What is reactive attachment disorder

Reactive attachment disorder is a rare but serious condition in which a child is not able to easily form a normal or loving relationship with parents or caregivers ¹. Reactive attachment disorder is considered to be a result of not forming an attachment to any specific caregiver when very young. Reactive attachment disorder may develop if the child’s basic needs for comfort, affection and nurturing aren’t met and loving, caring, stable attachments with others are not established. Because of the shared common cause and association with social neglect, reactive attachment disorder often co-occurs with developmental delays, especially in delays in cognition and language. Other associated features include stereotypies and other signs of severe neglect (e.g., malnutrition or signs of poor care) ². Children with reactive attachment disorder are more likely to have multiple comorbidities, such as with attention deficit-hyperactivity disorder (ADHD) (52%), post-traumatic stress disorder (PTSD; 19%), and autism spectrum disorder (14%) ³.

Reactive attachment disorder is usually identified when a parent (or prospective parent) is at high risk for neglect or when an adoptive parent has difficulty coping with a newly adopted child.

Signs and symptoms of reactive attachment disorder may include:

• Unexplained withdrawal, fear, sadness or irritability
• Sad and listless appearance
• Not seeking comfort or showing no response when comfort is given
• Failure to smile
• Watching others closely but not engaging in social interaction
• Failing to ask for support or assistance
• Failure to reach out when picked up
• No interest in playing peekaboo or other interactive games

If you have recently adopted a child from a foreign orphanage or another situation where neglect may have occurred and your child shows these symptoms, see your health care provider.

Signs can occur in children who don’t have reactive attachment disorder or who have another disorder, such as autism spectrum disorder. It’s important to have your child evaluated by a pediatric psychiatrist or psychologist who can determine whether such behaviors indicate a more serious problem.

Early recognition is very important for the child. Parents who are at high risk for neglect should be taught parenting skills. The family should be followed by either a social worker or doctor to make sure the child’s needs are being met.

With treatment, children with reactive attachment disorder may develop more stable and healthy relationships with caregivers and others. Treatments for reactive attachment disorder include psychological counseling, parent or caregiver counseling and education, learning positive child and caregiver interactions, and creating a stable, nurturing environment.

The prevalence of reactive attachment disorder is unknown, but the disorder is seen relatively rarely in clinical settings. The disorder has been found in young children exposed to severe neglect before being placed in foster care or raised in institutions. However, even in populations of severely neglected children, the disorder is uncommon, occurring in less than 10% of such children ².

Coping and support

If you’re a parent or caregiver whose child has reactive attachment disorder, it’s easy to become angry, frustrated and distressed. You may feel like your child doesn’t love you — or that it’s hard to like your child sometimes.

These actions may help:

• Educate yourself and your family about reactive attachment disorder. Ask your pediatrician about resources or check trusted internet sites. If your child has a background that includes institutions or foster care, consider checking with relevant social service agencies for educational materials and resources.
• Find someone who can give you a break from time to time. It can be exhausting caring for a child with reactive attachment disorder. You’ll begin to burn out if you don’t periodically have downtime. But avoid using multiple caregivers. Choose a caregiver who is nurturing and familiar with reactive attachment disorder or educate the caregiver about the disorder.
• Practice stress management skills. For example, learning and practicing yoga or meditation may help you relax and not get overwhelmed.
• Make time for yourself. Develop or maintain your hobbies, social engagements and exercise routine.
• Acknowledge it’s OK to feel frustrated or angry at times. The strong feelings you may have about your child are natural. But if needed, seek professional help.

Reactive attachment disorder DSM 5

• 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.

