February 01, 2013

Working with Children Who Have Reactive Attachment Disorder

Christina Rainville

The views expressed herein have not been approved by the House of Delegates or the Board of Governors of the American Bar Association, and accordingly, should not be construed as representing the policy of the American Bar Association.

Reactive Attachment Disorder (“RAD”) is a common disability for children who were abused or neglected when they were very young. It is essential that lawyers who work with children
understand this disability.

While RAD is rare in the general population, it is common in abuse cases. In one study of toddlers in foster care who had been maltreated, 38-40% of the children met the diagnostic criteria for RAD.1 Many older children who have delayed disclosure of their early abuse also suffer from undiagnosed RAD. 

Because these children frequent our criminal justice system, both as victims and offenders, lawyers need to learn to accommodate their special needs.

RAD Types

According to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV–TR), RAD symptoms develop before the child is five years old. The disability develops in two forms: (1) inhibited behavior, and (2) disinhibited behavior. Children can manifest symptoms from one type, but many children have symptoms of both types.2

Inhibited

A child with inhibited RAD is incapable of developing normal “attachments” to caregivers and behaves in socially inappropriate and inhibited ways. According to the DSM IV-TR, a child with the inhibited form is unable “to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest[ed] by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses.” As the Mayo Clinic explains on its website, these children “shun relationships and attachments to virtually everyone.”3

Disinhibited

A child with disinhibited RAD engages in behaviors at the other extreme: these children are incapable of differentiating between caregivers and total strangers, and are often dangerously comfortable with people they do not know. According to the DSM IV-TR, a child with disinhibited RAD “demonstrates a persistent failure to discriminate socially to create selective attachments that are appropriate,” and they often develop “diffuse attachments as manifest[ed] by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures).”

According to the Mayo Clinic, children with disinhibited RAD “seek attention from virtually everyone, including strangers.”4

Causes of RAD

RAD can result from early child abuse, neglect, fetal alcohol exposure or drug abuse, or something as simple as multiple changes in caregivers. RAD is very common in children adopted from orphanages in foreign countries and children who have been in multiple foster care placements. Adopted children can develop RAD even though there is no abuse or neglect in the adopted home.

RAD Increases the Risk of Abuse

One disturbing aspect of RAD is the disability makes a child who has already been abused more vulnerable to additional abuse. For children with inhibited RAD, their behavior—which can be socially inappropriate, defiant, belligerent and violent—creates a risk of further abuse as their behavior can make people angry.

For children with the disinhibited RAD, the risk of further abuse is also a concern. It can be extremely dangerous for any child to seek attention from a stranger, and children with disinhibited RAD seek attention from strangers routinely. Worse still, they lack the ability to distinguish between safe and unsafe situations when they are seeking that attention; if they have been abused in the past, they may even seek out similar abusive “attention.”

For all children with RAD, additional abuse only makes the RAD more uncontrollable. It is a vicious cycle that is difficult to stop. Without intervention, a child with RAD is a train wreck waiting to happen.

In recent years at the Bennington County Vermont Special Investigations Unit, we have had some tragic cases involving youth with RAD. A teen in a residential placement because of her history of running away and seeking out strangers for sex escaped from her school and had sex with three strangers over 24 hours.

Another child, age nine, was placed in residential treatment after her foster family could not stop her from asking strangers on the street if they wanted to have sex with her. These are extreme cases of RAD—most children with RAD do not engage in that level of dangerous behavior—but children who do not receive appropriate support and intervention can end up at that end of the RAD spectrum.

RAD May Increase Delinquent Behavior

In addition to making children more vulnerable to abuse, RAD creates other risks. While little research exists in this area, it is believed that children with RAD are at increased risk of alcohol and drug abuse, aggression, and other forms of delinquent behavior.5

Preparing the Child for Court

Preparing a child with RAD for court is a difficult and lengthy process. The first step is to try to build rapport, and that requires time, preparation, and a lot of patience.

A few years ago, I met with a nine-year-old sexual assault victim for the first time. She took charge before I could speak:

  •  “You’re really fat. You should go on a diet.”
  •  “You have a huge pimple in the center of your forehead. It’s really gross.”
  •  “I bet you don’t have any friends.”

She had RAD, and her goal was to stop the meeting so she did not have to talk about upsetting things. I agreed with her that a diet would be a good idea, and then I changed the subject. I told her that my job was to keep children safe, and that I was there to make sure she was safe. She stopped the caustic attacks and was finally able to focus.

