Reactive Attachment Reactive Attachment

Disorder Disorder
How to recognize, manage & treat How to recognize, manage & treat
effectively effectively
Brian Kadinger, MS, LMFT Brian Kadinger, MS, LMFT
Manager, Clinical Services Manager, Clinical Services
Importance of Reactive Attachment Importance of Reactive Attachment
Disorder (RAD) Disorder (RAD)
New disorder New disorder--diagnosis created in 1980 diagnosis created in 1980
Increase in prevalence Increase in prevalence
Divorce rate Divorce rate
Studies in Trauma Studies in Trauma
Single parent households have doubled since Single parent households have doubled since
1970 & continue to increase 1970 & continue to increase
Inherited quickly Inherited quickly
Definitions Definitions
Clinical DSM Clinical DSM--IV IV--R R
Based upon Attachment Theory Based upon Attachment Theory
Markedly disturbed and developmentally Markedly disturbed and developmentally
inappropriate social relatedness in most contexts, inappropriate social relatedness in most contexts,
beginning before age 5 years, as evidenced by either: beginning before age 5 years, as evidenced by either:
Persistent failure to initiate or respond in a Persistent failure to initiate or respond in a
developmentally appropriate fashion to most social developmentally appropriate fashion to most social
interactions, as manifest by excessively inhibited, interactions, as manifest by excessively inhibited,
hypervigilant, or highly ambivalent and contradictory hypervigilant, or highly ambivalent and contradictory
responses (cold, withdrawn, odd approaches, responses (cold, withdrawn, odd approaches,
avoidance) OR avoidance) OR
Diffuse attachments as manifest by indiscriminate Diffuse attachments as manifest by indiscriminate
sociability with marked inability to exhibit appropriate sociability with marked inability to exhibit appropriate
selective attachments (overly familiar with new folks, selective attachments (overly familiar with new folks,
too social) too social)
DSM DSM--IV IV--R (continued) R (continued)
The disturbance is not accounted for solely by The disturbance is not accounted for solely by
developmental delay (as in developmental delay (as in Mental Retardation) )
and does not meet criteria for a Pervasive and does not meet criteria for a Pervasive
Developmental Disorder Developmental Disorder
Pathogenic care as evidenced by at least one of Pathogenic care as evidenced by at least one of
the following: the following:
(1) persistent disregard of the child's basic (1) persistent disregard of the child's basic
emotional needs for comfort, stimulation, and emotional needs for comfort, stimulation, and
affection affection
(2) persistent disregard of the child's basic (2) persistent disregard of the child's basic
physical needs physical needs
(3) repeated changes of primary caregiver that (3) repeated changes of primary caregiver that
prevent formation of stable attachments (e.g., prevent formation of stable attachments (e.g.,
frequent changes in foster care) frequent changes in foster care)
DSM DSM--IV IV--R (continued) R (continued)
There is a presumption that the care is There is a presumption that the care is
responsible for the disturbed behavior responsible for the disturbed behavior
(e.g., the disturbances began following (e.g., the disturbances began following
the pathogenic care). the pathogenic care).
