Table of Contents

Definition of Reactive Attachment Disorder (RAD)

Reactive Attachment Disorder (RAD) is a relatively rare and severe condition that occurs in children, typically resulting from a lack of consistent and nurturing care during their early years. It is characterized by significant difficulties in forming emotional attachments or bonds with caregivers or parents.

Children with RAD often exhibit several symptoms, including:

  • Withdrawn behavior: Avoidance or resistance when it comes to physical or emotional closeness with caregivers.
  • Lack of responsiveness to others: Difficulty seeking or accepting comfort or support from caregivers, even when distressed or upset.
  • Irritability and emotional outbursts: Displaying persistent anger, sadness, or emotional instability.
  • Difficulty establishing and maintaining relationships: Struggling to form meaningful connections with others due to trust issues and emotional barriers.

RAD typically develops when a child experiences neglect, frequent changes in caregivers, or inconsistent care during early infancy or toddlerhood. This lack of consistent nurturing relationships in the early formative years can impair the child’s ability to develop trust, emotional security, and healthy attachments with caregivers. Early intervention involving therapy, counseling, and support for both the child and their caregivers is crucial in managing and treating Reactive Attachment Disorder. Therapy aims to help the child form secure attachments, develop trust, and improve their social and emotional skills, while also providing guidance and support to caregivers on creating a stable and nurturing environment for the child.


History of Reactive Attachment Disorder (RAD)

  • Reactive Attachment Disorder (RAD) has its roots in the late 20th century and was formally recognized as a psychiatric diagnosis in the Diagnostic and Statistical Manual of Mental Disorders (DSM) in the early 1980s.
  • The concept of attachment theory, which forms the basis of understanding RAD, was developed by British psychologist John Bowlby in the 1950s and 1960s. Bowlby proposed that a child’s early experiences with caregivers profoundly influence their social, emotional, and cognitive development. He emphasized the importance of a secure attachment between a child and their primary caregiver for healthy emotional and psychological development.
  • Mary Ainsworth, a developmental psychologist and colleague of Bowlby, further expanded on attachment theory by conducting the “Strange Situation” experiments in the 1970s. This study observed how infants responded to separations and reunions with their caregivers, leading to the identification of different attachment styles, such as secure and insecure attachments.
  • The specific term “Reactive Attachment Disorder” was introduced as a diagnostic category in the DSM-III (Diagnostic and Statistical Manual of Mental Disorders, Third Edition) in 1980. It was included as a disorder typically diagnosed in infancy and early childhood and was characterized by disturbances in social interaction and emotional attachment due to inadequate care.
  • Over subsequent revisions of the DSM, Reactive Attachment Disorder underwent modifications and refinements in its diagnostic criteria. The DSM-IV (published in 1994) further delineated two subtypes of RAD: inhibited type and disinhibited type, reflecting different ways the disorder might manifest in children.
  • Since its inclusion in the DSM, Reactive Attachment Disorder has gained recognition among mental health professionals, clinicians, and researchers. However, it remains a relatively less common diagnosis compared to other childhood mental health conditions.
  • Continued research, clinical experience, and advancements in understanding the impact of early relationships on child development contribute to ongoing discussions and refinements in identifying and treating Reactive Attachment Disorder. Therapeutic approaches continue to evolve to address the complex needs of children with RAD and their caregivers.

DSM-5 Criteria of Reactive Attachment Disorder (RAD)

The DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition) outlines the diagnostic criteria for Reactive Attachment Disorder (RAD) as a neurodevelopmental disorder that typically appears in early childhood due to a lack of adequate caregiving experiences. There are two subtypes of RAD described in DSM-5: the inhibited type and the disinhibited type. Below are the criteria for each subtype:

Reactive Attachment Disorder, Inhibited Type:

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

  • The child rarely or minimally seeks comfort when distressed.
  • The child rarely or minimally responds to comfort when distressed.

B. A persistent social and emotional disturbance characterized by at least two of the following:

  • Minimal social and emotional responsiveness to others.
  • Limited positive affect.
  • Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.

C. The child has experienced a pattern of extremes of insufficient care, as evidenced by at least one of the following:

  • Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
  • Repeated changes of primary caregivers that limit the child’s opportunities to form stable attachments (e.g., frequent changes in foster care).

Reactive Attachment Disorder, Disinhibited Type:

A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults, manifested by at least two of the following:

  • Reduced or absent reticence in approaching and interacting with unfamiliar adults.
  • Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and age-appropriate social boundaries).
  • Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.