Prepare before each meeting.

Before we meet with a child who has RAD, we try to get as much information as possible about how the child is doing at home, at school and, hopefully, in therapy. It is important to prepare for these meetings by collecting positive information about the child’s progress, because that information will be beneficial when the meeting with the child starts to go bad. We also try to learn the child’s interests—favorite sports, television shows, and the like — so we can change the subject and redirect the child if necessary.

Have frequent, short meetings.

We try to have frequent meetings— every month or two while the case is pending—with the RAD children. We discuss the status of the case generally, but the real purpose of the meetings is to build rapport. We do not talk about the case in any detail that may upset the child in these initial meetings. We try to hit the key points quickly and get the meeting over with before the child loses control. We may have several meetings to accomplish what could happen in one meeting with another child. We expect the children to be rude, surly, and miserable. We prepare ourselves to stay calm.

Stay positive and praise the child regardless of the behavior.

For children with inhibited RAD, the meetings will likely be full of abusive comments (directed at the lawyer), indifference, and generally surly behavior. The lawyer must have a tough skin and stay in control even if the child is screaming, swearing, or making personal verbal attacks. It can be hard to remain calm, and even harder to want to help the child whose behavior is so anger-provoking.

No matter what abuse may head our way, we never criticize the child for the behavior. We understand the behavior is beyond the child’s control and is a function of a disability. We try to keep things positive, and we find ways to praise the child regardless of the behavior. There is always something we can find to praise—an improved report from school, a parent’s report of something good that the child did at home, or a therapist’s report that the child is engaging in therapy. We repeatedly tell the children that our job is to keep them safe, and reaffirm that we are only there for their safety and nothing else.

If necessary, we change the subject to something that interests the child to redirect the child away from the disturbing conduct. Sometimes, when everything fails, we take breaks and step out for a minute to collect our thoughts and start over. Other times, we take a break to do the meeting on another day, with the hope that maybe the behavior will be better. Often, in the beginning, nothing seems to work. But more often, one day, something clicks and we know we are breaking through. It will begin with something subtle, like a smile, and we will know that our praise is being heard and we are making progress.

Helping the Child Feel Safe in Court

No child feels safe on the witness stand. For children with RAD, not feeling safe can bring out the worst behaviors. Every child with RAD has different issues, triggers, and social issues that need to be addressed before the child can testify. By meeting with the child several times beforehand and getting to know the child, the lawyer will better understand what issues are likely to arise on the stand.

Children with RAD have certain tangible or intangible things that make them feel safe. These need to be addressed for court because they might be wildly inappropriate in a courtroom setting. We try to help children plan for the trauma of testifying in advance to make the courtroom experience less traumatic.

For example, if a child was swearing and screaming in our initial meetings, we can expect the child will do the same under pressure in court. We will talk to the child about appropriate and inappropriate social behavior in court, and we will work with the child to come up with alternative strategies that might work better than yelling or swearing, such as asking the judge if the child can take a break in testimony. We have had several cases where a child looked up to the judge in the middle of testimony and asked for a break, and the judges have always readily agreed. While the breaks disrupt the flow of the testimony, the jurors understand that the child is suffering, and everyone comes back after the break with a keen interest in the testimony that will follow.

Tackle difficult issues slowly, over time.

We also take trial preparation with these children in small steps. Body piercings are a good example. Many teenagers with RAD use body
piercings as a means of protection: the piercings say, “I’m tough, don’t mess with me.” We have seen teenagers with multiple piercings in their lips, eyebrows, tongue, and nose (and various other places). Obvious piercings on the face always present a problem at trial, because they can create the wrong impression for the jury. The piercings (especially on the tongue and lips) can be extremely distracting, but, more importantly, jurors might think that the victim is a “thug,” rather than a vulnerable child who has been egregiously harmed. For court, piercings create the wrong impression.

Convincing the teenager with RAD to put the body piercings in his/her pocket until he/she is done testifying is a process that must be handled with care. As one teenage girl—who had two eyebrow rings, a lip stud, a nose stud, a tongue stud and countless piercings in her ears—once explained to me, the piercings “make me feel safe.” She asked me, “How would you feel if I asked you to go into court naked? Would you do it?” She explained that she feels naked and unsafe without her piercings. In our experience, her feelings are shared by many teens with RAD.

