Attachment disorder rad

Reactive attachment disorder - Symptoms and causes


Reactive attachment disorder is a rare but serious condition in which an infant or young child doesn't establish healthy attachments with parents or caregivers. 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.

With appropriate treatment, children who have reactive attachment disorder may develop more stable and healthy relationships with caregivers and others. Treatments for reactive attachment disorder include learning how to create a stable, nurturing environment and providing positive child and caregiver interactions. Parent or caregiver counseling and education can help.

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Reactive attachment disorder usually starts 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.

Signs and symptoms 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
  • Failure to reach out when picked up
  • No interest in playing peekaboo or other interactive games
  • Behavior problems
  • Failing to seek support or assistance

When to see a doctor

Consider getting an evaluation if your child shows any concerning signs that persist across time. Some signs can occur in children who don't have reactive attachment disorder or who have another disorder, such as autism spectrum disorder. Sometimes young children may display some temporary signs and symptoms, but they tend to be brief, minor or don't cause developmental problems. It's important to have your child evaluated by a pediatric psychiatrist or psychologist who can determine whether behaviors indicate a more serious problem.

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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 by caregivers. For instance, when a baby cries, the need for comfort, 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 who is 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

The risk of developing reactive attachment disorder from severe 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 repeated out-of-home placement, hospitalization or death of a primary caregiver

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


Without proper treatment, reactive attachment disorder can continue for several years and may have lifelong consequences. These can include problems with relationships, social interactions, mental and physical health, behavior, intellectual development, and substance abuse.

More research is needed to determine if problems in older children and adults are related to experiences of reactive attachment disorder in early childhood.


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.

  • 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.
  • 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.

By Mayo Clinic Staff


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Mental Health: Reactive Attachment Disorder

Written by WebMD Editorial Contributors

In this Article

  • What Is Reactive Attachment Disorder?
  • Reactive Attachment Disorder Symptoms
  • Reactive Attachment Disorder Causes and Risk Factors
  • How Common Is Reactive Attachment Disorder?
  • Reactive Attachment Disorder Diagnosis
  • Reactive Attachment Disorder Treatment
  • Reactive Attachment Disorder Prevention
  • Reactive Attachment Disorder Outlook



What Is Reactive Attachment Disorder?

Reactive attachment disorder (RAD) is a condition found in children who may have had grossly negligent care and don’t form healthy emotional attachments with their primary caregivers -- usually their mothers -- before age 5.

Attachment develops when a child is repeatedly soothed, comforted, and cared for, and when the caregiver consistently meets the child's needs. It is through attachment with a loving and protective caregiver that a young child learns to love and trust others, to become aware of others' feelings and needs, to regulate their emotions, and to develop healthy relationships and a positive self-image. The absence of emotional warmth during the first few years of life can negatively affect a child's future.

Reactive Attachment Disorder Symptoms

RAD can affect every aspect of a child's life and development. When babies and young children have RAD they may:

  • Not respond to others with the range of emotions that you’d expect
  • Not express emotions of conscience, such as remorse, guilt, or regret
  • Not make eye contact
  • Avoid physical touch, especially from caregivers 
  • Have tantrums or be more irritable, disobedient, or prone to argue than you’d expect for their age and situation
  • Be unhappy or sad without a clear cause

When children get older their RAD tends to take on two patterns, inhibited and disinhibited.

Common symptoms with inhibited RAD include:

  • Detachment
  • Unresponsiveness or resistance to comforting
  • Excessive inhibition (holding back emotions)
  • Withdrawal or a mixture of approach and avoidance
  • Failure to seek affection from caregivers and other people
  • A tendency to keep to themselves

Common symptoms with disinhibited RAD include:

  • Indiscriminate sociability
  • Inappropriate familiarity or selective in the choice of attachment figures
  • No preference for their primary caregivers over other people
  • A tendency to act younger than their age and to seek affection in potentially dangerous ways   

Reactive Attachment Disorder Causes and Risk Factors

RAD develops when attachment between a young child and their primary caregiver doesn’t happen or is interrupted due to grossly negligent care. This can happen for many reasons, including:

  • Constant disregard of the child's emotional needs for comfort, stimulation, and affection
  • Constant disregard of the child's basic physical needs
  • Repeated changes of primary caregivers that prevent them forming stable attachments (for example, frequent changes in foster care)

Other risk factors for RAD include these home and parental situations:

  • Live in a children’s home or other institutions
  • Parents have serious mental health conditions or abuse drugs or alcohol
  • Parents take part in criminal behavior
  • Parents or caregivers are hospitalized and separated from the child for long periods 

How Common Is Reactive Attachment Disorder?

