Reactive attachment disorder (RAD) is a mental health diagnosis in the Diagnostic and Statistical Manual (DSM-5) characterized by young children, under the age of five, with persistent difficulty establishing and maintaining a close relationship with others, poor emotional control, and withdrawal from social interaction.1 According to attachment theory, these behaviors are linked to early childhood maltreatment and neglect.
Cognitive and language delays are frequently present, and symptoms typically appear between 0-5 years of age.
What Is Attachment?
To clearly understand RAD, we first have to talk about the concept of attachment. According to Diane Benoit, MD,2 secure attachment is a relational bond that forms between infant and primary caregiver when their primary caregivers consistently meet an infant’s needs for love, warmth, safety, food, and attention.
If a child’s basic needs are well met, a secure, loving attachment between the child and the caregiver will develop. This secure form of attachment is identified by how the child reacts to their caregiver when in distress.2 If the child turns towards the caregiver for protection and comfort when distressed, this indicates a secure attachment.
If a child avoids or seems ambivalent about approaching their caregiver when in distress, the child displays one of three forms of insecure attachment. Insecure attachment develops if a child’s needs go consistently and deeply unmet or if the child experiences abuse or trauma at the caregiver’s hands. In this scenario, the child does not approach the adult for soothing because they have learned that their bids for comfort will be futile.
Signs of Reactive Attachment Disorder
In infancy, RAD looks like a child who is unable to be comforted, who refuses comforting, and cries inconsolably. Infants with RAD may also have trouble with feeding and gaining weight, and their muscle tone can be rigid due to a lack of affection.3
A toddler or preschool-age child with RAD will look like an explosive, disobedient, withdrawn child who finds great difficulty managing emotions, coping with everyday stressors, and trusting others enough to form close relationships. Children with RAD usually have cognitive and language delays, difficulty following directions, aggressive behaviors towards others, nightmares, hypervigilance, and frequent episodes of crying or tantrums. As children with RAD age, a pattern of relating to others forms, breaking RAD into two subtypes, Inhibited RAD and Disinhibited RAD.
Signs of Inhibited RAD include:
- Refusal to express emotions
- Use of aggression as a defense mechanism
- Rejection of affection or touching by others
- Unwillingness to make eye contact
- Withdrawal from social engagements, avoidance, keeps to themselves
- Flat, negative, or blunted affect
Signs of Disinhibited RAD include:
- Indiscriminately shows affection to others regardless of safety
- Overly affectionate with strangers but impartial or withdrawn to caregivers (the opposite of stranger anxiety)
- Sociable on a surface level
- Acts younger than physical age
- Attention seeking and then sabotaging, resulting in shallow emotional connections
In adults, the outcome of RAD is unclear, and we need more research in this area. As it stands in the DSM-5, symptoms must develop before the age of five. Over time, the impact of a RAD can have dire consequences. “As they approach adolescence and adulthood, socially neglected children are more likely than their neuro-typical peers to engage in high-risk sexual behavior, substance abuse, have involvement with the legal system, and experience incarceration,” Ellis, et al.4
A RAD diagnosis in childhood is a risk factor for:
- Difficulty maintaining healthy relationships
- Learning disabilities
- Unemployment/job loss
- Chronic disease
Symptoms of Reactive Attachment Disorder
A child with RAD is frequently in trouble at home and in the community, which causes extreme frustration and disruptions in the child/caregiver relationship. Their behavior is not a conscious choice but a defensive response to perceived threats to their safety. Research by trauma expert Bruce D. Perry shows that trauma impacts how the brain functions.5 The child’s aggressive and defensive behavior is an instinctual form of protection.
Many children with RAD learn to distract themselves from their emotional pain by seeking negative attention. For some children impacted by abuse and neglect, negative attention can feel more predictable and familiar than positive attention. From their early childhood trauma, children learn that relationships equal pain. Often, children raised in chaotic, angry homes feel comfortable within dysfunctional relationships because it feels familiar. Trying to navigate relationships where love and attachment are the goals can feel uncomfortable and anxiety-provoking.
According to the DSM-V, the symptoms of RAD in young children include:1
- Rarely or minimally seeking or responding to comfort when distressed
- Difficulty expressing positive emotions
- Unexplained irritability, sadness, or fear in connection with safe caregivers
- History of neglect, abuse, prolonged separation from biological parents, and changes in primary caregivers
- Witnessing abuse of others
- A child must be between the ages of nine months and five years old to receive a diagnosis
Causes of Reactive Attachment Disorder
Infants and young children need close, consistent, and warm relationships with adult caregivers to develop a sense of trust and safety in the world around them. Each time a child cries and a parent responds warmly, trust and attachment begin to form. With each repetition of this cycle, the relationship between the adult and the child deepens. However, if the child’s cries are ignored or responded to inconsistently, a breakdown in trust occurs, and disruptions in the attachment cycle between parent and child occur.6
Young children look to the adults in their lives for cues about what is safe and what is not. If a child does not receive consistent love and attention from a primary caregiver, they lose faith in the world around them. When a child gives up on finding a connection with others, RAD can develop.
