RAD In Foster Children

An in-depth essay/article written for a college "Writing in Psychology" class.

Reactive Attachment Disorder In Foster Children

Abstract
Reactive Attachment Disorder (RAD) is a psychological condition that significantly affects children's emotional development and social relationships, often originating from maltreatment during early childhood. RAD is closely associated with complex trauma, including neglect and inconsistent caregiving, which disrupts the formation of secure attachments. Children in foster care are at a heightened risk for RAD, with studies showing a significant correlation between the disorder and the foster care system. The disorder is most prevalent in children who have experienced multiple caregiver changes, institutionalization, or exposure to neglect and abuse, particularly between the ages of two and seven. This paper explores the onset of RAD, its connection to the foster care system, and current treatment approaches, including parent counseling and holding therapy. While treatments show promise in fostering secure attachments, the complexity of RAD, along with the presence of comorbid conditions such as PTSD or ADHD, necessitates individualized and tailored interventions. Addressing RAD within foster care requires a stable, supportive environment where children can rebuild trust and attachment with caregivers.

Reactive Attachment Disorder in Foster Children
Reactive attachment disorder (RAD) is a psychological disorder that causes complications in a child’s health, relationships, and social life (Follan & McNamara, 2013). RAD stems from various forms of maltreatment in childhood, like those that may cause removal by Child Protective Services (CPS). When a child is removed from their families by CPS, they are often placed into the foster care system.

Foster care is designed as a temporary service that serves children with experiences of abuse or neglect, as well as their families and foster parents (Barbell & Freundlich, 2001). It provides children with safe, stable, and loving environments until they can either be adopted or reunified with a family member. Common causes of removal done by CPS are homelessness, history of incarceration (McGuiness & Schneider, 2007), mental illness, drug addiction (Rongved, 2008), emotional abuse, physical abuse, sexual abuse, emotional neglect and/or physical neglect (Haselgruber, et. al., 2018).

Since the causes of RAD are similar to reasons for removal by CPS, there may be a correlation between RAD and foster children. Studies suggest roughly 1% to 2% of all children are diagnosed with RAD (Cleveland Clinic, 2022), but 15% of children in foster care are diagnosed with RAD (Bovenschen, et. al., 2016). This increase in probability supports a positive correlation between RAD and the foster care system.

Addressing the implications of RAD in foster care requires a multifaceted approach that includes understanding the causes of the disorder and its correlation with foster care, the impact of adverse childhood experiences, and the necessity for targeted interventions to promote emotional healing and resilience. This article focuses on the onset of RAD, its connection to the foster care system, and general treatments.

Onset of Reactive Attachment Disorder: Symptoms and Common Causes
Reactive Attachment Disorder (RAD) is characterized by a lack of social approach, a persistent failure to initiate or respond to social interactions in a developmentally appropriate way, avoidance of comfort, and an air of eerie watchfulness (Horner, 2008). Children with RAD are unable to or find it difficult to form or create attachments to anyone. Individuals with Reactive Attachment Disorder are frequently violent or manipulative, show less empathy towards others, and commonly have very high views of themselves (Sheaffer, 2009). Holding
therapists have also noticed other various clusters of behavioral troubles in children with RAD, such as aggression, fire setting, stealing, lying, cruelty to animals, and a lack of a “conscious” (Zilberstein, 2006).

A few factors that play into the onset of RAD in children are type of maltreatment, their age during maltreatment, number of placements after potential removal, and length of institutionalization, if applicable. The Diagnostic and Statistical Manual of Mental Disorders (DSM) requires diagnosable RAD behavior to stem from pathogenic care before the age of five (Drisko, & Zilberstein, 2008). Pathogenic care is defined as either a persistent disregard for emotional needs (i.e., emotional neglect), disregard for physical needs (i.e., physical neglect), or repeated changes in caregivers that prevent the onset of a secure attachment to a caregiver. This definition suggests a common cause of RAD is neglectful caregiving and complex trauma.

Studies suggest that children who experienced complex trauma (i.e., more than one type of maltreatment) were more inclined to insecure attachments to caregivers (Bovenschen, et. al, 2016) and experiences of maltreatment, neglect, and deprivation can affect the development of secure attachments far into the future (Bovenschen, et. al., 2016). This suggests that when a child experiences neglectful parenting or complex trauma, they are more likely to develop RAD than a child with only a history of sexual or physical abuse. Supporting this idea, Fujisawa, et. al. (2018) found that neglect is the most common single form of maltreatment that causes Reactive Attachment Disorder with complex trauma doubling the probability.

