Reactive Attachment Disorder is often caused by neglectful care of a child and results in them being unable to engage in social relationships or form emotional attachments with people.
For a child to develop secure attachment and form healthy relationships with others, they need to have stable, caring and sensitive parents or caregivers and a loving and nurturing environment. The quality of attachment between the child and the parent or primary caregiver affects the child’s future relationships and social success.
Attachment is essential in childhood development. It is a deep and enduring affectionate bond that connects one person to another.1 The quality of attachment between the child and the parent or primary caregiver affects the child’s future relationships and social success.2
Attachment theory explains why infants develop close relationships with their caregivers and how disturbances in such relationships affect normal development and individual differences in social, emotional and behavioural outcomes during infancy and early childhood.3
The primary function of the attachment system during infancy is to boost the safety and protection of the developing infant. During times of distress, infants want to be close to their caregivers. This closeness provides the infant with protection and security. As the infant grows to adolescence, they feel secure when they get a healthy dose of care, closeness, and attention. This leads to a secure attachment that allows them to form healthy relationships.3
What is reactive attachment disorder?
The Diagnostic and Statistical Manual 5th Edition (DSM-5) classifies reactive attachment disorder as a trauma and stressor-related condition of early childhood caused by social neglect or maltreatment.4 As a result, affected children experience difficulty bonding and forming healthy attachments. Children may be socially withdrawn and have trouble initiating and responding to social interactions.
The prevalence of RAD in the general population is unknown, as many cases don’t get reported, but RAD can occur in up to 1.4% of children.5
Causes and risk factors
Forming healthy attachments is vital for infants. Usually, infants move from responding to social situations where they react to smiling and facial expressions of caregivers to differentiating responses from known to unknown caregivers.
Infants become fond of the caregivers who provide support and guidance between eight months and three years. This forms the secure foundation in which they explore the world around them. During these early developmental stages, children view themselves as worthy of attention, praise, and love, which provides the basis for future positive relationships. When a child fails to bond with a caring adult, attachment becomes disordered, and the child may not be able to bond well or at all with other people.2
RAD is a disorder often caused by neglectful care and characterized by an inability of the child to engage in social relationships or form emotional attachments to others.2 Children who have experienced adverse neglectful caregiving environments or frequent disruptions in care have a high risk of RAD. 6
Symptoms and diagnosis
Your child’s doctor will ask about your child’s symptoms and medical history to diagnose reactive attachment disorder (RAD). The doctor may look for symptoms and patterns consistent with the Diagnostic and Statistical Manual 5th Edition (DSM-5), a professional reference on mental health and brain-related conditions.
Symptoms according to DSM-5 classification
According to DSM-5, the following are the criteria for diagnosis of RAD:4
- A chronic pattern of being emotionally withdrawn and inhibited, demonstrated by rarely seeking comfort or responding to comfort when distressed
- Evidence of a chronic social and/or emotional agitation characterized by at least two of the following: responding minimally or withdrawing socially to others, negative affect, unknown and unexplainable episodes of being irritable, fearful or sad, and inappropriate reactions to normal stress
- A history of extremely insufficient care caused by one of the following: deprivation or social neglect of basic emotional needs for stimulation, comfort, and affection by caring caregivers; the constant change of caregivers, resulting in a destabilized home environment; growing up in an unusual setting which limits the ability to form selective attachments
- The child doesn’t meet the diagnostic criteria for autism spectrum disorder (ASD). Both RAD and autism spectrum disorder are mutually exclusive
- The behavioural perturbation should manifest before the age of 5
- The child has a developmental age of at least nine months to qualify for the diagnosis
Differential diagnosis of RAD
RAD can be misdiagnosed as other disorders. That is why your child’s doctor will rule out certain disorders when diagnosing RAD. According to the DSM-5, your child’s doctor should rule out the following differential diagnoses before a diagnosis of RAD:4
Autism spectrum disorders
Children on the autism spectrum often show many of the same features as those with RAD but may also have a restricted range of interest, sensory processing difficulties (affects how the brain processes sensory information), and rigid adherence to rituals or routines.
According to DSM-5, diagnosis of RAD requires a developmental age of at least nine months. The child should be at least nine months before the diagnosis is confirmed. Secondly, another medical or mental health disorder must not cause social impairments. Your child’s doctor will rule out RAD if there are impairments in interests and desires attached to social behaviours commensurate with developmental age.
Children with depressive disorders may show withdrawal symptoms just like with RAD, but they still maintain the ability to form attachments and seek and receive comfort from preferred caregivers.
Impact of RAD on development
The diagnostic criteria according to DSM-5 provide an outline of symptoms for RAD. However, aside from the symptoms, RAD can also affect cognition, behaviour, and affective functioning.4
Effect of RAD on cognition
As a result of abuse that may be present in childhood, a child with RAD may have difficulties with working memory and executive functioning. Severe neglect may affect the development of the left cerebral hemisphere and the hippocampus. The left cerebral hemisphere is primarily responsible for speech and abstract thinking, while the hippocampus is involved in long-term memory formation and memory retrieval.
