The Problem with RAD {EP 112}

I'm so confused about the RAD diagnosis, my son's therapist suggested it, but everything I read online is super scary and hopeless. Can you please help?

Okay, yeah, so RAD, which stands for reactive attachment disorder, the diagnosis of RAD is indeed really controversial. In fact, I sat in a lecture with Dr. Dan Siegel, I don't know over a decade ago, at this point, where he stated that RAD is extremely rare and extremely over diagnosed. Yet, for families living with a child who has the kinds of behaviors that would lead to a diagnosis of RAD life can be a nightmare. It can be lonely, isolating traumatic, it's can be dangerous.

And when I talk about RAD and the problems with the RAD diagnosis, I don't want to minimize that at all, I absolutely am not going to contribute to the minimization of the gaslighting of families who are living with kids who have these behavioral symptoms. So I want to acknowledge that and then also go back to the listeners question, right, their feelings about being confused and feeling scared and hopeless, because everything they're reading online about RAD is scary and hopeless.

And that is why RAD is a diagnosis that I don’t actually think I've ever given. Sometimes kids would come to treatment with me, and they already have that diagnosis. But that's not a diagnosis I think I've ever given. And it's also not a diagnosis I ever talk about. I mean, I don't know that I've ever even talked about RAD on the podcast, and with the families that I've worked with, I talk about RAD, typically only when it comes up or when they're asking me a question that sounds a lot like this one, like somehow they've stumbled across the diagnosis of RAD, or maybe somebody else has suggested it to them.

And then they go to Google. And they start searching, and they're terrified. And that's because the information that you find online about read when you start Googling is super outdated. It is not based on what we understand about neuroscience, and the impact of trauma on attachment, and what behaviors really are. And frankly, a lot of the information you can find online is dangerous. It's suggesting outdated, and dangerous treatment interventions, both clinically and parenting.

So let's look a little bit more at what does it mean to get a diagnosis of reactive attachment disorder and why this can be a challenging diagnosis, even if it is accurate. So implicit in the idea of reactive attachment disorder is the fact that there has been trauma inside the developing attachment relationship in the field and the study of attachment, the language we use to talk about what happens when trauma occurs inside the developing attachment relationship is disorganized attachment. It's one of the categories of attachment. And it's developed when there is trauma inside the attachment relationship.

Let's back up just a tiny, tiny bit here. John Bowlby, who mostly is recognized as kind of the father of attachment theory, he identified three attachment behaviors, and we're not going to go a ton into this I can give you places to go where you can dive into this further, but I think this is important to contextualize what we're talking about. So these three attachment behaviors, one to seek, monitor and maintain caregiver proximity to to use the caregiver as a secure base. To be able to have the curiosity to go out and explore the world, and three to flee to a caregiver when distressed. All of those pieces are important when thinking about attachment and categories of attachment and disorganized attachment in particular.

But what I want to talk about today in this short episode, is that disorganized attachment happens when the caregiver is who is what's causing the distress. They're causing the distress and the child either by being scary, like abusive or emotionally weak or absent, either physically or emotionally absent. And all of those circumstances abuse, physical or emotional absence, being emotionally weak, all of those circumstances would cause distress in a child, right? But one of the attachment behaviors is that kids flee to their caregiver when they're distressed. So they flee to their caregiver because they're distressed, but it's the caregiver who's the one who is causing the stress.

Now, I did an episode about disorganized attachment like year and a half ago, and then it's contributed to the creation of my brilliance of attachment ebook, so you can go check out those resources. To understand more about disorganized attachment, Robyn gobbel.com/disorganized attachment, or just go get the whole ebook, which is Robyn gobbel.com/ebook.

Kids diagnosed with reactive attachment disorder certainly have disorganized attachment. Now, disorganized attachment is not a diagnostic category, you don't go to the diagnostic and statistical manual of mental health disorders, the DSM, and find disorganized attachment is not something that a clinician can diagnose, and then treat, it's a way of viewing and seeing and understanding attachment behaviors is not something we can use for clinical diagnosis. reactive attachment disorder is then what can be used as a clinical diagnosis.

