What is Reactive Attachment Disorder?
The 5th edition of the Diagnostic and Statistical Manual (DSM-5) categorizes Reactive Attachment Disorder as a condition related to trauma and stress that usually starts in early childhood due to neglect or abuse. This condition affects a child’s ability to connect emotionally with others, proving difficult for them to feel positive emotions or seek/accept love and comfort.
Children with this condition might react strongly, even violently, when they are held, cuddled, or comforted. They often exhibit unpredictable behaviors, are hard to calm down, and challenging to discipline. They go through rapidly changing moods and may always seem to be on the defensive, showing responses akin to “flight, fight, or freeze.” These children usually have a strong desire to be in control of their surroundings and their choices.
Any sudden changes to their routine, attempts to discipline them, or even unwelcome gestures of comfort can trigger reactions of anger, violence, or self-harm. In a school setting, these tendencies make it hard for them to learn fundamental academic skills and often lead to them being rejected by their teachers and fellow students.
As they get older, children who have been neglected socially are more likely to engage in risky sexual behaviors, substance abuse, have run-ins with the law, and even end up in jail, compared to children who develop typically.
What Causes Reactive Attachment Disorder?
Reactive attachment disorder usually happens because of traumatic experiences, especially severe emotional neglect. This is often seen in places like overcrowded orphanages, foster care, or homes with parents who are mentally or physically ill. Over time, babies who don’t form a steady, nurturing bond with a trusted caregiver and don’t get enough emotional interaction and mental stimulation stop trying to connect with others. They stop looking for comfort when they’re hurt, avoid being physically and emotionally close with others, and ultimately become emotionally empty.
The lack of enough emotional care can lead to problems with language learning, cognitive development (which involves thought, learning, and understanding), and can contribute to behavioral problems.
Risk Factors and Frequency for Reactive Attachment Disorder
Research indicates that between 1-2% of the population has a behavioral health disorder. However, the numbers go higher when we look at children who have been removed from their homes and placed in alternative settings, with 42% of such children meeting the criteria for a behavioral health disorder. Moreover, half to two-thirds of children entering foster care show signs of behavioral or social problems that require mental health services.
Looking at siblings raised in the same home, the agreement rates on behavior is quite high, ranging from 67% to 75%. Interestingly, neither gender nor ethnicity directly increases the risk of developing the disorder. But it’s worth noting that African American and multi-racial children, who experience more child maltreatment than non-minorities, are more likely to develop a reactive attachment disorder.
- Based on research, 1-2% people have a behavioral health disorder.
- 42% of children removed from their homes and placed in other settings meet the criteria for a behavioral health disorder.
- Half to two-thirds of kids entering foster care show signs of behavioral or social issues needing mental health services.
- Siblings raised in the same home agree on behavior between 67% – 75% of the time.
- Neither gender nor ethnicity is a direct risk factor for the disorder.
- African American and multi-racial children are at a higher risk due to increased exposure to maltreatment.
In 2010, horrifyingly, the National Survey of Child and Adolescent Well-Being reported that 79% of children who died from abuse or neglect were younger than 4 years old. In the same year, 48% of children entering the foster care system were younger than 5 years old.
Signs and Symptoms of Reactive Attachment Disorder
The DSM-5, the handbook used by health care professionals to diagnose mental disorders, defines reactive attachment disorder (RAD) through various criteria:
- The affected person shows regular behavior of emotional inhibition, rarely seeking or responding to comfort when distressed.
- The individual shows lasting social or emotional disruption, seen through at least two of the following: social withdrawal, minimal reaction to others, persistent negative mood, or sudden or unexplainable instances of irritability, fear, or sadness.
- The patient has a history of significantly inadequate care, including neglect of basic emotional needs, frequent changes in caregivers leading to unstable home life, or growing up in unusual settings that limit the opportunity to form secure attachments.
- The patient does not meet the diagnostic criteria for autism spectrum disorder, as these two disorders cannot coexist.
- The disrupted behavior is evident before the age of 5.
- The child must have a development equivalent to at least nine months to be diagnosed.
However, the diagnosis is not just about ticking boxes. Medical professionals also need to consider the widespread impact on the patient’s thinking, behavior, and emotional state.
For the cognitive aspect, childhood abuse can affect working memory and decision-making capabilities, as neglect can result in underdevelopment in certain brain regions.
Behaviorally, their social skills might be inferior to what’s expected for their age or developmental level. Children with RAD could respond with aggression or fear to normal interactions and are prone to rejection, negative self-image, physical symptoms of distress, restless movements, hyperactivity, or repetitive behaviors like hand flapping or rocking.
