My husband and I sat in a conference room with a dozen other people: lawyers, therapists, caseworkers, Court Appointed Special Advocate (CASA) volunteers, and clinical decision-makers from the Department of Child Services. After nearly a decade of trying to keep our family safe, they finally came together to support us.
Or that was our hope, at least.
The state-funded psychologist produced a 15-page report that included our son Joe’s reactive attachment disorder (RAD) diagnosis. Although five independent professionals had also diagnosed him with RAD, this psychologist had different recommendations.
Rather than suggesting out-of-home specialized treatment as past professionals had, the state-funded psychologist suggested that my husband and I have family game nights and cultivate better coping skills for Joe. She also told us to chat with our other children. We needed to let our kids know that their needs weren’t as important as Joe’s needs, she said.
I left that meeting utterly defeated, questioning where we had gone wrong. How did we end up here? What had we missed? What if we had recognized Joe’s reactive attachment disorder signs sooner? Would we still be in this place where the “help” was no help at all?
Why parents and clinicians miss reactive attachment disorder red flags
Reactive attachment disorder was never mentioned during our foster care training. There were no official “red flags” to look for early on because we didn’t even know that the disorder existed in the first place. The damage had already been done in our family by the time Joe did get the diagnosis.
Most clinicians look for symptoms of reactive attachment disorder based on the fifth and most recent edition of The Diagnostic and Statistical Manual of Mental Disorders (DSM-5). But the manual gives a generalized, impersonal, and subject-to-interpretation criterion (included at the bottom of this post for your reference). For this reason (and some others), clinicians often miss reactive attachment disorder in their assessments.
There were no official “red flags” to look for early on because we didn’t even know that the disorder existed in the first place. The damage had already been done in our family by the time Joe did get the diagnosis.
Over my parenting years, I began to recognize patterns as a defense mechanism against understandable and seemingly normal, yet disconcerting, RAD behaviors. I can now say with certainty that the DSM-5 is missing quite a bit of real-life red flags for reactive attachment disorder.
Joe and his two brothers were our first foster care placement. When they entered our home, Joe was two-years-old and his brothers were 3-years-old and 4-months-old. But only Joe was later diagnosed with reactive attachment disorder. Why? That’s what my husband and I and lots of professionals didn’t understand. It didn’t make sense considering they all came from the same situation.
Nearly all traumatized children exhibit similar behaviors including hyperactivity, dysregulated emotions, lying, stealing, trouble sleeping, nightmares, sensitivity to touch, and issues with food and bodily functions.
The difference between a child with “just” trauma and a child with reactive attachment disorder is the ability to trust caregivers and feel safe in a safe environment, allowing them to lessen those behaviors over time.
In retrospect, both of our other boys likely qualified for the diagnosis somewhere along a spectrum early on. I have theories as to why one’s behaviors lessened and one’s behaviors worsened. But they are only theories.
Over my parenting years, I began to recognize patterns as a defense mechanism against understandable and seemingly normal, yet disconcerting, RAD behaviors. I can now say with certainty that the DSM-5 is missing quite a bit of real-life red flags for reactive attachment disorder.
What I do have is the contrast in behaviors between two of our boys, one who no longer qualifies for the diagnosis and Joe who was diagnosed with severe, persistent reactive attachment disorder by six different professionals.
Looking back, these are some of the red flags we missed for reactive attachment disorder:
1. A past that includes many caregivers from a very early age.
Without a primary stable and attuned caregiver in the first years of life, the child learns the world is scary and their needs are likely to go unmet. This then can manifest as a lack of trust in any caregiver, and ultimately, a diagnosis of reactive attachment disorder. Unlike our oldest son who only had one caregiver disruption prior to the age of 3, Joe had three caregiver disruptions before the age of 2.
2. Self-isolation
The first weekend our boys spent with us was telling in retrospect. Our oldest son ran into his room, saw his dinosaur bed, and exclaimed, “This is my bed!” Joe, however, went straight to the toy vacuum and began vacuuming the floors. He spent much of that weekend alone, vacuuming.
I interpreted his behavior as that of a terrified toddler who was with people he didn’t know, which was accurate. However, he adamantly refused to engage with us despite our many attempts and his brother’s encouragement to do so.
The difference between a child with “just” trauma and a child with reactive attachment disorder is the ability to trust caregivers and feel safe in a safe environment, allowing them to lessen those behaviors over time.
This characteristic alone is not a red flag, especially on the first weekend we met. However, like most things with reactive attachment disorder, persistent patterns of behavior are the real red flags. As our son aged, he often played alone.
