Reactive Attachment Disorder (RAD)

What is reactive attachment disorder?

Reactive attachment disorder (RAD) is a condition where a child doesn’t form healthy emotional bonds with their caretakers (parental figures), often because of emotional neglect or abuse at an early age. Children with RAD 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 fearful of or anxious around their caretakers, even in situations where their caretakers are quite loving and caring.

Who does reactive attachment disorder affect?

Reactive attachment disorder is most common among children who experience physical or emotional neglect or abuse. While not as common, older children can also develop RAD. Children may be more likely to develop RAD if they:

• Have many different parent figures, like multiple foster care situations.
• Were taken away from their primary caretakers after bonding with them emotionally.
• Experienced several traumatic losses early in life.
• Have parental figures who didn’t try to become emotionally close to them.
• Spent time in an institution, like an orphanage, where they didn’t have a loving parent figure.

In some cases, parents who adopt children without knowledge of the child’s history might have trouble forming a bond with the new addition to their family, especially if the child has any emotional instability. If you are a new parent and your child shows symptoms of RAD or you have difficulty connecting with them, talk with your child’s healthcare provider for an evaluation.

How common is reactive attachment disorder?

The exact rate of occurrence is unknown since many cases aren’t reported, but reactive attachment disorder can occur in up to 1% to 2% of children. Kids who are removed from their homes and placed in other settings, like foster care, are much more likely to experience RAD. Almost half of these children have difficulty developing relationships over time.

What are the symptoms of reactive attachment disorder?

Symptoms of reactive attachment disorder are unique to each child. Common symptoms among infants and young children with RAD include:

• Not showing positive emotions, like comfort, love or joy when interacting with others.
• Avoiding eye contact and physical touch.
• Expressing fear or anger by throwing tantrums or frequently showing unhappiness or sadness.
• Trying to find things in their environment that they can control, which makes them likely to break rules.

What is the difference between inhibited reactive attachment disorder and disinhibited social engagement disorder?

Inhibited reactive attachment disorder (RAD) is related to disinhibited social engagement disorder (DSED), but there are differences between each type.

RAD

Children with reactive attachment disorder are aware of what happens around them, but they don’t respond emotionally to what’s going on. They may not show or seek affection from caregivers or others and prefer to be alone. Symptoms of inhibited reactive attachment disorder include:

• Avoids caretakers.
• Withdraws from social situations.
• Resistant to signs of comfort (hugging).

DSED

Children with disinhibited social engagement disorder may be overly friendly toward strangers and even go to them without checking with their parents. In most cases, children act younger than their age and may seek out affection from others in an unsafe way. Symptoms of DSED include:

• Selective relationships.
• Attention seeking from anyone.
• Showing behavior that is not appropriate for their age.
• Not understanding social boundaries.

What causes reactive attachment disorder?

There is no exact cause for children diagnosed with reactive attachment disorder. Studies suggest that there could be several factors that contribute to a child who doesn’t form a bond with their caretakers including:

• Abuse or neglect: The child feels abandoned or alone.
• Food insecurity: The child’s basic needs aren’t being met.
• Safety: The child fears that they are in danger.
• Lack of hygiene: The child sits in soiled diapers for hours at a time without being changed.
• Multiple caretakers: The child doesn’t know who to trust.
• Inconsistent caregiving: The child’s needs are only being met some of the time, particularly if they don’t know when to expect their caregivers to reward or console them.

Young children form healthy relationships when their basic needs are consistently attended to. This builds a sense of trust between the child and their caretakers. If a child’s physical and emotional needs aren’t being met, they are at risk of developing RAD.

How is reactive attachment disorder diagnosed?

To diagnose reactive attachment disorder, your child’s healthcare provider will ask you about your child’s medical history and what symptoms they’re experiencing. Your providers might ask the following questions to better understand your child’s symptoms:

• Has your child experienced any abuse or neglect?
• When did you first notice symptoms?
• What did you notice first?
• How do you and your child interact?
• What is your living situation?
• Are there other caregivers your child interacts with?

If your provider suspects RAD, they are likely to recommend you and your child visit a pediatric specialist, psychologist and psychiatrist to help diagnose your child correctly and recommend treatments that can help.

Can reactive attachment disorder be misdiagnosed as autism spectrum disorder?