Specify Specify type: type:
Inhibited Type Inhibited Type: : if Criterion 1 predominates in if Criterion 1 predominates in
the clinical presentation the clinical presentation
Disinhibited Type: : if Criterion 2 predominates if Criterion 2 predominates
in the clinical presentation in the clinical presentation
Real world symptoms Real world symptoms
Abandonment, abuse & neglect Abandonment, abuse & neglect
Bounced from place to place, never had a Bounced from place to place, never had a
connection or lost connection (death, divorce, connection or lost connection (death, divorce,
prison) prison)
Inability to learn from mistakes (poor cause Inability to learn from mistakes (poor cause--
and and--effect thinking) effect thinking)
Learning problems or delays in learning (not Learning problems or delays in learning (not
related to MR/DD issues) related to MR/DD issues)
Impulsive behavior Impulsive behavior
Destructive or cruel behavior Destructive or cruel behavior
Attempts to launch early Attempts to launch early
Heavy sexual interaction, long periods from home Heavy sexual interaction, long periods from home
Inhibited vs. Disinhibited Inhibited vs. Disinhibited
Armor & Naked Armor & Naked--two sides of the same coin two sides of the same coin
Armor (Inhibited) Armor (Inhibited)--withdrawn, extremely guarded, withdrawn, extremely guarded,
expecting others to screw or leave them expecting others to screw or leave them
Set self up for others to leave them due to this mistrust Set self up for others to leave them due to this mistrust
Self fulfilling prophecies Self fulfilling prophecies
Pick friends to bond to that will betray Pick friends to bond to that will betray
Test others & push them away Test others & push them away--expecting them to leave expecting them to leave
Naked (Disinhibited) Naked (Disinhibited)--clingy, overly attracted to folks clingy, overly attracted to folks
Emotional vomit Emotional vomit--tell entire life story to complete stranger tell entire life story to complete stranger
Jump from partner to partner, friend to friend Jump from partner to partner, friend to friend
Fake Fake--overly excited with folks, seem extremely attached overly excited with folks, seem extremely attached
quickly quickly
Goal for both is the same Goal for both is the same--hide vulnerabilities hide vulnerabilities
and reduce chance for hurt and reduce chance for hurt
World View of the RAD World View of the RAD
Logic of children Logic of children--blame self, low self blame self, low self
esteem esteem
Once you eliminate the impossible, whatever Once you eliminate the impossible, whatever
remains, no matter how improbable, must be remains, no matter how improbable, must be
the truth. the truth.
Imbalance of locus of control Imbalance of locus of control
Take responsibility for things they dont Take responsibility for things they dont
control, and give away responsibility for control, and give away responsibility for
things they do control things they do control
Pattern of objectification in relationships Pattern of objectification in relationships
Neurological Effects of Trauma Neurological Effects of Trauma
Children who suffer trauma have smaller brains Children who suffer trauma have smaller brains
overall overall
Deficits in frontal lobe that affect judgment & Deficits in frontal lobe that affect judgment &
planning planning
Anterior cingulate gyrus Anterior cingulate gyrus--The gear shifter of The gear shifter of
the brain the brain
Gets stuck Gets stuck--obsesses, holds grudges, inflexible obsesses, holds grudges, inflexible
lower levels of chemicals that affect rapid decision lower levels of chemicals that affect rapid decision
making, reward anticipation, empathy & neuron making, reward anticipation, empathy & neuron
health health
Micro Micro--expression understanding & emotional expression understanding & emotional
recognition recognition
Co Co--Morbidity Morbidity
Mood & Anxiety Disorders Mood & Anxiety Disorders
Attention Deficit Hyperactive Disorder Attention Deficit Hyperactive Disorder
Substance Abuse & Dependence Substance Abuse & Dependence
Acute and Post Traumatic Stress Disorders Acute and Post Traumatic Stress Disorders
Conduct Disorder & Oppositional Defiant Conduct Disorder & Oppositional Defiant
Disorder Disorder
Personality Disorders Personality Disorders
Family Structure & RAD Family Structure & RAD
Generational impact Generational impact
How many generations in a family How many generations in a family
experienced these issues? experienced these issues?
Homeostasis issues and dysfunction Homeostasis issues and dysfunction
Inconsistency in rules and follow through Inconsistency in rules and follow through
Enabling and manipulation Enabling and manipulation
Enmeshment & detachment Enmeshment & detachment
Poor regulation of emotions Poor regulation of emotions
Family Structure & RAD Family Structure & RAD
Parentified children & Adolescentified Parentified children & Adolescentified
parents parents
Usually DCS or CPS involvement Usually DCS or CPS involvement
Biological family contact may be limited or Biological family contact may be limited or
gone gone
Pedestal view of abuser/abandoner that Pedestal view of abuser/abandoner that
makes no sense to you makes no sense to you
Conceptualizing for Interventions Conceptualizing for Interventions
Maslows Hierarchy of Needs Maslows Hierarchy of Needs
If you dont achieve one, you get stuck If you dont achieve one, you get stuck
Physiological Physiological--Food, water, shelter Food, water, shelter
Safety Safety--Personal, financial, employment, safety against Personal, financial, employment, safety against
accidents/illness accidents/illness
Social Social--Friends & family Friends & family--belonging belonging
Esteem Esteem--Sense of contribution (is this for the client or Sense of contribution (is this for the client or
us?) us?)
Self Actualization Self Actualization--living up to full potential living up to full potential
Strange behaviors fill the need Strange behaviors fill the need
Conceptualizing for Interventions Conceptualizing for Interventions
Grief Model Grief Model
What did they lose? What did they lose?
