What Is… Reactive Attachment Disorder

In this series, I dig a little deeper into the meaning of psychology-related terms. This week’s term is reactive attachment disorder.

The DSM-5 classifies reactive attachment disorder (RAD) as a trauma-related disorder that develops in early childhood as a result of severe neglect and maltreament. It’s been observed in children whose parents have an illness that interferes with being able to attend to their child, as well as in foster care settings and orphanages.

Lack of nurturing can lead to poor language acquisition, impaired cognitive development with decreased IQ, and impaired social functioning. Children who experience RAD have difficulty forming emotional attachments and are less able to experience positive emotions. Their moods and behaviour are erratic, and communication can be challenging, especially around emotions.

As these children’s distress isn’t met with comfort, they eventually stop seeking it altogether. This leads to an inability to tolerate physical or emotional closeness. They may respond violently to attempts at closeness from others, or they may engage in self-injury. They tend to be highly reactive, even in non-threatening situations, and have low frustration tolerance.

Attachment disorders may be associated with changes in the brain, including increased volume and activation of the amygdala, which is in charge of threat detection.

The reactive attachment disorder diagnosis

Prior to the DSM-5, there were two subtypes, inhibited and disinhibited, but now, RAD refers strictly to the inhibited type, while there’s a new disorder for the disinhibited type called disinhibited social engagement disorder. I’m not going to list the diagnostic criteria because they seem particularly conducive to inaccurate self-diagnosis. You can find the diagnostic criteria here if you’re curious, but if you’re tempted to self-diagnose, resist that temptation.

If care providers are unaware of the developmental history, symptoms may be mistakenly attributed to other disorders, as there is overlap with symptoms of conditions like depression, anxiety, ADHD, and autism. Focus on treating co-occurring disorders may mean the RAD is missed completely. Key factors that would signal the possible presence of RAD rather than another disorder are a history of severe neglect and significant difficulties in interpersonal relationships.

RAD is not the only form of disordered attachment that may result from childhood trauma. Complex PTSD, dissociative identity disorder, and personality disorders are among the various potential manifestations that may arise from the effects of early trauma.

Consequences of RAD

Attachment disorders can contribute to the development of alexithymia, a personality trait that involves the inability to identify their own emotions.

Internalization of distress can contribute to depression and anxiety. Addiction is common, as people turn to substances to help with coping. Insecure attachment can fuel issues around self-identity and self-blame, which in turn can contribute to the development of eating disorders.

As they get older, people with RAD are more likely to engage in risky behaviours, including risky sex and substance abuse, and they may have problems with the law.

Controversial theories/approaches

The American Professional Society on the Abuse of Children (APSAC) published a position paper that gave an overview of what’s known about RAD, and it sounds like there are some fringe-y theories about RAD that aren’t backed up by science.

One such fringe theory is that suppressed rage fuels behaviour in RAD. According to this theory, children with RAD fail to develop a conscience, putting them at risk of becoming psychopaths. Behaviour is framed as manipulative, as the individual attempts to exert control over their environment. The child is seen as resisting attachment, and the belief is that this resistance needs to be broken down. And it gets even scarier; this is APSAC’s description of these controversial approaches, which proponents insist are necessary to prevent kids from becoming psychopaths (note that this is not APSAC’s view, and they take a clear stand against it):

“A central feature of many of these therapies is the use of psychological, physical, or aggressive means to provoke the child to catharsis, ventilation of rage, or other sorts of acute emotional discharge. To do this, a variety of coercive techniques are used, including scheduled holding, binding, rib cage stimulation (e.g., tickling, pinching, knuckling), and/or licking. Children may be held down, may have several adults lie on top of them, or their faces may be held so they can be forced to engage in prolonged eye contact. Sessions may last from 3 to 5 hours, with some sessions reportedly lasting longer.”

Rebirthing

Sometimes, fringe types will use a technique called rebirthing is used “to simulate the psychological death of the angry unattached child to allow the child to be psychologically reborn. This technique involved the child being held down by several adults, rolled up in blankets, and being instructed to fight her way free. In rebirthing and similar approaches, protests of distress from the child are considered to be resistance that must be overcome by more coercion.”

Jaw. Drop. Whoever the hell is doing that kind of whack-jobbery needs to be put in jail for child abuse.

Treatment

Most of the treatment recommendations are geared towards children and involve things like managing the environment and ensuring there is a consistently available attachment figure. A lot of those recommendations really don’t transfer well to dealing with adults who weren’t treated as children and are still experiencing the effects.

Psychotherapy is the treatment of choice. Transference-focused psychotherapy can allow patients to project their feelings towards caregivers onto the therapist, allowing them to explore and figure out how to work with emotions.

One paper I came across mentioned some success with a program for children that involved education about the disorder and work on communication and other skills. That seems like something that could potentially translate well to adults who went untreated.

I never worked in pediatrics, so childhood disorders were never my area of expertise. It seems like very little is known about how this type of reaction to trauma manifests itself later in life if it’s not dealt with in childhood. It also sounds like reactive attachment disorder is a different type of reaction than the disorganized attachment and dissociation route that may develop when abuse is the main source of trauma rather than neglect.

Are you familiar with RAD or other forms of attachment disorders?

References

• Chaffin, M., Hanson, R., Saunders, B. E., Nichols, T., Barnett, D., Zeanah, C., … & Miller-Perrin, C. (2006). Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. Child Maltreatment, 11(1), 76-89.
• Daubney, M., & Bateman, A. (2015). Mentalization-based therapy (MBT): An overview. Australasian Psychiatry, 23(2), 132-135.
• Davies, N. (2020). Understanding adult attachment disorders. PsychiatryAdvisor.
• Ellis, E.E., Yilanli, M., Saadabadi, A. (2022). Reactive attachment disorder. StatPearls.
• Hardy, L. T. (2007). Attachment theory and reactive attachment disorder: Theoretical perspectives and treatment implications. Journal of Child and Adolescent Psychiatric Nursing, 20(1), 27-39.
• Pritchett, R., Pritchett, J., Marshall, E., Davidson, C., & Minnis, H. (2013). Reactive attachment disorder in the general population: A hidden ESSENCE disorder. The Scientific World Journal, 2013.