B. The behaviors in Criterion A are not due to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but are a reflection of the child’s willingness to approach and interact with unfamiliar adults.

C. The child has experienced a pattern of extremes of insufficient care, as outlined in Criterion C of the inhibited type.

It’s important to note that the diagnosis of RAD should be made by a qualified mental health professional based on a comprehensive assessment of the child’s history, behavior, and interactions in various settings. Treatment often involves therapeutic interventions that focus on building secure attachments, addressing trauma, and improving social and emotional skills.

Etiology of Reactive Attachment Disorder (RAD)

The development of Reactive Attachment Disorder (RAD) is typically associated with early childhood experiences characterized by neglect, trauma, and disrupted attachment with primary caregivers. The disorder’s etiology is multifaceted, involving a combination of environmental, genetic, and neurological factors that contribute to its manifestation. Some key aspects of RAD’s etiology include:

Early Childhood Trauma and Neglect:

 RAD often emerges in children who have experienced significant neglect, lack of emotional responsiveness, or inconsistent caregiving during their early years. This could include being raised in institutional settings, frequent changes in primary caregivers, parental neglect, or emotional deprivation.

Disrupted Attachment:

Inadequate or disrupted attachment relationships during the critical period of infancy and early childhood play a significant role in RAD’s development. Children require consistent and responsive caregiving to form secure attachments, and when these are absent or disrupted, it can hinder their ability to trust and connect emotionally with others.

Biological and Genetic Factors:

There might be a genetic predisposition or vulnerability in some children that interacts with environmental stressors, contributing to the development of RAD. Additionally, neurological and developmental factors may influence a child’s ability to form secure attachments and regulate emotions.

Institutionalization and Early Adversity:

Children who have spent time in institutional settings or have faced significant adversity in their early years, such as neglect, abuse, or multiple changes in caregivers, are at higher risk of developing RAD.

Parental Mental Health and Attachment Style:

Parental mental health issues, substance abuse, or unresolved trauma in caregivers may hinder their ability to provide consistent and nurturing care, impacting the child’s attachment formation and increasing the risk of RAD.

Social and Cultural Factors:

Socioeconomic challenges, cultural practices, and societal factors can influence parenting styles, family dynamics, and access to resources, all of which can impact a child’s attachment experiences and the likelihood of developing RAD.

It’s important to note that while these factors contribute to the development of RAD, not all children exposed to adversity or disrupted attachment will develop the disorder. Diagnosis and treatment require careful evaluation by mental health professionals, considering a child’s individual history, behaviors, and developmental context. Early intervention through therapeutic approaches that focus on building secure attachments, addressing trauma, and enhancing caregiving skills are essential in managing RAD.

Theories related to Reactive Attachment Disorder (RAD)

Several theories help explain the development and manifestation of Reactive Attachment Disorder (RAD) in children. These theories provide insights into the psychological, social, and neurological aspects involved in RAD. Some of these theories include:

Attachment Theory:

Developed by John Bowlby and expanded upon by Mary Ainsworth, Attachment Theory suggests that a child’s early experiences with caregivers significantly shape their social, emotional, and cognitive development. RAD is often understood within the framework of attachment theory, where disruptions or absence of secure attachments during infancy and early childhood contribute to difficulties in forming relationships and regulating emotions.

Social Learning Theory:

This theory emphasizes the role of learned behaviors in the development of RAD. Children might learn to cope with inconsistent or neglectful caregiving by withdrawing or displaying behaviors that hinder the formation of emotional bonds. They may learn to avoid seeking comfort or closeness due to past experiences of rejection or lack of responsiveness from caregivers.

Trauma Theory:

RAD often occurs in children who have experienced trauma, neglect, or disruptions in caregiving. Trauma theory highlights the impact of adverse experiences on a child’s psychological and emotional well-being. Traumatic experiences, especially during critical periods of development, can affect attachment formation and emotional regulation, contributing to the manifestation of RAD symptoms.

Neurobiological Theories:

Research suggests that early adverse experiences, such as neglect or abuse, can impact brain development and the functioning of areas related to social and emotional processing. Disruptions in neural circuits involved in attachment and emotional regulation might contribute to the difficulties observed in children with RAD.

Biopsychosocial Model:

This model considers the interaction between biological, psychological, and social factors in the development of RAD. It recognizes that a combination of genetic vulnerabilities, early experiences, family dynamics, and environmental stressors collectively contribute to the emergence of RAD symptoms.

These theories provide different perspectives on how RAD develops and manifests in children. They emphasize the importance of early experiences, caregiver interactions, neurological functioning, and environmental factors in understanding and addressing RAD. Interventions and treatments for RAD often draw from these theories to promote healthy attachments, emotional regulation, and social development in affected children.

