Reactive Attachment Disorder

Medically Reviewed by Smitha Bhandari, MD on November 28, 2022
5 min read

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.

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   

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 

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.

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.

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.

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.

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.