When Joe was in first grade, his teacher took the class on a field trip to the zoo. I accepted the teacher’s invitation to parents to go along, thinking it’d be a good chance to spend some time with Joe and see how he interacted with his classmates.
The zoo had a tank of dog sharks that people were allowed to pet. Joe had no interest in touring the zoo with his classmates. All he wanted to do was pet the sharks. He asked me to leave him alone while he petted them. I sat on a nearby bench watching him for hours.
Joe thought the zoo was the best day ever. It probably was the best day he and I ever had together. And we barely interacted.
3. Constant disagreeability
Yes, saying no is a normal toddler phase. However, Joe reflexively said no to almost everything. I often couldn’t even finish my sentence before he said no. Sometimes I just had to look like I was about to speak before he said it. To avoid escalation and violence, I learned that it was best not to speak when Joe was objectionable (which was often). He often had lengthy arguments with me in which I never even opened my mouth.
Joe’s habit of disagreeability was deep and necessary to maintain emotional distance between us. It was stuck in autopilot. It’s incredibly difficult, if not impossible, to bond with someone who can’t or won’t pause even a fraction of a second to allow for connection. To give ourselves some needed stress relief, my husband and I wrote a song about Joe’s love of the word to the tune of Neil Diamond’s song “Hello Again.”
4. An inability or unwillingness to accept the word no
Although Joe loved the word for himself, his biggest trigger was when we told him no.
A well-attached child will generally accept their parents’ guidance and boundaries. They have the experience that their parents will provide for them and keep them safe. In contrast, a child with RAD does not have that experience and therefore does not trust caregivers to provide needs or safety. They relentlessly push against parental guidance, rules, and boundaries as a result.
Joe used emotional volatility to wear us down when we told him no. This looked like hours upon hours of screaming, throwing, and cursing. His previous foster mother told me that she couldn’t handle his emotions so she would not follow through on consequences whenever he raged.
Joe’s habit of disagreeability was deep and necessary to maintain emotional distance between us. It was stuck in autopilot.
By the tender age of 2, Joe had already learned that raging got him what he wanted–emotional distance and control. It took my husband and me over a year to realize this dynamic and allow him to rage to exhaustion. He tried other tactics to maintain control, but the rages became less frequent.
5. Can turn off rages like a light switch
The natural inclination of a parent is to console their child when they are upset, whether a hug, sitting nearby, or rubbing of the back. When our oldest son was upset, he became nearly catatonic and shut down completely. However, he did allow us to comfort and soothe him until he felt safe enough to express himself.
But Joe raged. A rage is not a temper tantrum. A rage is hours upon hours of screaming, threatening, throwing, breaking objects, profanity, and increasingly unsafe behavior usually until the child is simply too tired to continue. I don’t include raging in this list of red flags because it was how he used the rage that is the red flag.
We attempted to console Joe when he raged. However, when given attention during a rage, he instantly calmed. We never got the opportunity to console him because he turned it off like a light switch. I later realized it was a defense mechanism to maintain control and not allow us to help him regulate his emotions.
The first time I witnessed a two-year-old go from screaming, crying, and throwing things to breathing calmly and smiling in an instant was shocking. Normally, it takes time to deescalate big emotions, even for the most adept emotional regulators. I had never seen anything like it.
As Joe grew older and his rages became more dangerous, our safety plan included us calling law enforcement to ensure his and everyone else’s safety. By the time law enforcement arrived Joe would be completely calm and smiling, making me seem unreasonable for calling them in the first place. This led to parental blame and shame and lack of support.
6. Stiffens with physical touch
Unlike his older brother who sought out hugs and loved to sit on our laps to read together, it was clear from the beginning that Joe was uncomfortable with physical touch. We were never given a complete history of the time prior to him living in our home. Therefore, we do not know if he was ever physically or sexually abused.
What we do know is that Joe rarely sought physical comfort and often rejected physical touch altogether. When touched, especially by me, he withdrew and acted as if it were physically painful. Not long after the boys came to live with us, I stopped trying to hug Joe. I started asking if I could touch or hug him. He rarely consented.
A well-attached child will generally accept their parents’ guidance and boundaries. They have the experience that their parents will provide for them and keep them safe. In contrast, a child with RAD does not have that experience and therefore does not trust caregivers to provide needs or safety.
It’s clear in his adoption photos, almost two years after he’d come to live with us, Joe’s aversion to physical touch. Instead of his legs and arms wrapped around me as I held him, he is stiff and straight. I struggled to hold him as he pulled away.
There were times that I had to touch Joe. For example, I put my hand on his back to move him out of the way of an oncoming person or moved his head to protect him from hurting himself. As he got older, he claimed I was abusing him in those moments and started to make false allegations.
