Myths and Facts About Reactive Attachment Disorder Part 1 - Cause

(Note: this is part 1 of a 3 part series. You can read part 2 here, or part 3 here.)

Recently, I was taking a look at some of the information available online about Reactive Attachment Disorder, and it deeply concerned me. Unfortunately, there is a lot of misinformation out there. Although the official research base for RAD is reasonably good, many unofficial online sources present a very different picture of the causes and symptoms of RAD than the research does.

First of all, what is RAD? In the DSM-IV, Reactive Attachment Disorder is defined by both two sets of symptoms (defining two subtypes) and a form of environmental exposure presumed to cause those symptoms. In DSM-V, the two RAD subtypes have been split into two conditions, Reactive Attachment Disorder and Disinhibited Social Engagement Disorder, which are both diagnosed according to the same 'symptoms + cause' rule. They are part of only a small number of DSM diagnoses which include presumed cause in the criteria.

Cause: Pathogenic Care

So, what is the cause? The DSM-IV diagnosis of RAD requires:

"C. 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)
D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C)."

In the DSM-V, meanwhile, both RAD and DSED require that:

"C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
* Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults
* Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
* Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios)
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C)."

Although the wording has changed, both criteria imply that RAD/DSED can result from either receiving inadequate care from one caregiver, or good quality care from too many caregivers. Of course, some children experience both inadequate care and too many caregivers, and they would presumably be at even higher risk.

The inadequate care criteria are pretty clearly implying serious child neglect. Note that in DSM-IV, either physical or emotional neglect could meet criteria, while in DSM-V, emotional neglect is needed. This reflects a greater understanding that a child who is malnourished or showing other signs of inadequate physical care can still be receiving good emotional care - for example, if the family is suffering from extreme poverty. Although many children do experience both kinds of neglect, emotional neglect is the really crucial one for RAD.

Note also that physical and sexual abuse are not included in either set of criteria. That's because, while those experiences certainly are damaging to children, they do not seem to cause RAD. Instead, they would be more likely to lead to a diagnosis of post-traumatic stress disorder, although the DSM V committee did consider adding a diagnosis known as Developmental Trauma Disorder, which would likely have covered the symptoms of abused children more specifically. Of course, many abused children also experience neglect, especially emotional neglect, and for those children RAD is a possibility.

Repeated changes in caregiving, as well as institutional rearing, are both thought to contribute to RAD in a different way. Whereas emotionally neglected children have a caregiver who is consistently present but not engaged enough for the child to attach to them, children in foster care and institutions have many caregivers, most of whom would make perfectly fine caregivers on their own, but they are so transient in the child's life that the child cannot form an effective bond to any one person.

Note that, although the DSM doesn't mention it, there are also kids who experience placement changes outside of the child welfare system. My cousins first entered foster care at 11 and 14, but long before that, they had been passed around between their biological mother, biological father, stepmother and grandparents. My mother, as a family law lawyer, has also recounted tales of repeated placement changes in custody disputes. For example, in one case, a boy was living with his biological mother until she was found unfit due to drug abuse, at which point he went to live with his father and stepmother. Then, his biological mother cleaned up and regained custody. Just recently, she has suffered a relapse, so he's back with his father and stepmother again. Under the right circumstances, custody disputes or willingly passing custody off could place a child at risk for RAD as well.

Timing and Other Notes

Timing also matters. As quoted above, the DSM criteria require that the symptoms be present after the pathogenic care, not before. For example, if a child was observed to be showing symptoms suggestive of RAD at age two, and then at age 3 experienced a foster placement, the age 3 foster placement would not count towards the pathogenic care requirement. (However, if that child had been removed from the home due to neglect, and there was reason to believe the neglect started before age 2, that would count.)

In addition, while DSM-V DSED makes no mention of age of onset, both DSM-V RAD and DSM-IV RAD require symptoms to be evident before age 5. Which, by definition, requires that the pathogenic care occur before age 5. This is consistent with research data showing that placement changes in older children can trigger other psychiatric symptoms, but do not appear to cause symptoms of RAD. It's unclear why they left out the age of onset requirement for DSED, because in practice, both RAD and DSED symptoms appear equally age-dependent.

So, 5 or older is too late to develop RAD. But can pathogenic care occur too early, as well? The research says yes. In general, among children removed from pathogenic care environments and placed into healthy homes, children under 6 months old show no lasting effect, while children aged 6-12 months only show an effect if the deprivation was particularly severe (such as institutional care, where a child often experiences over 100 different caregivers in their first year as well as neglect due to high child-to-caregiver ratios).

In addition, some websites claim that RAD can be caused by prenatal or birth trauma. There is absolutely no evidence to support this claim. Certainly, such events can affect the mother's behaviour, and in some mothers this could be severe enough to cause them to provide pathogenic care, but in that case, it was the pathogenic care, not the prenatal or birth trauma, that caused the RAD. In addition, prenatal/birth trauma can sometimes cause a child to suffer a brain injury, which could affect the child's behaviour, but the symptoms of neonatal/prenatal brain injuries are distinct from RAD.

A special note about prenatal drug or alcohol exposure: parental addiction severely impacts on the quality of parenting. In fact, most if not all actively-addicted parents provide some sort of problematic caregiving, often of the type that can cause RAD. Since most drug or alcohol exposed children have experienced months or years of care by an addicted parent, and those that haven't have often experienced multiple foster care placements in their early years, it makes no sense to me why so many people think prenatal alcohol or drug exposure is a cause of RAD symptoms.

It is conceivably possible that such prenatal exposure could cause symptoms that resemble RAD in some ways (such as the hypersociability seen in Williams Syndrome, which has nothing to do with quality of care), but so far I have not seen any conclusive evidence for it. Instead, I've seen people claiming that their child adopted at 18 months, or 3 years, or even older, clearly has RAD because of their prenatal exposure, as if the child's postnatal experiences made no difference whatsoever. My best guess is that FASD or prenatal drug exposure has filled up the child's difference slot, and they can't conceive of the child having multiple separate disabilities. Or maybe it's less upsetting to think your child acts like that because their brain is damaged than to think they act like that because it helped them cope during their early years of life.