What is Reactive Attachment Disorder?
Reactive attachment disorder (RAD) is a mental health-related issue in which a child doesn’t form healthy emotional bonds or relationships with caregivers, guardians, or parents. Children with the disorder have trouble trusting caregivers, even when those caregivers are supportive and affectionate. As a result, the children rarely seek comfort from or emotional connection with caregivers, and they may appear anxious in the presence of caregivers.
RAD is most common in children who have experienced neglect or abuse in early childhood. The disorder is especially common in children who have come from an unstable home environment and have been placed in foster care or some other institutional setting.
Symptoms of RAD
RAD symptoms usually begin early in childhood, even sometimes in infancy. Common symptoms include:
- Appearing sad, fearful, or irritable
- Withdrawing and avoiding social interaction
- Not seeking comfort and not responding when comfort is offered
- Unwillingness to smile or show positive emotion
- Avoiding physical contact
- Avoiding eye contact
- Having tantrums
What Causes Reactive Attachment Disorder?
The cause of RAD is not yet known. Many different factors in a child’s life may increase the risk of RAD, but not every child exposed to those situations develops the disorder. Scientists don’t understand why some children experience RAD and others don’t. However, it is clear that certain risk factors significantly increase a given child’s chance to experience RAD.
Risk factors include:
- Experiencing neglect or abuse (physical, emotional, or sexual)
- Experiencing food insecurity or unsafe situations at home
- Experiencing trauma or violence
- Having parents or caregivers who struggle with mental health issues or substance abuse
- Having parents or caregivers who engage in criminal activity
- Being separated from parents or caregivers
- Frequently changing caregivers or foster homes
- Living in a group home or other institution
Is Reactive Attachment Disorder Hereditary?
Some scientists believe that there is a genetic component to attachments disorders like RAD. However, no specific gene or genes have yet been associated with RAD. Some children may have a genetic predisposition that puts them at increased risk for developing the disorder, which is then triggered by external circumstances.
How Is Reactive Attachment Disorder Detected?
Sometimes symptoms of RAD may appear very early in childhood, even in infancy. Warning signs of RAD in very young children may include:
- Constant crying or weak crying
- Frequent flinching or startling
- Stiffness or resistance to physical contact
- Feeding difficulties
- Poor eye contact
- Absence of smiling
- Developmental delays
How Is Reactive Attachment Disorder Diagnosed?
Diagnosis of RAD begins with determining that the patient has a cluster of symptoms that meet the diagnostic criteria for the disorder. A doctor will start with a physical exam to rule out biological problems that may be causing symptoms. After these exams, if the doctor suspects that RAD or another mental health issue is the cause of the symptoms, they may recommend a psychological or psychiatric assessment to solidify the diagnosis further.
Diagnostic steps may include:
- A physical exam. This exam aims to rule out physical conditions that could be causing the symptoms.
- Psychological assessments. These assessments may take the form of questionnaires or talk sessions with a mental health professional to assess the patient’s mood, mental state, and mental health history. Family members or caregivers may also be asked to participate in these assessments.
The results of the psychological assessments will be compared to the diagnostic criteria for RAD in the Diagnostic and Statistical Manual of Mental Disorders (DSM). The DSM criteria for RAD include:
- The child is emotionally withdrawn from adult caregivers.
- The child is emotionally unresponsive, shows limited positive emotions, or expresses negative reactions around caregivers.
- The child has experienced negative circumstances that are presumed to have caused the symptoms.
- The child doesn’t meet the diagnostic requirements for autism spectrum disorder.
- The symptoms are noticeable before age five.
- The child is at least nine months old.
PLEASE CONSULT A PHYSICIAN FOR MORE INFORMATION.
How Is Reactive Attachment Disorder Treated?
There is no cure for RAD. However, early intervention may help control the disorder’s symptoms and prevent future complications. Psychotherapy is the most common course of treatment, and treatment options typically include both the child and their caregivers.
Types of therapy commonly used to treat RAD include:
- Individual talk therapy
- Family therapy
- Parent training
- Social skills training
How Does Reactive Attachment Disorder Progress?
Without treatment, the effects of RAD may continue through childhood and into adulthood. People who experience symptoms of RAD in childhood may have persistent difficulty forming and maintaining healthy relationships. Their problems with social interaction may also increase their risk of developing other mental health issues.
Long-term adverse effects of these disorders can include:
- Alcohol or substance abuse
- Problems with social interaction (e.g., anger management issues)
- Problems at school or work
- Impulsive or risky behavior
How Is Reactive Attachment Disorder Prevented?
Scientists are unsure whether RAD is preventable, but it seems clear that providing a child with a caring, supportive, safe environment during their early development is likely to reduce the child’s risk.
Reactive Attachment Disorder Caregiver Tips
Caregivers can help to reduce the risk of RAD by following some simple guidelines as they care for children:
- Provide a consistent, reliable, emotionally supportive relationship with the child.