But something really important happens when we say RAD or reactive attachment disorder instead of disorganized attachment. I think it's that we inadvertently focus on the result, instead of on the cause. We talk about disorganized attachment, I think it's a little easier to remember what caused the problems that we're seeing now. And maybe it's just simply because for whatever reason, the language disorganized attachment hasn't received the level of stigmatization that the label reactive attachment disorder has. But for whatever reason, I have found that staying focused on disorganized attachment helps us stay focused on what caused the behavioral symptoms, as opposed to when so often when folks are using the diagnosis of RAD. What we're thinking most about is the symptoms.

Okay, so now in order to manage the intensity of the internal distress, that has absolutely no solution, or soothing, which is what caused the disorganized attachment in the first place, in what is a woken in the moment when kids are demonstrating the behaviors of disorganized attachment or they're having the behaviors that folks often are labeling, reactive attachment disorder, right, that's about internal distress that has no solution are soothing. And so yes, that results in really, really bizarre ways of behaving, kind of in general, but definitely behaving in relationship.

These kids also missed out on a ton of experiences that aid in the development of relational skills, like empathy, for example. They get really stuck in what we call here on this podcast protection mode, because everything is dangerous, including connection, so their nervous system is constantly operating in protection mode.

So Bessel Vander Kolk, who is the author of the Body Keeps the Score you may have heard of Bessel Vander Kolk. He introduced the idea of complex developmental trauma, which really does feel like from a treatment provider standpoint, like I'm a treatment provider, I was a treatment provider. Complex developmental trauma has just always felt like a much more accurate way of describing or categorizing kids who ultimately have disorganized attachment. developmental trauma disorder has seven different what ventricle calls domains of impairment and includes things like cognition and biology and sense of self and yes, attachment is one of the was seven domains of attachment. But that's an really important piece of this. It's just one of seven domains of impairment.

So complex developmental trauma disorder, when we think of that as a diagnosis instead of RAD is a much more accurate and comprehensive assessment of a child to has the kind of behavioral symptoms and the history that would lead to a diagnosis of reactive attachment disorder. Attachment is just one piece of developmental trauma disorder. But with rad and the diagnosis of RAD attachment is the focus. I mean, it's not even just the focus, it's all that's being considered. And developmental trauma disorder, we are going to continually reorient back to the cause, which helps us remember what is needed in treatment, which is safety, presents, and CO regulation. Children's in Yeah, adults too. But we talked about children here with disorganized attachment can have behaviors that are harmful, both to themselves and others, physically harmful. And of course, relationally harmful, they severely lack the ability to regulate themselves, and they don't trust other people to be safe, and to offer them the CO regulation that they're really quite desperate for. Yet, at the same time, connection remains their biological imperative. They're terrified of connection, and in many ways convinced or only know that connection is going to hurt and maybe kill them. Yet, at the same time, connection remains their biological imperative. They literally need something to survive, that they also believe, could kill them. So yeah, of course, that leads to bizarre, chaotic, overwhelming harmful behaviors.

But the treatment is to treat the trauma, to offer safety, connection and CO regulation. And then yet to do this in a way that's titrated, because too much connection feels dangerous. So rad, as a diagnosis can actually feel so relieving to a family. Receiving rad as a diagnosis might be the first time a family feels really seen and believed about the chaos that is just completely consuming their lives, it might be the first time that they aren't blamed for all of their problems, or told that they're making it all up. And it might be the first time that their services could actually get paid for, but also can send that family to Google, and then down a rabbit hole of more terror as well as down a rabbit hole of tactics and techniques that do not help. In fact, they are harmful. Being in a relationship with a kid with organized attachment causes so much chaos, that these parents are vulnerable to falling victim to experts, so called experts, I've got air quotes going, who are ultimately are recommending coercive and controlling treatment tactics. Again, clinical tactics or parenting tactics. And the parents who kind of fall into this aren't bad parents, they're desperate parents, the cast that they live inside of is desperate for any kind of just coherence or organization and, and sometimes that can just lead them very, very vulnerable to believing these controlling and honestly at times abusive tactics, that they're the right approach. But the treatment to trauma, which is why I like to like to stay focused on the developmental trauma disorder and the disorganized attachment.

