|Reactive Attachment Disorder (RAD)—
Reactive attachment disorder (RAD) is the broad term used to
describe the severe and relatively uncommon disorders of attachment
characterized by markedly disturbed and developmentally
inappropriate ways of relating socially in most contexts, beginning
before the age of five. It can either take the form of a persistent
failure to initiate most social interactions or respond to them in a
developmentally appropriate way, or present as indiscriminate
sociability, such as excessive familiarity with relative strangers.
Reactive attachment disorder is a disturbance of social interaction
caused by neglect of a child's basic physical and emotional needs,
particularly during infancy. Babies placed in orphanages at birth and
raised by multiple caretakers without primary parent-figures can also
develop this disorder, even if physical care was adequate.
RAD arises from a failure to form normal attachments to primary
caregiving figures in early childhood. Such a failure would result from
severe early experiences of neglect, abuse, abrupt separation from
caregivers between the ages of six months and three years, frequent
change of caregivers, or a lack of caregiver responsiveness to a child's
communicative efforts. Not all, or even a majority of such experiences
result in the disorder.
Reactive attachment disorder is a rare but serious mental health
condition in which infants and young children don't establish healthy
bonds to parents or caregivers. Children with reactive attachment
disorder typically were neglected or abused in infancy, passed through
many foster homes, or lived in orphanages where their emotional
needs weren't well met.
Because their basic needs for comfort, affection, nurturing and
stimulation weren't met, these infants and children didn't learn how
to create loving and caring attachments with other people. They can't
give or receive affection.
Reactive attachment disorder is often enmeshed in controversy. Both
its diagnosis and treatment are difficult, and parents and caregivers
are commonly distressed as they try to cope with the disorder and a
seemingly uncaring child. Some non-conventional treatment methods
have been associated with the deaths of several children, escalating
the controversy. Despite the challenges, a commitment to proven
psychiatric treatment may help these children enjoy a better quality
of life and develop more stable relationships.
There are four attachment 'styles' known as secure, anxious-
ambivalent, anxious-avoidant, (all organized) and disorganized.
The latter three are characterized as insecure.
A securely attached toddler will explore freely while the caregiver is
present, engage with strangers, be visibly upset when the caregiver
departs, and happy to see the caregiver return.
The anxious-ambivalent toddler is anxious of exploration, extremely
distressed when the caregiver departs but ambivalent when the
The anxious avoidant toddler will not explore much, avoid or ignore
the parent - showing little emotion when the parent departs or
returns - and treat strangers much the same as caregivers with little
emotional range shown.
The disorganized/disoriented toddler shows a lack of a coherent style
or pattern for coping. Evidence suggests this occurs when the care-
giving figure is frightening thus putting the child in an irresolvable
situation regarding approach and avoidance. On reunion with the
caregiver children can look dazed or frightened, freezing in place,
backing toward the caregiver or approaching with head sharply
averted, or showing other behaviors that seem to imply fearfulness
of the person who is being sought. It is thought to represent a
breakdown of an inchoate attachment strategy and it appears to
affect the capacity to regulate emotions.
Signs and symptoms—
· Avoids caregiver
· Avoids physical contact
· Difficult to comfort
· Indiscriminate sociability with strangers
· Resists social interaction
· Seeks isolation
· Disregard for child's basic emotional needs for comfort, stimulation,
· Disregard for child's basic physical needs like food, toileting, and play
Reactive attachment disorder is broken into two types — inhibited and
disinhibited. While some children have signs and symptoms of just
one type, many children have both.
In inhibited reactive attachment disorder, children shun relationships
and attachments to virtually everyone. This may happen when a baby
never has the chance to develop an attachment to any caregiver.
Signs and symptoms of the inhibited type may include:
· Appearing to be on guard or wary
· Appearing to seek contact but then turning away
· Avoiding eye contact
· Avoiding physical contact
· Difficulty being comforted
· Engaging in self-soothing behavior
· Failing to initiate contact with others
· Preferring to play alone
· Resisting affection from parents or caregivers
In disinhibited reactive attachment disorder, children form
inappropriate and shallow attachments to virtually everyone, including
strangers. This may happen when a baby has multiple caregivers or
frequent changes in caregivers.
Signs and symptoms of the disinhibited type may include:
· Appearing anxious
· Exaggerating needs for help doing tasks
· Inappropriately childish behavior
· Readily going to strangers, rather than showing stranger anxiety
· Seeking comfort from strangers
Although increasing numbers of childhood mental health problems
are being attributed to genetic defects, reactive attachment disorder
is almost by definition based on a problematic history of care and
social relationships. However, reactive attachment disorder may
resemble many other emotional disorders with an etiology in which
a predisposition or constitutional weakness is affected by an
environmental stressor. It has been suggested that types of
temperament, or constitutional response to the environment, may
make some individuals susceptible to the stress of unpredictable or
hostile relationships with caregivers in the early years. In the absence
of available and responsive caregivers it appears that some children
are particularly vulnerable to developing attachment disorders.
