“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on ... It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”
― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook
The DSM-5 gives the following criteria for a diagnosis of reactive attachment disorder (RAD):
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
1. The child rarely or minimally seeks comfort when distressed.
2. The child rarely or minimally responds to comfort when distressed.
B. A persistent social and emotional disturbance characterized by at least two of the following:
1. Minimal social and emotional responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care).
3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder.
F. The disturbance is evident before age 5 years.
G. The child has a developmental age of at least 9 months.
Persistent: The disorder has been present for more than 12 months.
Specify current severity:
Reactive attachment disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels (American Psychiatric Association, 2013)1.
Criterion A specifies that reactive attachment disorder is a childhood condition that involves emotional withdrawal from caregivers as shown by the child rarely or minimally seeking comfort when distressed and rarely or minimally responding to comfort when distressed.
Criterion B lists social and emotional disturbances, of which a combination of two can meet the criteria for reactive attachment disorder. These disturbances involve: minimal social and emotional responsiveness to others; limited positive affect (thoughts, feelings, emotions); episodes of unexplained irritability, sadness, or fearfulness that are visible when the child is having what should be a healthy interaction with an adult caregiver.
Criterion C explains what traumatic situations (manifested by insufficient care) must have occurred for the child to have developed the disorder. These include: adult caregivers not having met the child's needs for comfort, stimulation, or affection; the child has not been able to form a stable attachment with one adult caregiver due to being shuffled around between caregivers; the child was raised in a setting that did not allow for the child to become close to any specific adult caregivers.
Criterion D states that the emotional withdrawal is caused by the insufficient care.
Criterion E excludes those with autism spectrum disorder.
Criterion F clarifies that the disturbance must have been visible before the child was 5.
Criterion G clarifies that the child must be older than 9 months and have the intellectual abilities of a child older than 9 months.
The disorder may be transient or last longer than a year.
The disorder may be severe when all of the above criteria are exhibited in extreme ways.
The most important aspect of RAD is the absent or severely underdeveloped attachment between the child and their caregiver due to the limited opportunities to develop and strengthen appropriate attachment. Because of this, children with RAD will not seek comfort from adults nor respond to comfort offered. They have comprised emotional regulation abilities and respond negatively to interaction with adults. Just as neglect is often associated with developmental delays, especially those in cognition and language, RAD is often associated with the same. Other associated features include repeated or ritualistic movements, postures, or utterances (stereotypies) and signs of severe neglect, such as malnutrition and signs of poor care. Depressive symptoms are also possible. Signs of the disorder are often present in the first few months of the child with RAD's life (American Psychiatric Association, 2013)1.
RAD is found in approximately 10% of severely neglected children who are placed into foster care or institutions; the prevalence of RAD outside these settings is unknown as neglected children are unlikely to be brought into an environment in which they could be diagnosed without child protective services first becoming involved (American Psychiatric Association, 2013)1.
A child who is not treated for reactive attachment disorder will become an adult who presents with a personality disorder.
1 American Psychiatric Association. (2013). Trauma- and Stressor-Related Disorders. In Diagnostic and statistical manual of mental disorders (5th ed.). http://dx.doi.org/10.1176/appi.books.9780890425596.dsm07