Reactive Attachment Disorder

What Is Reactive Attachment Disorder (RAD)?

Reactive attachment disorder (RAD) occurs when a baby or young kid fails to build a strong, healthy emotional link with his or her primary caregivers (parental figures). Children with RAD frequently struggle with emotion management. They have difficulty making genuine connections with others. Children are more sensitive in their developmental ages. RAD is a condition wherein the child fails to form an emotional and healthy bond with his or her parental figures. The condition is characterized by –

Difficulty forming an emotional attachment with others
Showing a decreased ability to experience positive emotions
Unable to seek or accept physical or emotional closeness, and
Reacting violently when held, cuddled, or comforted

Infants and children with RAD may fail to smile, appear withdrawn and refuse to interact with parents or caregivers. The Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), classified reactive attachment disorder as a trauma and stress-related condition of early childhood caused by social neglect and maltreatment. Researchers [mfn] Ellis EE, Yilanli M, Saadabadi A. Reactive Attachment Disorder. [Updated 2021 Aug 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537155/ [/mfn] described the behavior of this condition as, “moods fluctuate erratically, and children may live in a flight, fight or freeze mode.”

Understanding Reactive Attachment Disorder

According to the American Psychological Association (APA), RAD is “a disorder of infancy and early childhood characterized by disturbed and developmentally inappropriate patterns of social relating that are not due to intellectual disability or pervasive developmental disorder.” Reactive attachment disorder may often develop during infancy, due to a lack of stable attachments, care and love from others. Not only do children with this condition struggle with forming meaningful attachments, they also find it hard to regulate their own emotions.

Even when their parents are loving and caring, they may seem afraid of their primary caretakers. Moreover, they may also seek comfort and may appear sad, irritable and fearful in nurturing and safe environments without any clear reason. Sufferers may also refrain from social interactions or may even respond inappropriately. Changing their routines, attempting to comfort them forcefully or trying to control them can make the affected child engage in angry outbursts, self-injurious behavior and even violence.

Failure to form positive relationships and healthy attachments can often result –

Abuse
Emotional and physical neglect
Lack of responsiveness from caregivers
Separation from parents between the ages of 6 months to 3 years

This may lead to distorted inner models of relationships in children that may result in behavioral and interpersonal challenges in later years. Due to limited research [mfn] Boris, N. W., Zeanah, C. H., & Work Group on Quality Issues (2005). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 44(11), 1206–1219. https://doi.org/10.1097/01.chi.0000177056.41655.ce [/mfn] on the long-term effects of the condition, it is unclear how the condition may affect a child after the age of 5 or if it may be present beyond that age. However, with proper treatment the child may be able to develop healthy attachments and relationships.

Patterns Of Reactive Attachment Disorder

When the child suffering from RAD grows older they usually develop two patterns:

Inhibited RAD
Disinhibited RAD

1. Inhibited Reactive Attachment Disorder

A consistent pattern of a child with inhibited reactive attachment disorder is usually recognized as being emotionally withdrawn towards caregivers characterized by seeking minimal affection and showing minimal response to affection. Common symptoms with inhibited RAD include:

Detachment
Resistance towards comforting
Excessive inhibition (holding back emotions)
Failure to seek affection
Keeping to themselves
Withdrawal from others

2. Disinhibited Reactive Attachment Disorder

Due to recent revision, the DSM 5 has classified disinhibited RAD form as a “separate diagnosis”. International Classification of Diseases (ICD-10) [mfn] ICD-10 Version:2010. (n.d.). ICD-11. https://icd.who.int/browse10/2010/en [/mfn] defines this condition as “a particular pattern of abnormal social functioning that arising during the first five years of life and tend to persist despite marked changes in environmental circumstances e.g. diffuse, non selectively focused attachment behavior, attention-seeking and indiscriminately friendly behavior, poorly modulated peer interactions; depending on circumstances there may also be associated emotional or behavioral disturbance”.

Disinhibited attachment disorder is a subtype of ICD-10 category F94, which is defined as “social functioning disorders with onset in childhood or adolescence.”

Common symptoms of disinhibited RAD include:

Social indiscrimination
Inappropriate familiarity
No preference for their primary caregivers
A proclivity to act younger than their actual age and to seek affection in potentially hazardous ways

Read More About DSM 5 Here

Symptoms Of Reactive Attachment Disorder

A data analysis report, conducted by the National Survey of Child and Adolescent Well Being (NSCAW), indicated that “42% of children removed from their home and placed in an alternate setting met DSM-IV (1994) criteria for behavioral health disorder.” The contributing factor for attachment disorder is always trauma and severe emotional negligence. These factors are most commonly found in institutional settings, such as overcrowded orphanages, foster care, or homes with physically or mentally ill parents.

