Reactive Attachment Disorder

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) outlines specific criteria for a child’s symptoms to meet the criteria for a reactive attachment disorder diagnosis. These symptoms include:

• Consistently acting emotionally withdrawn around adult caregivers, characterized by not seeking or responding to comfort when distressed
• Social and emotional disturbances that happen frequently and include at least two of the following behaviors:
  • Not responding to other people (adults or fellow children), either through social interaction or emotional expression
  • Limited positive emotions, sometimes rising to the level of anhedonia, an inability to feel pleasure
  • Irritability, sadness, or fearfulness with no apparent cause, even during non-confrontational interactions with adult caregivers
• A history of receiving insufficient care early in life, which can look like:
  • Social neglect, specifically involving consistently not having one’s emotional needs (affection, stimulation, comfort) met by adult caregivers
  • Frequent changes in caregivers that prevented the development of emotional attachment (most often seen in children who have lived in multiple foster homes)
  • Living in settings that do not provide an opportunity to form emotional attachments to adult caregivers, like orphanages, group homes, or other childcare institutions with high ratios of children to adult caregivers

According to the Diagnostic and Statistical Manual, the above symptoms must be present after the child is at least nine months old and before they are five years old. The child also cannot have received a diagnosis of autism spectrum disorder (ASD). 

Other symptoms 

Children with reactive attachment disorder, a condition where the child is unable to establish healthy attachment with their caregivers, may experience the symptoms listed below, but not every child and adolescent with the disorder will experience these symptoms, and they are not necessary to receive a diagnosis:

• Difficulty managing emotions
• Avoiding eye contact
• Demonstrating movements like rocking back and forth or flapping hands
• Having no interest in peekaboo or other interactive games
• Lack of social competency
• Acting scared or anxious around their adult caregiver, even when their caregiver is supportive and loving
• Frequent tantrums
• Rule-breaking
• Attempting to create an environment they can control
• Preferring to spend time alone
• Difficulty forming connections with other people, including peers
• Acting quiet and withdrawn in social situations, though watching others closely
• Experiencing delays in physical milestones and developmental growth
• Learning difficulties
• Avoiding caretakers
• Engaging in risky behavior
• Appearing sad and listless
• Not reaching out when picked up
• Calming down when left alone
• Wanting to always make their own decisions
• Memory difficulties
• Lack of responsiveness to discipline
• Moodiness and unpredictability
• Seeming to exist in a constant fight-flight-freeze response 
• Behaving violently towards others or toward themselves 
• Being rejected by their peers
• Experiencing mental health disorders, such as depression, anxiety, or post-traumatic stress disorder (PTSD)¹
• Having lower frustration tolerance than would be expected for their age
• Acting restless and hyperactive
• Avoiding physical contact, such as hugs
• Apathy
• Not responding to stimuli or being described as having a “failure to thrive” if the individual is an infant 

Reactive attachment disorder has not been thoroughly studied in children older than five years of age. Still, research indicates that children with reactive attachment disorder (RAD) may be more likely to experience further mental health concerns and adverse life circumstances as they grow older. These conditions or challenges can include eating disorders, personality disorders, PTSD, substance use disorders,² early sexual activity, and involvement with the justice system.   

According to the American Academy of Child and Adolescent Psychiatry, reactive attachment disorder is caused by experiencing severe social neglect in infancy or early childhood, as described in the diagnostic criteria. The American Academy of Child and Adolescent Psychiatry notes that because children who experience such neglect are not given the chance to form attachments to caregivers in their early development, they have learned not to seek any comfort or response from caregivers. 

Note that not every child who experiences social neglect develops mental disorders like reactive attachment disorder (RAD), a stressor-related condition of early childhood caused by social neglect and by markedly disturbed and developmentally inappropriate ways of relating to others. A majority of children raised in these conditions do not, as reactive attachment disorder (RAD) is a rare disorder, like other attachment disorders, such as disinhibited social engagement disorder (DSED).³ DSED involves overly friendly behavior in social situations. Researchers through the American Academy of Child and Adolescent Psychiatry and other organizations have identified several potential risk factors that may elevate the chance that a neglected child develops RAD, including the following.

Environmental risk factors

Below are some of the environmental risk factors for a child developing RAD: 

• Continuing to live with lower-quality caregiving
• Having caregivers who lack healthcare literacy
• Experiencing physical abuse and neglect in addition to social and emotional neglect
• Undergoing a number of traumatic losses early in one’s life
• Having adult caregivers who never tried to form bonds 
• Developing bonds with adult caregivers but then being separated from those caregivers
• Living with inconsistent caregiving, such as caregivers who show responsiveness only some of the time and cannot always be trusted to console a child when needed
• Experiencing food insecurity, danger, or a lack of hygiene (such as not having diapers changed when needed) in early childhood
• Having adult caregivers with serious mental health concerns (particularly depression) or substance use that inhibits their ability to provide care
• Living with caregivers who are experiencing poverty, incarceration, a lack of childcare access, or other extreme psychosocial stressors
• Having co-occurring disinhibited social engagement disorder (DSED) or having a family member with disinhibited social engagement disorder

Individual risk factors

Below are individual risk factors that may increase one’s chances of developing RAD: 

• Being of African American or multiracial descent—potentially because of societal conditions and chronic lack of resources in specific demographics that lead to higher rates of child maltreatment 
• Having a temperament that makes one more susceptible to the stress of hostile or unpredictable caregiver relationships
• Neurobiological factors that may impact one’s ability to regulate emotion
• Living with another mental health disorder, such as disinhibited social engagement disorder or autism spectrum disorder (ASD)

The goal of treatment for reactive attachment disorder (where children don't form an emotional bond with their caretakers) and disinhibited social engagement disorder is to foster healthy attachment bonds between a child and their caregivers. This goal may be accomplished by repairing damaged or fearful relationships with current caregivers or helping the child create healthy relationships with new caregivers.

