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Overview

What is reactive attachment disorder (RAD)?

Reactive attachment disorder (RAD) is a condition in which an infant or young child does not form a secure, healthy emotional bond with his or her primary caretakers (parental figures).

Children with RAD often have trouble managing their emotions. They struggle to form meaningful connections with other people. Children with RAD rarely seek or show signs of comfort and may seem almost fearful of their caretakers, even in situations where the current parent figures seem quite loving and caring. These children are often irritable or sad, and may report feeling unsafe and/or alone.

Who is likely to have reactive attachment disorder (RAD)?

Reactive attachment disorder is most common among children between 9 months and 5 years who have experienced physical or emotional neglect or abuse. While not as common, older children can also have RAD since RAD sometimes can be misdiagnosed as other behavioral or emotional difficulties. Children may be more likely to develop RAD if they:

• Have had many different foster care providers or spent time in an orphanage
• Were taken away from primary caretakers after forming a healthy bond
• Have had multiple traumatic losses early in life

Symptoms and Causes

What causes reactive attachment disorder (RAD)?

Although there is no exact cause, researchers believe that lack of an appropriate level of loving and consistent caretaking contributes to development of RAD. Inadequate caregiving can make a child feel abandoned, alone and uncared for – all of which can prevent that child from developing a healthy and secure emotional bond with his or her primary caretakers.

Young children form healthy relationships when their basic needs are consistently attended to – this builds a sense of trust between the young child and caretakers. Examples of inappropriate, ongoing caretaking situations that place a child at greater risk of developing RAD include:

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• A baby whose diaper is soiled and not changed for many hours.
• A baby who is hungry and not fed for many hours.
• A baby who is crying and not attended to and who is not comforted when they are in distress.
• A baby who is not held, touched, talked to, or interacted with for many hours at a time.
• An infant whose needs are met only some of the time (the caregiving is not consistent).
• A young child who only gains the attention of caretakers by acting up/or being disruptive.
• A baby or young child who has had multiple primary caretakers (especially if the care provided is inconsistent and/or from unfamiliar people).
• Any situation in which the child has been physically or emotionally neglected or abused by primary caretakers or other adults.

What are the symptoms of reactive attachment disorder (RAD)?

Symptoms of reactive attachment disorder vary from child to child. Infants and young children who may have RAD show common signs such as:

• Failure to show an expected range of emotions when interacting with others; failure to show “emotions of conscience” such as remorse, guilt, or regret
• Avoiding eye contact and physical touch, especially with caregivers
• Expressing anger; having tantrums; being irritable, unhappy and sad; disobedience and arguing (beyond what would be “usual” for the child’s age and situation)
• Displaying inappropriate affection toward strangers while demonstrating a lack of affection for and/or fear of their primary caretakers.

When children with RAD grow older, their symptoms usually fall into one of two general patterns:

• Inhibited RAD symptoms. Children are aware of what happens around them, but they do not respond typically to outside stimuli. Children showing inhibited RAD symptoms are withdrawn and emotionally unresponsive. They may not show or seek affection from caregivers or others, keeping largely to themselves.
• Disinhibited RAD symptoms. Children may be overly friendly toward strangers. Children with disinhibited RAD symptoms do not prefer their primary caretakers over other people. In most cases, these children act younger than their age and may seek out affection from others in an unsafe way.

Diagnosis and Tests

How is reactive attachment disorder (RAD) diagnosed?

Your child’s doctor may assess for reactive attachment disorder by asking you about patterns in behavior suggesting withdrawal from primary caretakers. Your child’s personal history, including any history of neglect or abuse, is important for making an accurate diagnosis. Children must be between the ages of 9 months and 5 years (or at least have developed the specific patterns of behavior associated with this disorder during this age range) to be formally diagnosed with RAD. It is not uncommon, however, for the diagnosis to first be raised in a child who is somewhat older where it has never been identified.

