Parallel lives: a case series of three boys with persistent reactive attachment disorder

Reactive Attachment Disorder (RAD), only diagnosed in the context of early abuse and neglect, is characterised by failure to seek and accept comfort. It involves lack of activation of the - developmentally essential - attachment system, hence has profound developmental disadvantages. RAD usually resolves quickly in the context of adequate care and has been assumed never to persist once the child is in a nurturing placement. We challenge this existing paradigm by presenting three cases of children whose RAD symptoms have persisted despite living in placements judged, by both social and child health services, to be of good quality. All three boys met DSM 5 criteria for RAD in late childhood/early adolescence and had had stable RAD symptoms since before age 5. In the absence of longitudinal data, except from unusual institutionalised samples, it has been impossible to evidence RAD beyond pre-school and virtually nothing is known about factors predicting its stability. This case series and systematic review provides the first opportunity to generate testable hypotheses about environmental circumstances and coexisting symptomatology that may influence RAD trajectories. As predicted more than a decade ago, persistence of RAD has had profoundly negative developmental implications for the children and an extremely detrimental effect on family life and relationships. Recognition of RAD symptoms is challenging because symptoms are classically internalising and therefore easy to miss. This case series will allow paediatricians to better recognise the subtle symptoms of RAD in order to improve their care of these children and their families.