So, when we begin to address proper courtroom appearance for a child with RAD, we take it slowly. When we first suggest putting the piercings in a pocket, we expect to get yelled at. By the third or fourth time, the child might be able to engage in a discussion about why it is important for trial. With encouragement and praise, we have had success with teens who are able—usually, at the last moment, before they take the stand—to put their piercings in their pocket and hold them while they testify. But getting there is a slow process that takes patience for the lawyer.

A teen with RAD might also insist on wearing inappropriate clothing, or wildly-dyed hair, or to keep his/her hair completely blocking his/her face. The lawyer must choose battles carefully and raise these issues weeks in advance. We typically tell these children their clothing may be an issue at trial, but that they do not need to make any decisions right now. We give them time to think about it, bring them back in for a short meeting, and raise the issue again. After we have raised the issue a few times on different occasions in a nonthreatening manner, the child may finally be ready to discuss why we are making that recommendation. We then explain the pros and cons of what a jury will think; and give lots of praise and encouragement when the child starts to lean toward the right decision. Ultimatums will not work and are a waste of time: they will only increase the child’s anxiety about testifying.

Consider video testimony.

Children with RAD will likely do best if they testify outside the courtroom by video. Keeping their behavior under control can be difficult under the best circumstances; the heightened fears of a courtroom setting may simply make courtroom testimony impossible. With an older child, we will get the child’s input before deciding to have the child testify by video.

Prepare for unexpected behaviors during testimony.

Finally, the lawyer needs to be ready for the unexpected when the child with RAD is testifying. Despite the best preparation, the child’s behavior can still become unexpectedly out of control in court. In one case, we had a teenager who repeatedly mouthed an obvious expletive at a lawyer during cross-examination every time the lawyer looked away. Since it was the middle of cross-examination, there was nothing we could do but watch and hope it did not escalate. The cross-examination finally ended without incident, but it was a close call. Expect the unexpected with these children when they are in stressful situations.

Intervention is Key

While the lawyer is focused on helping the child prepare for a potential court case, an intervention team is essential to help the child in other regards. The intervention team usually involves the foster parents (or parents), treating therapists, a social worker from the Department of Children and Families, and teachers and special education case managers who are working with the child at school, but the lawyer also can play a role.

The lawyer or victim advocate will need to keep the team informed of the status of the case so that the team can work to ease the child’s anxiety and accurately answer the child’s questions and fears about an upcoming trial. In addition, the prosecutor should keep apprised of the team’s work. For example, the intervention team may know that the child is feeling great anxiety and wants to drop the case, and the prosecutor may want to meet with the child to address those concerns before they escalate and cause the child to destabilize further.

Make sure the child is in a safe place.

The first step is to make sure that the child is placed in a safe environment free from abuse and neglect and where the child’s physical and emotional needs are being met.

Set up an intervention team to support the child.

Then, an intervention team needs to be put in place:

  • The child should receive an Individualized Educational Plan (“IEP”) at school (if the child is performing below grade level), or a 504 Accommodations Plan (if the child is performing at grade level). These plans will focus on the child’s disability and ensure the child’s educational needs are met.
  • The child needs to engage in regular therapy with a therapist who has experience treating RAD.
  • The child’s caregivers need support and potential regular monitoring to make sure that the child’s needs are being met in the home.
  • Lawyers and other advocates working with the child need to be generally aware of the child’s progress (or lack thereof), and monitor the child’s progress at school, home, and in therapy.

Offer school supports.

The child’s IEP or 504 plan should address the child’s needs, and should include regular therapy in addition to school-based counseling. School staff need to be advised of the child’s disability, and plans must be in place for when the child “misbehaves.” The therapist can play a key role working with the school to develop appropriate supports and strategies for school discipline.

The school must also pay attention to bullying. Children who shun everyone are, in turn, shunned by everyone. Bullying can potentially cause the child to spiral further, and to lose any ground that has been gained.

Children with RAD lack social skills. Social skills classes and
conversational-skills classes can be life-changing. Education to develop empathy skills can also help these children.

Arrange psychological therapy.

Regular psychological therapy is imperative, although children with RAD often do not want to engage with a therapist. Children who shun relationships with everyone will not go willingly; if forced, they will not cooperate. This is an area where the lawyer working with the child (either the prosecutor or defense lawyer) can make a difference in the child’s recovery.

In our prosecution office, we take a hard line on therapy for all children —victims or offenders—who need psychological counseling.

