What Is Reactive Attachment Disorder?

What causes reactive attachment disorder and how to treat it

Lonely child sitting on play park playground bench
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Babies bond with adults who provide them with consistent, loving care. They recognize the adults who protect them and calm them when they’re feeling stressed.

In most cases, they develop healthy attachments to their primary caregivers, like their parents, daycare provider, or perhaps a grandparent who is very involved.

But sometimes, babies struggle to form healthy relationships with a stable adult.

Consequently, they may develop reactive attachment disorder, a mental health condition that makes it difficult to form healthy and loving relationships.

Causes of Reactive Attachment Disorder

Reactive attachment disorder may result when children aren’t given proper care by stable and consistent caregivers. If a caregiver doesn’t respond to an infant’s cries or a child isn’t nurtured and loved, he may not develop a healthy attachment.

Here are some examples of times when a child may not be able to form a secure attachment to a primary caregiver:

  • A child’s mother is incarcerated off and on. The child resides with various relatives while she is in jail and the baby is never in the same home long enough to form a strong bond with any adults.
  • A mother has depression. Consequently, she struggles to care for her child. She is not responsive to him when he cries and she doesn’t show him much affection.
  • A child is removed from his birth parents and placed in foster care. He lives in several different foster homes over the course of a year. He doesn’t form secure relationships with any caregivers.
  • Two parents have serious substance abuse problems. Under the influence of drugs and alcohol, they aren’t able to provide their child with adequate care.
  • A baby is placed in an orphanage. There are many different caregivers but the baby is rarely held or consoled when she cries. She spends most of her time in a crib.
  • A young mother doesn’t understand child development basics. She lacks the knowledge to care for her child physically and emotionally. The child doesn’t bond with his mother because she isn’t responsive to his needs.

Any time there’s a consistent disregard for a child’s emotional or physical needs, a child may be at risk for developing reactive attachment disorder. A lack of stimulation and affection can also play a role.

Symptoms of Reactive Attachment Disorder

Children with reactive attachment disorder often refuse to follow rules and they may lash out against others with little empathy. But reactive attachment disorder goes beyond behavior problems.

In order to qualify for a diagnosis of reactive attachment disorder, a child must exhibit a consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers. Children with reactive attachment disorder:

  • Rarely or minimally seek comfort when distressed
  • Rarely or minimally respond to comfort when distressed

To meet the criteria, they must also exhibit two of the following symptoms:

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

In addition to exhibiting those symptoms, the child must also have a history of insufficient care as evidenced by at least one of the following:

  • Changes in primary caregivers that limit the child’s opportunity to form stable attachment
  • Persistent lack of emotional warmth and affection from adults
  • Being raised in an unusual setting that severely limits a child’s opportunity to form selective attachments (such as an orphanage)

    The symptoms must be present before the age of 5. And the child must have a developmental age of at least nine months to qualify for a diagnosis of reactive attachment disorder.

    Prevalence of Reactive Attachment Disorder

    Since reactive attachment disorder is a relatively new diagnosis—and many children go untreated, it’s uncertain how many children may meet the criteria. In 2010, one study found less than 0.4 percent of Danish children had reactive attachment disorder.

    A 2013 study estimated about 1.4 percent of children living in an impoverished area in the United Kingdom had an attachment disorder.

    It’s estimated that children in foster care—and those who resided in orphanages—exhibit much higher rates of reactive attachment disorder. A history of maltreatment and disruptions to a child’s care likely increases the risk.

    How Reactive Attachment Disorder Is Diagnosed

    Teachers, daycare providers, and primary caregivers are likely to notice that a child with reactive attachment disorder exhibits emotional and behavioral issues.

    A thorough examination by a mental health professional can establish whether a child has reactive attachment disorder.

    An evaluation may include:

    • Direct observation of the child interacting with a caregiver
    • A thorough history of a child’s development and living situation
    • Interviews with the primary caregivers to learn more about parenting styles
    • Observation of the child’s behavior

    There are several other conditions that may present with similar emotional or behavioral symptoms. A mental health professional will determine whether a child’s symptoms may be explained by other conditions such as:

    Sometimes, children with reactive attachment disorder experience comorbid conditions. Research shows that children with attachment disorders experience higher rates of ADHD, anxiety disorders, and conduct disorders.

    The History of the Reactive Attachment Disorder Diagnosis

    Attachment disorder is a relatively new diagnosis. It was first introduced in 1980.

