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Child Abuse & Neglect: Reactive Attachment Disorder

Background: Attachment disorders are the psychological result of negative experiences with caregivers, usually since infancy, that disrupt the exclusive and unique relationship between children and their primary caregiver(s). Oppositional and defiant behaviors that were previously considered a manifestation of conduct disorder now may be explored from attachment theory as expressions of disruptions in attachment.

Many children in the United States and elsewhere experience the loss of primary caregivers either because they are physically separated from them or because the caregiver is incapable of providing adequate care. Removal from harmful situations, which often involves placement in foster homes or institutions, may expose the child to alternate capable caregivers, but the attachments formed in these environments are often broken.

Attachment disorders have been described in the psychological and psychiatric literature for approximately 50 years. The condition Rene Spitz called anaclitic depression is now considered an attachment disorder. Spitz observed young children in an orphanage who were fed and kept clean and were initially in good physical condition but who received no consistent affection from a sole caregiver. The long-standing absence of emotional warmth took an enormous toll on the children, primarily on their emotional development but also on their physical growth and development condition. Spitz concluded that providing only for a baby's physical needs is not sufficient for normal development.

A short while later, John Bowlby, a psychoanalyst interested in the parallels between human infants and animal babies, incorporated Harlow's research on rhesus monkeys into his study of the child's tie to its mother. He concluded that separations during the first few months of life negatively impact a baby's psychic organization and that separation from a mother figure causes separation anxiety.

In a film entitled A-Two-Year-Old Goes to Hospital, Bowlby shows that an infant goes through several phases in reaction to separation. The infant goes from protest to crying to a sad state and, finally, to a more desolate state of resignation regarding the loss.

Bowlby later produced a report for the World Health Organization (WHO) highlighting the importance of maternal sensitivity in adequate child development. Maternal sensitivity refers to the ability of a mother to read internal states and emotions in her baby and to respond to them in a positive and supportive manner. The development of attachment theory is attributed to John Bowlby.

Attachment refers to a set of behaviors and inferred emotions that can be observed in humans older than 6 months. Humans need attachments with others for their psychological and emotional development as well as for their survival. The earliest manifestation of attachment is the unique and exclusive relationship between an infant and its caregiver after the sixth month of life. The quality of this relationship colors the person's relationships for the rest of his or her life. In the second half of the first year, the caregiver and the infant establish a continuous relationship that has specific features. Both caregiver and baby have biological preprogrammed instinctive equipment to foster that relationship.

The baby has highly appealing features, such as round cheeks, a relatively large head, wide-open eyes, and a social smile. These physical characteristics evoke a strong desire to care for the baby. Other features, such as crying and clinging (signaling behaviors), reinforce the baby's efforts to obtain care and attention. The mother also has instinctive behaviors, such as soothing the crying infant, caressing it, making sounds that are appealing to the infant, and mirroring the infant (ie, playfully imitating the baby's facial expressions), all of which trigger tenderness and a maternal instinct.

Attachment develops through repeatedly being looked after and responded to by the caregiver. This convinces the baby that a person is available to soothe, console, and comfort. Infants may develop attachments to other people who are consistent in their lives, such as grandparents, aunts, or uncles; however, the relationship with the primary caregiver(s) plays the most critical role in determining the child's basis for future attachments. The attachment figure(s) cannot suddenly be replaced by any other caregiver because that relationship is unique and stable.

Based on the nature and quality of early attachments, children develop an internal working model of relationships that serves as a template for future relationships. These working models of relationships can be positive (ie, people can be trusted, confided in, helpful in distress) or negative (ie, no one can be trusted, people are not caring, one is all alone in the world). Babies internalize their mother (and other attachment figures) as a secure base. This allows infants to feel internally safe and to confidently explore the world around them. It also allows them to experience positive interpersonal exchanges with other children. The infant can come back to the caregiver to refuel emotionally before proceeding with further explorations.

Reactive attachment disorder

Reactive attachment disorder (RAD), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), requires etiologic factors, such as gross deprivation of care or successive multiple caregivers, for diagnosis.

In inhibited RAD, the child does not initiate and respond to social interactions in a developmentally appropriate manner. It is a disorder of nonattachment and is related to the loss of the primary attachment figure and the lack of opportunity for the infant to establish a new attachment with a primary caregiver. Also, a nonattachment disorder may develop because the baby never had the opportunity to develop at least one attachment with a reliable caregiver who was continuously present in the baby's life.