Before diagnosing a child with reactive attachment disorder, your provider will offer tests to rule out other causes, including autism spectrum disorder. Autism spectrum disorder is a developmental condition that affects a person’s behavior and communication and can, on the surface, have similar symptoms as RAD. For example, abuse or neglect doesn’t cause autism spectrum disorder but could contribute to a RAD diagnosis.

How is reactive attachment disorder treated?

Treatment for reactive attachment disorder focuses on creating emotionally healthy bonds and/or repairing fearful or uncomfortable relationships between children and their caregivers. It strengthens children emotionally in a way that can later help the child to develop other healthy relationships. Both children and caregivers benefit from treatment plans. Treatment may include:

• Psychotherapy/counseling: A mental health provider works with the child and parents to build healthy emotional skills and reduce problematic patterns of behavior that prevent bonding.
• Family therapy: This therapy involves working together with the primary caretakers and child to develop healthy ways to interact.
• Social skills intervention: This therapy teaches the child how to interact appropriately with other similar-aged children in typical social settings. Parents are usually involved to help the child use the skills they learn outside of therapy.
• Special education: If a child needs it, school-based programs can 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 difficult behaviors.

Are there complications associated with reactive attachment disorder?

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

• Delays in developmental milestones and physical growth.
• Emotional problems, such as depression, anxiety, post-traumatic stress disorder and anger management issues.
• Eating disorders.
• Substance use disorder.
• Trouble in school (learning and/or behavioral problems).
• Problems in relationships (with peers or adults, and later with partners).
• Risk-taking, like early or frequent sexual activity.

How soon after treatment will my child have healthy relationships?

Without treatment, children with RAD could experience symptoms into adulthood that will affect how they function in society. Treatment will be long term to offer emotional support to your child. It may be lifelong. There is no timeline for when your child will develop healthy relationships, but treatment, with support from their caregivers, leads to the best outcome.

How can I prevent reactive attachment disorder?

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 loved.
• Support children through the phases of their development.
• Always meet the basic needs of the child.

What can I do to help my child develop healthy relationships?

As their caretaker, you can help your child develop healthy bonds by:

• Setting limits: All children benefit from an environment in which there is a consistent pattern, so setting limits is very important. By setting reasonable limits and appropriate non-physical discipline, children know what's expected from them and what happens when they break the rules. This decreases kids’ fear and helps them to behave appropriately.
• Keeping your cool even when your child acts up: During times when your child is acting inappropriately, remain calm; do not respond if you’re angry. Discipline the child according to the rules you established and rules that your child knows. As soon as your child settles down and is ready for positive contact, show love and care. This helps the child know that you will still be there for them even through 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 is never an acceptable form of punishment.

What can I expect if I have a child with reactive attachment disorder?

Many children who receive treatment for reactive attachment disorder form stable, healthy bonds with their primary caretakers and others in their life. Children who don’t receive treatment can face risks of ongoing emotional issues. Fortunately, it’s never too late to seek treatment for developmental and mental health conditions, including RAD. It is important to remember:

• Many children who are adopted from foster placements develop into very healthy and well-adjusted children. Not all adopted children experience RAD.
• Children with significant trauma in their past may 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.

How long does reactive attachment disorder last?

Reactive attachment disorder is a lifelong condition. Treatment and support for the child helps them develop healthy relationships throughout their life and can improve their emotional and social wellbeing.

When should I see my healthcare provider?

If you notice that your child has trouble developing normal relationships or you see any symptoms of reactive attachment disorder in your child, contact your child’s healthcare provider for an evaluation or referral. Early diagnosis and treatment lead to more successful outcomes for children with this condition.

What questions should I ask my doctor?

• Do I need to enroll my child in counseling?
• What is causing my child to show symptoms of reactive attachment disorder?
• Can you refer me to a specialist or support group that works with children and families who have a similar diagnosis?
• Will my child’s symptoms change as they become teenagers? Is there anything I should look out for?

A note from Cleveland Clinic

It’s important to create a bond with your child and make sure they feel loved. Reach out to your regular healthcare provider if your child does not form a comfortable emotional bond with you or their primary caretaker. Asking your provider for advice or treatment doesn’t mean that you’re a bad parent. Instead, it opens the door to building a strong, healthy and lifelong relationship with your child.