    In 1987, two subtypes of reactive attachment disorder were introduced; inhibited and disinhibited. In 2013, the diagnosis was updated again. The DSM-5 refers to the disinhibited type as a separate condition called disinhibited social engagement disorder.

    Disinhibited social engagement disorder is an attachment disorder that is also caused by a lack of a secure attachment with a caregiver—like reactive attachment disorder. Children with disinhibited social engagement disorder approach and interact with unfamiliar adults without any fear. They are often willing to go off with a stranger without any hesitation.

    Reactive Attachment Disorder Treatment

    The first step in treating a child with reactive attachment disorder usually involves ensuring the child is given a loving, caring, and stable environment. Therapy won’t be effective if a child continues moving from foster home to foster home or if he continues living in a residential setting with inconsistent caregivers.

    Therapy usually involves the child as well as the parent or primary caregiver. The caregiver is educated about reactive attachment disorder and given information about how to build trust and develop a healthy bond.

    Sometimes, caregivers are encouraged to attend parenting classes to learn how to manage behavior problems. And if the caregiver struggles to provide a child with warmth and affection, parent training may be provided to help a child feel safe and loved.

    Controversial Therapies That Are Not Recommended

    In the past, some treatment centers used several controversial therapies for children with reactive attachment disorder.

    For example, holding therapy involves a therapist or a caregiver physically restraining a child. The child is expected to go through a range of emotions until he eventually stops resisting. Unfortunately, some children have died while being restrained.

    Another controversial therapy involves rebirthing. During rebirthing, children with reactive attachment disorder are wrapped in blankets and therapists simulate the birthing process by acting as though the child is moving through the birth canal. Rebirthing became illegal in several states after a child suffocated.

    The American Psychiatric Association and The American Academy of Child and Adolescent Psychiatry caution against holding therapies and rebirthing techniques. Such techniques are considered pseudoscience and there is no evidence that they reduce the symptoms associated with reactive attachment disorder.

    If you consider any non-traditional treatments for your child, it’s important to talk to your child’s doctor before beginning treatment.

    Long-Term Prognosis for Children With Reactive Attachment Disorder

    Without treatment, a child with reactive attachment disorder may experience ongoing social, emotional, and behavioral problems. And that may put a child at risk for bigger problems as he grows older.

    Researchers estimate that 52 percent of juvenile offenders have an attachment disorder or borderline attachment disorder. The vast majority of those teens had experienced maltreatment or neglect early in life.

    Early intervention may be key to helping kids develop healthy attachments earlier in life. And the sooner they receive treatment, the fewer problems they may have over time.

    How to Reduce the Risk of Reactive Attachment Disorder

    There are several ways in which primary caregivers may be able to reduce the risk that a child will develop reactive attachment disorder.

    • Educate yourself about child development. Learning how to respond to your baby’s cues and how to help reduce your child’s stress can be instrumental in developing a healthy attachment.
    • Provide positive attention. Playing with your baby, reading to her, and cuddling with her can help establish a loving and trusting relationship.
    • Nurture your child. Simple everyday activities, like changing your baby’s diaper and feeding her, are opportunities to bond.
    • Learn about attachment issues. If you are raising a child who has a history of neglect, maltreatment, or caregiver interruptions, educate yourself about attachment issues.

    Where to Find Help

    If you have concerns that your child may have an emotional or behavioral disorder, start by talking to your child’s doctor. The pediatrician can evaluate your child and determine whether a referral to a mental health provider is appropriate.

    Sources:

    Mayes SD, Calhoun SL, Waschbusch DA, Breaux RP, Baweja R. Reactive attachment/disinhibited social engagement disorders: Callous-unemotional traits and comorbid disorders. Research in Developmental Disabilities. 2017;63:28-37.

    Minnis H, Macmillan S, Pritchett R, et al. Prevalence of reactive attachment disorder in a deprived population. The British Journal of Psychiatry. 2013;202(5):342-346.

    Moran K, Mcdonald J, Jackson A, Turnbull S, Minnis H. A study of Attachment Disorders in young offenders attending specialist services. Child Abuse & Neglect. 2017;65:77-87.

    Skovgaard, A.M. Mental health problems and psychopathology in infancy and early childhood. An epidemiological study. Danish Medical Bulletin. 2010; 57: 193.

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