Individuals Individuals
Answers to givens Answers to givens
Moms and dads love their kids Moms and dads love their kids
Safety & Security Safety & Security
Trust and understanding Trust and understanding
Exponential grief Exponential grief--what other grief issues from what other grief issues from
the past may be going on with this? the past may be going on with this?
Conceptualizing for Interventions Conceptualizing for Interventions
Grief Model Grief Model--Kubler Kubler--Ross Ross
Denial Denial--not going to affect me. Im fine not going to affect me. Im fine
Anger Anger--mad @ lots of people, things (may feed mad @ lots of people, things (may feed
guilt) guilt)
Bargaining Bargaining--the fuel for Anger and Depression the fuel for Anger and Depression
depending upon thought process depending upon thought process
Depression/Sadness Depression/Sadness--self explanatory (looks self explanatory (looks
like anger in adolescents & young adults) like anger in adolescents & young adults)
Acceptance Acceptance--not happy, but can deal with it not happy, but can deal with it
Attachment Theory Attachment Theory
Basis for Reactive Attachment work Basis for Reactive Attachment work
Humans are pack animals Humans are pack animals--attach to attach to
caregiver for security, comfort, pleasure caregiver for security, comfort, pleasure
Experiments Experiments
Home port, rhesus monkeys Home port, rhesus monkeys
When lost, person feels unsafe and fearful When lost, person feels unsafe and fearful
of exploration of exploration
Develops into mistrust of world Develops into mistrust of world
Conceptualizing for Interventions Conceptualizing for Interventions
Homeostasis and Family Preservation Homeostasis and Family Preservation
Every behavior is designed to keep us Every behavior is designed to keep us
balanced balanced
Context of normal life after this Context of normal life after this
How do you get to normal after something How do you get to normal after something
like this? Is it possible? like this? Is it possible?
What happens when askew becomes What happens when askew becomes
normal? normal?
Developing Interventions Developing Interventions
Based upon the conceptualization you Based upon the conceptualization you
choose choose
May be mixed at times depending upon May be mixed at times depending upon
the clients needs, understanding and skill the clients needs, understanding and skill
set set
Not about the why, focus on the what Not about the why, focus on the what
Address impact on here and now Address impact on here and now
Goals for Interventions Goals for Interventions
Create a safe, secure environment to grow, Create a safe, secure environment to grow,
learn and thrive learn and thrive
Create the opportunity to learn to connect with Create the opportunity to learn to connect with
others and work in society appropriately others and work in society appropriately
Challenge the understanding of their impact on Challenge the understanding of their impact on
self and others, and how they can lower the self and others, and how they can lower the
costs of their behaviors to gain their goals costs of their behaviors to gain their goals
Ensure interventions do not re Ensure interventions do not re--traumatize traumatize
those involved those involved
What not to do! What not to do!
Trust me Trust me--think used car salesman think used car salesman
Its not that bad. Others have gone through . . . Its not that bad. Others have gone through . . .
I promise I promise
Be wishy Be wishy--washy washy--confidence is vital to success confidence is vital to success
You need to, You should, You have to, You need to, You should, You have to,
Make yourself the savior Make yourself the savior--Youre the only one . . . Youre the only one . . .
Upping the ante on consequences again and again Upping the ante on consequences again and again
Intentional dishonesty Intentional dishonesty
Logic them Logic them--it doesnt work it doesnt work
Medications Medications
Focus on the co Focus on the co--morbid diagnosis morbid diagnosis
Anti Anti--depressants or mood stabilizers depressants or mood stabilizers
ADHD ADHD
Sleep/anti Sleep/anti--anxiety medications helpful as anxiety medications helpful as
well well
Dependence issues Dependence issues
May use old school blood pressure medications May use old school blood pressure medications
Watch for interactions Watch for interactions--meds for physical meds for physical
ailments vs. psychological ailments vs. psychological
Maslow & Grief Models Maslow & Grief Models
Identify with the stage the client thinks Identify with the stage the client thinks
they are in they are in
Work to build upon safety for Maslows Work to build upon safety for Maslows
Hierarchy by developing structure and Hierarchy by developing structure and
social connection social connection
Identify problem areas which may trigger Identify problem areas which may trigger
negative reactions and implement safety negative reactions and implement safety
plans plans
Attachment Theory Attachment Theory
Trauma Informed Care Trauma Informed Care
Systems (Team) approach Systems (Team) approach
Works best with younger clients and very Works best with younger clients and very
involved/invested families involved/invested families
Family is the change agent Family is the change agent--clear delineation of clear delineation of
power structure is vital to success power structure is vital to success
If they connected once, they can do it again. If they connected once, they can do it again.