Risk factors of Reactive Attachment Disorder (RAD)

Reactive Attachment Disorder (RAD) can develop in children exposed to specific risk factors that impede their ability to form secure attachments and bond emotionally with caregivers. Some of the key risk factors associated with the development of RAD include:

Early Neglect or Abuse:

Persistent neglect, emotional deprivation, or physical or emotional abuse during a child’s early years can significantly increase the risk of RAD. Lack of consistent nurturing care and inadequate responsiveness to a child’s needs can hinder the formation of secure attachments.

Frequent Changes in Caregivers:

Children who experience multiple changes in primary caregivers, such as frequent placements in foster care, institutionalization, or abrupt separations from caregivers, are at a heightened risk of developing RAD. Instability in caregiving relationships disrupts the continuity necessary for healthy attachment formation.

Institutionalization or Orphanage Care:

Children raised in institutional settings or orphanages with limited opportunities for one-on-one caregiving and individualized attention are at an increased risk of RAD due to a lack of consistent and responsive care.

Prenatal and Perinatal Factors:

Prenatal exposure to substances (like drugs or alcohol), maternal stress, or complications during birth might contribute to neurological and developmental vulnerabilities in infants, potentially impacting their ability to form secure attachments.

Parental Factors:

Parental mental health issues, substance abuse problems, unresolved trauma, or parental absence due to various reasons (incarceration, chronic illness, etc.) can hinder the parent-child relationship, increasing the risk of RAD.

Traumatic Experiences:

Children who have experienced traumatic events, such as loss of a primary caregiver, community violence, or natural disasters, are at an elevated risk of developing RAD.

Environmental and Socioeconomic Factors:

Socioeconomic challenges, poverty, lack of access to resources, and unstable living conditions can contribute to stressful environments that impact a child’s development and attachment relationships.

It’s important to note that while these risk factors increase the likelihood of RAD, not all children exposed to these circumstances will develop the disorder. The interaction between multiple risk factors, as well as individual differences in resilience and coping mechanisms, contributes to the complexity of RAD’s development. Early identification, intervention, and support for both the child and caregivers are crucial in mitigating the impact of these risk factors and promoting healthy attachment relationships in at-risk populations.

Treatment for Reactive Attachment Disorder (RAD)

Treating Reactive Attachment Disorder (RAD) typically involves comprehensive interventions aimed at addressing the child’s attachment difficulties, trauma-related issues, and improving relationships with caregivers. It requires a multidisciplinary approach involving mental health professionals, therapists, and caregivers. Here are some common components of treatment for RAD:

Therapeutic Interventions:

Various forms of therapy, such as attachment-based therapies, play therapy, trauma-focused therapy, and family therapy, are essential in addressing RAD. These therapies aim to promote secure attachments, emotional regulation, and social skills development in the child. Therapists work with the child to build trust, process past trauma, and improve relational skills.

Parent/Caregiver Training and Support:

Education and training for caregivers or parents are crucial in understanding RAD, learning effective parenting strategies, and creating a nurturing environment. Caregivers receive guidance on providing consistent, responsive, and emotionally attuned care to the child. Therapists might conduct sessions involving caregivers to improve interactions and strengthen the parent-child relationship.

Trauma-Informed Care:

Recognizing and addressing the impact of trauma on the child’s development is fundamental in RAD treatment. Trauma-informed approaches focus on creating a safe and supportive environment, understanding trauma triggers, and employing techniques to help the child cope with distress.

Behavioral Interventions:

Behavioral modification techniques may be used to address specific behavioral issues observed in children with RAD. These interventions aim to reinforce positive behaviors, teach coping skills, and manage challenging behaviors through positive reinforcement and consistent boundaries.

Medication (if necessary):

In some cases, medication may be prescribed to manage symptoms such as anxiety, depression, or disruptive behaviors associated with RAD. Psychiatric evaluation and medication management should be conducted by a qualified healthcare professional.

Consistency and Structure:

Providing a consistent and structured environment is crucial for children with RAD. Establishing routines, predictable schedules, and clear boundaries help create a sense of safety and stability, which is essential for their emotional well-being.

Early Intervention:

Early identification and intervention are critical in addressing RAD. The earlier the intervention begins, the better the chances of promoting healthy attachment and addressing behavioral and emotional challenges.

Treatment for RAD is individualized, considering the unique needs and history of each child. It often requires a long-term commitment from caregivers and mental health professionals. Collaboration among therapists, educators, social workers, and other involved parties is essential to ensure a comprehensive and supportive approach to treatment.

