Intensive In-Home Treatment for RAD Shows Promise

For the past few years Faye Hall, the mother of four children (including one who has reactive attachment disorder or RAD), has been diligently working to help adoptive parents heal children who suffer from RAD. Together with Jeffrey Merkert, a therapeutic support professional, she has co-authored a manual outlining a team approach to parenting children who have RAD with help from Pennsylvania´s wraparound mental health services. Below they share the story of one family´s experience using an intensive in-home team approach to therapy. This article was first published with North American Council on Adoptable Children (NACAC).

Jimmy was nine months old when his birth mother abandoned him and left him in his dad´s care. Unfortunately, life with Dad involved domestic violence and drug use. When Jimmy was five, his dad went to jail, and Jimmy was placed in foster care. For the next few years, he moved through a variety of different foster homes and shelters until he was adopted by the Spruce family1 at age nine. Shortly thereafter, Jimmy was diagnosed with reactive attachment disorder (RAD).2

Infants and young children who experience neglect and abuse learn quickly that the world is unsafe, they have no value, and adults cannot be relied upon to meet their needs. This belief paradigm forms a protective shell around the children that helps them survive in a hostile world. When such children enter an adoptive family, this shell prevents them from accepting parental kindness and direction. In fact, children with RAD feel most comfortable when they can recreate and control the chaos from their pasts.

A healthy parent and a child with RAD have a fundamental clash in belief systems. The more the parent tries to nurture and help the child, the more he will reject the closeness and fight to drive the parent away. Normal parenting, when applied to a child with RAD, can leave parents exhausted, stressed, isolated, and feeling like failures. As frustration rises, parents are more likely to reinforce the child´s negative beliefs, and be sucked into a downward spiral. To break the spiral, parents (often mothers, the most common target of adopted children´s rage) need to be supported by a tightly focused team composed of treatment professionals and educated family members and friends.

Pennsylvania Services

By the time he was 15, Jimmy had spent time in a residential treatment facility and was so violent and unpredictable that the Spruces were afraid to leave him alone or take him out. That´s when they sought help through their county´s wraparound services program. Offered through a network of private service providers, Pennsylvania´s wraparound services are designed to help youth under age 21 who have a serious mental health diagnosis, a state Medicaid card or other insurance, and a professional referral. The goal is to support children and their families within the home and community instead of a more restrictive (and expensive) setting.

After learning all she could about RAD and possible treatments, Jimmy´s mother, Sharon, went on to educate a therapeutic support staff person or TSS (an impartial figure who facilitates therapeutic work with the family) made available through the wraparound program. Other family members, as well as family friends, also learned about the disorder and the plan for treatment. This tightly woven team approach created a uniform environment for Jimmy and facilitated stronger therapeutic consistency. He needed to perceive that his mother would monitor all the adults in his world to keep him safe.

During the intensive treatment, the TSS worked directly with Jimmy and Sharon in the Spruces´ home for more than two years. Nearly 5,000 professional hours were devoted to Jimmy´s case centering on two key problems: Jimmy´s inability to attach, and his distorted belief system—issues that are inextricably intertwined in children with RAD.

Promoting Attachment

New babies form attachments with loving and consistent caregivers. Babies who begin life with neglectful, unresponsive, or inconsistent caregivers learn to distrust adults, and may grow to resist efforts to nurture and guide them. Some lack the ability to give and receive genuine affection and love. In severe cases, unattached children may fail to develop a moral foundation—no empathy, remorse, conscience, or compassion.

Because Jimmy had missed many stages of normal infant development, Sharon and the TSS began by limiting Jimmy´s world and encouraging him to recapture some of his lost babyhood in a new, safe environment. Some days Jimmy would lie on the living room floor like an infant. Gradually he moved up to toddler building blocks, and progressed onward from there.

During this time, the TSS introduced the concept of different parts within Jimmy: healthy and unhealthy. Sharon could then compare and contrast the parts with empathy through statements such as, “It must really be hard for you when you want something, but the part of you that does not think you´re worth it won´t let you ask for it.” The TSS also encouraged Sharon to follow through with attachment activities (like swinging at a playground, playing Simon Says, playing together with building blocks, etc.) and identified and reframed communications and behaviors that Jimmy used to push Sharon away.