Further, studies have found that children with maltreatment in their early lives (0-5) struggle to form attachments with caregivers and often show high rates of RAD symptoms (Breivik, et. al., 2016) and children removed from adverse environments after 12 months of age are less securely attached to consistent caregivers than children who were given consistent caregiving at a younger age (Bovenschen, et. al., 2016). This suggests a risk between 12 months and roughly five years of age. Fujisawa, et. al. (2018) did a study on the visual cortex in connection to RAD and found children between the ages of two and seven at the highest risk of
developing RAD, apart from children aged 3-4.

As Bovenschen, et. al. (2016) mentioned, the prevalence of RAD symptoms in children with pathogenic caregivers is about 27%, with higher rates found in children who have previously been institutionalized. In an institution, caregivers often change or have many children to care for and cannot create meaningful relationships or attachments to the children. Children who spend more time institutionalized show lower security and higher disorganization in attachment (Bovenschen, et. al., 2016). Like institutionalization, the number of placement disruptions in foster care (i.e., the number of times a child is removed from a home) showed a significant influence on the onset of RAD as well (Fox, et. al., 2017). Placement disruptions can be caused by maltreatment, inability to handle certain behaviors, a more suitable placement, or simply not wanting the child which results in a change in caregivers, preventing a child from creating secure attachments.

Reactive Attachment Disorder and its Connection to Foster Care
As previously discussed, Reactive Attachment Disorder is categorized as a disorder caused by exposure to pathogenic care before the age of five (Drisko, & Zilberstein, 2008). Most children who enter the foster care system have already spent the majority of their developmental years abused or neglected (McGuiness & Schneider, 2007). The most common forms of maltreatment in foster children are neglect, physical abuse, and sexual abuse, with neglect showing the highest rates (Goldbeck, et. al., 2010). Roughly 76% of children who have experienced child maltreatment have experienced neglect (The Annie E. Casey Foundation,
2022) and up to 81% of children in foster care have experienced complex trauma (Haselgruber, et. al., 2020), the leading characteristics of pathogenic care.

As well, children between the ages of 12 months and five years are the most common group placed in foster care, taking up roughly 30% of all children in foster care (The Annie E. Casey Foundation, 2022). This suggests that as young as newborn to five years of age, these children are most likely exposed to abuse, neglect, and complex traumas. Further, as the highest risk for developing RAD is between two and seven (Fujisawa, et. al., 2018), children removed between the ages of six and ten years is almost equal to the number of children removed between 12 months and five years (Barbell & Freundlich, 2001), suggesting the further likelihood of children in foster care experiencing abuse or neglect in such a vulnerable time.

Placement disruptions are often the main cause of foster children experiencing repeated changes in caregivers (i.e., one of the characteristics of pathogenic care). Disruptions in foster care typically occur under three main conditions; when the foster parent feels inadequate to care for the child, when placing agencies remove the child due to a concern about how well the foster parent is providing for the child’s needs, or where a child chose to end the placement (Roe, 2023). As Bullens, et. al. (2007) found, roughly 20 to 50 percent of all long-term foster children experience a premature end to their stays at foster homes, preventing them from creating secure attachments to caregivers. Placement disruption causes a cycle most foster families struggle to break. For example, the most vulnerable children, such as those with mental or attachment struggles, receive less stability in placement. This instability can result in additional disruptions, which causes further issues (Barnett, et. al., 2019).

These causes, common ages of removal, and flaws in the foster care system each individually suggest the possibility of an onset of Reactive Attachment Disorder. This leads to confirming statistics suggesting a positive correlation between RAD and the foster care system (Bovenschen, et. al., 2016). This is important to understand, as it can lead to the potential for further studies to discover how to avoid abuse, neglect, removal, or placement disruptions in the developmental years of children. However, as complex trauma and neglect are difficult to prevent without the removal of a child, RAD is currently difficult to prevent in these high-risk
children, but there are options for treatment that caregivers of current or previous foster children can consider (Drisko & Zilberstein, 2008).

Treatments for Reactive Attachment Disorder
There are options for the foster families of children with RAD. Screening measures such as the Relationship Problem Questionnaire (RPQ) and the Reactive Attachment Disorder Checklist (RAD-C) are the most common screening measures utilized in diagnosing RAD, with strong consistencies supporting their use (Golden, et. al., 2009). Once diagnosed, families can begin looking for treatment.

