EVIDENCE IN-BRIEF Best practice guidelines for treatment of reactive attachment disorder MAIN MESSAGES OVERVIEW • Reactive attachment disorder (RAD) is thought to develop in children demonstrating a disorganized style of attachment with their caregiver and is related to the development of psychopathology later in life. Reactive attachment disorder (RAD) is diagnosed in children who demonstrate disturbed or developmentally inappropriate social relationships and have a history of pathogenic care. RAD is thought to be linked with the disorganized style of attachment and related to the development of psychopathology later in life. • An important practice in the treatment of RAD is to improve the relationship between the child and parent or caregiver. • Recommended practice parameters in assessing and treating RAD include ensuring that direct observation of the child with the primary caregiver is structured, so that patterns in child behaviour can be observed. TREATMENT AND BEST PRACTICES Interventions exclusively targeting RAD are limited. There are, however, some well-supported interventions that do not specifically focus on RAD but do centre on improving the child-parent relationship – a best practice treatment recommendation. Common themes for treatment include focusing on improving the child’s understanding of emotions and social cues, working on behaviour management and recognizing culture as an important consideration, especially in the case of international placement or adoption. In 2005, the American Academy of Child and Adolescent Psychiatry published practice parameters on the assessment and treatment of RAD. Practice recommendations include ensuring that assessment involves direct observation of the child with the primary caregiver, as well as unfamiliar adults and other adults who may be able to attest to the child’s early relationship with the caregiver (pediatrician, case worker, school employee and others). Initial observations should be relatively structured, so that patterns in behaviour with multiple adults can be observed. It is important also to gather a history of the child’s attachment behaviour. Evidence In-Sight is a free service that responds to practice-related questions from Ontario child and youth mental health agencies. Evidence-In-Brief summarizes those answers to provide a snapshot of available knowledge on a particular topic. The information is not exhaustive, and is intended to support – rather than direct – evidence-informed decision making. The Ontario Centre of Excellence for Child and Youth Mental Health is pleased to offer these products as part of our continuum of practical tools and resources designed to help agencies use evidence to strengthen care. Reactive attachment disorder continued Assessing the caregiver’s attitude toward, and perception about, the child is important for treatment selection. Parents may react with anger or anxiety because of their child’s maladaptive attachment behaviour, which may affect their style of discipline and further escalate the problematic relationship. After ensuring the child is in a stable and safe environment, treatment should focus on creating positive interactions with caregivers. There are three options for intervening to improve interactions between the child and caregiver: working with the caregiver alone; working with the child-caregiver dyad; or working with the child alone. Since RAD may result from pathogenic care, the child could be at risk for other conditions such as developmental disorders, untreated medical conditions, or speech and language difficulties. Referral to other professions for medical examination is a recommended practice. Children who display aggressive or defiant behaviour may require adjunctive treatment. Parent education or even multi-systemic therapy used for the treatment of aggression in oppositional defiant disorder may be useful. For the full Evidence In-Sight report on treating reactive attachment disorder, please contact Valerie Repta. See the full list of Evidence In-Sight reports available on our website. SUGGESTED KEYWORDS Reactive attachment disorder, best practice, treatment guidelines, attachment disorders, treatment for attachment disorders, RAD