7. No sleep
Sleep is necessary for healing. Aside from our heart beating and our lungs breathing, sleep may be the most crucial bodily function we have for both physical and mental well-being. However, sleeping requires feeling safe enough to allow yourself to be unconscious and vulnerable. Children with RAD do not do vulnerable. Children with RAD are hypervigilant.
When I say Joe didn’t sleep, I don’t mean he had trouble sleeping or he only slept a few hours a night. I mean he didn’t sleep. He sat up cross-legged in his crib all night long. He also did not nap. His older brother, on the other hand, was then and still is a sleeper. He slept 10 hours at night and took 2-3 hour naps each day. As a 15-year-old now, he is asleep by 10 pm and wakes on his own for school each morning.
When Joe was 3 years old, he was sick with a high fever. Even then, he did not sleep. He lay on the couch. But he did not sleep.
We tried melatonin and over-the-counter sleep aids to no avail. His psychiatrist eventually put him on prescription medication to help him sleep. Even then, with great effort and grogginess, he was able to keep himself awake through sheer willpower most of the time.
8. Indiscriminate use of the word mommy
A securely attached child learns that the labels mommy and daddy both refer to specific people and mean something important. They recognize these words as their own safe people who meet their needs and protect them. And those labels are only used to apply to those specific people.
When our youngest son was about 11 months old, our nanny had a baby. One day, I was holding the baby and my youngest came up to us, smacked the baby, and said, “MY mommy!” While I wasn’t happy that he smacked the baby, I was so relieved that he viewed me as his mommy.
Children with reactive attachment disorder learn something very different about the labels of mommy and daddy. It is not uncommon for children with RAD to call new caregivers mom and dad immediately, before any sort of trust or bond has time to form. This can be mistaken as a positive sign. However, it is one of the most common red flags.
In our case, both of our older boys initially called every middle-aged woman mommy. They had no attachment to the word or the person who made that word special and exclusionary. I tried to encourage them to call people, especially me, by their first names. But it didn’t stick.
We started adding first names after the word mommy. So, they had Mommy Jane and Mommy Sarah, and Mommy Jenny. Eventually, with time and work helping them define the word, their biological mother and I became the only people they referred to as mommy.
Joe, however, then began mommy shopping. Whenever he was upset with me, he yelled that he wanted a new mommy. He would walk up to strangers and ask them to be his new mommy. Because we had worked so hard at establishing the importance of the role of mommy, he knew asking for a new mommy was hurtful to me.
Children with RAD desperately do not want to need others or crave their approval or love, especially from their primary caregivers. Joe had previous experiences with multiple mother figures, so of course he wanted a new one when he felt too vulnerable with me.
During an assessment when he was 10 years old, when asked if he wanted his biological mother or me to be his mom, he responded without hesitation, “I don’t want any mom. They just get in the way of what I want.”
9. Unusual potty training and subsequent regression
Children have few things in their lives they have complete control over. Eating or not eating is one. Bodily functions are the other. A child who desperately wants or needs control to feel safe will exhibit maladaptive behaviors involving one, if not both, of those things.
A child with reactive attachment disorder may refuse food from a primary caregiver but gladly accept it from another person. Or they may refuse to eat around other people. Both of those are red flags. Joe had issues with sneaking, stealing, and overindulging in food. But refusing food was never an issue. He did, however, have red-flag behaviors involving bodily functions.
When our boys came to live with us, they were all in diapers. While my husband and I did not have previous experience with potty training, the most prevalent advice we received was that the child will tell you when they are ready to learn.
We began potty-training our oldest when he was 3.5 years old so he could attend school. We rewarded him with one M&M every time he went in the toilet. Upon seeing his brother potty train, Joe seemed very interested in learning as well. So, we began potty training him as well.
Children with RAD desperately do not want to need others or crave their approval or love, especially from their primary caregivers.
Our oldest eliminated completely and accepted his one M&M. But Joe would let out two drops of urine multiple times an hour just to get the M&M. As our oldest began to recognize body signals, we gradually removed the M&M reward. He continued to use the toilet appropriately.
When we tried to wean Joe off the M&M’s, he immediately regressed to wetting and soiling himself. We assumed it was because of his young age. He was, after all, only 2.5 years old. We continued to use the M&Ms every now and then checking to see if he would maintain potty training without the reward.
When it was time for Joe to go to school, he had to be fully potty trained. He seemed enthusiastic about the idea of riding the bus and going to school and began using the toilet consistently without a reward. It was going well until a week before school started.
He defecated in the HVAC vent in his room. It took three days to find the source of the smell. I removed the feces from the vent and emphasized the need to properly use the toilet so he could go to school, something he claimed he really wanted to do.
