Reactive Attachment Disorder (RAD)

Reactive attachment disorder (RAD) is a mental health condition that occurs when a child does not form a healthy bond with their parents or caregivers. Children who develop RAD often do so because of emotional neglect or physical abuse from caregivers. This can cause a wide range of symptoms that affect a child's emotions and behaviors.

Symptoms of RAD can vary depending on the child and their individual experiences. Possible symptoms include difficulty managing emotions, trouble making meaningful connections with others, and fear around parents or caregivers.

Unlike other conditions, treatment for RAD caters to parents and caregivers. Treatment goals are to ensure the child's safety and offer support and parenting skills to the caregivers. 

Reactive Attachment Disorder Symptoms 

Children with reactive attachment disorder have difficulty forming loving and connected relationships with others. Because abuse and neglect are the common causes of this condition, RAD can affect a child's emotions, behaviors, social interactions, and overall development. As such, a child with RAD may exhibit the following symptoms:

• Disliking physical contact
• Avoiding caregivers
• Not wanting to be comforted 
• Preferring to be alone 
• Being hesitant around others
• Never seeking help or comfort from their caregivers or loved ones
• Reacting violently to physical touch 
• Trying to control their environment 
• Seeming low energy or fatigued
• Experiencing depression or sadness
• Emotional dysregulation such as irritability, angry outbursts, and excessive fear
  

Causes

Reactive attachment disorder occurs when a child is unable to form loving, connected bonds with their parents, caregivers, and others. Researchers believe that most cases of RAD are caused by abuse or neglect from a child's caregivers. It's classified as a trauma- and stressor-related condition in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

Everyone has certain needs, and children with RAD have not had their basic needs met. These needs may include comfort, food, affection, stimulation, toileting or diapering, and play. When an infant or child does not have their needs met, they cannot form a nurturing bond with their caregivers. Over time, a child turns inward and stops trying to engage with others, which can stunt their emotional growth and affect their behaviors. 

Risk Factors

Any child who experiences (or has experienced) abuse or neglect from their caregivers is at risk of developing RAD. About 1-2% of American children develop this condition. Children living in the following settings may be at a higher risk:

• Foster care
• Orphanage 
• Adopted homes
• Homes with a caregiver who has a mental health condition

Caregivers play a large role in their child's susceptibility to developing RAD. Environments or contexts that can strain caregivers' resources and contribute to neglect or abuse include:

• Living with a mental health condition, disability, or substance use disorder
• Becoming parents as teenagers
• Social isolation
• Poverty
• Previous incarceration
• Lacking adequate parenting skills, family support, or childcare resources
  

Diagnosis

If your child is experiencing symptoms of reactive attachment disorder, it may help to see their pediatrician for support. During an initial appointment, your provider can perform a physical exam to look for signs of abuse or neglect. They'll also ask you and your child questions about their home life and upbringing.

If your provider believes that a mental health provider can offer better support, they'll likely refer you and your child to a psychologist or psychiatrist for a more thorough evaluation.

To have a diagnosis for RAD, your child must meet the following diagnostic criteria: 

• Emotionally withdrawn: Does not seek care or comfort from their caregivers
• Emotional outbursts: May easily become angry, violent, irritable, fearful, or sad. The child may also appear restless or hyperactive
• Flat affect: Does not show emotion or seem to display feelings of happiness
• Cognitive delay: Experiences difficulties with memory and executive functioning
• Lower frustration tolerance: May be highly reactive, especially during stress or frustration
• Emotional age: Emotional age (developmental level) is at least 9 months old, and symptoms must start before age 5
• History of abuse: History of abuse or insufficient care from caregivers 

During the diagnostic process, your child’s mental health provider will also conduct several tests to rule out other mental health conditions that could cause similar symptoms. These conditions may include autism spectrum disorder, intellectual disability, or depression, among others.

How To Treat RAD

The goal of treatment for reactive attachment disorder is twofold: ensure the child’s immediate safety and change the relationship between the child and their caregivers.

If the child is currently experiencing abuse or neglect, they need to be removed from their home situation. Healthcare providers are mandated to report suspected abuse to their state. Children in abusive situations require immediate intervention. 

However, parents and caregivers may benefit from parenting classes or stress management programs. If a caregiver is experiencing substance use disorder, they'll need access to proper intervention to help improve their condition and habits. The child's healthcare team will also work with the caregivers to implement a positive, non-punitive behavior management plan. Healthcare providers want caregivers to develop a more empathetic approach to parenting.

Children with RAD may benefit from trauma-based therapy (especially as they grow older) to work through past abuse or neglect. RAD is a serious condition that affects every area of a child’s life and can cause extreme stress. Fortunately, symptoms of this condition can improve with early diagnosis and treatment. 

Is Prevention Possible?

RAD cannot always be prevented because it is caused by caregiver abuse or neglect. Early diagnosis and intervention are essential to improve a child’s outcome. Children need to be removed from abusive situations immediately, and caregivers need interventions and resources to improve their parenting skills.

To lower the risk of child abuse, healthcare providers can work with caregivers who may be at risk of becoming abusive. This includes parents and caregivers who are very young, lack social support, live in poverty, or have a substance use disorder. Pediatricians and social workers can partner with these caregivers to teach parenting skills and provide support. 

Related Conditions

Children with RAD are at an increased risk of other mental health conditions. They often lack the skills to cope with routine changes or stressful situations. As a result, they may experience the following conditions and behaviors at higher rates:

• Anxiety
• Depression
• Post-traumatic stress disorder (PTSD)
• Substance use disorder
• Delayed language skills
• Self-harm
• Behavioral problems in school
• Sex at an early age
• Juvenile detention or incarceration

Living With Reactive Attachment Disorder

Children with RAD and their caregivers require long-term support, treatment, and education. The child’s healthcare provider will see the child and caregivers regularly to monitor the child’s symptoms and observe the caregiver relationship. The child will also likely meet with a mental health provider regularly to work through past trauma and learn new coping skills. Other healthcare providers will offer resources like education and support groups to improve parenting skills.

This condition can be challenging for the child living with RAD and other family members. However, with proper support and safety for the child and adequate resources for the caregiver, symptoms of RAD can improve over time, making it more likely for a child to better their quality of life.