When reactive attachment disorder looks like something else and the medication consequences
Updated: Sep 1, 2021
As parents of kids with reactive attachment disorder (RAD), many of us are familiar with the litany of diagnoses that tend to get tagged on and the roller-coaster of trying to find medications that help. It’s frustrating and rarely effective.
While all children with reactive attachment disorder need effective therapeutic support, some find relief much faster with the help of appropriate medication. Getting the right medication begins with the right diagnosis. To the surprise of many parents, this combination is not easy to find.
RAD Advocates guides parents who have a child with reactive attachment disorder. Learn more.
John F. Alston M.D. is a child, adolescent, family and adult psychiatrist with a significant national reputation within the attachment community. He has an approach to diagnosis and medication management that has proven effective as he’s evaluated and treated over 3,000 patients with disruptive behavioral disorders associated with early life abuse and neglect.
Dr. Alston has published several articles in medical journals and a book chapter emphasizing the co-existence of childhood mood disorders, especially bipolar disorder, with reactive attachment disorder. He’ll be speaking on “Co-existing Disorders with RAD and their Effective Medical Treatment” at the first-ever Navigating RAD 2021 conference, to be held Aug. 20-21, 2021, in Denver.
How diagnoses go awry
When psychiatrists and psychologists see a history of trauma, they often diagnose post-traumatic stress disorder (PTSD).
“Reactive attachment disorder is a PTSD of infancy and toddlerhood,” Dr. Alston says.
To understand why the PTSD diagnosis alone doesn’t quite fit for children with RAD, however, one must consider human nature. Humans survive through adaptation to their environment. Pain avoidant is the most crucial form of adaptation. “All living things need to avoid pain before they do anything else,” he says. “By avoiding pain, their chances of survival are pretty good.”
A true diagnosis of PTSD with RAD would imply the child would naturally prioritize self-protection and be overly compliant to avoid pain. “If you are scared, you’re going to do what that authority tells you to do,” Dr. Alston says. “Yet, most kids with RAD have substantial overt defiance, overt opposition and overt aggressivity. This makes no sense in terms of PTSD.”
That opposition comes from somewhere other than the PTSD. Because many children with reactive attachment disorder were abused or neglected, Dr. Alston believes the key to an accurate diagnosis and treatment can be found in looking at birth parents’ history, behavior and ultimately genetics.
“The number one diagnosis of abusive parents is alcohol and substance abuse,” Dr. Alston says, adding that drug abuse has a high correlation with bipolar disorder, a mood disorder that is genetic, inherited and runs in families. “It consists of fluctuating moods between hypo-mania (high-energy, high-motivation, opposition, controlling, grandiosity, a mood of exceptional self-importance) coupled with fluctuating or simultaneous moods referred to as dysphoria (negativity, pessimism, being hard-to-please or satisfy, self-doubt, low-motivation).”
He continues, “These abusive parents not only have histories of mental illness, but these histories include opposition, defiance and severe mood swings.”
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Kids with reactive attachment disorder are commonly misdiagnosed with depression with PTSD, but may actually have bipolar disorder. Historically people tend to seek treatment when they’re in a low-energy, low-mood, low-motivation, low-enthusiasm place.
“So many doctors prescribe antidepressants, medications commonly prescribed for depression and PTSD,” Dr. Alston says. “The worst medications for someone with bipolar disorder to be on are antidepressants. They accentuate both the mania and rapid cycling (a rapid shift of mood). There is also a wrongful belief that antidepressants relieve aggression, which they do not.”
Many psychiatrists believe bipolar disorder is either extreme up or down moods without realizing that the overwhelming number of people with bipolar disorder have a “mixed” disorder—meaning one has both sets of symptoms at the same time, Dr. Alston says.
He says that other, less common correlations with child abuse include parental diagnoses of antisocial personality disorder, borderline personality disorder (many are actually bipolar), schizophrenia (especially paranoid), and Autism Spectrum Disorder. But the two that tend to be most linked in Dr. Alston’s experience are alcohol and substance abuse with mixed bipolar disorder.
“If you take your child to a child psychiatrist, they often don’t seem to consider the genetics of birth parents,” Dr. Alston says.
“While these kids have a PTSD history, their symptoms are not of PTSD. They are not pain-avoidant, isolative or withdrawn,” Dr. Alston says. “Their symptoms are of bipolar disorder. One has to treat the symptoms not the history. Until we start looking at these kids as having bipolar disorder and putting them on medications that are consistent with bipolar, they don’t get better.”
Another common mistake with children with RAD is medicating for attention-deficit/hyperactivity disorder (ADHD).
“Stimulant medications are also commonly prescribed for RAD kids with opposition and defiance,” Dr. Alston says. “The most common medications prescribed for RAD kids are antidepressants and stimulants—the two worst medications a kid with bipolar disorder can be on. Stimulant medications may help them focus slightly better, but if you look at symptoms, they’re all intense kids. Their moods are intense. Stimulant medications primarily make the intensity and mood swings worse.”
A different approach to medication
Back in the mid-1990s, Dr. Alston started treating kids with RAD symptoms of mood intensity, opposition, and verbal and physical aggressivity with medications for bipolar disorder. “They started to get better within days to weeks,” he says. “I’ve been prescribing more effective and appropriate medications ever since and writing about it.”
At the conference, he’ll be providing a handout about the characteristics of ADHD vs. RAD vs. bipolar disorder. “A high percentage of these kids will match the characteristics of bipolar disorder even more than RAD,” he says. “Once these kids are prescribed mood-stabilizing medications and atypical antipsychotic medications, they tend to improve quickly and be much more receptive and responsive to treatments for their RAD.”
The hardest part of his lengthy career has been the fact that most psychiatrists don’t understand this approach, and bipolar is significantly under-diagnosed.
What can parents do?
If this scenario sounds familiar, and the medications you’re using aren’t working, you can try educating your psychiatrist on this approach as a possibility for a medication trial.
In addition to sharing this blog, you can share his other publications.
Dr. Alston’s 1996 article from Attachments can be found here:
And his 2007 article from Psychiatric Times can be found here:
https://www.psychiatrictimes.com/view/complex-issue-attachment-disorders
He also published a book chapter on the subject:
https://www.sciencedirect.com/science/article/pii/B9780124458604500095
A trial of medications like Abilify and Lamictal may produce positive results once they reach therapeutic levels. This therapeutic level is important because prescribers will often prescribe the right medication (Abilify is a good example), but at such low doses as to be ineffective.
“Abilify is an atypical antipsychotic medication that treats the hypo-manic side—the emotionally intense, aggressive, oppositional side,” Dr. Alston says. “Lamictal is a mood-stabilizing medication that stabilizes mood and elevates mood so they’re less dysphoric. They’re in a better mood. They’re more receptive, responsive and agreeable. The combination of these two medications and some others help these kids significantly. Within two to four weeks, most are substantially improved.”
Medication alone isn't the answer to reactive attachment disorder, but the right diagnosis and medication can sure help to set kids along the path of least resistance toward therapeutic healing.
RAD Advocates guides parents who have a child with reactive attachment disorder. Learn more.
About the author:
Micaela Myers and her husband adopted a pair of siblings from foster care in 2015, when the children were 9 and 13. Since then, she has become an advocate for foster care reform and the support and education of adoptive parents. Micaela earned her MFA in writing from Vermont College of Fine Arts and works as a professional writer and editor in Wyoming.