Abuse can occur alongside the required factors, but on its own does
not explain attachment disorder. Abuse is associated with developed,
albeit disorganized attachment. This style is a risk factor for a range
of psychological disorders although it is not in itself considered an
attachment disorder under the current classification.
There is as yet no explanation for why similar abnormal parenting
produces two distinct forms of the disorder. The issue of
temperament and its influence on the development of attachment
disorders has yet to be resolved. RAD has never been reported in
the absence of serious environmental adversity yet outcomes for
children raised in the same environment vary widely.
Reactive attachment disorder is caused by neglect of an infant's
needs for physical safety, food, touching, and emotional bonds
with a primary and/or secondary caretaker.
The risk of neglect to the infant or child is increased with parental
isolation, lack of parenting skills, teen parents, or a caregiver who
is mentally retarded. A frequent change in caregivers (for example,
orphanages or foster care) is another cause of reactive attachment
Children adopted from foreign orphanages are commonly affected,
particularly if they were removed from their birth parents during the
first weeks of life.
Most children are naturally resilient, and even those who have been
neglected, have lived in orphanages or have had multiple caregivers
develop healthy relationships and strong bonds. It's not known what
causes some babies and children to develop reactive attachment
disorder. But a variety of theories about attachment may help explain
some of the emotional processes that give rise to the disorder.
Traditional attachment theory says that to feel safe and develop
trust, infants and young children need a stable, nurturing
environment. Their basic emotional and physical needs must be
consistently met. In addition, interactions with babies must be caring
and positive, not harsh or negative. For instance, when a baby cries,
his or her need for a meal or a diaper must be met promptly with a
shared emotional exchange that may include eye contact, smiling and
A child whose bottle is propped up on his or her chest to self-feed or
whose diaper is changed roughly without kind words and warm facial
expressions may feel rejected and insecure. When this happens
repeatedly, the baby learns that he or she can't rely on adults for
nurture and love. The baby becomes distrustful and unattached.
Babies who seek comfort from a caregiver but are met with hostility
or abuse become confused and conflicted — wanting closeness but
turning away from it for fear of rejection or harm.
Some attachment theories suggest that emotional interactions
between babies and caregivers actually shape neurological
development in the brain. They say that interactions cause the
formation of neural networks within the brain that ultimately influence
a baby's personality and relationships throughout life. In babies
whose needs aren't met with caring and love, these neural networks
don't form properly, creating attachment problems.
Reactive attachment disorder is considered uncommon. However,
there are no accurate statistics on how many babies and children
have the condition. It can affect children of any race or either sex.
By definition, reactive attachment disorder begins before age 5,
although its roots start in infancy.
Factors that may increase the chance of developing reactive
attachment disorder include:
· Extreme poverty
· Forced removal from a neglectful or abusive home
· Frequent changes in foster care or caregivers
· Inexperienced parents
· Institutional care
· Living in an orphanage
· Parents who have a mental illness, anger management problems,
or drug or alcohol abuse
· Physical, sexual or emotional abuse
· Postpartum depression in the baby's mother
· Prolonged hospitalization
· Significant family trauma, such as death or divorce
When to seek medical advice—
This disorder is usually identified when a parent (or prospective
parent) is identified as being at high risk for neglect or when an
adoptive parent has difficulty coping with a newly adopted child.
If you have recently adopted a child from a foreign orphanage or
another situation where neglect may have occurred and your child
exhibits these symptoms, see your health care provider.
If you think your baby or child may have reactive attachment disorder
or you feel that a strong bond isn't developing, consider seeking a
medical or psychological evaluation.
Consider getting an evaluation if your baby or child:
· Avoids you
· Doesn't seek out physical contact
· Prefers not to be held
· Seems uninterested in you
· Usually likes to play alone
· Will readily go to strangers
Screening and diagnosis—
RAD is one of the least researched and most poorly-understood
disorders in the DSM. There is little systematically gathered
epidemiologic information on RAD, its course is not well established
and it appears difficult to diagnose accurately. Several other
disorders, such as conduct disorders, oppositional defiant disorder,
anxiety disorders, post traumatic stress disorder and social phobia
share many symptoms and are often comorbid with or confused with
RAD leading to over and under diagnosis.
