Reactive Attachment Disorder

Reactive attachment disorder (RAD) is a rare condition of emotional dysfunction in which a baby or child has difficulty forming a bond with parents or caregivers due to early neglect or mistreatment. The symptoms of RAD can mimic other conditions, so it is important to have the affected child evaluated by a specialist in order to get the correct diagnosis and treatment. Without treatment, RAD may persist for years.

Symptoms

Children with Reactive Attachment Disorder, as defined by the DSM-5, exhibit:

  • A consistent pattern of inhibited and emotionally withdrawn behavior toward caregivers; only occasional or minimal signs of seeking or responding to comfort when distressed
  • At least two of the following:
    • Minimal social and emotional responsiveness to others
    • Limited positive affect
    • Unexplained instances of irritability, sadness, or fear
  • A past experience of extremely insufficient care, involving at least one of the following:
    • Social neglect or deprivation, with basic needs for comfort, stimulation, and affection unmet
    • Repeated change of primary caregivers that limits opportunities to form a stable attachment with a caregiver
    • Growing up in an environment that seriously limits opportunities to form a stable attachment with a caregiver

In a child diagnosed with RAD, the experience of insufficient care is believed to account for the subsequent inhibited behavior toward caregivers. A child who receives this diagnosis should have a developmental age of at least 9 months, and the symptoms should be apparent before age 5. The child must not meet the criteria for Autism Spectrum Disorder.

Causes

Infants and children whose basic physical and emotional needs are neglected may learn not to expect normal caregiving and comfort. The risk of developing RAD is higher than average in babies and children who have a mother with postpartum depression, live in orphanages and other institutions, live in multiple foster-care situations, are separated from parents for an extended period, or have neglectful parents or caregivers. 

Treatment

Symptoms of RAD may lessen or disappear completely when a child is moved to a consistently supportive and caring family environment or to caregivers who are emotionally available to respond to the child’s needs. Since children with RAD often have multiple issues, therapy and medical treatment may be advised to treat co-existing conditions. In some cases, attachment-based family therapy (ABFT) administered by a licensed, experienced therapist can help children and adults heal damaged family relationships and strengthen the parent-child bond. Medication may be considered when psychotherapy alone is not effective. 

Note: Attachment-based therapy as described here should not be confused with unconventional, unproven, and potentially harmful treatments that are also referred to as attachment therapy, which involve physical manipulation, restraint, deprivation, “boot camp-type” activities, or physical discomfort of any kind.

References

  • Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • Pritchett R, Pritchett J, Marshall E, Davidson C, Minnis H. Reactive Attachment Disorder in the General Population: A Hidden ESSENCE Disorder.
  • The Scientific World Journal. 2013. Article ID 818157.
  • Zeanah CH, Gleason MM. Annual research review: Attachment Disorders in Early Childhood—Clinical Presentation, Causes, Correlates, and Treatment. The Journal of Child Psychology and Psychiatry. March 2015;56(3):207-222.

Last reviewed 06/21/2017