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Interventions for children with reactive attachment disorder

Vega, Heather ASN, RN, CNOR, RNFA; Cole, Kimberly ASN, RN; Hill, Kenneth ASN, RN

doi: 10.1097/01.NURSE.0000554615.92598.b2

Abstract: Characterized by aggressive or violent behaviors, reactive attachment disorder (RAD) affects children who have been repeatedly exposed to traumatic experiences. This article discusses the underlying causes of RAD and provides insight on therapies and interventions.

Characterized by aggressive or violent behaviors, reactive attachment disorder (RAD) affects children who have been repeatedly exposed to traumatic experiences. This article examines the underlying causes of RAD and introduces an evidence-based therapy that supports formation of healthy relationships.

At Methodist Le Bonheur Healthcare in Memphis, Tenn., Heather Vega is a nurse in the surgical ICU and Kenneth Hill is a nurse in the medical-surgical ICU. Kimberly Cole is a nurse in the postanesthesia care unit at West Tennessee Healthcare in Jackson, Tenn. All of the authors are also BSN students at the University of Tennessee at Martin.

The authors have disclosed no financial relationships related to this article.



REACTIVE ATTACHMENT DISORDER (RAD) is a serious condition in which infants or young children do not establish healthy attachments with a primary caregiver and their basic needs for comfort, affection, and nurturing are not met.1 It is a developing issue in psychology and healthcare, affecting children between ages 6 months and 2 years who have experienced disrupted attachment and lacked individual attention during fundamental periods of development. RAD is commonly seen in foster children who have been repeatedly exposed to traumatic experiences, including neglect; physical, sexual, and/or emotional abuse; or other maltreatment.2

Children with RAD are more likely to develop behavioral health disorders, social disorders, substance abuse disorders, and other attachment disorders such as disinhibited social engagement disorder.3 Additionally, foster children diagnosed with RAD or developmental trauma disorder (DTD), which is characterized by symptoms that overlap with but extend beyond those of posttraumatic stress disorder (PTSD) due to interpersonal trauma during development, are at increased risk for criminal behavior and incarceration as adults.4,5 Increasing awareness and implementing early interventions is necessary to gain a complete understanding of these children and increase their chances of success as adults. This article examines the role of healthy attachments in early childhood development and discusses how nurses can intervene to mitigate RAD and other trauma-related disorders.

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Early childhood development

John Bowlby outlined attachment theory in the 1960s, proposing that early caregiver interactions are a reliable predictor of future interpersonal relationships.6 The concept relies on the theory that an infant's primary instinct is to form a close bond of comfort and security with a primary caregiver in the first year of life.7

Infants rely on caregivers to recognize their physical and psychological needs during growth and development. Those who do not form bonds with caregivers in infancy are at an increased risk for developing future behavioral problems, such as withdrawal, aggression, impulsiveness, and other socially inappropriate behavior. Inconsistent care, continual neglect of basic and emotional needs, and the inability to form a secure, stable attachment make up the clinical criteria for diagnosing RAD.1

The impact of complex developmental trauma at a young age may also lead to the development of RAD. Many of these children have experienced neglect, physical and/or sexual abuse, and emotional trauma at vulnerable stages.2 Additionally, scientific research has demonstrated that chronic child maltreatment permanently alters brain maturation, formation, structure, and function, resulting in an inability to regulate cognition, emotion, and behavior. Cumulative childhood adversities combined with the subsequent chronic stimulation of the neuroendocrine system and inflammatory pathways may also impair brain development.8

Stimulation of a developing brain encourages neural activity and prompts the formation of synaptic connections. In neglected and abused children, these neural connections fail and the neurons die. The prefrontal cortex is responsible for personality expression, decision-making, impulse control, and social behavior. These functions are compromised in children with RAD.8

RAD was first recognized by the American Psychiatric Association in 1987 in the Diagnostic and Statistical Manual of Mental Disorders, third edition. Neglect is a core factor, and symptoms typically manifest by age 5.1 Due to limited research, the diagnostic criteria are controversial, and the disorder has been misunderstood and underdiagnosed since its introduction.9

Children with RAD typically exhibit aggressive or violent behaviors, which can negatively impact their lives and place in society without proper intervention and support from those responsible for their care. They are often described as withdrawn, with unexplained fear, sadness, or irritability. These children do not seek or show any response to comfort, and they cannot maintain significant relationships. Additionally, they demonstrate a need to control their environment and others around them.1,10