It’s hard to know exactly how many children have RAD, since many families never seek help. However, it’s generally believed that RAD is uncommon.

Reactive Attachment Disorder Diagnosis

As with adults, mental disorders in children are diagnosed based on signs and symptoms that suggest a particular condition. If a child has symptoms, the doctor may do a complete medical history and physical exam, including a review of the child’s developmental milestones. There are no lab tests to diagnose RAD, but the doctor may use various tests to see what may be causing the symptoms. Tests may include neuroimaging or blood tests, to see if physical illness or medication might be causing symptoms.

If the doctor can’t find a physical cause for the symptoms, they will likely refer the child to a child and adolescent psychiatrist or psychologist. These mental health professionals are specially trained to diagnose and treat mental illnesses in children and teens. They’ll assess the child to rule out other causes for their unusual behavior, such as autism spectrum disorder.

Psychiatrists and psychologists use specially designed interview and assessment tools to evaluate children for mental disorders. They base their diagnoses on what they’ve been told about the symptoms, and on observation of children’s attitudes and behaviors.

Reactive Attachment Disorder Treatment

Treatment of RAD has two important goals. The first is to ensure that the child is in a safe environment. This is especially important in cases where the child has been abused or neglected. The second goal is to help the child develop a healthy relationship with an appropriate caregiver.

Treatment for RAD often focuses on the caregiver. Counseling may help address issues that are affecting the caregiver's relationship with -- and behavior toward -- the child. Teaching parenting skills also can help improve the relationship and develop attachment.

Treatment may also include play therapy. This technique allows the child and the caregiver to express their thoughts, fears, and needs in the safe context of play.

There is no medication to treat RAD itself. However, the doctor may sometimes use medication to help manage severe behavioral symptoms, such as explosive anger or problems sleeping.

The use of so-called holding therapies and "rebirthing" techniques is controversial. There’s no scientific evidence to support the effectiveness of such interventions and some evidence that indicates that it is actually not safe.

Reactive Attachment Disorder Prevention

Recognizing a problem with attachment and getting help as soon as possible are essential to preventing RAD. It may not always be possible to prevent RAD, but doing these things may help stave off its development:

  • Engage often with your child through play and frequent talk, eye contact, and smiles.
  • Learn to understand your baby’s cues, such as what their different types of cries tell you about how they feel and what they need.
  • Show warmth and nurture your child when you bathe or feed them or change their diapers.
  • Respond to your child with a warm tone of voice and with caring facial expressions and physical touches. 
  • Take classes or volunteer with your child so you can build skills to nurture your child.

Reactive Attachment Disorder Outlook

If not treated, RAD can have a negative impact on a child's physical, emotional, behavioral, social, and moral development. Children with RAD generally are at higher risk for:

  • Depression
  • Aggressive and/or disruptive behavior
  • Learning difficulties and behavior problems in school
  • Inability to form meaningful relationships
  • Low self-esteem
  • Eating disorders 
  • Alcohol or drug dependence or abuse 

With treatment, it is possible for children with RAD to learn to trust others, and to lead healthy and productive lives.

Attachment Disorder: 8 Tips for Parents and Carers

Photo from

It is human nature to seek another person, establish close relationships, become attached to someone who shows warmth and care. It is in the nature of a child to become attached to parents, grandparents, brothers and sisters, or to those who in their lives replace blood relatives.

Man is a social being, and therefore, even in conditions when parents neglect their duties, not satisfying the basic needs of the baby for food, comfort, affection, in the overwhelming majority of cases, he still loves a cruel mother or a father who drinks heavily and does not want to be separated with them. nine0003

But it happens in a different way. The difficult conditions in which the early development of the child proceeds can lead to a disease that is difficult to treat.

Most often, this problem is faced by adoptive parents whose child has experienced trouble in the birth family, and then ended up in an orphanage. The situation is even more difficult when the child has already been adopted by the family and then returned back to the children's institution.