Reactive attachment disorder of infancy or early childhood is characterized by a pattern of markedly disturbed and developmentally inappropriate attachment behaviors, in which a child rarely or minimally turns preferentially to an attachment figure for comfort, support, protection, and nurturance ². The essential feature is absent or grossly underdeveloped attachment between the child and putative caregiving adults. Children with reactive attachment disorder are believed to have the capacity to form selective attachments. However, because of limited opportunities during early development, they fail to show the behavioral manifestations of selective attachments. That is, when distressed, they show no consistent effort to obtain comfort, support, nurturance, or protection from caregivers. Furthermore, when distressed, children with reactive attachment disorder do not respond more than minimally to comforting efforts of caregivers. Thus, reactive attachment disorder is associated with the absence of expected comfort seeking and response to comforting behaviors. As such, children with reactive attachment disorder show diminished or absent expression of positive emotions during routine interactions with caregivers. In addition, their emotion regulation capacity is compromised, and they display episodes of negative emotions of fear, sadness, or irritability that are not readily explained. A diagnosis of reactive attachment disorder should not be made in children who are developmentally unable to form selective attachments. For this reason, the child must have a developmental age of at least 9 months ².

Reactive attachment disorder signs and symptoms

Reactive attachment disorder can start in infancy. There’s little research on signs and symptoms of reactive attachment disorder beyond early childhood, and it remains uncertain whether it occurs in children older than 5 years.

In a child, reactive attachment disorder symptoms may include:

• Avoiding caregiver
• Avoiding physical contact
• Difficulty being comforted
• Not making distinctions when socializing with strangers
• Wanting to be alone rather than interacting with others

The caregiver will often neglect the child’s:

• Needs for comfort, stimulation, and affection
• Needs like food, toileting, and play

What causes reactive attachment disorder

Reactive attachment disorder is caused by abuse or neglect of an infant’s needs for:

• Emotional bonds with a primary or secondary caretaker
• Food
• Physical safety
• Touching

An infant or child may be neglected when the:

• Caregiver is intellectually disabled
• Caregiver lacks parenting skills
• Parents are isolated
• Parents are teenagers

A frequent change in caregivers (for example, in orphanages or foster care) is another cause of reactive attachment disorder.

To feel safe and develop trust, infants and young children need a stable, caring environment. Their basic emotional and physical needs must be consistently met. For instance, when a baby cries, the need for a meal or a diaper change must be met with a shared emotional exchange that may include eye contact, smiling and caressing.

A child whose needs are ignored or met with a lack of emotional response from caregivers does not come to expect care or comfort or form a stable attachment to caregivers.

It’s not clear why some babies and children develop reactive attachment disorder and others don’t. Various theories about reactive attachment disorder and its causes exist, and more research is needed to develop a better understanding and improve diagnosis and treatment options.

Risk factors for developing reactive attachment disorder

The risk of developing reactive attachment disorder from serious social and emotional neglect or the lack of opportunity to develop stable attachments may increase in children who, for example:

• Live in a children’s home or other institution
• Frequently change foster homes or caregivers
• Have parents who have severe mental health problems, criminal behavior or substance abuse that impairs their parenting
• Have prolonged separation from parents or other caregivers due to hospitalization

However, most children who are severely neglected don’t develop reactive attachment disorder.

Reactive attachment disorder diagnosis

Reactive attachment disorder is diagnosed with a:

• Complete history
• Physical examination
• Psychiatric evaluation

A pediatric psychiatrist or psychologist can conduct a thorough, in-depth examination to diagnose reactive attachment disorder.

Your child’s evaluation may include:

• Direct observation of interaction with parents or caregivers
• Details about the pattern of behavior over time
• Examples of the behavior in a variety of situations
• Information about interactions with parents or caregivers and others
• Questions about the home and living situation since birth
• An evaluation of parenting and caregiving styles and abilities

Your child’s doctor will also want to rule out other psychiatric disorders and determine if any other mental health conditions co-exist, such as:

• Intellectual disability
• Other adjustment disorders
• Autism spectrum disorder
• Depressive disorders

Your doctor may use the diagnostic criteria for reactive attachment disorder in the DSM-5 ⁴, published by the American Psychiatric Association. Diagnosis isn’t usually made before 9 months of age. Signs and symptoms appear before the age of 5 years.