Disrupted attachment, the underlying cause of RAD, can stem from various circumstances. These include living in an orphanage or foster care, prolonged hospitalization, abuse or neglect by primary caregivers, multiple out-of-home placements, and the prolonged separation from or death of a primary caregiver. Trauma-based disruptions alter childhood development and produce children who are impulsive; rage-filled; unable to give or receive love; and lacking in conscience, remorse, and empathy. These impairments can have lifelong consequences.10

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Factors related to foster care

Attachment disorders are typically associated with and diagnosed in (but not limited to) foster children.10 As of 2017, over 430,000 children in the US were in the foster care system.11 Of these, 61% were removed from their homes due to neglect.12

According to a 2012 statistic, approximately 80% of US prison inmates have been in foster care.13 Data show that men placed in foster care as children are 23% more likely to have an arrest, conviction, and incarceration than those who remained at home.14,15 Similarly, a 2014 study found that 55% of young men between ages 19 and 31 who aged out of foster care were involved in criminal activity since leaving the system.14

A review of the literature yielded limited evidence regarding the prevalence, diagnosis, treatment, and outcomes for RAD. According to the International Child and Youth Care Network, 800,000 children with severe attachment disorders have been brought to the attention of child welfare services, but the actual number may be up to 16 times higher than the given statistics.16 One US study of foster children ranging from ages 10 to 47 months identified RAD in 38% of participants.17 Another comparable study identified RAD in 19% of foster children between ages 6 and 12 years.17 These figures indicate a significant prevalence of RAD in the foster care population.

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RAD management

Traditional parenting styles and behavior modifications have not proven successful for disruptive behaviors. These include verbal criticism, time-outs, harsh punishments or threats, and guilting or ignoring the child. These methods can have negative effects and are not productive or conducive to change.18,19 Psychotherapy is crucial in managing delayed development, but evidence-based studies are lacking in the treatment of RAD.

Since the 1980s, many treatments have been implemented (see Developmental disorders and therapies). These include:20-22

  • trauma-focused cognitive behavioral therapy, which targets “inaccurate or negative thinking”20 to help patients manage challenging circumstances and “includes education, relaxation exercises, coping skills training, stress management, or assertiveness training.”21
  • dialectical behavioral therapy, which incorporates “skills training, mindful practice, and close monitoring of and intervention in crises” for patients who have difficulty regulating their emotions.21
  • eye movement desensitization and reprocessing therapy, which utilizes bilateral stimulation to help patients focus on and reduce the emotions related to past trauma.22


Medication therapies have been used successfully as well, including psychopharmacologic agents to address the associated behavioral symptoms such as “explosive anger, hyperactivity, and difficulty in focusing or sleeping.”8 Rather than the traditional behavioral methods, however, effective treatments seem to have focused on attachment-based therapies, which have proven successful in promoting positive healing and recovery in children with RAD.3,18,23

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Understanding TBRI

Trust-based relational intervention (TBRI) is an attachment-based therapy focused on safety, human connection, and regulation.24 Regulation refers to the neurobiological aspects of attachment. Proposed by Schore, regulation theory explores how early parent-child interactions have a large impact on an infant's regulatory capacities.9

TBRIs have the potential to impact the lives of children who have experienced complex developmental trauma such as RAD.24 A 2013 study supported the effectiveness of TBRIs in decreasing maladaptive and violent behaviors and promoting healthy attachment relationships.24

TBRI is designed to connect and build a relationship with children of all ages and follows three principles to encourage healthy attachment: empowerment, connection, correction.18,24-26

Empowerment focuses on the ecologic and physiologic concerns of the child, with emphasis on a safe and structured environment, sensory needs, and nutrition to encourage trust in traumatized children. Traumatized children often have sensory processing deficits, which may negatively affect behavior, social and motor skills, and academic performance. Sensory stimulation improves physiological, mental, and emotional health. Proper nutrition is important for healthy children, and those with prenatal exposure to drugs and/or alcohol may experience fluctuations in blood glucose that affect behavior. Proper hydration and a nutritious snack every 2 hours stabilizes blood glucose levels, improves mood, and optimizes cognitive functioning.18,24