Young children or babies may experience the following symptoms in such cases:

Unable to express emotions of conscience, like remorse, guilt, or regret
No eye contact
Avoid physical contact with caregivers
Have tantrums
Being irritated
Being disobedient
Being unhappy or sad without any reason
Have arguments with others that’s unusual for someone that age
Inability to smile
Crying inconsolably
Not interested in playing interactive games with the parents or other kids
Spends a significant amount of time rocking or comforting themselves

Causes Of Reactive Attachment Disorder

In order to develop emotional attachment, a child must be nurtured and loved. The basic emotional and physical needs must be met consistently. For example, when a baby cries the need for a meal or a diaper change is the physical need that the baby must have. Attention to emotional need in such cases with the help of exchange of eye contact, smiling, and caressing is also of paramount importance.

A child who has been emotionally neglected in their initial years doesn’t expect any sort of emotional connection or comfort from a stable attachment. Thus, when they receive care or comfort they tend to lash out and may even throw tantrums.

Here are some of the most common risk factors that may lead to the development of reactive attachment disorder in a child:

1. Environmental Factors

The risk factors for all children suffering from this disorder are often related to the environment they are nurtured in. They can influence the child in the following way:

Consistent disregard for the child’s emotional needs for comfort and affection
Constant disregard for the child’s physical needs
Frequent changes in primary caregivers adversely affect the establishment of a strong emotional bond (e.g. frequent changes in foster homes).

2. Genetic Factors

Reactive attachment disorder is, by definition, a problem that stems from a troubled history of care and social relationships. A genetic factor may be a contributing factor for this disorder since it is often found in cases where the child had abusive parents or parents having a hostile relationship with each other. Studies [mfn] Zeanah, C. H., & Fox, N. A. (2004). Temperament and attachment disorders. Journal of clinical child and adolescent psychology: the official journal for the Society of Clinical Child and Adolescent Psychology, American Psychological Association, Division 53, 33(1), 32–41. https://doi.org/10.1207/S15374424JCCP3301_4 [/mfn] suggest the disorder has never been found in the absence of serious environmental adversity yet children raised in the same environment remain the same.

3. Other Risk Factors

Apart from the factors mentioned above, there are some other elements that may influence the occurrence of RAD, such as:

Frequently changing foster homes or caregivers
Having parents who have severe mental health problems, criminal behavior, or substance abuse that impairs their parenting.
Having prolonged separation from parents due to hospitalization

Without the right treatment, this disorder can continue for a long period of time and can have extreme life-changing consequences. Children with Reactive Attachment Disorder may display callous, unemotional characteristics such as behavioral issues and cruelty to animals or people.

In various cases, it has also been found that most children who were severely neglected do not develop this disorder. However, research is still being conducted to have a better understanding and to develop an improved diagnosis and treatment plan.

How To Diagnose Reactive Attachment Disorder?

The DSM-5 gives the following diagnostic criteria for this disorder:

A consistent pattern of emotionally withdrawn behavior toward adult caregivers is characterized by rarely or minimally seeking and responding to comfort when distressed.
A persistent social or emotional disturbance characterized by at least two of the following:
- Minimal social and emotional responsiveness to others
- Limited positive affect
- Episodes of unexplained irritability, sadness, or fearfulness that are evident even during non-threatening interactions with adult caregivers.

The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults
- Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios)

The criteria are not met for autism spectrum disorder.
The disturbance is evident before age 5 years.
The child has a developmental age of at least nine months.

Adults are usually diagnosed based on the signs and symptoms of the disorder. If the child has symptoms, the doctor may conduct a:

Complete medical history
A physical exam that includes a review of the child’s developmental stages
Neuroimaging
Blood tests

Currently, there is no lab test to detect this disorder in children. The doctor may look for physical or psychological symptoms that are triggering the behavior. In the case of psychological issues, the doctor will refer to a psychologist. The psychologist will assess the child and rule out all the causes of their unusual behavior.

Psychiatrists and psychologists have specially designed interviews and tools in order to diagnose the child’s mental health condition. They usually base their diagnoses on the symptoms they have been told, their evaluation, and the child’s behavior during the session.

How To Treat Children With Reactive Attachment Disorder?

According to a recent scientific analysis [mfn] Ellis EE, Yilanli M, Saadabadi A. Reactive Attachment Disorder. [Updated 2021 Aug 6]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537155/# [/mfn], treatment of this disorder requires a “multi-pronged approach incorporating parent education and trauma-focused therapy.” It is important to seek professional help if your child is experiencing severe attachment issues. The earlier the issue is addressed, the more likely the child will recover. The treatment for this disorder involves a combination of therapy, counseling, and parental education. This treatment procedure is designed to ensure that the child has a safe environment, develops positive interactions with parental figures, and improves relationships with peers.

