Reactive Attachment Disorder

Eva Perez
43803022
EPSE 436
July 8th, 2013

Reactive Attachment Disorder, by Gail Hornor, examines one of the

possible psychological consequences of child abuse and neglect. The
article examines Reactive attachment disorder (RAD), a markedly
disturbed and developmentally inappropriate social relatedness usually
beginning before age 5 years as described in the Diagnostic and
Statistical Manual of Mental Disorders (DSM) third edition (Hornor,
2008, p. 234.) Throughout the article, Hornor (2008) references
multiple studies that highlight the problem of child abuse and neglect
in society. Although physical injury and death are recognized, she
outlines the difficulty of detecting psychological consequences that
result from child abuse and neglect. The most abused, neglected and
abandoned children are those most often placed in foster care. These
children, Hornor (2008) argues are at a greater risk for developing
RAD. Hornor first defines RAD and attachment, outlines the risk factors,
briefly touches on epidemiology and finally discusses implications for
practices, specifically with pediatric nurse practitioners (PNP).
Although early studies in the 1940s of institutionalized children showed
behavioral symptoms of RAD, it was not until 1980 that the disorder
appeared in the DSM. Persistent disregard for the emotional and
physical needs of a child by the primary caregiver and/or repeated
changes of that caregiver, can lead to symptoms of RAD (Hornor,
2008). Two types of RAD exist: inhibited and disinhibited. Children
displaying inhibited RAD are unable or have difficulty forming
relationships with anyone and those with disinhibited RAD form
attachments to just about anyone (Hornor, 2008, p. 235). To fully
understand RAD, knowledge of attachment theory is important.
Appearing in the first year of life, infants develop either a secure or
insecure attachment to their caregiver. This attachment affects future
mental health. Secure attachment allows infants to explore their
surroundings and environments safely, confident that their caregivers

will respond to their needs and comfort them in times of distress or

danger. Infants with insecure attachment do not expect their
caregivers to support and/or comfort them. The development of
attachment helps individuals form a sense of self and others and
ultimately guides them to become interpersonally competent or
incompetent (Hornor, 2008).
Stable and predictable environments help infants and young children
to form secure attachments. The presence of a caregiver who is
consistent and will respond to the child increases the likelihood of that
child to develop a secure attachment. Risk factors for the development
of an insecure attachment and therefore an increased likelihood of
reactive attachment disorder include: physical and sexual abuse,
neglect, parental alcoholism and drug use, parental mental health and
absence of a consistent primary caregiver (Hornor, 2008). Hornor
(2008) states that those children most severely abused, neglected,
and/or abandoned are placed in foster care and at a greater risk to
develop RAD.
Hornor provides a clear and concise overview of the disorder and its
history. The symptoms of RAD are also reviewed in detail. When
describing the two types of RAD (inhibited and disinhibited), Hornor
successful explains the symptoms but leaves confusion around their
mutual exclusivity. In the DSM, either type can be presented mutually
exclusive of each other, yet the research referenced suggests
otherwise. A study by Zeanah and Emde done on 94 foster children
found that 17% of children displayed signs of both types of RAD
(Hornor, 2008). This, as well as consistent findings in other studies of
children who were formerly institutionalized, suggests that RAD types
are not completely independent. Hornor (2008) concludes that little
data are available and leaves the reader without a definitive answer
regarding the types of RAD and whether or not they present

independently. Although Hornor includes details of different studies

about children with RAD, she is unclear with her conclusions. At times,
they seem contradictory and difficult to follow.
She does successfully provide evidence that children in foster care are
at a higher risk but there seems to be a clear disorganization of the
literature review. Also, difficulty in isolating behaviors specific to RAD is
expressed, no real conclusion as to how to resolve this is offered. The
importance of the PNPs ability to recognize RAD and ensure mental
health care is stated a number of times, but suggestions do not include
specific assessments that ensure RAD behaviors are being measured.
The difficulty in recognizing and differentiating between the symptoms
of RAD and other disorders continues to be a problem. The tools used
are not well validated and the symptoms overlap with those of other
disorders. Even child temperament can present similar characteristics.
She does make some suggestions for PNPs which include: psychosocial
assessment, assessment of risk factors, documentation of the history
of pathogenic care, and detailed history of behavior from the caregiver
(Hornor, 2008). Also, the importance of a competent licensed mental
health provider with experience in child development and differential
diagnosis is emphasized to diagnose this complex disorder (Hornor,
2008). Finally, as stated by the author, the studies (and therefore the
article) only include studies that have looked at children raised in
institutions and not those who experienced early child abuse and/or
neglect. Studying children who experience abuse and/or neglect but
are not raised in institutions could shed more light on the topic and
provide implications for the future.
Although Hornor stresses the importance of including data regarding
the interactions of the child from multiple people (teachers, day care
providers, and peers), the article fails to include implications for these

caregivers. Similar to the implications suggested for the PNPs,

educators and other people who interact with children could assess the
history and behavior of the child. If there is concern, in school for
example, the teacher could collaborate with the school based team to
discuss next steps. Ideally, the family, general practitioner, and school
would work together to assess and if necessary refer to a mental
health practitioner who can provide proper treatment. The school team
could then create a school plan and document long-term progress.

Works Cited
Hornor, G. (2008). Reactive Attachment Disorder. Journal of Pediatric
Health Care. Volume 22, Issue 4, 234-239. Retrieved from
http://www.journals.elsevierhealth.com/periodicals/ymph/article/S
0891-5245(07)00269-6/abstract