Delinquent children

For children who have been found delinquent, therapy can be a mandatory condition in any disposition, and the child’s participation and success in therapy will be a condition of probation. The child’s defense lawyer can play a role by helping the child understand why therapy is so important. The defense lawyer can explain that therapy will help them feel happier and make them more successful in life. For children at greatest risk, the defense lawyer can explain that the child is heading to a life in prison, and that therapy can help prevent that. The defense lawyer can motivate a delinquent child to get the help the child needs.

Abuse victims

For victims of abuse with RAD in our prosecution office, we talk to the children directly about the need to engage in therapy. For young children, we talk in simple terms and address the child’s fears about the therapist. We talk about the therapist being “a safe person who will not hurt you,” and reassure the child that the therapist will work to make sure the child stays safe in the future. We also tell stories of children who had been subjected to similar kinds of abuse and how therapy helped them.

For older children who have an understanding of their disability and are refusing to go to therapy, it sometimes takes months of meetings with prosecutors and victim advocates to get the child to agree that therapy is worth a try. Our discussions with the children are difficult and frank. We talk a great deal about their personal safety, and how a therapist will teach them the skills to stop the cycle of abuse. We give examples of horrible cases where we see the same children, as victims, again and again, because they did not get help. And we tell them about the amazing children whom we have seen recover and what their lives are like now. We make sure the child knows he/she can recover from the past.

Our victim advocates schedule therapy appointments and provide transportation. Sometimes, if the child is especially dreading the therapy session, the advocate will plan something special afterward, like a trip to the local dairy bar for ice cream.

Once a child agrees to try therapy, we keep in touch with the therapist to monitor the child’s progress. We make clear that the therapist does not share anything about the discussions taking place in therapy. (The child needs to know that his/her confidences in therapy are safe and will not be shared with anyone.) We get general reports about whether the child is attending appointments and engaging in therapy. We always pass on praise from the therapist, even if the praise is limited to something as simple as making an appointment or two. In every meeting, we praise the child for continuing with therapy, and we keep encouraging the child to engage even more with the therapist. We keep it positive, full of praise, and we remind the child of the success stories.

Support caregivers.

Parenting a child with RAD can be challenging and overwhelming. Parents or foster parents will need education and ongoing support to learn how to parent a child with RAD. They should engage with the child’s therapist, and, if they are the parents of the child, we also recommend family therapy. Foster parents face particular challenges, because if the placement fails and the child gets sent to another foster family, the RAD may only get worse with each change in caregiver.

Lawyers should check in with the caregivers from time to time to learn how the child is doing. Additional supports, such as expanded accommodations at school or respite care, to give the foster parents a break, may need to be put in place for the child’s well-being.

Children Can Recover from RAD

While the effects of RAD can be life-long, children can recover if they receive proper support and treatment. Using the team approach described above, we have had great success stories of preparing children for trial while we watch them get better.

One child in particular comes to mind. After being repeatedly raped by her father, she was placed in three foster placements, which all failed. Every time we saw her or spoke to her, she was verbally brutal and disrespectful. Every person on the team dreaded meeting with her because her behavior was so intolerable. But when the last foster home clicked, and she started to feel safe, the transformation was extraordinary. She went from failing every class at school to ending the year with honors, and she went from shunning everyone to being adopted by her new foster parent. Years later, she is still a joy to behold. She is an academic star who is writing a book about her experience, and she laughs about her past because she has overcome it all and is focused on her future. She is our favorite success story because no child ever abused us more.

Recovering from RAD is a long process, which can take a year or more, but with the right supports, these children can have bright futures.

Christina Rainville, JD, is the Chief Deputy State’s Attorney for Bennington County, Vermont, where she heads the Special Investigations Unit. She is also a former recipient of the ABA’s Pro Bono Publico Award.

Stay tuned: This article is one in a series addressing advocacy for abused children with disabilities. 

Endnotes
1. Zeanah, Charles H., Michael Scheeringa, Neil W. Boris, Sherryl S. Heller, Anna T. Smyke, Jennifer Trapani. “Reactive Attachment Disorder in Maltreated Toddlers.” Child Abuse & Neglect 28(8), August 2004, 877-888.
2. See http://www.mayoclinic.com/health/reactive-attachmentdisorder/ds00988/dsection=symptoms.
3. Ibid.
4. Ibid.
5. Ibid.