APA Statement on RAD Warns Against Dangerous Treatments

Reactive attachment disorder (RAD) is a psychiatric condition affecting a small number of children and is widely misunderstood by the general public. In addition, unproven treatment strategies used in children who are suspected to have the disorder can be harmful and even fatal, according to an APA position statement released in July.

In response to a number of requests from psychiatrists to develop a policy on the disorder and provide the public with the most accurate information available, members of the APA Council on Children, Adolescents, and Their Families (now the Council on Child and Adolescent Psychiatry) worked in conjunction with the Committee on Preschool Children to craft the statement.

Term Misused

RAD is a complex disorder characterized by a child’s inability to form normal attachments to others, according to the statement, and a parent or physician may first notice problems in attachment to the caregiver in the latter part of the child’s first year.

“I think there is a lot of confusion in the public about the diagnosis of RAD, and the term is frequently misused,” said David Fassler, M.D., an APA trustee-at-large and former chair of the Council on Children, Adolescents, and Their Families.

Fassler, who led the effort to create the position statement, added that council members “were also concerned over reports about the use of scientifically unproven and potentially dangerous approaches to treating what has been referred to as RAD.”

The position statement warns both clinicians and caretakers of the dangers associated with so-called coercive holding therapies and “rebirthing” techniques that have sometimes been used to treat children with RAD.

In one recent case, such treatment proved fatal when uncredentialed therapists in a Colorado counseling center bound a 10-year-old girl in a sheet and sat on pillows placed around her head in an effort to simulate labor contractions. The goal? To let the girl be “reborn” into a world where past traumas would no longer exist for her. The girl died at a Denver hospital the day after the procedure.

Children with RAD may appear to be detached, unresponsive, inhibited, or reluctant to engage in age-appropriate social interactions. However, some children with RAD can be overly and inappropriately social, even with strangers. These problems may persist as the child grows older.

Many children with RAD have been physically, emotionally, or sexually abused, according to the policy statement, while others may have experienced long periods of isolation or neglect. In addition, some of these children have had “multiple or traumatic losses or changes in their primary caregiver.”

Although there are no prevalence estimates available for the disorder, Fassler stressed that it is relatively rare and that not all children who have endured traumatic circumstances in early life will develop RAD. “The child’s temperament figures in his or her ability to cope with various stressful early life experiences,” he said.

Advice to Parents, Caregivers

The statement advises parents or caregivers of children who show symptoms of RAD to do the following:

• Seek a comprehensive evaluation by an appropriately trained, qualified, and experienced mental health professional prior to the initiation of any treatment plan.

• Ask questions about the results of the evaluation.

• Be clear about the potential risks and benefits of any intervention.

• Feel free to seek a second opinion if questions or concerns remain.

APA position statements are policy documents approved by APA’s Assembly and Board of Trustees and define APA policy on specific topics. The position statement on reactive attachment disorder is posted on APA’s Web site at www.psych.org/archives/200205.pdf. ▪