Over the years I have treated many children with reactive attachment issues and, while sometimes heartbreaking, there is also a great deal of joy in the work. Reactive Attachment Disorder (RAD) is a cluster of behavioral and emotional issues that are believed to relate to a child’s lack of appropriate early bonding with a primary caregiver. RAD is often what is going on when a child asks if I can be his mommy during the first session, or when a child makes little or no eye contact and behaves as if he doesn’t want to interact with me. Usually with RAD, there are clear markers in the child’s history — sometimes in utero, sometimes after birth in the first three years — when there was no stable primary caregiver.

It happens a lot with foster children, naturally, if they have been moved around a lot, or if their reunification plans with bio family keeps falling through. I also think there is an argument to be made that reactive attachment can start off in utero, when a child is exposed to high levels of stress hormones. Mark Brady, PhD, has a great post in which he describes the developmental problems resulting from neglect and early stress. He quotes Dr. Bruce Perry, author of The Boy Who Was Raised by a Dog, talking about how the human brain responds to childhood neglect:

“As you grow, the brain is essentially like a sponge. It’s absorbing all kinds of experiences. So if a child is not held, touched, talked to, interacted with, loved, literally neurons do not make those connections, and many of them actually will die.”

“Big, big ventricular spaces (show up in stressed out kids), which will impact sleep, regulation of anxiety, regulation of mood, whether or not you’re very happy or sad.”

“Simple things like eye contact, touch, rocking and humming can make all the difference to a baby. It makes neurons grow, it makes them make connections. Then, it makes the brain more functional.”

One of the most impactful experiences I have had working with a RAD client was working with a little boy who had been raised for his first three years in an extremely neglectful environment — to the point where when he was moved to foster care, he did not know how to play other than to lay on his belly on the floor and put his fingers in front of his face and move them around. There were very few toys in his early home, and even less of a primary person paying attention to his needs and giving him the closeness he would need to understand the world emotionally. He had come a long way by the time I was seeing him, could play and interact with others, had probably quadrupled his vocabulary in the year he had been in a stable home, but he was still a very skinny kid with rotted teeth that had to be capped and lots of ear infections and other illnesses constantly weighing him down.

Part of my message to RAD kids is the constant reminder to them (and to their brains!) that they are growing, expanding, developing, changing, become whole, becoming strong. I say these things not only because they are true but also because they are the mantra of our shared hope — that their growth will now take place, that they will be able to make up for lost time and accelerate fast enough to get the ABC’s and color identification and some decent social skills in before kindergarten starts. And most of all, because I want them to know that I see them. I see them. They are here.

The importance of this knocked my socks off one day in session with this little guy, who I’ll call James. I was giving him the message that he was growing, asking him how old he would be turning on his next birthday, reinforcing that he would soon be in kindergarten, when suddenly James said, “When I was a baby, I was invisible. Now that I’m older, I have skin and bones.”

“Indeed,” I said, to draw out the moment. “And you have your whole body. And you’re growing bigger all the time.” When I had James create himself on “Mi” on the Wii (I did the controls as he was behind most kids on video game skills) he created a person who was as tall and big-boned as possible, with a big head of black hair. He wanted to be big. And compared to how small he had been made to feel in his birth home, he was indeed a big guy now.

We all need closeness in order to know we exist. If no one knows who you are, knows you internally, knows your needs and how to fill them, you grow up feeling invisible. Anyone who has ever been in a situation where everyone around them was deliberately ignoring them knows how awful it is to feel invisible. Imagine this being the world you are born into. Imagine how devastating that would be.

The good news is that most of us are not born into such cruel environments. Even in families where there is physical and emotional abuse, there is often still a sense of attachment for the child — that their needs are still very high on the list of things that get taken care of. It was enlightening, but also frightening, working with James — realizing just how powerfully he was experiencing the arrival of his identity, and how much catching up there was to do.