However, there are cases of RRS in families with many children, where no one helps the mother and some of the children receive very little attention and care. The disorder can develop if the child was separated early from the parents for a long time as a result of a long hospital stay, or if the child spent most of the time with a mother suffering from depression or other serious illness that prevented her from properly caring for the child. nine0003

What is reactive attachment disorder?

Photo courtesy of

This is a condition in which a child does not form an emotional attachment to parents or persons acting in their stead. Symptoms of the disorder appear before the age of 5 years, often as early as infancy. This is lethargy, refusal to communicate, self-isolation. A small child is indifferent to toys and games, does not ask to be held, does not seek solace in physical pain. He rarely smiles, avoids eye contact, and appears sad and apathetic. nine0003

As they grow older, signs of self-isolation can manifest themselves in two seemingly opposite types of behavior: disinhibited and inhibited.

With disinhibited behavior, the child seeks to attract the attention of even strangers, often seeks help, performs acts that are inappropriate for his age (for example, comes to bed with his parents).

Misunderstanding, lack of patience, severe negative reaction to the child's behavior on the part of a significant adult can cause irritation, anger or an outburst of aggression on the part of the child, and if the violation persists in adolescence, alcohol abuse, drug addiction and other types of antisocial behavior. nine0003

With inhibited behavior, the child avoids communication and refuses help. In some cases, both types of behavior, both disinhibited and inhibited, are alternately observed in him.

Reactive attachment disorder can manifest in forms that sometimes cause despair in adoptive parents: the child constantly lies, steals, behaves impulsively, shows cruelty to animals and a complete lack of consciousness. He does not express regret or remorse after unacceptable behavior. nine0003

Diagnosing RRP is not an easy task. Some features of this disorder can be seen in attention deficit hyperactivity disorder (ADHD), anxiety disorder, autism, and post-traumatic stress disorder. In order to make an accurate diagnosis, it is necessary to observe the child's behavior in various situations over a certain period of time, analyze his biographical data, and evaluate the interaction of parents with the child.

Even harder to treat him

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Psychiatrists sometimes prescribe drugs to children with RAD, but in some cases they can only slightly improve the background against which the therapeutic interaction with the child will take place.

A child's parents or guardians play a key role in treatment. It is they who, with the help of doctors and psychologists, will have to create such an environment in which he can experience a healthy addiction, believe that an adult can be relied upon, and begin to trust him. nine0003

Experts believe that the therapeutic environment has 3 essential components: safety, stability and sensitivity.

In order to overcome the consequences of those events that caused the child's inability to form close and warm relationships, an adult must have enough time and patience to listen and hear the child with an open mind and without trying to judge him.

The child needs boundaries, but they must be set in a context of understanding and empathy. Only if the child feels emotional safety , that is, he understands that his story about himself will not cause a negative assessment from an adult, he will be filled with confidence and tell his foster mother or psychologist about the difficult experiences of his early childhood.

The second component after security is stability . The figure of an adult for the formation of a primary attachment must remain the same. It takes a long time to establish trust between a significant adult and a child with RAD. Changing such a figure, moving from one foster family to another, not only slows down the process, but also aggravates the disorder. nine0003

Having gone through the painful experience of ignoring his needs, the child must re-learn to be aware of them, as well as the fact that the same person can satisfy them over and over again: feed, give clean clothes, put in a warm bed, play, listen and comfort, help with the performance of tasks. Such children are often afraid that the new mother will abandon them or die, and only after a long period of stability do these fears subside.

Some children need at least a year of stability to begin to trust their significant adult, others become imbued with trust in foster parents after a few months. It depends on the temperament of the child (it is important, for example, whether he is an extrovert or an introvert), as well as how well the child and his new parent fit together in various ways. nine0003

Photo from

Long separations between a foster child and mother are undesirable: they can activate his defensive reaction, which is self-isolation.

And finally sensitivity . This is the emotional availability of an adult, his attentiveness to the needs of the child. Adoptive parents should be informed by specialists that while the mental development of a child with RAD may be age appropriate, his emotions often remain immature, which means that during the process of attachment formation, the need for an adult may be greater than that of a healthy child of the same age. nine0003

During this transitional period, parents must be very patient, be prepared for unexpected behaviors that are signals that the child is going through some earlier stages of development and attachment.