Before diagnosing a child with RAD, doctors will want to rule out other causes for a child’s atypical functioning, including autism spectrum disorder (ASD). Autism spectrum disorder is a developmental condition that that affects behavior and communication and can, on the surface, present with some similar features as RAD. Although presenting in early childhood, abuse or neglect doesn’t cause autism spectrum disorder.

Management and Treatment

How is reactive attachment disorder (RAD) treated?

Treatment for reactive attachment disorder focuses on repairing and/or creating emotionally healthy family bonds. It aims to strengthen relationships between children and their caretakers in a way that can later help the child to develop other healthy relationships

Both children and parents benefit from tailored treatment plans. Treatment may incorporate:

• Psychotherapy/Counseling. A mental health provider works with the child and parents in a variety of ways, sometimes one-on-one with the child, sometimes with just caretakers, and sometimes in combination, to build skills and reduce problematic patterns of behavior.
• Family therapy. This therapy involves working together with the primary caretakers and child to develop ways to interact in healthy ways.
• Social Skills Intervention. This therapy teaches the child how to interact more appropriately with other similar–aged children in typical social settings. Parents are usually also involved to help the child to use the skills they learn.
• Special education. If a child qualifies, these are school-based programs that help children learn skills to succeed both academically and socially.
• Parenting skills classes. In these sessions parents may learn more effective ways of managing their child’s challenges. This can be particularly beneficial as managing discipline for children with RAD can be more difficult.

What complications are associated with reactive attachment disorder (RAD)?

Physical, emotional, and social neglect and abuse put children with RAD at higher risk for complications in later childhood and adolescence. These complications may include:

• Delays in developmental milestones
• Delays in physical growth (which can be linked to eating difficulties)
• Emotional problems, such as depression, anxiety, and anger management issues
• Drug and alcohol abuse and dependency
• Trouble in school (learning and/or behavioral)
• Problems in relationships (with peers or adults, and potentially later with partners)

Prevention

Can reactive attachment disorder (RAD) be prevented?

The best way to prevent reactive attachment disorder is by ensuring children form healthy bonds with their parents and/or other primary caretakers. Healthy bonds form when caretakers:

• Promote family bonding through secure and consistent relationships
• Help children feel secure and loved
• Support children through the phases of their development

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Specific actions that can lead to the development of healthy bonds include:

• Setting limits. Because children with RAD have a need to have control and benefit from an environment in which there is a consistent pattern that can be counted on, setting limits is very important. By setting consistent and reasonable limits, children will know what is expected of them and what happens if rules are broken.
• Keeping your cool even when your child acts up. During times when your child is acting inappropriately, remain calm; do not respond if you are in an “emotionally heightened” state. Discipline the child according to the rules you have established and made known to your child. As soon as the child has settled down and is ready for positive contact, show love and care. This helps the child know that you will still be there for them, through even difficult times.
• Showing consistent love and attention. Spend one-on-one time with your child. Talk or sing with them. Play with them. Rock or hold them or show other signs of caregiver love and affection, acknowledging that some children are more open to this type of affection than others. Withholding love and affection should never be used as punishment.

Outlook / Prognosis

What is the prognosis (outlook) for people with reactive attachment disorder (RAD)?

Many children who receive treatment for reactive attachment disorder form stable, healthy bonds with primary caretakers and others, providing models for later important relationships.

Children who don’t receive treatment can face risks of ongoing emotional issues. Fortunately, it is never too late to seek treatment for developmental and mental health conditions, including RAD.

Key points to keep in mind

• Many children who are adopted from foster placements or orphanages develop into very healthy and well-adjusted children; not all such youth experience RAD. Children can be amazingly resilient!
• Children with significant trauma in their past may also have other risk factors for mental health and behavioral challenges, such as exposure to drugs or alcohol during prenatal development or a family history of emotional disorders, both of which may contribute to RAD and other difficulties.

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Living With

When should I call my doctor?

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If you notice any symptoms of reactive attachment disorder in your child, contact your child’s doctor for an evaluation or referral. Early diagnosis and treatment leads to more successful outcomes for children with this condition.