Reactive attachment disorder (RAD) is a childhood mental health condition characterized by persistent difficulties establishing and maintaining close relationships, poor emotional control, and withdrawal from social interaction.1 These behaviors often stem from early childhood maltreatment and neglect. Symptoms of reactive attachment disorder typically include problems expressing emotions, refusal to seek help, and flat affect.
What Is Reactive Attachment Disorder (RAD)?
Reactive attachment disorder (RAD) can occur when a child does not form healthy bonds with their caregivers due to neglect, abuse, or childhood trauma. This attachment disorder in children can result in problems regulating emotions and connecting with others in relationships. Symptoms can include isolation, withdrawal from others, emotional dysregulation, and an inability or unwillingness to show emotions.2
Inhibited Reactive Attachment Disorder Vs. Disinhibited Social Engagement Disorder
Children with inhibited reactive attachment disorder tend to be withdrawn and emotionally detached. They often show little emotion and will become isolated or non-responsive. On the other hand, children with disinhibited reactive attachment disorder behave in opposite ways, seeking comfort from anyone and becoming dependent on others for care and attention.
How Common Is Reactive Attachment Disorder?
While parents, caregivers, or other figures may not report many cases of reactive attachment disorder in children, some research indicates RAD occurs in roughly 1-2% of children.3 Children removed from their homes and placed in foster care or similar situations are most at risk for developing the disorder. Children with severe attachment disorder may be unable to accept comfort or closeness, possibly reacting violently when they receive affection.3
Signs of Reactive Attachment Disorder
Signs of reactive attachment disorder look differently depending on the child. However, children diagnosed with RAD often resist comfort and may cry inconsolably. Infants may also have trouble feeding and gaining weight, and their muscle tone can be rigid due to a lack of affection.4
A toddler or preschool-age child with RAD may appear explosive, disobedient, and withdrawn. They may have difficulty managing emotions, coping with everyday stressors, and trusting others enough to form close relationships. Reactive attachment disorder in teenagers may manifest as increased aggression, anger, and control issues.
Signs of inhibited RAD include:
- Refusing to express emotions
- Using aggression as a defense mechanism
- Rejecting affection or touch by others
- Unwillingness to make eye contact
- Withdrawing from social engagements
- Flat, negative, or blunted affect
- Unresponsiveness to comfort or support
- Typically keeping to themselves
Signs of disinhibited RAD include:
- Indiscriminately shows affection to others regardless of safety
- Overly affectionate with strangers but impartial or withdrawn to caregivers
- Sociable on a surface level
- Acts younger than physical age
- Attention seeking and then sabotaging, resulting in shallow emotional connections
Symptoms of Reactive Attachment Disorder
RAD behavior is not a conscious choice but a defensive response to perceived threats to their safety. In many ways, this aggressive and defensive behavior is an instinctual form of protection.5 Children with RAD often have histories of trauma or neglect, contributing to these maladaptive coping strategies.
From their early childhood trauma, children with RAD learn that relationships equal pain. Children raised in chaotic, angry homes often feel comfortable in dysfunctional relationships because they feel familiar. Because of this, children may exhibit symptoms of reactive attachment disorder to elicit the same treatment from others as they received from caregivers.
Symptoms of reactive attachment disorder include:1
- Rarely or minimally seeking or responding to comfort when distressed
- Difficulty expressing positive emotions
- Avoiding eye contact
- Resisting physical touch
- Unexplained sadness, fear, or unhappiness
- Watching others but not engaging
- Frequent tantrums
What Causes Reactive Attachment Disorder?
Infants and young children need close, consistent, and warm relationships with caregivers to develop a sense of trust and safety. Trust and attachment form every time parents respond to their children with warmth. However, a breakdown in this trust occurs if the parent ignores or neglects their children.6 Over time, children with neglectful caregivers may lose faith in the world around them, sometimes contributing to the development of RAD.
Possible causes of reactive attachment disorder include:
- Childhood abuse: Physical, mental, sexual, or emotional abuse damages a child’s sense of safety, interrupts the development of healthy attachments, and can result in RAD.
- Having multiple caregivers: Children moving from one caregiver to another, such as those in foster care, have difficulties forming emotional bonds due to uncertainty and inconsistency.
- Having uninvolved caregivers: Uninvolved parents or caregivers may inadvertently expose their children to emotional neglect. Children learn they cannot trust caregivers to meet their needs for comfort, emotional connection, or trust. This parental behavior can result in childhood anxiety and attachment problems.
- Childhood neglect: Neglected children lack emotional, psychological, or even basic needs for healthy development. Some may isolate themselves from others and lack an understanding of healthy emotional bonds.
- Having a parent with mental health conditions: Parents struggling with their own mental health may be unable to provide their child with the necessary comfort, care, and closeness.
- Being separated from caregivers: Being separated from caregivers is a terrifying and traumatic experience that can interrupt the ability to form healthy bonds, often contributing to attachment trauma and RAD.
How Is RAD Diagnosed?
Mental health professionals can diagnose RAD based on parent interviews, observation, and clinical assessment. While experts have yet to develop a specific reactive attachment disorder test, these assessments can provide insight into the extent of the condition.
