Reactive Attachment Disorder (RAD)

Reactive Attachment Disorder (RAD) is a disorder of infancy and early childhood, characterized by a pattern of significant disturbance and developmentally inappropriate attachment behaviors. The infant or child will rarely or minimally turn preferentially to an attachment figure for comfort, support, protection, and/or nurturance. At its core, there is an absent or severely underdeveloped attachment between the child and the caregiving adult(s).

Epidemiology
  • The prevalence of RAD has been estimated to be as high as 1.4%.[1][2]
  • It is more prevalent in young children exposed to severe neglect before being placed in foster homes or institutions.[3]
Prognosis
  • RAD severely impairs young children's abilities to relate interpersonally to adults or peers and is associated with major impairment across numerous domains of early childhood.[4]
  • The prognosis of RAD depends on the quality of the caregiving environment the infant or child receives following serious neglect.[5]
    • Without a corrective or normative caregiving environment, the signs of RAD may continue to persist for several years.[6]
  • It is unknown whether RAD can occur in older children and thus, there is an age cut off of 5 years in the diagnostic criteria.[7]
Comorbidity
  • Disorders and conditions associated with neglect, including cognitive delays, language delays, and stereotypies, are comorbid with RAD.[8]
  • Medical conditions including severe malnutrition, may be present
  • Depressive disorders may also be comorbid.[9]
Risk Factors
  • Serious social neglect is a diagnostic requirement for RAD and thus is also the only known risk factor for the disorder.[10]
  • However, it is important to note that the majority of severely neglected children do not actually develop RAD (less than 10%).[11]
Criterion A

A consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers, manifested by both of the following: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.
Criterion B

A persistent social and emotional disturbance characterized by at least 2 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 non-threatening interactions with adult caregivers.
Criterion C

The child has experienced a pattern of extremes of insufficient care as evidenced by at least 1 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).
Criterion D

The care in Criterion C is presumed to be responsible for the disturbed behaviour in Criterion A (e.g. - the disturbances in Criterion A began following the lack of adequate care in Criterion C).

Criterion E

The criteria are not met for autism spectrum disorder.

Criterion F

The disturbance is evident before age 5 years.

Criterion G

The child has a developmental age of at least 9 months.

Episode Specifier

Specify if:

  • Persistent: The disorder has been present for more than 12 months.

Severity Specifier

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.
  • Children with RAD show diminished or no expression of positive emotions during routine interactions with caregivers.[12]
  • Their emotion regulation capacity is also compromised, and they display episodes of negative emotions of fear, sadness, or irritability that cannot be explained.
  • Children with reactive attachment disorder are believed to actually have the capacity to form selective attachments, but due to limited opportunities during early childhood development, they fail to develop these selective attachments.
  • Thus a diagnosis of RAD should not be made in children who are developmentally unable to form selective attachments (e.g. - intellectual disability), and this is also why there must be a developmental age of at least 9 months.[13]
    • Aberrant social behaviors manifest in young children with RAD, but they also are key features of ASD. Individuals with either condition can have decreased expression of positive emotions, cognitive and language delays, and impairments in social reciprocity. Children with RAD have a history of severe social neglect, while those with ASD will only rarely have a history of social neglect. The restricted interests and repetitive behaviors of ASD are not a feature of RAD. ASD is characterized by an excessive adherence to rituals and routines; restricted, fixated interests; selective impairments in social communicative behaviors, such as intentional communication (i.e. - impairment in communication that is deliberate, goal-directed, and aimed at influencing the behaviour of the recipient); and unusual sensory reactions. Additionally, in ASD, children regularly show attachment behaviour that is typical for their developmental level.[14] In contrast, children with RAD do so only rarely or inconsistently, if at all.
    • However, children with either condition can have stereotypic behaviors such as rocking or flapping, and a range of intellectual functioning. Children with RAD will show social communicative functioning comparable to their overall level of intellectual functioning.
  • Intellectual disability (intellectual developmental disorder).
    • Developmental delays can accompany RAD, but they should not be confused for intellectual disability. Children with intellectual disability have social and emotional skills comparable to their cognitive skills, and do not have the profound reduction in positive affect and emotion regulation difficulties seen in RAD. Additionally, developmentally delayed children with a cognitive age of 7 to 9 months will have selective attachments regardless of their chronological age. In contrast, children with RAD show a lack of preferred attachment despite reaching a developmental age of at least 9 months.
  • Depressive disorders
    • Depression in young children can also be associated with reductions in positive affect. However, young children with depressive disorders will still seek and respond to comforting efforts by caregiver(s).[15]

Reactive Attachment Disorder (RAD) vs. Disinhibited Social Engagement Disorder (DSED)

Reactive Attachment Disorder Disinhibited Social Engagement Disorder
Etiology Social neglect, inconsistent parenting Social neglect, inconsistent parenting
Internal/External Internalizing Disorder Externalizing Disorder
Clinical Presentation Withdrawn emotions, depressive symptoms, flat affect, unexplained sadness, and irritability. Overly familiar with strangers, lack of hesitation to approaching and interact with them. Diminished checking back with adult caregiver.
Treatment Caregiving environment Caregiving environment
Prognosis Not well understood Superficial relationships with peers, more peer-to-peer conflicts
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Research
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
10) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
11) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
12) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
13) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
14) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
15) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.