The most developed treatments are parent counseling and holding therapy. Parent counseling refers to placing a child with Reactive Attachment Disorder in conditions such as those where infants and young children create attachments to caregivers (Drisko & Zilberstein, 2008). This helps parents become further attuned to their child and establish secure attachments with the child (Zilberstein, 2023). Holding therapy involves a parent holding a child, typically through physical confinement by multiple people or swaddling in a blanket (Drisko & Zilberstein, 2008). They allow the child to scream or sob and once the child has regulated, he can see that the parent or caregiver knows and accepts him at his worst and will not harm him in return. As Hansen and Sprat (2000) discussed, holding therapy often involved restraining the child, then the therapist would poke and prod the child until irritated, before giving the child to their parent to regulate.

Both holding therapy and parent counseling emphasize an aspect of safety or stability in the environment. As Zilberstein (2023) noted, the environment in which a child with RAD heals must be safe, stable, and psychologically supportive. A foster parent should strive to provide a setting where the child can trust their caregivers, receive and expect stability, and comfortably try new behaviors without repercussion. It is important to create an environment that replicates the conditions necessary to develop a secure attachment during infancy (Zilberstein, 2023). Other studies suggest the first and most important step is to ensure safety, trust, and boundaries with the child for therapists and families (Hansen & Sprat, 2000).

Some practitioners believe children with RAD need holding therapy to improve the lives of these children and some studies suggest this connection (Zilberstein, 2023). For example, one study found significantly fewer problem behaviors and improvement in mood after a group of children was treated with holding therapy. However, Studies suggest that children were able to make and sustain progress without holding therapy. Many parents have found that attunement between a child and parent, consistency in parental behavior, structure in rules and routines, predictability, physical affection, and empathetic attunement to their child’s maladaptive behaviors are more beneficial for progress (Drisko & Zilberstein, 2008)

There are boundaries, however, to treatments of Reactive Attachment disorder. For example, Bruce (2018) found that 84% of children with RAD symptoms showed no change in symptoms after a year with a changed and reliable care system. This can be due heavily to comorbid disorders either caused by the traumatic backgrounds that often cause RAD, such as PTSD, or potentially unrelated causes, such as ADHD or autism spectrum disorder (Drisko & Zilberstein, 2008). Bruce (2018) also found that there is a very strong association between RAD and various other mental health disorders. With so many comorbid disorders that could affect the treatment of a child with RAD, each child must be considered a fully unique individual who requires their specialized treatment according to their various diagnosis (Drisko & Zilberstein,
2008).

As well as this, there is the question of whether the behavioral problems used to diagnose RAD better fit the symptom criteria for only RAD of other diagnoses that are not based on attachment (Hansen & Spratt, 2000). It is possible that they could be better classified as separate disorders or even related to parental depression or substance abuse. To overcome these obstacles, it is important to pursue a positive environment and understanding of their child and their needs.

Conclusion/Discussion
This paper examined Reactive Attachment Disorder (RAD), its onset, and its relationship to the foster care system, highlighting how foster children are particularly vulnerable to developing this disorder due to their early experiences of abuse, neglect, and complex trauma. Also, this paper highlighted treatments and treatment struggles, illuminating the need for further understanding of what is beneficial to children with RAD.

So far, there have been limitations to the articles referenced in this paper. For example, each article mentioned a significant limitation of small sample sizes. Another common trait is the limitation of a reliance on caregiver feedback on the children (Fox, et. al., 2017). A limitation addressed by Bruce, et. al., (2018) was that between the two trials, some of the foster children experienced a placement disruption, which could have affected the results. Further limitations include a limitation to the diagnoses of RAD (Fujisawa, et. al., 2018), cross-sectional designs (Bovenschen, et. al., 2023), and an inability to observe the full range of RAD behavior (Breivik, et. al., 2016).

Further studies should be done to analyze the potential prevention of RAD. These studies should be done to find the best ways to prevent or better treat the onset of RAD both before and after CPS removals. To reach this goal, there needs to be more in-depth study on the causes and the implications, as well as what works in treating this disorder. Once there is a stronger understanding of the causes, treatments, and prevention, action can be taken to protect children
from the development of RAD.

In conclusion, while Reactive Attachment Disorder presents a significant challenge for foster children and their caregivers, targeted interventions, early identification, and a deeper understanding of the disorder’s causes and impacts can help children with RAD build more secure attachments to caregivers and pursue recovery.

References
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