The DSM V-TR divides criteria for reactive attachment disorder into inhibited type (isolation and withdrawal from affection and comfort) and disinhibited type (being overly attached to any available person). Untreated and severe attachment disorders may result in long-lasting relationship, behavioral, academic, emotional, and mental difficulties throughout childhood and adulthood.
Complications of Reactive Attachment Disorder
Reactive attachment disorder can result in severe complications that impact a person throughout their life. RAD can interfere with cognitive functioning, create behavioral problems, and affect physical health. Reactive attachment disorder symptoms in adults can include substance use, work disruptions, and relationship problems.
Below are possible complications associated with reactive attachment disorder:7
- Developmental delays
- Substance abuse and addiction
- Academic struggles
- Relationship problems
- Risky or impulsive behaviors
- Childhood depression
- Anxiety
- Childhood PTSD
- Incarceration
- Unemployment/job loss
- Chronic disease
Treatment for Reactive Attachment Disorder
Treatment for reactive attachment disorder frequently involves educating family members about the psychological impact of trauma and learning therapeutic parenting skills to rebuild trust and attachment.RAD is not a disorder children will outgrow. The earlier children receive treatment, the better the long-term outcomes.
Therapy
Therapy for reactive attachment disorder is a crucial component in treatment. However, talk therapy is not always the most effective approach for young children. Seek a therapist experienced in treating attachment issues in children because many providers do not understand the unique behavioral challenges associated with RAD.
Therapy aims to help the child process traumatizing events to move forward and feel safe. Treatment aims to rebuild the child-caregiver relationship to create an attachment of mutual empathy and compassion. Most children learn to regulate emotions and cope with stressors in safe, supportive environments.
Types of therapy for reactive attachment disorder may include:
- Play therapy: Often, children with RAD struggle to express their emotions verbally. Play therapy can help them learn to process their feelings through play and creative activities.
- Art therapy: Art therapy also helps children express their thoughts and emotions nonverbally through painting, clay, drawing, or other creative outlets.
- Animal-assisted therapy: Therapy with animals, such as dogs, cats, or horses, can help children with RAD develop trust, emotional regulation, empathy, and healthy bonds with others.
- Eye movement desensitization and reprocessing (EMDR): EMDR helps by reprocessing early traumatic events and changing the negative beliefs one has about oneself based on those events. Healing childhood trauma can open the door to forming healthy attachments.
- Trauma-focused cognitive behavior therapy (TF-CBT): Trauma-focused CBT helps change negative thoughts and cognitions about oneself and the world. Changing those thoughts can improve relationships with emotions and other people.
- Parent/child interaction therapy: Therapists guide parents in connecting with their children through play, helping improve closeness, attachment, and bonding through healthy communication.
Medication
There are no specific medications for reactive attachment disorder. However, professionals may prescribe medications to help manage symptoms associated with anxiety and depression stemming from RAD.
These medications may help alleviate symptoms but do not treat the underlying cause. Reach out to a pediatric psychiatrist for a full evaluation if you are considering medication for a child. Consider the risks, benefits, and possible side effects before discussing any options with a professional.
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 this medication, and how will we end use?
- Will my child experience withdrawal or discontinuation symptoms after use?
- Can this medication be addictive?
- Are doses adjusted for the height and weight of my child?
- What does the school nurse need to know about this medication?
Can RAD Be Prevented?
Determining if reactive attachment disorder is preventable is difficult because unpredictable early life experiences often onset development. However, we can minimize the risks by providing consistent care, unconditional love, opportunities for trust-building, and education about positive parenting skills and attachment.2
Raising children impacted by childhood trauma means accepting them for who they are without taking their behavior personally. Adults often give up right before a child learns to trust. Keep going! Your child will likely test you repeatedly before they believe you are safe.
Below are ways to reduce the risk of RAD in children:
- Dedicate time to your child: Spend one-on-one time together each day, observing your child play and providing unconditional love and affection.
- Listen to your child and react appropriately: Empathetically respond to your child’s needs when they are hungry, hurt, upset, sick, or tired.
- Acknowledge their emotions: Accept your child’s uncomfortable emotions instead of invalidating or rejecting their experience. Stay calm and present with their feelings without reacting negatively.
- Physically engage with your child: Frequently delight in your child, make eye contact, smile, and have fun together!
- Be patient: Children process trauma in bits and pieces over months, sometimes years. Stay consistent and patient with your child as they heal.
- Discuss their trauma: Do not be afraid to talk about the traumatizing event. Clarify the causes with the child. Children frequently distort the experience and blame themselves, so remind them their past is not their fault.
- Start and maintain a schedule: Maintain routines and a predictable schedule, letting them know of possible changes or events.
- Model healthy emotional regulation: Learn to manage your emotions so you can stay calm when your child is upset. This behavior shows them how to handle their own emotions in difficult situations.
- Practice boundary setting: Teach children about safe body boundaries with others by respecting their personal space. Seek consent before showing affection or touching their body. Only yes means yes.
Final Thoughts
Please remember there is hope if you think your child or family member could suffer from RAD. The sooner you get support for your child, the better the outcome. Children are malleable–with each positive relationship they encounter, there are opportunities for corrective emotional experiences. As an adult, you can help them feel safe, secure, and loved. You might not immediately see the fruits of your labor, but the stability you provide will be the foundation for their future well-being.
For Further Reading
Reactive Attachment Disorder (RAD) Infographics
