Understanding Reactive Attachment Disorder: Causes, Symptoms, and Treatment

 1. What is Reactive Attachment Disorder?

Clinical Definition

Reactive Attachment Disorder (RAD) is a severe and rare condition in which children exhibit a pattern of

inhibited and emotionally withdrawn behavior toward adult caregivers. The disorder typically manifests

in the first few years of life, and the child may fail to seek comfort when distressed or show minimal

emotional response to others . RAD is diagnosed when the child does not develop appropriate attachment

behaviors, such as seeking or responding to comfort in distressing situations, engaging in social

reciprocity, or showing affection in a developmentally appropriate manner.

The disorder is recognized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as a

condition that arises from extreme neglect or inconsistent caregiving, with symptoms including failure to

form secure attachments, emotional dysregulation, and difficulties in establishing normal peer

relationships (Shah et al., 2014) . If untreated, RAD can result in long-lasting behavioral and emotional

challenges, including difficulties in forming stable relationships later in life.

Differences Between RAD and Other Attachment Disorders

RAD showcases different symptoms compared to Disinhibited Social Engagement Disorder because

RAD patients disengage from caregivers while patients with DSED behave openly with unfamiliar

people. RAD mainly develops because of early caregiving problems yet forms differently than the social engagement symptoms of DSED.

RAD needs separate identification from autism spectrum disorder (ASD) because ASD patients show

social and communication challenges but their condition results from different causes. Children with ASD

have problems interacting socially yet unlike RAD patients they show normal emotional interest and

attachment behaviors (Minnis et al., 2020) .

2. Causes of Reactive Attachment Disorder

Early Childhood Neglect or Abuse

Early neglect or abuse is thought to be just one of the most important risk factors for the development of

RAD. A child who’s been abused physically, sexually, or emotionally, or who has been neglected, has a

much greater risk of developing attachment disorders, according to studies (Zeanah et al., 2005) . It can

affect the ability to have a secure attachment to the primary caregiver, which affects long-term emotional

difficulty. The child’s need for affection, safety, and consistent care, in most cases, are not met and this

greatly affects their ability to trust people.

Frequent Changes in Caregivers

A child who moves between different caregivers in foster care or adoption often finds it hard to create

proper emotional bonds. Moving between caregivers frequently makes children develop the notion that

others cannot be depended on which pushes them to stay distant from attachments (Mountain et al.,

2017) . Children adjust their behavior to keep others at a distance when their lives continue to be marked

by caregiver changes.

Inconsistent Parenting and Emotional Unavailability

If the parents are emotionally unavailable, inconsistent in response, and not able to offer a stable

emotional environment, then it can inadvertently contribute to getting a RAD. Secure attachments are

essential for children and they only develop if children are cared for in a consistent, loving, responsive

manner. If it were not there, they may grow up believing that their emotional needs will not be met as

such, and as such have difficulty forming emotional bonds with others (Rich, 2017) .

Biological Factors

Environmental factors contribute greatly to RAD, but there is some research indicating that RAD usually

is determined by a genetic or neurological predisposition to the disorder in a child. The brains of children

with a history of trauma or neglect have different development in the areas that orchestrate emotional

regulation and attachment (Pollak & Sinha, 2002) . However, a child has to experience these biological

changes, and that can make it more difficult for the child to form secure attachments even when placed in

a more stable and loving one later on in life.

Environmental and Social Factors

RAD can also develop as a result of social factors such as socioeconomic status, the stability of

the family environment, and the availability of facilitative community support systems. Children

from low-income families or whose family lives constantly under chronic stress are the ones who

may suffer from the disruption in an attachment related to the unavailability of resources or

support (Betcher et al., 2023) . Further, cultural factors and community support systems serve as

either a buffer or as an exacerbating effect to the effects of early attachment disruption.