Emotionally, RAD can increase the risk of anxiety, depression, hyperactivity and a decreased ability to handle frustration. Affected children might react excessively, even in situations that aren’t threatening.
Testing for Reactive Attachment Disorder
Doctors should be quick to suggest that children who have been adopted, abused, undergone foster care, or lived in an institution, see a child psychologist or psychiatrist. This professional can conduct a thorough assessment of the child’s psychological, biological, and social history. They can detail the symptoms the child has experienced over time, and observe the child’s interactions with their parents.
Important behaviors associated with attachment and signs of a secure relationship, such as seeking comfort, maintaining good eye contact, and initiating interaction, should be checked at every visit. Doctors should also be ready to refer the child to a specialist in child development, a child psychiatrist, or a child psychologist if needed.
Treatment Options for Reactive Attachment Disorder
Reactive Attachment Disorder (RAD) needs a multi-faceted treatment approach, including educating parents and providing therapies focused on past traumas. Parents can learn several strategies to manage their child’s behavior without punishing them. These strategies could be about understanding the child’s non-verbal signals, anticipating triggers and how to handle them, and build stronger bonds through parent-child therapy sessions.
Being empathetic and compassionate is very important to regain the child’s trust. Creating a caring and strong parent-child relationship is key to healing the effects of previous severe neglect and abuse.
What else can Reactive Attachment Disorder be?
When diagnosing reactive attachment disorder (RAD), according to the guidelines in the diagnostic manual known as the DSM-5, doctors need to rule out other conditions that can cause similar symptoms. These conditions include:
- Autism Spectrum Disorders: Kids with autism often show similar behaviours as those with RAD. However, autism is distinct in terms of limited interests, difficulty handling sensory information, and strict habits or routines.
- Intellectual Impairment: For a diagnosis of RAD, the child should be at least 9 months old developmentally. Additionally, the social difficulties should not be caused by another medical or mental health disorder. If the child has developmental delays, the social issues should fit with their developmental age, rather than strictly due to serious neglect.
- Depressive Disorders: RAD withdrawal symptoms may look like anhedonia (the inability to feel pleasure) which is a symptom of depression. But kids with depression can still form bonds and seek and receive comfort from their preferred caregivers, which isn’t the case with RAD.
What to expect with Reactive Attachment Disorder
Even when help is given, children who have been harmed often face challenges in all parts of their lives. This includes learning in school and building a strong sense of self. The distress caused by traumatic situations can lead to attachment disorders, which cause a constant state of stress and reduce their ability to bounce back.
Identifying and treating these issues early on can lead to better results. However, it is also important for parents to be educated and supported. For example, parents who adopt children from state care or overseas orphanages should be taught about the effects of social deprivation. They should also be connected with service agencies or specialists who deal with attachment disorders.
Possible Complications When Diagnosed with Reactive Attachment Disorder
The symptoms of RAD (Reactive Attachment Disorder) are often not recognized by healthcare professionals who are not familiar with the child’s background or when the child’s background is unknown. The symptoms can be wrongly diagnosed as other common mental health conditions such as depression, anxiety, attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder, conduct disorder, genetic or neurological disorders, or autism spectrum disorder. While these disorders can have similar symptoms and can occur together, each one requires a different treatment approach. It’s crucial to get the right diagnosis since treatment for one disorder can often make RAD worse.
Common Misdiagnoses:
- Depression
- Anxiety
- Attention Deficit Hyperactivity Disorder (ADHD)
- Oppositional Defiant Disorder
- Conduct Disorder
- Genetic or Neurological Disorders
- Autism Spectrum Disorder
Preventing Reactive Attachment Disorder
Many studies have been conducted on how severe social isolation and neglect affects children. These studies usually focus on children rescued from abusive homes or raised in care facilities. However, we still need to understand the impact of sub-standard care received at home. Factors like poverty, lack of good childcare facilities, parents’ drug misuse or imprisonment, or serious mental health issues can increase the risk of different types of abuse, especially neglect.
Parents dealing with severe psychosocial issues often struggle to provide more than the bare minimum for their child. They might also lack the knowledge needed to understand the essentiality of their baby’s emotional development. Therefore, professionals who are working with such families must be aware of the impact these issues can have on a parent’s ability to provide steady emotional feedback to their child. The professionals should step in and provide additional support when needed.
Healthcare providers should specifically check for signs of depression in mothers and evaluate parent-child relationships during regular appointments.