1. Medication

Medication can be used in some cases when the child is suffering from depression or anxiety. However, there is no medication that can directly treat the disorder and there is no quick fix for it.

2. Counseling And Therapy

The combined efforts of counseling, therapy, and medication may help the child to develop a healthy emotional attachment with its parental figures. Some of the most effective treatment options adopted by the doctors are as follows:

A. Individual Counseling

Therapists may assess and counsel the child in order to understand their mindset. They may meet the child individually or while the parents are present. This session allows the child to directly address its concerns to the doctor and allows the doctor to monitor the behavioral and emotional patterns of the child.

B. Family Therapy

Family therapy is psychological counseling that helps family members to improve communication and improve conflicts. Therapy with attachment problems usually involves two parties- the child and its parental figures. This therapy involves fun and rewarding activities between the child and parent in order to develop an emotional bond or connection between them. The child may be surprised at first or even show signs of anger or resentment but it is important to continue building the bond to establish an emotional attachment between the parents and the child.

C. Play Therapy

This therapy is used to help children learn the appropriate skills and behavior that needs to be established among peers. This also helps in learning how to handle social situations.

3. Special Educational Services

This may include the following types of learning strategies:

A. Child Special Classes

There are specifically designed services in some schools that can help the child to learn the skills required to be an academic and social success. It also helps them to address their behavioral and emotional issues.

B. Parenting skill classes

It is also essential for parents to learn how to address their child’s behavior. There are dedicated educational programs that help parents to learn how to take care of a child suffering from Reactive Attachment Disorder.

How To Parent A Child With Attachment Issues?

It can be emotionally exhausting to parent a child with attachment problems. But with time, patience, and a dedicated effort your child will be able to develop a loving attachment with you. It is of utmost importance to remain calm while dealing with your child. This will enable the child to realize that they are in a safe environment and they can trust you.

A child suffering from Reactive Attachment disorder is under a lot of stress and hence it is essential for you to evaluate and manage your own stress levels before trying to help your child. There are certain things to keep in mind in order to help a child with attachment issues:

1. Have Realistic Expectations

You will be less disappointed if you have realistic expectations. Focus on small steps towards your goals and create a safe environment for your child.

2. Have Patience

It is important to have patience while dealing with your child. The progress may not be as fast as you’d like but it is important for your child to feel loved.

3. Have Fun

It is important to have fun with your child in order to develop a good relationship. Introduce fun activities to do with your child that will help him or laugh and feel good.

4. Get Support

Seek help from educational services that help parents with children suffering from attachment disorder. Having support is an essential part of the process.

5. Be Hopeful

Don’t give up on your child if you see signs of irritability and anger. Stay positive and hopeful and keep nurturing your child. Understand the fact that children are sensitive towards picking up feelings and hence it is essential for the parent to show their child the support that it subconsciously seeks for.

Is It Preventable?

In order to prevent Reactive Attachment Disorder, it is crucial to recognize the problem and get the help your child needs as soon as possible. It may not be preventable but there are several measures that you can take to make sure your child doesn’t develop it. They are as follows:

Engaging with your child is an important step to establish a strong connection. This involves playing with your child, talking to them frequently and smiling.
Understand baby cues in order to address what they really need. Like understanding how the baby cries when they want food, or cuddles or want to sleep.
Showing love and warmth is an essential part of a baby’s development. Speak to them in a loving way while you bathe him or her or change its diaper.
Reply to your child with a loving warm tone with caring facial expressions and physical touches.
Volunteer or take classes in which your child is interested to develop a strong emotional bond with him or her.

What Is The Outcome Of This Disorder?

What Is The Outcome Of This Disorder

Nurturing a child while it is growing up is important. This helps the child to build nurturing and loving relationships with its peers and other people. However, if the child develops this disorder and is untreated it can give rise to serious consequences. Some of the consequences can be:

Depression
Aggressive behavior
Having behavioral problems in school
Not being capable of building meaningful relationships
Low self-esteem
Anxiety
Stress
Eating disorders
Alcohol or drug abuse

Read More About Eating Disorders Here

Recovery Is Possible

Paying attention to your child’s behavior goes a long way in detecting early signs of the disorder. The right treatment and attention, allow the child suffering from Reactive Attachment disorder to recover and establish a strong bond with its family members and peers.

With therapy and a little help from the parental figures it is possible for the child to trust them as well as others and lead a happy and healthy lifestyle.