More research is needed about the exact cause of RAD, but contributing factors include:
- Extended separation from primary caretakers, such as in foster care
- Frequent changes in primary caretakers
- Institutional upbringing
- Prolonged hospitalizations of parent or child
- Parental substance abuse and untreated mental health problems that impair parenting ability
- Experiencing or witnessing trauma, abuse, and neglect
Can RAD Be Prevented?
It is unclear if RAD can be prevented in children because it arises from unpredictable early life experiences. However, we can minimize the risks of a child developing RAD by providing consistent care, unconditional love and acceptance, opportunities for trust-building with caretakers, and education for at-risk families about positive parenting skills and attachment.7
Suggestions for caregivers include:
- Spend one-on-one time with your child each day, observing them play and providing unconditional love and affection
- Respond to your child’s needs when they are hungry, hurt, upset, sick, or tired with empathy
- Accept your child’s uncomfortable emotions instead of invalidating or rejecting their experience. Stay calm and present with their feelings without reacting negatively
- Frequently delight in your child, make eye contact, smile, and have fun together!
Treatment for Reactive Attachment Disorder
Treatment for RAD should involve mental health counseling with both the child and the current caregiver, trauma parenting education, and trauma-sensitive care in school.8 RAD is a relational disorder, and healing happens within the connection to others.9
There is no standard treatment for RAD, and it is not a disorder that children will outgrow. The earlier children receive treatment, the better their long-term outcome for mental health will be. It is also vital that the child has a stable living environment, physical and emotional safety, and a consistent caregiver. Treatment strategies frequently involve educating the family members about the psychological impact of trauma and learning therapeutic parenting skills to rebuild trust and attachment.
Psychotherapy is a crucial component in the treatment of RAD, but talk therapy is not always the most effective treatment for young children. It is critical to seek out a therapist specializing in treating attachment trauma because many therapists are not trained in the unique behavioral challenges that arise from the neurological impact of childhood adversity.
Types of therapy often include:
- Play therapy
- Art therapy
- Animal-assisted therapy
- Eye Movement Desensitization and Reprocessing (EMDR)
- Trauma-Focused Cognitive Behavior Therapy
- Parent/Child Interaction Therapy
There is not an exact timeline that reveals when attachment trauma will occur. However, the purpose of therapy is to help children express their emotions about the trauma and rebuild the broken trust with a safe adult. In therapy, children with RAD learn what healthy attachment and boundaries look and feel like so they can replicate these behaviors in the future.
The goal of therapy is to help the child process the traumatizing events in an effort to move forward, and feel safe enough to bond with others who are trustworthy. Treatment aims to help the child and the caregiver rebuild trust and create an attachment to each other through mutual empathy and compassion. Within a safe relationship, most children learn how to regulate their emotions and cope with life stressors.
There is no medication prescribed explicitly for RAD. However, the most commonly used drugs include those that help manage symptoms associated with anxiety and depression that stem from RAD. These medications may help alleviate the symptoms, but do not treat the underlying cause. It is important to reach out to a pediatric psychiatrist for a full evaluation if you are considering medication for a child. Before using a medication, consider the risks, benefits, and possible side effects.
The following are questions you can ask your doctor about RAD medications:
- What are the potential side effects?
- How long will my child need to take it, and how will we end use?
- Will my child experience withdrawal or discontinuation symptoms after use?
- Does the medication have the potential to be addictive?
- Is the dose adjusted for the height and weight of my child?
- What does the school nurse need to know about this medication?
RAD is exceptionally stressful for the child/caregiver relationship, and often the caregiver will feel as though the child is rejecting them personally. It is important to remember that the behaviors of a child with RAD are not intentional. Trauma impacts the way the brain functions, and how the brain responds to perceived threats in the environment due to a lack of safety and trust created by the traumatic experiences.12
Lifestyle recommendations for the child include:
- A healthy diet, remove caffeine for anxious children
- Mindfulness, yoga, and meditation
- Coping skills for anxiety and depression
- Trust building activities with caregivers
- Consistent warmth and love from an adult caregiver
- Spending time in nature and with animals (more comfortable to create attachment bonds)
- Limit over stimulation in their environment
- Implement a sensory “diet” – allowing the child to get the right amount of sensory input throughout the day. Some children require more and sometimes less sensory information, depending on how they are feeling.