3. Symptoms of Reactive Attachment Disorder

Signs in Infants and Toddlers

When RAD appears in young children it shows their inability to display emotional reactions and their

failure to go to caregivers for support while feeling anxious. Signs may include:

•  No eye contact or limited smiling: The child does not look into the eyes of the caregivers or, at

least disturb a smile or facial expressions.

•  Failure to console: This is a very alarming sign that contrasts with children’s normal response; a

child with RAD will not run to the primary caregiver when he or she is upset.

•  Mutism: Children with RAD may avoid contact with other individuals and even in situations that

demand care and affection, these kids may not seek comfort (Zeanah, 2018) .

Signs in Older Children

Some of the symptoms of [RAD] worsen with time as the child advances in age. It goes without

mentioning that the symptoms of RAD in older children are, among others:

•  Lack of companions: Children with RAD could have little or no friends or they may have

trouble conversing with peers and other people.

•  Post-traumatic stress reaction: Behaviors that reveal emotional abuse through RAD may range

from aggressive, and easily annoyed, to the child or the teenager becoming overly aggressive and

even socially awakened. Some children may have behavior issues that are informed of aggression

while others may withdraw themselves from interacting with other children (Baumgart, 2020) .

•  Inability to express emotions or empathy: Children with RAD are likely to lack the ability to

express or own emotions and rarely display any sympathy to others, thus, social issues (Betcher et
al., 2023) .

4. Diagnosing Reactive Attachment Disorder

Diagnostic Criteria According to DSM-5

RAD has been assessed by the DSM-5 along with certain symptoms such as persistent social and

emotional problems, avoidance of caregivers, and a history of neglect or unresponsiveness from

caregivers (Shah et al., 2014) . Children must show at least two of the following symptoms:

 Limited emotional responsiveness to others

 Failure to seek or respond to comfort when distressed

 Lack of social reciprocity in interactions

 A history of insufficient care (e.g., neglect or multiple caregivers)

Challenges in Diagnosing RAD

It is difficult to diagnose RAD because the symptoms look like the symptoms from other childhood

disorders, like anxiety, depression, or conduct disorders. In addition, the disorder is not rare enough, and

often the RAD is misdiagnosed as a behavioral problem more so in place of being diagnosed as a

psychological attachment disorder – which may go other ways and render the proper treatment (Mountain

et al., 2017) . RAD can only be correctly diagnosed by a thorough assessment by a trained mental health

professional.

Role of Medical and Mental Health Professionals

Diagnosis of such kind requires input from various professionals. These professionals carry out detailed

evaluations that may include interviews with caregivers, behavioral assessments, and developmental

history (Cuyvers et al., 2020) . Early diagnosis by qualified professionals is necessary to allow an early

intervention of appropriate therapeutic intervention as soon as possible.

5. Treatment Options for Reactive Attachment Disorder

Therapeutic Interventions

The cornerstone of treating RAD is therapeutic intervention. The primary goal is to help children form

healthier attachments to caregivers. Some common therapeutic approaches include:

•  Attachment-Based Therapy: This therapy focuses on improving the child’s ability to form
• secure emotional connections with caregivers by providing a safe and nurturing environment
• (Mountain et al., 2017) .
•  Cognitive Behavioral Therapy (CBT): CBT can help children develop skills to manage
• emotions and behavioral responses, enabling them to better interact with others healthily (Briscoe
• et al., 2021).
•  Play Therapy: Play therapy allows children to express emotions nonverbally, helping them
• process feelings of fear or sadness in a safe, controlled environment (Zeanah, 2018) .
• Parenting Approaches
• For RAD treatment to be effective, caregivers must adopt consistent and nurturing approaches.
• Interventions often focus on helping parents:
•  Provide consistent and emotionally available care.
•  Establish stable routines and clear expectations.
•  Use positive reinforcement to encourage attachment behaviors.
•  Engage in regular therapeutic sessions to improve parenting skills and reduce stress (Baumgart,
• 2020) .