and scooting. The third stage of attachment, according to Bowlby, occurs from 12 weeks of age through the second birthday. This is the stage that Ainsworth, Blehar, Waters, and Wall (1978) believed to be the true process of attachment. In this stage, infants and toddlers begin to anticipate caregiver actions and adjust their own behavior in accordance with these anticipated events. Thus, primary caregiver consistency in the display of affection and attention to needs of the child are critical components in the formation of healthy adjustments on the part of the child. An understanding of caregiver independence and the development of reciprocity in the infant-caregiver relationship characterize Bowlby's fourth stage of attachment development, thus moving into a more sophisticated aspect of the process. The key facet across all of these stages is consistency in the provision of behavioral reinforcement to infant and toddler basic emotional and physical needs, which, in essence, is a method of conditioning the child to utilize human relationships as a sense of security and comfort (Wilson, 2001).

When the provision of infant and toddler basic needs is not conducted in a consistent fashion, attachment becomes disrupted, causing difficulty in the conditioned response to rely on human relationships and also resulting in insecure attachment patterns. Chronic inconsistency in meeting infant and toddler needs as well as the introduction of early childhood trauma (i.e., abuse) may result in the formation of RAD. In research, attachment insecurity or disturbances have been linked to psychiatric syndromes, criminal behavior, and drug use (Allen, Hauser & Borman-Spurrell, 1996; Rosenstein & Horowitz, 1996).

The Diagnostic and Statistical Manual of Mental Disorders: Text Revision (American Psychiatric Association, 2000) criteria for RAD includes: (a) "evidence of a clearly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5" (p. 130), (b) evidence of pathogenic care, and (c) a presumption that the pathogenic care is responsible for the disturbed behavior. There are two types of RAD, Inhibited and Disinhibited, that...


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