How to Get Help for Reactive Attachment Disorder
Finding help for a child with an attachment disorder can be challenging. Often medical professionals are not aware of RAD, and you can get sent down the wrong path if you receive a misdiagnosis. Because early intervention is critical with RAD, it is best to put in the work ahead of time to find the professionals who understand childhood trauma and attachment. When searching for a counselor or psychiatrist, look at the description of what they specialize in and their educational credentials to make sure they are licensed to provide counseling.
For a child with RAD, look for a licensed professional counselor, psychologist, or psychiatrist specializing in childhood trauma. Next, set up a phone interview with at least three professionals to see if their personality is a good fit for you and the child. A positive counselor/client relationship correlates with successful outcomes in therapy. If the counselor seems like a good fit, make an appointment, and show up!
Trauma therapy can make things more challenging before they get more comfortable. Trauma healing is a process, and memories and emotions might come up that need time to be expressed. Remember that this is a typical reaction to growth. Stay focused on the long-term goals of the child. If you go to the appointment and you don’t feel comfortable with the therapist, you can always start over and find someone more compatible.
Lastly, if you have trouble finding a childhood trauma therapist, reach out to a local college or university psychology or social work department. Often they have programs and free resources that could be helpful to you and your family. As a last resort, you can also consider online therapy, but most therapists highly recommend in-person sessions to treat RAD.
Co-Occurring Disorders With Reactive Attachment Disorder
Symptoms of RAD are often misattributed to other mental health disorders such as autism spectrum disorders (ASD), attention deficit hyperactivity disorder (ADHD), conduct disorder (CD), and oppositional defiant disorder (ODD). Because symptoms of RAD mimic these other disorders, mental health professionals, and the child’s pediatrician should be aware of the child’s history of trauma. RAD frequently co-occurs with one or more of the disorders mentioned above.10 It is crucial to consult a psychologist or psychiatrist with experience in attachment disorders and childhood trauma to receive a proper diagnosis.
Due to their overlapping symptoms, your mental health professional should rule out ASD before a RAD diagnosis.11
Reactive Attachment Disorder Statistics
Research statistics on RAD are hard to come by, and much more research is needed to accurately identify the rate at which it occurs in the world. The studies we have access to show some remarkable findings. Children with RAD have a higher rate of comorbid diagnoses, such as ADHD and ASD, compared to other mental health disorders.
We also see higher rates of RAD within minority and poverty stricken populations. In a report published by Sutton Trust in 2014, research from a longitudinal study of 14,000 children in the United States showed that 4 in 10 infants lack secure attachment to their primary caregivers.13
Additional statistics on RAD indicate:
- A prevalence rate of 1.4% in the general population
- A prevalence rate of 19.4% for children in foster care or other out of home placement
- 40% of children in the longitudinal study experience insecure attachment, which is a precursor for developing RAD
The above data suggest that RAD could be much more prevalent than anticipated.
Parenting a Child With RAD
As adults, we often believe that if we love children enough eventually they will heal. This isn’t always the case with children who have RAD. Raising children impacted by childhood trauma means accepting them for exactly who they are without taking their behavior personally. Children let their internal rage from the abuse or neglect show to those they trust the most. You might not “deserve” their wrath, but their outrage is valid. If a child is acting out with you, it is not because she thinks you are an easy target; it is because she believes you are someone who will not abandon her.
Adults often give up right before a child learns to trust. Keep going! Children impacted by trauma will have to test you repeatedly before they believe that you are safe. This behavior isn’t a conscious choice but a survival mechanism built into our brain to respond to the trauma we experience in life. They are seeking safety at all costs, and being in harmony with others feels unsafe.
Dr. Bruce D. Perry recommends the following strategies for parenting children with RAD:12
- Do not be afraid to talk about the traumatizing event
- Be patient; children process trauma in bits and pieces and over months, sometimes years
- Notify caregivers, teachers, doctors, and people closest to the child about the trauma
- Clarify the cause of the trauma with the child. Children frequently distort the experience and blame themselves
- Maintain routines and provide a predictable schedule each day. Make them aware of changes that are coming up
- Learn how to manage your emotions so you can stay calm when the child is upset
- Accept big emotions with empathy and compassion, let the outbursts come and go
- Teach children about safe body boundaries with others by being respectful of their personal space. Seek consent before showing affection or touching their body. Only yes, means yes.
If you think your child or family member could be suffering with RAD, please remember there is hope. The sooner you get support for your child the better the outcome. Children are malleable, and with each positive relationship they encounter, there is the opportunity for a corrective emotional experience to take place. As the adult in their life, you can be the person who helps them to feel safe, secure, and loved. You might not see the fruits of your labor right away, but in time, the stability you provide will be the foundation for their future well-being.
For Further Reading
The following are helpful additional resources for Reactive Attachment Disorder: