Reactive attachment disorder (RAD) occurs when children have difficulty bonding with their parents or caregivers because of neglect or mistreatment early in life. It is rare and can be difficult to diagnose, as many of its symptoms overlap with other conditions. Without treatment, the disorder can last for years, and even with treatment, some children have a difficult time adjusting and have problems that last into adulthood.
Researchers have not identified an exact cause for reactive attachment disorder, but they suspect it has roots in a lack of consistent love and inadequate care. These things can cause children to feel alone and abandoned, which can prevent them from forming healthy attachments. Not all children and babies in these conditions develop reactive detachment disorder. It is unclear why some do and some do not.
For an accurate diagnosis of reactive attachment disorder, children should be older than nine months; symptoms usually appear before age 5. To qualify, the doctors must first rule out a diagnosis of autism. As for prevalence, it is difficult to determine how many children develop RAD, but data suggests it affects between 1 and 2 percent.
The risk of developing reactive attachment disorder increases for children who experience significant physical and emotional neglect, as well as those living in institutions. Other risk factors include frequent shuffling from one foster home or caregiver to another, having parents with significant mental health problems or behaviors that impair their interaction with the child, and being separated from their parents for long periods for things like illness or hospitalization.
Examples of Unhealthy Situations
Infants and young children form healthy attachments when their needs are met; this builds trust between the child and the caregiver or parent. But inappropriate situations prevent this trust from forming. Some examples include not feeding, comforting, or changing a baby’s diaper for many hours, having multiple primary caregivers who provide inconsistent care, and not holding, touching, talking to, or interacting with the baby for hours at a time.
The DSM-5 gives specific diagnostic criteria for reactive attachment disorder. The child must demonstrate a chronic pattern of emotional withdrawal, rarely seeking comfort from others when distressed. They may exhibit episodes of fear, sadness, or irritability out of proportion to a normal reaction to stress and may engage in social withdrawal.
Reactive attachment disorder manifests in many ways. Most children with RAD do not exhibit normal emotions when interacting with others and may not feel or express guilt, remorse, or regret. They generally do not make eye contact and are disobedient beyond what is normally expected of children of their age. Children with RAD may also exhibit inappropriate amounts of affection for strangers while showing no affection for or even fear of their primary caretakers.
Before diagnosing reactive attachment disorder, doctors usually attempt to rule out other causes for the child’s behavior, including autism spectrum disorder. Autism is a developmental condition that can affect communication and behavior. Children with autism may exhibit similar behaviors to those with RAD, which is why attempting to rule out autism helps the doctor make a correct diagnosis. After ruling out other causes, the doctor will assess the child’s behavior by asking questions about patterns in behavior and any history of abuse or neglect.
In some cases, symptoms of reactive attachment disorder may improve or disappear when the child is placed in a supportive environment with consistent caregivers. Psychotherapy or family therapy can help heal the relationship between the child and the caregiver and strengthen the bond between them. Some medications can also help the child or caregiver cope if therapy alone is not effective.
Children with reactive attachment disorder can have different symptoms as they get older. Inhibited RAD symptoms occur when older children know what is happening around them but do not respond to any external stimuli, appearing unresponsive and withdrawn and keeping to themselves. Disinhibited RAD symptoms are when children are over-friendly with strangers and prefer people they do not know to their caregivers, even seeking out affection in unsafe ways.
Prognosis and Complications
Reactive attachment disorder creates a chronic state of stress for the child, creating widespread difficulties and making them less resilient. Identifying RAD early and getting prompt treatment can improve outcomes, but caregiver support and education are necessary for the best results. Several complications are also associated with RAD, including developmental delays, emotional problems, eating disorders, drug and alcohol abuse, difficulties in school, and problems in relationships with friends and romantic partners.