The treatment to trauma is never ever anything but safety. I'm not going to pretend at all that this is easy. Offering safety presents connection co regulation to somebody whose nervous system is trapped inside disorganization and then has bathed viewers. Right behaviors are just what we see on the outside that lets us know about what's happening on the inside. And so these are disorganized and chaotic, out of control dangerous behaviors, right? It is not easy, right? Like parenting, these kids can feel impossible. Right? And I'm definitely not talking about how to treat rad in a short little q&a episode, but I can say with certainty, the treatment for relational trauma, which is what's underneath reactive attachment disorder is never ever coercive control and manipulation. So unfortunately, that is the problem with a bad diagnosis.

So if you have a RAD diagnosis for your child, use that diagnosis to get you the services your family needs. But do this while staying really focused on the underlying trauma, which means seeking treatment providers who can navigate the complexities of RAD diagnosis and still remember what's underneath that diagnosis, which indeed is the trauma. If we can remember that it was coercive and manipulative, dangerous and dissociated experiences that caused the attachment disorganization in the first place becomes much much, much easier to remain clear.

And committed to the fact that coercive and manipulative practices could never treat attachment disorganization. Kids with the kinds of histories and behaviors that leave them diagnosed with rad are very hard to be in relationship with. I know that I am not pretending for a second that it's not. But we have to stay focused on the trauma.

One other thing that I have found that can come along with a RAD diagnosis is that it makes it really easy for us to overlook and disregard and not pay any attention to other contributing factors for the challenging behaviors, which could be things like fetal alcohol, right or other nervous system vulnerabilities, like pans, or pandas. And we just get so myopically focused on on the attachment trauma and those behaviors that we miss treating, or noticing or assessing for her compensating for very important, brain based differences.

Y'all kids with disorganized attachment absolutely can have destructive and dangerous behaviors. I definitely never want to contribute to the gaslighting of these families or, or to the family who wrote in with this question, right families who are dealing with behaviors that really truly most people can't even begin to comprehend. We can recognize the truth in that while also holding close to the reality that our attachment systems are brilliant and adaptive. Kids with disorganized attachment act in bizarre ways, because they expect relationships to hurt them, yet they need relationships to survive. As hard as it is. The first step is always to recognize that all behavior makes sense. These kids are doing exactly what they believe they need to do in order to be okay. We want to look at this through the lens of disorganized attachment inside the overall diagnosis of complex developmental trauma. And yeah, we can do that while using rad as a diagnosis. Again, sometimes that's the only way we can get treatment kind of paid for. Right. But if RAD is the diagnosis, still take a step back from that. So constantly taking a step back from that, and reminding ourselves what that means. It means disorganized attachment, it means trauma, terror, despair, inside early attachment experiences, that helps us remember what the treatment is. Connection, safety, co regulation presents, and again, y'all I'm not pretending that this is easy.

Okay, so if you want to learn a little bit more about attachment and disorganized attachment, you can go to my episode about disorganized attachment Robyn gobbel.com/disorganized attachment, you can just go right to my full eBook Robyn gobbel.com/ebook. In the show notes for this episode, I'll put some links to Dr. Bessel. Vander Kolk says complex developmental trauma disorder white paper, so that if you want to you can learn a little bit more about that. So in summary, if you have a child who has a diagnosis of RAD, or has somebody suggesting that they may have rad, I want you to take a breath, and then I want you to not Google reactive attachment disorder. Instead, I want you to Google complex developmental trauma disorder, or helping kids with disorganized attachment, something like that. Stay focused on the trauma. It's not easy, but it is the right path.

All right. Thanks for joining me on this extra bonus episode of the parenting after trauma podcast. We have four Fridays in February so I'll be doing for you q&a. This is number two. On a regularly scheduled Tuesday podcast. We're in the middle of a big series on boundaries, which I'm really excited about. So make sure you're checking out that series as well. And I will see you back here next week for next week's q&a. The absolute best way to make sure that you do not miss an episode of the parenting after trauma podcast is to go to your podcast app and hit subscribe. That way you'll be notified of every new episode that comes out, always on Tuesdays sometimes give you a bonus on Fridays. Alright y'all, I'll see you next time. Bye.