Can reactive attachment disorder persist in nurturing placements? A systematic review and clinical case series

Reactive Attachment Disorder (RAD), is characterized by failure to seek and accept comfort in maltreated children. This lack of activation of the attachment system has profound developmental disadvantages yet, in early childhood, usually resolves quickly after placement in nurturing care. Persistence of RAD into middle childhood has been demonstrated in children reared in Romanian Institutions but, in family-reared children older children, there is controversy regarding whether RAD-like behaviors are genuinely attachment-related and stable from early childhood or are, in fact, related to PTSD. We conducted two pieces of research to investigate this: 1. a systematic review to examine persistence/resolution of RAD and 2. a case series of three boys whose RAD symptoms persisted despite living in placements judged by both social and child health services to be of good quality. Our systematic review revealed a paucity of longitudinal data. Except in atypical institutionalized samples, RAD had not been evidenced beyond pre-school. All three boys in the case series met DSM 5 criteria for RAD in late childhood/early adolescence and had stable RAD symptoms since before age 5. Qualitative interviews with their families revealed common themes of family strain, frustration and resentment at the lack of support from services. This paper provides the first opportunity to generate testable hypotheses about environmental circumstances and coexisting symptomatology that may influence RAD trajectories. Persistence of RAD has profoundly negative implications for children and their families. Recognition of RAD symptoms is challenging but crucial in order to improve care of these children and their families.