- Show affection.
- Consistently meet the child’s basic needs for food, shelter, hygiene, medical care, and other essentials.
- Give the child your consistent attention.
- Set limits and be consistent with rules.
Many people with RAD also suffer from other brain and mental health-related issues, a condition called co-morbidity. Here are a few of the disorders commonly associated with RAD:
Reactive Attachment Disorder Brain Science
Some scientists suspect that abuse or neglect during specific critical periods of a child’s development could lead to structural changes in the child’s brain. However, it’s unclear exactly how; these changes could be responsible for RAD symptoms.
One study used magnetic resonance imaging (MRI) to examine the brains of children with RAD. The study found several potentially significant associations between the children’s brain development and their past traumas, including:
- Children with RAD showed smaller than typical brain volume in a rear part of the brain called the visual cortex.
- Children exposed to abuse or neglect between the ages of 5 and 7 showed the most significant decreases in visual cortex volume.
- The more different types of mistreatment experienced by the child, the greater the effects on the brain.
- Children who experienced neglect showed more reduction in brain volume than those who experienced other types of mistreatment.
Reactive Attachment Disorder Research
Title: Promoting Infant Mental Health in Foster Care
Principal investigator: Susan J. Spieker, PhD
University of Washington
Infants who enter foster care are at risk of developing multiple social and emotional problems later in life. These behavioral issues often result in foster children being placed with multiple different families during their childhoods. In turn, an unstable family life can lead to serious conduct disorders and mental health problems. The infants’ loss of their first attachment relationship heightens the risk of developing these problems, even if the quality of care was poor prior to removal. Infants’ reactions to this loss, combined with other vulnerabilities, complicate the development of new secure attachments to their foster care families. Garnering a secure attachment relationship between foster parents and foster infants may reduce the infant’s risk of developing problematic mental health and conduct issues. PFR is a family therapy intervention focused on aiding foster care parents to cultivate secure attachments with their foster infants. This study will evaluate the effectiveness of the PFR program versus an EES program in promoting attachment security and infant well-being, preventing emotional and behavioral problems, countering developmental delay, and reducing placement instability in young foster care children.
Participants in this single-blind study will be randomly assigned to receive either PFR or EES. Both interventions will be administered by a trained staff member of a community agency. Participants assigned to PFR will receive ten weekly home visits that will focus on promoting the development of a secure attachment between foster parents and infants. EES will consist of three monthly home visits, during which infants will be assessed and referred for additional care if necessary. EES participants will not receive any training. Outcomes will be assessed at 1, 6, and 12 months post-intervention for all participants.
Title: Promoting Caregiver-child Attachment and Recovery Through Early Intervention (pCARE): A Pilot Randomized Control Trial (pCARE)
Principal investigator: Elizabeth Peacock-Chambers, MD, MSc
Baystate Medical Center
The purpose of this study is to use the existing infrastructure and therapeutic relationships developed by Early Intervention, a national system of child development programs, to make an evidence-based intervention for parents with substance use disorder, Mothering from the Inside Out, more readily accessible to postpartum women with substance use disorder. This study will assess the feasibility, acceptability, and preliminary outcomes of the intervention in a pilot randomized controlled trial. We will also identify key implementation domains that impact successful delivery. Researchers hypothesize that the intervention will be feasible and acceptable to the study participants.
Title: The Trauma of Betrayal: Treating Adjustment Disorder With Reconsolidation Blockade Under Propranolol
Contact: Alain Brunet, PhD
Douglas Mental Health University Institute
Attachment injuries occur within couple relationships that involve betrayal or abandonment by a significant other during times of need (e.g., infidelity). They can be understood as relationship traumas, which can lead to debilitating symptoms consistent with post-traumatic stress disorder (PTSD), depression, and generalized anxiety for the injured partner. Research has demonstrated that the presence of an attachment injury represents a barrier to empirically effective couple’s therapy. However, disrupting memory reconsolidation with the beta-blocker propranolol has been shown to alleviate PTSD symptoms by attenuating the salience of the emotional trauma memory, representing an interesting avenue for the treatment of adjustment disorders stemming from attachment injuries. Moreover, evidence suggests that a certain degree of mismatch, or an error between what is expected/predicted to occur and what actually occurs, must be present for a memory to destabilize and enter the reconsolidation phase following retrieval. Here, the investigators aim to extend the conditions under which reconsolidation therapy with propranolol can be used in a clinical setting, as well as assess whether incorporating mismatch enhances treatment effects. The investigators hypothesize that, compared to a wait-list control, 4-6 sessions of memory reactivation under propranolol will significantly reduce trauma-related and general anxio-depressive symptoms associated with an attachment injury. Moreover, the investigators hypothesize that participants randomized to the mismatch group will improve substantially more than the standard treatment group on all variables of interest.