Therapies for Reactive Attachment Disorder (RAD)

Several therapeutic approaches are used in treating Reactive Attachment Disorder (RAD). These therapies focus on addressing attachment difficulties, trauma, social skills deficits, and emotional regulation issues. Here are some common therapies utilized for RAD:

Attachment-Based Therapy:

This form of therapy emphasizes creating a secure and trusting relationship between the child and therapist. The therapist aims to build a secure attachment with the child, providing a safe environment for the child to express emotions, learn trust, and develop healthy relationships.

Trauma-Focused Cognitive Behavioral Therapy (TF-CBT):

TF-CBT is designed to help children process and cope with traumatic experiences. It combines cognitive-behavioral techniques with trauma-focused interventions to address symptoms related to trauma exposure.

Play Therapy:

Play therapy allows children to express their emotions and experiences through play. It helps therapists observe and understand the child’s inner world, emotions, and struggles, facilitating communication and healing in a non-threatening environment.

Dyadic Developmental Psychotherapy (DDP):

DDP focuses on improving the parent-child relationship in cases of RAD. It involves both the child and the caregiver in therapy sessions, aiming to build trust, enhance emotional connections, and improve communication between them.

Family Therapy:

Family therapy involves the entire family in the therapeutic process. It addresses family dynamics, communication patterns, and relationships to promote understanding and support for the child with RAD and the caregivers.


Theraplay focuses on enhancing the parent-child relationship by incorporating playful, structured activities. It aims to strengthen attachment, regulate emotions, and improve social skills through engaging interactions between the child and caregiver.

Eye Movement Desensitization and Reprocessing (EMDR):

EMDR is a therapy primarily used to treat trauma-related symptoms. It involves guided eye movements or other forms of bilateral stimulation while recalling distressing memories to reduce their impact.

Sensory Integration Therapy:

Some children with RAD may have sensory processing difficulties. Sensory integration therapy helps regulate sensory input, supporting the child in managing sensory issues that might contribute to emotional dysregulation.

It’s important to note that the effectiveness of these therapies may vary based on the individual needs and circumstances of each child. A comprehensive treatment plan for RAD often involves a combination of these therapies, tailored to address the specific challenges and strengths of the child. Collaboration between therapists, caregivers, and other involved professionals is essential in providing consistent and supportive care for children with RAD.

Preventions of Reactive Attachment Disorder (RAD)

Preventing Reactive Attachment Disorder (RAD) involves promoting healthy caregiver-child relationships, providing nurturing environments, and addressing risk factors that contribute to attachment difficulties. While it may not be possible to prevent RAD in every circumstance, several strategies can help mitigate risks and promote healthy attachment in children:

Early and Responsive Caregiving:

Encourage parents and caregivers to be responsive to infants’ needs, such as feeding, comforting, and providing affection. Prompt and consistent responses to a child’s cues for comfort and care can foster secure attachment.

Education and Support for Parents:

Provide parenting education and support programs that focus on promoting healthy attachment, effective communication, positive discipline, and understanding child development. Supporting parents in understanding the importance of responsive caregiving can be crucial in preventing attachment difficulties.

Promoting Stable and Nurturing Environments:

Create stable and nurturing environments for children by minimizing disruptions and instability in their lives. Limiting frequent changes in caregivers, providing a consistent routine, and offering a safe and predictable environment can support healthy development.

Early Intervention Services:

Identify and intervene early when children are at risk due to factors such as neglect, trauma, or parental mental health issues. Early access to support services, counseling, and interventions can help mitigate the impact of risk factors on attachment development.

Support for Foster and Adoptive Families:

Children in foster care or those who have been adopted might have experienced disruptions in attachment. Providing training, resources, and support services for foster and adoptive parents can help them create a nurturing environment and understand the unique needs of these children.

Trauma-Informed Care:

Professionals working with children should be trained in trauma-informed approaches. Creating environments that prioritize safety, trust, and empowerment can help prevent further trauma and support healthy attachment.

Community Support Services:

Access to community resources such as mental health services, parenting classes, support groups, and early childhood programs can provide additional support for families facing challenges that might impact attachment relationships.

While it might not be possible to completely prevent RAD, early interventions, supportive environments, and promoting healthy caregiver-child relationships can significantly reduce the risk and mitigate the impact of factors that contribute to attachment difficulties. Early identification and intervention remain essential in supporting healthy attachment and addressing challenges that may arise in children’s development.

author avatar