Reactive Attachment Disorder: Causes, Symptoms, And Treatment

There are many ways children are affected by reactive attachment disorder that may create challenges later in adulthood. Below, we’ll discuss how reactive attachment disorder manifests, its symptoms, and what kinds of treatments are available.

What is reactive attachment disorder (RAD) and what causes it?

As mentioned above, reactive attachment disorder can occur when an emotional bond isn’t formed between a child and his or her primary caregiver. This situation can happen due to the absence of an emotionally available attachment figure, neglect, and abuse (either physical or emotional). These factors are sometimes referred to as pathogenic care, the general disregard for a child’s basic emotional needs, which can impede child development and create severe cognitive and psychosocial dysfunction.

Below are a few possible scenarios that can cause RAD:

• Failing to feed a child or infant, even after they express their hunger

• Neglecting a crying baby

• Not interacting (such as talking and playing) with the baby, which results in loneliness

RAD can be more common among children in the foster care system, especially if they have to change homes frequently. It can also occur in children of parents with mental health conditions or substance use challenges. In either case, it can become a major obstacle for children to develop healthy relationships with caregivers.

Despite this, RAD is uncommon, and most children who experience neglect don’t develop the condition. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), for a diagnosis of RAD to be made, a child must be at least nine months old, and the symptoms must be present by the age of 5. 

Reactive attachment disorder symptoms

At its core, RAD is a disorder that impairs social functioning, among other symptoms that can greatly interfere with a child’s ability to function with ease. Compared to those without the condition, individuals with reactive attachment disorder tend to display more behavioral and psychosocial concerns, which can manifest in childhood and adulthood.  include the following:

• Problematic eating behaviors

• Delayed language and motor skill development

• Anxiety and/or depression

• Excessive self-monitoring

• Emotional lability

• Lack of empathy

• Problems with concentration and attention

• Hyperactivity

• Oppositional behaviors

• Maladaptive behaviors, such as destroying property, lying, and stealing

• Suicidal or homicidal ideation

A person experiencing reactive attachment disorder may have difficulty showing affection and experience challenges with their anger. They may dislike being touched or making eye contact, and have a lack of remorse for negative behavior.

Additionally, reactive attachment disorder can present as two sub-types: inhibited and disinhibited. Inhibited RAD might be described as hypervigilance. Children with this type may be more wary and watchful than usual. Those with the disinhibited type may interact freely with strangers and disregard the need to stay near the safety of their caregivers. This kind of behavior can also be known as indiscriminate friendliness.

Some of these reactive attachment disorder symptoms may only be apparent past the age of 5, but there are warning signs that can sometimes be observed in infants. Even though they cannot speak coherently, infants typically show many cues to express how they are feeling. However, an infant with RAD may:

• Not smile

• Avoid eye contact

• Reject being picked up

• Cry frequently

• Not want to play with toys or games

If left untreated, the symptoms of RAD can carry over into adulthood. They can have serious implications and consequences.

Reactive attachment disorder in adults

Some of the symptoms listed above can be present in reactive attachment disorder in adults and can affect interpersonal relationships. There is also some supporting evidence that shows that RAD in childhood is associated with different personality disorders, such as borderline personality disorder, later in life. Symptoms of RAD may include the following:

Adults with RAD who have difficulty adjusting to social situations and making safe connections may also experience challenges with forming relationships. This can include social relationships with friends or colleagues as well as intimate relationships. 

Risk factors of reactive attachment disorder

Beyond relational challenges, RAD in adults can also lead to criminal behavior, such as vandalism, arson, homicide, and cruelty to animals. In the worst cases, the individual may show no remorse for criminal behavior and may repeat such actions. Social isolation and a sense of hopelessness can also lead to substance use problems and other addictions, such as gambling or sex addiction.

Is reactive attachment disorder related to autism spectrum disorder? 