RAD can also be confused with neuropsychiatric disorders such as
autism spectrum disorders, pervasive developmental disorder,
childhood schizophrenia and some genetic syndromes. Some children
simply have very different temperamental dispositions. Because of
these diagnostic complexities, careful diagnostic evaluation by a
trained mental health expert with particular expertise in differential
diagnosis is considered essential.
While RAD is likely to occur in relation to neglectful and abusive
childcare, automatic diagnoses on this basis alone cannot be made as
children can form stable attachments and social relationships despite
marked abuse and neglect.
A thorough medical and psychological evaluation is in order when it's
thought that a baby or child may have reactive attachment disorder.
The disorder can be similar to other disorders, including autism,
developmental disorders, social phobia, conduct disorders and
attention-deficit/hyperactivity disorder. In fact, a child with reactive
attachment disorder may also have other disorders as well.
A complete and thorough evaluation should include:
· Examples of behavior in a variety of situations
· Parenting and caregiver styles and abilities
· The baby's or child's pattern of behavior over time
· The baby's or child's relationship with parents or caregivers as well
as others, including other family members, peers, teachers and child
· The home and living situation
To be diagnosed with reactive attachment disorder, a baby or child
must meet criteria spelled out in the Diagnostic and Statistical Manual
of Mental Disorders (DSM). This manual is published by the American
Psychiatric Association and is used by mental health providers to
diagnose mental conditions and by insurance companies to reimburse
The main criteria for the diagnosis of reactive attachment disorder
· Disturbed and developmentally inappropriate social relationships
beginning before age 5
· Failure of early care to meet the baby's or child's emotional needs
for comfort and affection, failure of early care to attend to the child's
physical needs, or repeated changes in the primary caregiver
· Failure to respond to or initiate social interactions, or being
inappropriately friendly and familiar with strangers
Consider getting a second opinion if you have questions or concerns
about the diagnosis or treatment plan.
Without treatment for reactive attachment disorder, a child's social
and emotional development may be permanently affected.
Complications and related conditions may include:
· Academic problems
· Bullying or being bullied
· Developmental delays
· Drug and alcohol addiction
· Eating problems
· Growth delays
· Inappropriate sexual behavior
· Lack of empathy
· Relationship problems in adulthood
· Temper or anger problems
· Trouble relating to classmates or peers
· Unemployment or frequent job changes
All mainstream prevention programs and treatment approaches for
attachment disorder for infants and younger children are based on
attachment theory and concentrate on increasing the responsiveness
and sensitivity of the caregiver, or if that is not possible, placing the
child with a different caregiver. These approaches are mostly in the
process of being evaluated. The programs invariably include a detailed
assessment of the attachment status or caregiving responses of the
adult caregiver as attachment is a two-way process involving
attachment behavior and caregiver response.
Some of these treatment or prevention programs are specifically
aimed at foster carers rather than parents, as the attachment
behaviors of infants or children with attachment difficulties often do
not elicit appropriate caregiver responses. Approaches include 'Watch,
wait and wonder,' manipulation of sensitive responsiveness, modified
'Interaction Guidance,' 'Preschool Parent Psychotherapy,' 'Circle of
Security', Attachment and Biobehavioral Catch-up (ABC), the New
Orleans Intervention, and Parent-Child psychotherapy. Other
treatment methods include Developmental, Individual-difference, and
Relationship-based therapy (DIR, also referred to as Floor Time) by
Stanley Greenspan, although DIR is primarily directed to treatment of
pervasive developmental disorders.
The relevance of these approaches to intervention with fostered and
adopted children with RAD or older children with significant histories
of maltreatment is unclear.
In 2005 the American Academy of Child and Adolescent Psychiatry
laid down guidelines (devised by N.W.Boris and C.H.Zeanah) based
on its published parameters for the diagnosis and treatment of RAD.
Recommendations in the guidelines include the following:
1. "Although the diagnosis of reactive attachment disorder is
based on symptoms displayed by the child, assessing the caregiver's
attitudes toward and perceptions about the child is important for
2. "Children who meet criteria for reactive attachment disorder
and who display aggressive and oppositional behavior require
adjunctive (additional) treatments."
3. "Children with reactive attachment disorder are presumed to
have grossly disturbed internal models for relating to others. After
ensuring that the child is in a safe and stable placement, effective
attachment treatment must focus on creating positive interactions
4. "The most important intervention for young children
diagnosed with reactive attachment disorder and who lack an
attachment to a discriminated caregiver is for the clinician to advocate
for providing the child with an emotionally available attachment figure."