Criteria include:

• A consistent pattern of emotionally withdrawn behavior toward caregivers, shown by rarely seeking or not responding to comfort when distressed
• Persistent social and emotional problems that include minimal responsiveness to others, no positive response to interactions, or unexplained irritability, sadness or fearfulness during interactions with caregivers
• Persistent lack of having emotional needs for comfort, stimulation and affection met by caregivers, or repeated changes of primary caregivers that limit opportunities to form stable attachments, or care in a setting that severely limits opportunities to form attachments (such as an institution)
• No diagnosis of autism spectrum disorder

Reactive attachment disorder possible complications

If not treated, reactive attachment disorder can permanently affect the child’s ability to interact with others. It can be connected with:

• Anxiety
• Depression
• Other psychological problems
• Post-traumatic stress disorder (PTSD)

Without treatment, reactive attachment disorder can continue for several years and may have lifelong consequences.

Some research suggests that some children and teenagers with reactive attachment disorder may display callous, unemotional traits that can include behavior problems and cruelty toward people or animals. However, more research is needed to determine if problems in older children and adults are related to experiences of reactive attachment disorder in early childhood.

Reactive attachment disorder prevention

While it’s not known with certainty if reactive attachment disorder can be prevented, there may be ways to reduce the risk of its development. Infants and young children need a stable, caring environment and their basic emotional and physical needs must be consistently met. The following parenting suggestions may help.

• Take classes or volunteer with children if you lack experience or skill with babies or children. This will help you learn how to interact in a nurturing manner.
• Be actively engaged with your child by lots of playing, talking to him or her, making eye contact, and smiling.
• Learn to interpret your baby’s cues, such as different types of cries, so that you can meet his or her needs quickly and effectively.
• Provide warm, nurturing interaction with your child, such as during feeding, bathing or changing diapers.
• Offer both verbal and nonverbal responses to the child’s feelings through touch, facial expressions and tone of voice.

Reactive attachment disorder treatment

There’s no standard treatment for reactive attachment disorder, but it should involve both the child and parents or primary caregivers. Goals of treatment are to help ensure that the child:

1. Has a safe and stable living situation
2. Develops positive interactions and strengthens the attachment with parents and caregivers

Treatment has two parts. The first goal is to make sure the child is in a safe environment where emotional and physical needs are met.

Once that has been established, the next step is to change the relationship between the caregiver and the child, if the caregiver is the problem. Parenting classes can help the caregiver meet the child’s needs and bond with the child.

Counseling may help the caregiver work on problems, such as drug abuse or family violence. Social Services should follow the family to make sure the child remains in a safe, stable environment.

Treatment strategies include:

• Encouraging the child’s development by being nurturing, responsive and caring
• Providing consistent caregivers to encourage a stable attachment for the child
• Providing a positive, stimulating and interactive environment for the child
• Addressing the child’s medical, safety and housing needs, as appropriate

Other services that may benefit the child and the family include:

• Individual and family psychological counseling
• Education of parents and caregivers about the condition
• Parenting skills classes

Most children are naturally resilient. And even those who’ve been neglected, lived in a children’s home or other institution, or had multiple caregivers can develop healthy relationships. Early and the correct intervention appears to improve outcomes.

1. Reactive attachment disorder. https://www.mayoclinic.org/diseases-conditions/reactive-attachment-disorder/symptoms-causes/syc-20352939
2. American Psychiatric Association, DSM-5 Task Force . Diagnostic and Statistical Manual of Mental Disorders: DSM-5. 5th ed. American Psychiatric Association: Arlington, VA; 2013.
3. Minnis H., MacMillan S., Pritchett R., Young D., Wallace B., Butcher J., Sim F., Baynham K., Davidson C., Gillberg C. Prevalence of reactive attachment disorder in a deprived population. Br. J. Psychiatry. 2013;202:342–346.
4. American Psychiatric Association, editor. Diagnostic and Statistical Manual Of Mental Disorders. Fifth ed. D.C; American Psychiatric Association, Washington: 2013. DSM-5