For example, a child who behaved suspiciously and aloofly suddenly begins to obsessively follow his mother, constantly report his fears, climb on his knees or come to sleep in his parent's bed - in a word, behave as if he suddenly stood on 2-3 years younger. In this case, parents should accept the situation and meet the child's need for greater dependence on them. nine0003

It is important for adoptive parents to understand the logic of changes happening to the child. Some adopted children initially seem emotionally cold, as experience has taught them that it is not safe for them to express their feelings and communicate their desires. At the same time, the child gives the impression of being completely obedient, because he does not show any irritation or discontent, does not talk about his needs.

Feeling safe, he intuitively feels that adults accept him and will not refuse him, which means that it is quite safe to declare your desires in any form, up to whims and tantrums. nine0003

If earlier the child remained indifferent to whether the mother was at home or she had gone somewhere, now he may burst into tears, cling to her and not let her go if she was about to leave without him. This is not easy for parents, but such behavior should be seen as a positive sign: attachment is gradually formed, the child overcomes the destructive consequences of his difficult early childhood.

In the case of RAD, the task of the psychologist is primarily to educate the parents and support them in creating a safe and stable environment for the child at home, but activities with the child can also be useful. Play therapy and other techniques can help the child to realize their own needs, to build trusting relationships with a new significant adult. nine0003

Photo courtesy of

At the same time, parents should be wary of offerings to work with their child using methods that are collectively called Attachment Therapy.

Not only does this therapy lack scientific evidence and documented efficacy, it is also not safe.

Attachment therapy combines a number of violent methods, the most famous of which are holding therapy (holding) and rebirthing (“rebirth”). nine0003

In "rebirth", the baby's body is wrapped in a blanket and forced to crawl through compressed pillows, simulating passage through the birth canal. It is assumed that "having been born again", he overcomes past negative experiences and is ready for intimacy with his mother. In 2000, a 10-year-old girl suffocated during such a procedure in Colorado (USA), and this therapy has since been banned in the state.

Until now, there are quite a few adherents of holding therapy for the treatment of autism and RRP, among them the well-known psychologists in our country, Dr. OS Nikolskaya and M. M. Liebling. nine0003

The essence of therapy is that the mother forcibly holds the child in her arms and, despite his resistance, tells him how much she needs him and how much she loves him. It is assumed that after a period of resistance, when the child tries to escape, scratches and bites, relaxation occurs, during which contact is established between mother and child.

Critics of the method argue that it is not ethical, as it is based on physical coercion, and can provoke a regression in the development of the child. Indeed, how can trust be established on the part of a child in an adult who uses physical violence against him? nine0003

Raising a child with a reactive disorder is associated with enormous emotional costs, sometimes with stress for parents who blame themselves if they do not see positive changes in the child's condition and behavior for a long time.

If your child is diagnosed with RDD

Photo from

  1. Remember that there are no miracle cures to achieve a breakthrough in a child's condition in a short time. There is no substitute for a therapeutic home environment, security, stability, and your willingness to respond emotionally to your child's needs. nine0102
  2. Be sure to find an opportunity and a way to restore your own emotional balance. A child with RAD is already stressed, and your anxiety or irritability can make it worse. To feel safe, the child must feel your calmness and firmness.
  3. Set boundaries for what is allowed. The child must understand what behavior is unacceptable and what consequences await him in case of violation of the rules. It is important to explain to the child that your rejection does not apply to him, but to certain of his actions. nine0102
  4. After a conflict, be ready to quickly reconnect with your child to let him feel that the reason for your dissatisfaction was a particular behavior, but you love him and cherish the relationship with him.
  5. If you were wrong about something, don't be afraid to admit your mistake. This will strengthen your bond with your child.
  6. Set a daily routine for your child and monitor his performance. This will reduce the level of anxiety in the child.
  7. If possible, show your love for your child through bodily contact: rocking, hugging and holding. However, keep in mind that if a child has been abused or traumatized, he will initially resist being touched, so you will need to work slowly. nine0102
  8. Set aside time that you will completely devote to the child, you will play, talk, walk with him, without being distracted by other activities or other people. This is a very important part of your relationship.

You have a difficult task ahead of you, but it can be done. Do not rush things, be patient and do not lose hope.


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Reactive attachment disorder



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