Unfortunately, he did it again. And, unfortunately, I didn’t respond well to it the second time. He learned defecating outside the toilet is one of the few things that will make me angry. From that point on, he regularly weaponized his bodily functions. And not just with me. When he was upset with the nanny, he would urinate all over the kitchen and then laugh at her as she cleaned it up.
He hid soiled underwear all over the house. I found them in kitchen cupboards, under the couch, and between clean towels. One day when he was around 9 years old, he threatened to smear feces on his brother’s walls in the morning. Later that day, during the few unsupervised minutes he had, he followed through. His younger brother came home to find it all over his walls.
As effectively as Joe used his bodily functions to maintain emotional distance from his family, he didn’t need to maintain distance in hospitals and residential treatment centers that had multiple caregivers and rotating staff. Therefore, when he wasn’t living in our home, he didn’t exhibit any maladaptive behaviors involving elimination.
10. A seeming lack of a learning curve
A common complaint I and other parents like me often have is that our child with reactive attachment disorder never seems to actually learn anything.
One day they can tie their shoes, the next they can’t. One day they know how to read, the next they can’t. One day they can recite the rules verbatim and give examples of where they have broken them. The next they don’t remember the rules and are innocent of all wrongdoing. One day they execute a perfect apology, the next they are cackling as they stomp on their brother’s hand. As a parent, this is crazy-making and leads to a sense of futility.
Our oldest son, who no longer qualifies for the RAD diagnosis, has learning disabilities in math. His early school years were torture for both of us. Math homework led to spectacular meltdowns. What should have taken 20 minutes usually took upwards of three hours. Most of my focus during those years was working on his refusal to accept help and take breaks when he was emotionally distraught. I never praised him for good grades. But I went overboard praising and thanking him when he asked for help or when he voluntarily participated in breaks. Now, at 15 years old, he still struggles with math. However, he willingly participates in tutoring, asks for help, takes breaks when he’s overwhelmed, and is proud of himself when he does well.
Unlike our oldest son, we were never able to determine if Joe had any learning disabilities. Did he struggle academically because he couldn’t, or wouldn’t, do well? It was the same question I had when trying to teach safe behaviors, empathy, and basic life skills.
The first time Joe took an IQ test, he tested incredibly low. So low, in fact, that the examiner decided to retest. The second time around, the examiner gave Joe a reward for every question answered. That test showed he had an above-average IQ. Nearly every test done over the years came back with the same qualifying statement, “These results are unreliable due to the subject’s unwillingness to participate.”
By the time Joe was in sixth grade, he was so far behind academically that we hired a tutor. Three tutors quit before we gave up. He spent the sessions probing into their personal lives, acting defiant and threatening them. Occasionally he simply turned off the computer and walked away.
Over the years, I’ve concluded that my son absolutely does have a learning curve. However, it is not for the socially responsible and relationally oriented outcomes I wanted for him. It is for the pure survival mode he is tragically stuck in. For that reason, his learning curve involves all things that will keep others at a distance.
He learned the rules to break them. He learned how to read people to manipulate them and keep them at bay. He learned the system to exploit it and maintain control. He learned what he needed to learn to ensure a false sense of invulnerability and control. And there were no boundaries he would not cross to maintain that control.
When red flags matter for kids with reactive attachment disorder
I’ve spent a lot of time regretting things I did or didn’t do for my kids. I think lots of moms do. But, looking back, I ultimately wonder if anything would’ve made a difference. After all, six professionals did diagnose Joe with reactive attachment disorder. But still, not many people knew how to help.
Nonetheless, I still wish we would’ve recognized Joe’s diagnosis earlier. Maybe I would’ve felt less crazy. Maybe it would’ve led us to the people that have helped, like RAD Advocates, sooner. Maybe my family would’ve gone through less turmoil as a whole.
Every family’s journey through reactive attachment disorder is different, yet many are very similar. Based on the RAD parents I’ve encountered, many paths usually include confusion, loneliness, and pain. Everyone in the family is impacted in one way or another.
Maybe we can’t prevent the heartache. But, hopefully, our journey can help another family feel a little less of it. And that makes a difference to me.
*Name changed to protect the identity of the person
The DSM-5 includes the following criteria for a diagnosis of reactive attachment disorder:
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
The child rarely or minimally seeks comfort when distressed.
The child rarely or minimally responds to comfort when distressed.
B. A persistent social or emotional disturbance characterized by at least two of the following:
Minimal social and emotional responsiveness to others
Limited positive affect
Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults
Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios)
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder.
F. The disturbance is evident before age 5 years.
G. The child has a developmental age of at least nine months.
Photo by Priscilla Du Preez on Unsplash