Finally, after six months, Jimmy developed a strong desire to play roller hockey at the local YMCA. His desire gave Sharon and the TSS an opening to institute a level system aimed at giving Jimmy some mastery of his own world (hygiene, self-control, school work, etc.). Under the system, Sharon and the TSS challenged Jimmy to perform simple tasks (like brushing his teeth every day). If he could control his behavior for one week, he would earn the chance to play roller hockey the next week.

This system promoted attachment because Sharon could share Jimmy´s goal of playing roller hockey. She bought hockey equipment and paid the fees. All Jimmy had to do was control his behavior to get what he wanted. If Jimmy failed, he wouldn´t get to play, and Sharon could commiserate with him. Every week, Sharon and the TSS framed the challenge as a constant battle within Jimmy over which part of him would win.

After a long struggle, success earned Jimmy the right to play. Sharon never praised Jimmy´s success though, because any overt warmth that signaled their closeness might have caused him to act out. Once the first level of tasks became habit, Sharon and the TSS raised the bar and set new conditions that would keep Jimmy eligible to play. Today, Jimmy plays if his grades are satisfactory.

Reframing Core Beliefs

Long before Jimmy joined the Spruce family, early neglect, abuse, and instability had firmly convinced him that he was worthless, the world was a very dangerous place, and adults could not be trusted. When he was young, these deeply held beliefs enabled him to adapt to and accept his harsh reality. In his adoptive home, instinctively believing his new parents were unreliable, Jimmy projected chaos with disruptive behaviors—lying, fighting, stealing, gorging, hoarding, etc.—to feel safe.

The goal of the therapeutic team was to slowly reframe Jimmy´s destructive belief system—beliefs that were keeping him and his family in a dysfunctional rut. And, as Sharon and the TSS knew, consistent behavior and consequence patterns would only make things worse.

For example, say a child with RAD steals a box of cereal and angers his brother by eating the whole box without sharing. The brother yells at the injustice, which prompts Mom to intervene. She ends up yelling even louder and threatens punishment (which proves to the child that Mom is bad), and when Dad gets home, the whole family is in an uproar. The child has successfully recreated the familiar discord and turmoil of earlier days and feels comfortable. He is happy that he ate the cereal, too; at least he´s not hungry. A child with RAD is completely satisfied with the least when he is in control.

With help from the TSS, Sharon practiced new ways to intervene when Jimmy stole food:

  • Sharon encouraged Jimmy to say “thank you” when he stole food. She empathetically explained that he was learning new ways to express his feelings: “Thank you for buying the food for me. You do a lot of nice things for me.”
  • She portrayed her behavior in terms of positive emotions: “I know this is hard for you to believe, but Mom wanted you to have this food. That´s why it was here in the first place.”
  • She used paradoxical parenting techniques in short, unpredictable segments. One time after Jimmy was caught hoarding food in his room, Sharon went straight to the store and bought several packages of food for Jimmy to keep in his room. “I love you and do not want you to be afraid when you are hungry,” she told him.

Another time, Jimmy destroyed his new bike. He left the bike in the rain, rode it over impossible terrain, and finally took it apart to “fix” it.

Before reacting, Sharon and the TSS considered why typical interventions prevent healing in a child with RAD:

  • Mom says, “You are careless and inconsiderate of my time and money.” (Child thinks: “I am worthless.”)
  • Mom threatens: “I´ll never buy you a bike again,” and throws the bike away. (Child thinks: “This parent cannot be trusted to meet my needs.”)
  • Mom puts the bike away for the child or fixes it. (Child processes: “I can control this parent because she has more invested in the bike than me.”)

With help from Jimmy´s attachment therapist, Sharon and the TSS worked out more constructive interventions:

  • Without rescuing the bike, Sharon used the behavior to highlight Jimmy´s negative self-image. “It must really be hard for you to have a new bike. If you like it, what is inside of you that causes you to leave it in the rain?”
  • The TSS projected to Jimmy a positive belief about Sharon: “You must have a pretty good mom to buy you a bike like that.”
  • The Spruces created opportunities for Jimmy to feel the loss of the bike without an “I told you so.” They took family bike rides while Jimmy walked with them. Sharon expressed her sympathy and sorrow for her son (being very careful to avoid sarcasm).