While reactive attachment disorder (RAD) and autism spectrum disorder (ASD) are distinct conditions that may affect an adult’s or child’s behavior, there can be overlap and co-occurrence between them. Some children with ASD may exhibit symptoms reminiscent of RAD due to challenges in social interaction and attachment behaviors. However, it's important to assess each individual's symptoms carefully with a comprehensive psychiatric assessment by a child psychiatrist to provide accurate diagnosis and tailored intervention strategies.

Other potential mental illnesses that may co-occur with RAD

Other potential mental illnesses that be seen alongside RAD include oppositional defiant disorder, depression, anxiety disorders, and conduct disorder. These co-occurrences often stem from the interplay between early attachment disruptions and ongoing psychosocial stressors.

Each condition features its own diagnostic criteria and potential behavior problems. It’s important to find a skilled professional to diagnose reactive attachment disorder based on trauma symptoms. These professionals are accustomed to interacting with young children diagnosed with conditions like RAD, ASD, depression, and other mental health concerns. They may also be able to provide valuable resources for parent education. 

Treatment for reactive attachment disorder

According to a 2022 study, “Assessment of social interaction and developmental milestones should be completed following Centers for Disease Control (CDC) or World Health Organization (WHO) guidelines to ensure delays in meeting expected milestones are addressed as early as possible.  Developmental pediatricians, child psychologists, or child psychiatrists can complete comprehensive assessments to narrow the differential diagnosis.”

Furthermore, the WHO emphasizes the importance of understanding child maltreatment* and its impact on emotional problems in institutionalized children. Through research published in renowned journals like the Journal of the American Academy of Child and Adolescent Psychiatry, experts explore how children interacting within these environments may form selective attachments, often due to heightened vulnerability to emotional challenges.

RAD can be difficult to diagnose, and research into the condition is ongoing. Researchers have yet to agree on a standardized treatment intervention, but some methods have shown promise, including behavior management training (BMT). BMT assists caregivers by providing psychoeducation about their child’s behavioral challenges while teaching them parenting skills that encourage healthy behavior. BMT typically involves 10 steps (broken down into 10 sessions) that deliver training to the child’s caregivers. In one study, BMT was highly successful at treating the symptoms of RAD, and researchers recommended it for broader clinical testing.

Other types of treatment, such as play therapy and art therapy, have demonstrated some effectiveness in the treatment of other attachment disorders, but few clinical trials have been carried out to measure their effectiveness with RAD. However, spending time engaging a child in these activities can be supplemental in forming attachments between a caregiver and a child because they encourage bonding. Additional parenting strategies can include teaching the child about emotions and consequences and reassuring the child that they are safe and loved. 

Treatment for RAD in adults can be different since they are legally independent and there is a chance that their former caregivers are unavailable. An adult with RAD may choose to bring a friend to therapy sessions so that trust can be formed. If no friends are available, treatment may focus on the development of social skills and the formation of a secure attachment with a therapist.

Therapy can help with reactive attachment disorder

If you are concerned that your child is showing signs and symptoms of an attachment disorder, specifically reactive attachment disorder (RAD), it may help to make an appointment with a qualified healthcare provider or mental health professional. If the challenges of parenting make it difficult to visit a therapist’s office, you might consider online therapy. With online therapy, you can get support as a parent from the comfort of home at a time that works for your schedule. You can connect with a therapist via phone, live chat, or videoconferencing—or a combination of these methods.

A growing body of evidence shows that online therapy is an effective option for mental health treatment. For example, a study published in Clinical Child and Family Psychology Review explored the efficacy of telehealth for family therapy. The review reported that research supports telehealth-delivered therapeutic sessions as an effective delivery of family therapy services. Furthermore, the study concluded that evidence shows equivalent efficacy for mental health and child behavioral outcomes between remote and in-person delivery.

With an online therapy service like BetterHelp, you can receive support from a licensed online therapist if you have a child who is displaying symptoms of reactive attachment disorder. Likewise, if you are an adult who has difficulty forming meaningful relationships with others, treatment is available to you, too.