What is Reactive Attachment Disorder in Children?

Babies develop attachments to parents or caregivers when those adults comfort them and otherwise attend to their needs. If a baby or young child experiences a severe disruption in these early relationships, especially if he or she has been neglected or physically or emotionally abused, the child may develop serious problems with emotional attachments to others. This rare condition is known as reactive attachment disorder (RAD). Some children who develop RAD have received inadequate care outside their home – like in a hospital, residential program, foster care or orphanage. Some have lost parents or caregivers or experienced multiple caregiver changes. In the case of adopted children, early years in an unstable or abusive home may contribute to the disorder.

Signs and Symptoms

For a diagnosis of RAD, a child must exhibit the following symptoms:

• A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers exhibited by:
  • Rarely or minimally seeking comfort when distressed
  • Rarely or minimally responding to comfort when distressed
• A persistent social and emotional disturbance characterized by at least two of the following:
  • Minimal social and emotional responsiveness to others
  • Limited positive moods/emotions (joy, interest and alertness)
  • Episodes of unexplained irritability, sadness or fearfulness that are evident even during nonthreatening interactions with adult caregivers

To be diagnosed with RAD, a child must have experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:

• Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults
• Repeated changes of primary caregivers that limit opportunities to form stable attachments
• Rearing in unusual settings that severely limit opportunities to form selective attachments (institutions with high child-to-caregiver ratios)

Children diagnosed with RAD show emotional disturbances before age 5, but must have a developmental age of at least 9 months. They do not meet criteria for the autism spectrum.

Inhibited RAD Symptoms

According to the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-5), inhibited RAD symptoms appear in children between the ages of 9 months and 5 years old. The symptom characteristics include consistent patterns of withdrawing behavior and an inability to seek comfort from safe adults or caregivers. A child with inhibited RAD will find it difficult to seek comfort from caregivers, and will be minimally responsive when given comfort from a caregiver. 

A child with inhibited RAD may also exhibit persistent emotional and social disturbances. This may appear as minimal social or emotional responsiveness to others, minimal positive affect (emotional expressions, positive facial expressions), and episodes of irritability, sadness, or fearfulness toward safe caregivers (even in non-threatening situations or environments). 

More often than not, a child with inhibited RAD has experienced a pattern of extremes in inadequate caregiving. Examples of this may include, a severe neglect in basic life needs being met, repeated changes or disturbances in primary caregivers that impacts attachment or bondedness, or uprearing happening in a setting that limits opportunities for selective attachment or bondedness to a primary caregiver. The symptom characteristics must not be due to autism spectrum disorder. 

Disinhibited RAD Symptoms

In contrast with inhibited RAD, characteristics of disinhibited RAD symptoms demonstrate a pattern of behavior in which a child often approaches and interacts with unfamiliar adults without signs of hesitancy or understanding of potential danger. This is represented by a child’s lack of fear in approaching unfamiliar adults, exhibiting familiar verbal or physical behavior with an unfamiliar adult, a minimal or absent checking back at their primary caregiver when wandering off, and a willingness to venture away with an unfamiliar adult with minimal hesitancy. Similar to symptom characteristics of inhibited RAD, the child will have experienced a pattern of extremes in inadequate caregiving (i.e., social neglect, repeated changes in primary caregiver, and rearing in an unusual setting that limits opportunities to form selective attachments).

Causes

A baby or young child whose needs are ignored or met with a lack of emotional response may not come to expect care or comfort or form a stable attachment to parents or caregivers. Behavioral health researchers don’t know why some babies and children in these situations develop RAD and others don’t.

Risk Factors

Risk factors that could contribute to RAD in children include:

• Frequent changes in caregivers and homes: Foster children or those constantly moved between caregivers may have a higher risk of developing the disorder.
• Growing up in an institutional setting: Babies and children in orphanages or other institutional settings may be more likely to develop RAD.
• Impaired parents/caregivers: If a parent has a severe mental illness, substance abuse problem or criminal lifestyle, his or her ability to be a caring and effective parent may be impaired. This can lead to attachment issues.
• Prolonged separation: If babies and young children are separated from parents for long periods of time, like during hospitalization, they may be at a higher risk of developing RAD.

Diagnosis

Diagnosing RAD requires a thorough psychological evaluation by a pediatric psychiatrist or psychologist. Your child’s behavioral health provider will use the criteria for RAD listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association, to determine if his or her symptoms indicate the condition.

The evaluation may include:

• Direct observation of the child’s interactions with parents or caregivers
• Discussion with parents about behavior patterns over time and related to certain situations
• Questions for the child and caregivers about the child’s home and living situations since birth
• An evaluation of parenting/caregiving styles and abilities.

Your child’s provider will also evaluate for other mental health conditions that could be causing your child’s symptoms or co-existing with, and worsening, RAD. These include:

• Intellectual disabilities
• Other adjustment disorders
• Autism spectrum disorders
• Depressive disorders

Prognosis

With treatment and caregiver support, most children with RAD are eventually able to develop healthy and stable relationships with others.

RAD Treatment for Children

Early intervention improves outcomes for children with RAD. The most important interventions for these children are ensuring safe and stable living situations and connecting them with services and strategies that can help them develop positive interactions and attachments with parents or caregivers.

As a parent or caregiver, you can help a child with RAD by:

• Being as nurturing, responsive and caring as possible
• Providing a positive and stimulating environment for your child
• Addressing any medical or safety needs the child may have.

Parenting skills classes, caregiver education programs and individual and family psychological counseling may help you develop the strategies you need to forge a strong bond with your child and overcome his or her emotional issues.

Complications

Children with RAD need stable, emotionally supportive caregivers and psychological support to recover. Untreated, some children with RAD may – as older children, teens or adults – display callous, unemotional behaviors such as cruelty toward people or animals. 

How to Prevent RAD

Attending to your child’s physical and emotional needs appropriately is the best way to prevent RAD. If you adopt or foster a child, you don’t have control over what has happened in his or her past, but your responsiveness, comfort and care can help the child develop healthy attachments and emotional responses.