Effect of RAD on behaviour
Children with RAD have poor social skills. They may respond to normal interactions with aggression, fear, defiance, or rage. As a result, these children are more likely to be rejected by adults and their peers and may develop a negative self-perception of themselves. Children with RAD commonly experience a state of restlessness and anxiety that results in repetitive and unintentional movements and hyperactivity like hand flapping or rocking.
Effect of RAD on affective functioning
Affective functioning is the motivational, behavioural, and subjective aspects of emotions. Children with RAD are at increased risk of anxiety, depression, and hyperactivity. They may get more easily frustrated than usual, which makes them likely to be highly reactive, even in non-threatening situations.
Treatment and intervention
Treatment for children with RAD involves providing them with emotionally available parents or caregivers and trauma-focused therapy. This will require parent education focused on developing positive behaviour management strategies, finding ways to respond to nonverbal communication, establishing positive interactions with a difficult-to-reach child, and coping strategies to help both the parent or caregiver and the child. When parents or caregivers are adequately educated and informed, practising what they know can help the child bond better, develop an internal sense of security, and form healthy attachments.4,6
Clinicians can also help the parent or caregiver address their feelings of anxiety, frustration, or anger when needed. Taking care of a child with RAD is not easy. Parents or caregivers can feel disconnected from the child and may react with anger or anxiety. Responding harshly to your child can further worsen the child’s attachment behaviour.6
Typically, clinical professionals don’t treat RAD with any medicine but may treat related disorders or symptoms such as anxiety.6 Treatment of RAD aims to develop positive interactions and strengthen the attachment with parents and caregivers.
The causes of RAD are related to social, emotional and environmental issues (e.g. neglectful parenting). Prevention of RAD requires parents or caregivers to provide sensitive and responsive nurturing of infants and children.7
There may be legitimate reasons some parents or caregivers may not provide a caring and nurturing environment for their children. Perhaps they have been through a lot and are trying to get through life. As a result, they unintentionally neglect their child. Some may also suffer from depression, isolation, lack of social support, poverty, and abuse during childhood. All of these are risk factors for raising children with RAD.
Recognition of the risk factors of parents or caregivers is the first step towards getting the education and support needed to raise and nurture a child most appropriately. Therapy also helps address the underlying cause of the parent’s lack of nurturing so that they can provide a safe and nurturing environment for their child.7
Reactive Attachment Disorder (RAD) is often caused by neglectful care, where the child cannot engage in social relationships or form emotional attachments with people.
Forming healthy attachments is necessary for infants. The primary function of the attachment system during infancy is to boost the safety and protection of the developing infant. As the infant grows to adolescence, they feel secure when they get a healthy dose of care, closeness, and attention. This allows them to form healthy relationships. When infants don’t get the care and nurturing environment they need, it can result in RAD.
Infants who have experienced neglectful care, constant change of caregivers, abuse, and were brought up in a non-nurturing and neglectful environment are at risk of RAD. RAD can be misdiagnosed as autism spectrum disorders (ASD), intellectual disorders, and depressive disorders. For an accurate diagnosis, your child’s doctor has to rule out these disorders.
Children with RAD find it difficult to bond and form healthy attachments. They may be socially withdrawn and have trouble initiating and responding to social interactions. RAD can also affect children’s cognition, behaviour, and affective function.
RAD is treated by providing the child with emotionally available parents or primary caregivers and taking the child through trauma-focused therapy, depending on the case. Providing infants with care and a loving and nurturing environment can prevent them from developing RAD.
- Bergin C, Bergin D. Attachment in the classroom. Educ Psychol Rev [Internet]. 2009 Jun 1 [cited 2023 Aug 29];21(2):141–70. Available from: https://doi.org/10.1007/s10648-009-9104-0
- Floyd K, Hester P, Griffin H, Golden J, Canter LS. Reactive attachment disorder: challenges for early identification and intervention within the schools. International Journal of Special Education [Internet]. 2008 Jan 1;23(2). Available from: https://digitalcommons.odu.edu/cdse_pubs/6
- Lerner RM, Steinberg L. Handbook of adolescent psychology, volume 1: individual bases of adolescent development. John Wiley & Sons; 2009. 801 p.
- Ellis EE, Yilanli M, Saadabadi A. Reactive attachment disorder. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2023 Aug 29]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK537155/
- Pritchett R, Pritchett J, Marshall E, Davidson C, Minnis H. Reactive attachment disorder in the general population: a hidden essence disorder. ScientificWorldJournal [Internet]. 2013 Apr 18 [cited 2023 Aug 29];2013:818157. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3654285/
- Zeanah CH, Chesher T, Boris NW, American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder and disinhibited social engagement disorder. J Am Acad Child Adolesc Psychiatry. 2016 Nov;55(11):990–1003.
- King M. Reactive attachment disorder: a review. LC Journal of Special Education [Internet]. 2022 Jun 28;1(1). Available from: https://digitalshowcase.lynchburg.edu/lc-journal-of-special-education/vol1/iss1/16