Medication

No medication has been approved by the US Food and Drug Administration (FDA) to treat reactive attachment disorder. However, medications may manage disruptive symptoms like angry outbursts or difficulty sleeping in the short term while therapeutic treatment is underway. 

Children with RAD often present with comorbid mental health conditions like depression, post-traumatic stress disorder, and attention deficit hyperactivity disorder (ADHD).⁴ They may be prescribed medications via child or adolescent psychiatry, such as selective serotonin reuptake inhibitors (SSRIs) to treat symptoms of these additional conditions. Research is still being conducted on whether these interventions may also have tangential benefits on RAD symptoms. 

When using medication with a young child, caregivers can ask doctors about side effects, the duration of the prescription, any withdrawal or discontinuation symptoms, and the potential for addiction, as well as ensure the child’s dose is adjusted for their height and weight. Consult a medical doctor in child and adolescent psychiatry before starting, changing, or stopping a medication for any condition. The information in this article is not a replacement for medical advice or diagnosis.

Other treatment options

Alternative treatments for reactive attachment disorder have been proposed. Many of these treatments fall under the umbrella of a school of thought referred to as “attachment therapy.” 

Attachment therapy can be confused with attachment theory. However, these treatments are not based on attachment theory or scientific research and can border on child abuse. Attachment therapy features punitive, controlling methods of “treating” RAD, such as forced eye contact, coercive holding, and “rebirthing” therapy, which has resulted in several child deaths from asphyxiation. Attachment therapy is not effective in reducing RAD symptoms. 

If you are working with a mental health professional who is proposing these techniques for your child, consult your medical provider and investigate the scientific basis of these treatments. When seeking a therapeutic modality, be sure to research its effectiveness and whether multiple studies have found it evidence-based or not. 

Self-care

Because reactive attachment disorder is a trauma- and stressor-based disorder, before any treatment can be effective, it may be helpful for the individual to be in a situation where the trauma⁵ is not recurring. Treating RAD may sometimes require the removal of a child from an unstable caregiving situation if caregivers continue to be unable to provide consistent, compassionate care for the child. Creating a stable and predictable environment for a child with RAD can be the first step toward developing a safe environment for a child, helping them have the capacity to form healthy attachments.

Loving a child who does not demonstrate any attachment may lead caregivers to believe they are “bad parents.” Shame and embarrassment can prevent caregivers from reaching out for help. In these situations, online therapy through a platform like BetterHelp may be a beneficial option. With online therapy, people can connect with a therapist from the comfort of their homes via phone, video, or live chat sessions. 

Although reactive attachment disorder is a rare diagnosis, resources exist to help caregivers who are taking care of children who have experienced neglect and abuse. The National Child Traumatic Stress Network has compiled information on the impact of traumatic experiences in childhood, as well as treatment options. Harvard University’s Center on the Developing Child conducts research on the effects of traumatic stress, including neglect in childhood, and provides information on building resilience and helping children move beyond adverse experiences.

For help with substance use, contact SAMHSA’s National Helpline at 1-800-662-HELP (4357).

For those experiencing abuse, contact the Domestic Violence Hotline at 1-800-799-SAFE (7233). Support is available 24/7. Please also see our Get Help Now page for more immediate resources.

Please see our Get Help Now page for more immediate resources.

Symptoms of reactive attachment disorder can manifest outside of the home and the relationship with primary caregivers, most commonly in school settings. RAD in school-age children typically manifests as acting withdrawn but can sometimes appear in bursts of aggression that may provoke a disciplinary response from teachers. However, punitive measures towards children with RAD (in school settings or home settings) can worsen aspects of the disorder, as it may reinforce the child’s belief that caregivers are not sources of safety and security. 

Teachers can be a form of temporary secondary attachment figure for young children, with the potential to help children be comfortable and form stable attachments, which may reduce some symptoms of reactive attachment disorder. One study examining the most effective way for teachers to support children with RAD found that symptoms could be alleviated when teachers:

• Demonstrated high levels of sensitivity and responsiveness to a child’s needs
• Provided reassurance, encouragement, and acceptance
• Gently challenged children’s defense mechanisms

These findings indicate that different techniques in school settings could be a complement to therapeutic intervention when working with children with reactive attachment disorder.

Below are several statistics on reactive attachment disorder:

• Reactive attachment disorder is believed to affect between 1% and 2% of the general population.
• In a study of almost 300 children living in foster care, roughly 20% met diagnostic criteria for RAD.
• While RAD has primarily been studied in the context of young children, researchers interested in learning more about whether symptoms can persist into adolescence found that almost 10% of teenagers living in institutional care settings continued to show RAD symptoms.
• A report analyzing data from the Early Childhood Longitudinal Study found that 40% of children do not have strong attachments to their caregivers, putting them at risk for developing RAD and other attachment-related disorders. 
• A recent study found that teachers can play a significant role in supporting children with RAD. Teacher sensitivity and empathy have been associated with a reduction in RAD symptoms like aggression and anti-social behavior.