Treatment is twofold. The first priority is to make sure the child is
currently in a safe environment where emotional and physical needs
Once that has been established, the next step is to alter the
relationship between the caregiver and the child, if the caregiver has
caused the problem. Parenting skills classes can help with this. These
skills give the caregiver an ability to meet the child's needs and help
them bond with their child.
The caregiver should also undergo counseling to work on any current
problems, such as drug abuse or family violence. Social Services
should follow the family to make sure the child remains in a safe,
Parents who adopt babies or young children from foreign orphanages
should be aware that this condition may occur and be sensitive to the
needs of the child for consistency, physical affection, and love.
These children may be frightened of people and find physical affection
overwhelming at first, and parents should try not to see this as
rejection. It is a normal response in someone who has been
maltreated to avoid contact. Hugs should be offered frequently, but
Treatment of reactive attachment disorder often involves a mix of
psychotherapy, medications and education about the disorder. It may
involve a team of medical and mental health providers with expertise
in attachment disorders. Treatment usually includes both the baby or
child and the parents or caregivers.
Goals of treatment are to help ensure that the baby or child has a
safe and stable living situation and that he or she develops positive
interactions with parents and caregivers. Treatment can also boost
self-esteem and improve peer relationships.
There's no standard treatment for reactive attachment disorder.
However, treatment often includes:
· Education of parents and caregivers about the condition
· Family therapy
· Individual psychotherapy
· Medication for other conditions that may be present, such as
depression, anxiety or hyperactivity
· Parenting skills classes
· Recreation therapy or occupational therapy
· Residential or inpatient treatment for children with more serious
problems or who put themselves or others at risk of harm
· Special education services
Because symptoms of reactive attachment disorder can last for years,
treatment may be long term. Parents and caregivers also may want to
consider seeking professional treatment or counseling for themselves
or other family members to help cope with the stress of having a child
with reactive attachment disorder.
Some forms of treatment of reactive attachment disorder remain
highly controversial, and this has heightened in the last several years
after the deaths of several children were attributed to these methods.
Some of these methods are sometimes called re-parenting, re-
birthing, and compression or holding treatment, and they often
involve physical restraint. However, not all of these methods are used
the same way by all practitioners.
The American Academy of Child and Adolescent Psychiatry, the
American Psychiatric Association, and the American Professional
Society on the Abuse of Children have all denounced as dangerous
and unproven any practices that involve tightly wrapping, binding or
holding children while forcing eye contact, intentionally triggering a
rage, or ignoring pleas about breathing difficulties.
Early recognition is very important for the child. Once a parent is
identified as being at high risk for neglect, parenting skills should be
taught. The patient should be followed by either a social worker or
doctor to make sure the child's needs are being met.
While it's not known if reactive attachment disorder can be
prevented with certainty, there may be ways to reduce the risk
of its development:
· Be actively engaged with babies and children in your care by
playing with them, talking to them, making eye contact or smiling at
them, for example.
· Don't miss opportunities to provide warm, nurturing interaction
with your baby or child, such as during feeding, bathing or diapering.
· If you lack experience or skill with babies or children, take
classes or volunteer with children so that you can learn how to
interact in a nurturing manner.
· If your baby or child has a background that includes
orphanages or foster care, educate yourself about attachment and
develop specific skills to help your child bond.
· If you're an adult with attachment problems, it's not too late
to get professional help. Getting help may prevent you from having
attachment problems with your children, who otherwise may also be
· Learn to interpret your baby's cues, such as different types
of cries, so that you can meet his or her needs quickly and effectively.
· Teach children how to express feelings and emotions with
words. Lead by example, and offer both verbal and nonverbal
responses to the child's feelings through touch, facial expressions
and tone of voice.
If you're a parent or caregiver whose baby or child has reactive
attachment disorder, it's easy to become angry, frustrated and
distressed. You may feel like your child doesn't love you — or that
it's hard to like your child sometimes.
You may find it helpful to:
· Acknowledge that the strong or ambivalent feelings you may have
about your child are natural
· Be willing to call for emergency help if your child becomes violent
· Continue friendships and social engagements
· Find respite care so that you can periodically have downtime if
caring for your child is particularly troublesome
· If your child was adopted, reach out to your adoption agency for
· Join a support group to connect with others facing the same issues
· Practice stress management skills
· Take time for yourself through hobbies or exercise
Right click on the links below, then select
"Save Target As" or "Save Link As"...
CHILDREN DIAGNOSED WITH ATTACHMENT
DISORDER: A QUALITATIVE STUDY
Report: APSAC Task Force on Attachment
Therapy, Reactive Attachment Disorder
Practice Parameter for the Assessment and
Treatment of Children with RAD