Connection focuses on observational awareness, self-awareness, attachment skills, playful engagement, and attunement. Observational awareness helps caregivers recognize anxiety and allows them to respond appropriately. Many traumatized children cannot verbalize their needs. TBRI helps caregivers become aware of nonverbal cues, such as dilated pupils, increased heart and respiratory rates, and muscle tension.18,24

Self-awareness is also important, as caregivers must always be emotionally available to promote healing. Similarly, attachment skills are also modeled under the connection principle of trust-based relational intervention. TBRI teaches caregivers to give the child a voice, allowing children to be heard and promoting connection. Playful engagement and interactions promote warmth and trust to enhance attachment, socialization, and language. Attunement refers to verbal and nonverbal communication of the caregiver and child, including appropriate tone of voice, eye contact, and body position, as well as matching, in which the child mimics the caregiver.18,24

Correction modifies behavioral needs and focuses on building social competence. This is achieved after empowerment and connection have been established and focuses on proactive and responsive behavioral strategies. Proactive behavioral strategies use preventive teaching methods, such as role-playing, verbal reminders or demonstrations, rehearsals, and life value terms, to demonstrate problem behaviors. Life value terms create a culture of mutual respect by using words instead of negative behaviors, accepting “no,” accepting consequences, and making eye contact. Responsive behavioral strategies are used when children exhibit more challenging behaviors and guide them to the appropriate behavior and response to assist with self-regulation.18,24

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Assessment and treatment

To individualize treatment plans for children at risk for RAD, a comprehensive psychiatric assessment by a behavioral health professional is needed. The American Academy of Pediatrics recommends that children receive a full behavioral health evaluation, including assessments for trauma and suicide risk, by a trauma-informed pediatric behavioral health professional within weeks of their placement in foster care.27 An initial health screening is recommended within 72 hours. Additionally, children in foster care should be seen by a pediatrician monthly during their first 6 months of life, every 3 months until age 24 months, and a minimum of every 6 months thereafter.27

Children with RAD may benefit from individual, group, and family psychological counseling.28 For guardians, parenting skills classes may also be beneficial. The treatment goals focus on providing a safe and stable living situation for children at risk for or diagnosed with RAD, and encouraging positive interactions between primary caregivers and children. A 2014 study demonstrated potential for maltreated children to develop secure attachments to foster parents in adolescence even without appropriate attachment to a biological parent.29

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Safety and support

The impulsive and unpredictable behaviors of children with RAD can put them at risk, as well as others.8 Children with RAD are at risk for self-destructive behaviors, and their caregivers are at risk for violence secondary to aggression, manipulation, and triangulation, in which a child disrupts communication between three parties for control.8,9 Caregivers may also need support and reassurance when caring for these children. As such, routine safety assessments should be conducted to ensure that these children and families are not at risk. Additionally, healthcare professionals should advocate for and provide access to the appropriate behavioral health services.8,9,30

Parental influence is a key factor in healing and attachment, but nurses, mental health professionals, and societal awareness may also encourage growth in children with RAD.24 Nurses and those knowledgeable in TBRIs may have a better understanding of how best to care for these populations. Educating clinical professionals and caregivers about complex trauma from events with a long-term impact on development, expanding insight on TBRIs, and facilitating the use of this technique in schools and healthcare settings can support healing in children with RAD.31 It can also help parents and other caregivers develop healthy attachments with their children. Additionally, healthcare professionals and educators can help to promote awareness with training and education on healing and brain development.7

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Future directions

Early interactions and relationships with caregivers are key to establishing healthy infant and child development. Children who have been abused or neglected become fearful and develop hostility toward attachment figures, potentially becoming disconnected from society without the appropriate intervention. Stable, consistent, loving relationships are necessary to establish a secure relationship, build trust, and strengthen child-caregiver connections.

The key to success is for healthcare professionals, teachers, families, communities, and society to have awareness, proper education, and training on childhood development for children with RAD and DTD. An overall awareness of developmental issues, early interventions, and specific therapies can facilitate healthy development and minimize the risk of criminal behavior in adulthood. Increasing awareness and implementing strategies and therapeutic interventions benefit not only children diagnosed with RAD, but also society as a whole. The earlier an intervention is implemented, the more likely a child diagnosed with RAD will become a successful and productive adult.

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        aggression; behavioral therapy; developmental trauma disorder; early childhood development; foster care; foster children; pediatrics; reactive attachment disorder; trauma; trust-based relational intervention

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