Inconsistent, kindly delivered consequences force the child with RAD to look not at the discipline tool, but at the larger picture of Mom´s love. In all consequences, even negative consequences, the consistency is Mom working to benefit the child because she loves him. Once Mom´s loving decisions are identified for the child, he must explain to himself why good things happen if his negative beliefs are real. No longer can he rest in the security of an external world that matches his destructive beliefs.

Another key aspect of reframing Jimmy´s belief system consisted of cognitive reprogramming. Simply stated, cognitive reprogramming involves showing a child how his beliefs affect his emotions and actions, and encouraging and facilitating a shift in beliefs that will in turn yield more desirable feelings and behaviors. Jimmy´s therapeutic team used several reprogramming techniques:

  • The team helped Jimmy to verbally analyze cause-and-effect sequencing, interpret layers of behaviors and emotions, and explain why things were happening to him.
    For example, a week after getting a new watch, Jimmy took it apart. The TSS said to Jimmy, “You have a nice watch.” Then, “Why would a person have a nice watch and take it apart? What would the person´s feelings be? Happy? Sad? Mad? Scared?” Jimmy´s first response: “Mad.” The TSS: “Why would someone be mad about a new watch? What would someone believe that would make them mad, sad, or scared about a new watch?” Jimmy´s answers eventually revealed a negative core belief. At that point, Sharon and the TSS encouraged Jimmy to understand that his negative belief did not match the facts.
  • To help monitor Jimmy´s violent behaviors, the TSS, in conjunction with the attachment therapist, started a control logÐa record of Jimmy´s negative behaviors that he and Jimmy examined for meaning. As violent outbursts decreased and positive behaviors became more frequent, the log was rewritten as a Positive Attachment Log (PAL). The TSS then used the PAL to discuss emotions and beliefs with Jimmy after positive behaviors.
  • To reinforce (negatively or positively) emotions and behaviors tied to a belief, the TSS also created cognitive reprogramming cards. Negative messages went on red cards. One red card, placed in an area where Jimmy was pacing, read: “When I pace around, unable to do what I know I want to be done…I am locked up, afraid of losing control to my mom.” The TSS posted positive messages, like “I can trust this mom,” on yellow paper in prominent places—Jimmy´s dresser, the bathroom mirror, etc.

Then and Now

“We had some wild times!” says Sharon about her family life before the intensive therapy. In the winter, Jimmy wouldn´t wear a coat because his body temperature was so far off. He used to run barefoot through the woods in deep snow. He was aggressive with Sharon, combative with his brother and sisters, and completely unconcerned about personal hygiene.

These days, though Jimmy, Sharon, and the TSS still attend attachment therapy sessions two hours each week (and Jimmy spends an extra hour receiving neurofeedback), life is much better. The family can go on field trips and to church without dreading Jimmy´s behavior or battling over winter clothes. And, after three years of in-home instruction from his local school district, Sharon and Jimmy are making cautious progress toward transitioning him into back into public school for his senior year. Jimmy is scared (a sign that he is more in tune with his emotions), but is beginning to visualize the possibility of college after high school. He´s even expressed an interest in wildlife biology as a career.

As the Spruce family can testify, RAD is a very serious disorder that requires extremely intense treatment. Treatment cannot be conducted in isolation, and even the best treatment is not likely to produce a trouble-free youth. Intensive team treatment can, however, help save damaged children and their adoptive families, and heal the effects of one of society´s most heinous crimes—child neglect and abuse.

1. Family members´ names have been changed to protect privacy.
2. The Diagnostic and Statistical Manual of Mental Disorders broadly defines RAD as a disorder that begins before age 5 and is characterized by “social relatedness” that, in most every situation, “is markedly disturbed and developmentally inappropriate.” There is a wide range of behaviors and degrees of severity among children diagnosed with RAD.

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