Image: "Wrath" by RichardAlan

CC BY-NC-ND 2.0

Reactive Attachment Disorder

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A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: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.

Specify if:

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 not having been able to form a stable attachment with any one adult caregiver due to being shuffled around between caregivers; the child having been 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. The child's symptoms are not due to another condition or disorder and began in reaction to the lack of care.

Criterion E excludes those with autism spectrum disorder from being diagnosed with RAD because autism can cause similar attachment disturbances.

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. This is because children younger than 9 months are generally not capable of forming selective attachments to caregivers.

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 interactions with adults. RAD, like neglect in general, is associated with broad developmental delays, especially in cognition and language. Other associated features include repeated or ritualistic movements, postures, or utterances (stereotypies). Depressive symptoms are also possible (American Psychiatric Association, 2013)¹.

Other signs of RAD may include a lack of a preferred attachment figure, social withdrawal, hypervigilance, and a tendency to react with aggression when exposed to sadness or distress. RAD has been shown to be associated with emotional problems, conduct problems, difficulty socializing with peers, hyperactivity, and fewer prosocial behaviors. A negative self concept is common, as are distrust towards others and the child attempting to mask negative emotions (Zimmermann & Iwanski, 2018)².

RAD is found in approximately 10% of severely neglected children who are placed into foster care or institutions. The prevalence of RAD outside of these settings is unknown because neglected children are unlikely to be brought into an environment in which they could be diagnosed without child protective services first becoming involved. The diagnosis is usually made in younger children (American Psychiatric Association, 2013)¹, although similar symptoms can be observed in older children as well. A lack of placement with supportive caregivers may prolong the disorder and worsen prognosis (Zimmermann & Iwanski, 2018)².

A wide variety of outcomes is possible for children who have RAD. Some, especially those who are placed in the care of a well trained caregiver, will develop normal attachment and emotional regulation abilities. However, there are anecdotal reports that adults who had untreated RAD as children are likely to have a personality disorder, depressive disorder, anxiety disorder, or dissociative disorder. Difficulties forming and maintaining relationships might be the most prominent feature (Peterson, 2016)³.

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

² Zimmermann, P. & Iwanski, A. (2018). Attachment disorder behavior in early and middle childhood: Associations with children’s self-concept and observed signs of negative internal working models. Attachment and Human Development.

³ Peterson, T. J. (2016, August 30). Reactive attachment disorder in adults. Retrieved from https://www.healthyplace.com/ptsd-and-stress-disorders/reactive-attachment-disorder/reactive-attachment-disorder-in-adults