Defining Reactive Attachment Disorder

Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children. RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. Previously in the DSM-IV-TR, RAD was divided into two different types: inhibited type took the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way, while disinhibited type presented itself as indiscriminate sociability, such as excessive familiarity with relative strangers. In the recent revisions to the DSM-5 (2013), however, RAD was narrowed to encompass only the symptoms of the inhibited form, and a new diagnosis of disinhibited social engagement disorder (DSED) was created to encompass the symptoms previously known as RAD-disinhibited type. Both RAD and DSED are categorized in the DSM-5 as types of trauma and stressor-related disorders.

Children with RAD are presumed to have grossly disturbed internal working models of relationships which may lead to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years. However, the opening of orphanages in Eastern Europe following the end of the Cold War in the early-1990s provided opportunities for research on infants and toddlers brought up in very deprived conditions. Such research broadened the understanding of the prevalence, causes, mechanism, and assessment of disorders of attachment and led to efforts from the late-1990s to develop treatment and prevention programs and better methods of assessment. Mainstream theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined beyond current classifications.

Attachments in childhood

Children need sensitive and responsive caregivers to develop secure attachments. RAD arises from a failure to form normal attachments to primary caregivers in early childhood.

DSM-5 Diagnostic Criteria

Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the disorder. The initial presentation varies according to the child's developmental and chronological age, although it always involves a disturbance in social interaction. The core feature is severely inappropriate social relating by affected children. In order to be diagnosed with RAD under the DSM-5 criteria, a child under the age of 5 must: 

• exhibit emotionally withdrawn and inhibited behaviors in relation to their caregivers (for example, not seeking comfort when they are sad or upset);
• exhibit some kind of emotional or social disturbance (for example, limited responsiveness, lack of positive affect, inexplicable instances of irritability or sadness, etc.); and
• have a history of significant neglect and/or unstable living situations in which they were unable to form stable and secure attachments.

While RAD is likely to occur in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect. In addition, the disturbance cannot be accounted for solely by developmental delay and does not meet the criteria for pervasive developmental disorder or autism spectrum disorder.

Etiology

Although increasing numbers of childhood mental health problems are being attributed to genetics, reactive attachment disorder is by definition based on a problematic history of care and social relationships. RAD arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts. Not all, or even a majority, of such experiences result in the disorder.

It has been suggested that types of temperament, or constitutional response to the environment, may make some individuals susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years. In the absence of available and responsive caregivers, it appears that some children are particularly vulnerable to developing attachment disorders. In discussing the neurobiological basis for attachment and trauma symptoms in a seven-year twin study, it has been suggested that the roots of various forms of psychopathology—including RAD, borderline personality disorder (BPD), and post-traumatic stress disorder (PTSD)—can be found in disturbances in affect regulation (i.e., the ability to regulate one's emotions).

Treatment

Assessing the child's safety is an essential first step that determines whether future intervention can take place in the family unit or whether the child should be removed to a safe situation. Interventions may include psychosocial support services for the family unit (including financial or domestic aid, housing, and social work support), psychotherapeutic interventions (including treating parents for mental illness, family therapy, individual therapy), education (including training in basic parenting skills and child development), and monitoring of the child's safety within the family environment.

Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors are based on attachment theory. These approaches concentrate on increasing the responsiveness and sensitivity of the caregiver—or if that is not possible, placing the child with a different caregiver. These approaches are mostly in the process of being evaluated.