Focuses on developing the safety and connection Focuses on developing the safety and connection
the child missed or lost the child missed or lost
Therapeutic interactions occur in home & office Therapeutic interactions occur in home & office
Build from familys identified strengths Build from familys identified strengths
Limited outside interference Limited outside interference--can be tough if can be tough if
family isnt supportive of probation and family isnt supportive of probation and
expectations expectations
Homeostasis Homeostasis
Every behavior is a way to balance Every behavior is a way to balance
someone in the family and themselves someone in the family and themselves
Encourage family therapy and challenge Encourage family therapy and challenge
family to deal with their stuff instead of family to deal with their stuff instead of
putting it all on kid putting it all on kid
Look for the Personality Disorder Drama Look for the Personality Disorder Drama
Hero/Victim/Villain (persecutor) Hero/Victim/Villain (persecutor)
Roles balance one another and avoid Roles balance one another and avoid
responsibility of change responsibility of change--Hot Potato! Hot Potato!
Call out the roles, and return the focus of Call out the roles, and return the focus of
attention on the client instead of attention on the client instead of
defending or explaining defending or explaining
Specifics for all cases Specifics for all cases
New Golden Rule New Golden Rule--Focus on Self Focus on Self
If you focus on others, a power struggle If you focus on others, a power struggle
occurs immediately occurs immediately--Make someone is a bad Make someone is a bad
call call
Provide choices, but decide the choices for Provide choices, but decide the choices for
them them--this goes for consequences as well this goes for consequences as well
Space to move vs. lording over Space to move vs. lording over--Spare the Spare the
rod . . . rod . . .
Guard rails, not slot cars Guard rails, not slot cars
Fun ways to create change Fun ways to create change
Use the resistance to your advantage Use the resistance to your advantage
Reframes current situation and gives new solutions Reframes current situation and gives new solutions- -
I think you want to be placed in detention I think you want to be placed in detention--its safe its safe
and away from others. We can do that, but you must and away from others. We can do that, but you must
tell me to do it with more than your actions. tell me to do it with more than your actions.
Dont trust me, dont trust anyone Dont trust me, dont trust anyone--normalize normalize
distrust distrust
Balance Locus of Control Balance Locus of Control--cant be all on one side or cant be all on one side or
the other the other
Could there be a benefit to this still affecting them? Could there be a benefit to this still affecting them?
Dexter approach Dexter approach
How can they use their mistrust as an advantage to How can they use their mistrust as an advantage to
self? self?
Fun ways to create change Fun ways to create change
Tell them to do the symptom Tell them to do the symptom
Give control to the client Give control to the client--sets up for a win/win sets up for a win/win
Out catastrophize them Out catastrophize them
The yeah, but . . s of the world The yeah, but . . s of the world
Randomize the symptoms Randomize the symptoms--coin flip coin flip
Plan for life being awful Plan for life being awful
Agree with them that they have no control and their life Agree with them that they have no control and their life
will be terrible will be terrible
Takes away the battle and power struggle Takes away the battle and power struggle--they usually they usually
switch sides & argue why their life can be better switch sides & argue why their life can be better
They can either fight you or accept the help and plan to They can either fight you or accept the help and plan to
cope with it cope with it--win/win situation win/win situation
Roll dice or play odd/even to decide the next steps and Roll dice or play odd/even to decide the next steps and
recommendations recommendations
Things to remember Things to remember
Focus on self Focus on self--not controlling them and what not controlling them and what
you will make them do you will make them do
Avoid getting wrapped up in drama Avoid getting wrapped up in drama
(hero/victim/persecutor) by keeping (hero/victim/persecutor) by keeping
boundaries boundaries
Its good to be blunt without being abusive Its good to be blunt without being abusive--
remember the resilience remember the resilience
Take the unconventional approach Take the unconventional approach--they know they know
the old patterns the old patterns--give something new give something new