In disinhibited RAD, the child participates in diffuse attachments, indiscriminate sociability, and excessive familiarity with strangers. The child has repeatedly lost attachment figures or has had multiple caregivers and has never had the chance to develop a continuous and consistent attachment to at least one caregiver. Disruption of one attachment relationship after another causes the infant to renounce attachments. The usual anxiety and concern with strangers is not present, and the infant or child superficially accepts anyone as a caregiver (as though people were interchangeable) and acts as if the relationship had been intimate and life-long.

Attachment disorders independent of DSM-IV

In reversed attachment, the child becomes the source of comfort to the parent, who is insecure and vulnerable; the relationship is inverted and the infant, although unable to reassure the parent completely, provides the security.

In angry attachment, a strong relationship exists between parent and infant that is unique and exclusive; however, the relationship is marked by angry features and exchanges. The dyad members are angry with each other but not with other people around them.
Mary Ainsworth developed an attachment classification based on the behavior of infants (typically aged 10-13 mo) in the presence of a stranger during and after a short separation from their primary caregivers.

Behavioral patterns associated with secure attachments include some distress at separation, preference for mother over stranger, and a search for comfort from mother upon reunion.

Behavioral patterns associated with insecure attachments, such as avoidant and ambivalent styles, include lack of distress upon separation and avoidance of, or anger toward, mother upon reunion.

Approximately 65% of American middle-class children are thought to have secure attachments with primary caregivers, whereas 35% exhibit an insecure attachment style. Not all children who show an insecure attachment to primary caregivers are diagnosed with RAD, either because they did not receive pathological care or because their insecure attachment is not severe. The lack of a secure attachment style affects the child throughout life; however, an insecure attachment should not be confused with a disorder. The Ainsworth attachment study is only a suggestion of an internal state of the child. It is not a diagnostic tool for attachment disorders.


Inhibited RAD

If caregivers are not reliably or consistently present or if they respond in an unpredictable and uncertain way, babies are not able to establish a pattern of confident expectation. One result is insecure attachment, or a less than optimal internal sense of confidence and trust in others, beginning with caregivers. The child then uses psychological defenses (eg, avoidance or ambivalence) to avoid disappointments with the caregiver. This is thought to contribute to a negative working model of relationships that leads to insecurity for the rest of the child's life.

Disinhibited RAD

Young children exposed to multiple caregivers simultaneously or sequentially do not easily experience the sense of security associated with unique and exclusive long-standing relationships. No opportunity exists to trust one person because past relationships were interrupted, disrupted, or consistently unreliable. Children with disinhibited attachment resort to psychological defense mechanisms (eg, relying only on themselves and not expecting to be soothed, cared for, or consoled by adults) to survive. Instead of relying on one person, any sense of fear or loneliness is inhibited and the children develop a pseudocomfort with whoever is available. The child is thought to suppress the conscious experience of fear only as a result of a psychological defense. The child is afraid of trusting anyone and being further disappointed.


In the US: No epidemiologic studies of frequency or prevalence of attachment disorders in children exist; however, statistical data regarding adoptions and foster care placement are available. One might estimate, based on the number of foster care placements and disruptions in relationships, approximately how many children can have attachment disorders.

Internationally: Many children, examples being certain children from Romania and China, have lived in orphanages and have had little opportunity for attachment or they have lived in bleak conditions with multiple caregivers and are emotionally and cognitively deprived. In the midst of such deprivation and so many disruptions in relationships, determining exactly what causes a child to have difficulties in relating and communicating, in development of trust, and in linguistic and cognitive development can be difficult.
Race: No evidence suggests greater prevalence of attachment disorders in a particular racial or ethnic group unless as noted above in specific countries with unusual child care practices.

Sex: No information in the scientific literature suggests a sex predilection exists.

Age: Onset of attachment disorders is in children younger than 5 years. Typically, the disorder has its roots in infancy. The more serious effects of disruptions in attachment relationships tend to persist and manifest themselves in the preschool and school years. In more muted forms (eg, mistrust and difficulties in establishing supportive, sensitive, and intimate relationships), they last into adolescence and adulthood.

For more information, please follow this link to the article...


Reactive Attachment Disorder (RAD) - Disorder Information Sheet

There are several different sub-types of Reactive Attachment Disorders. The ambivalent sub-type can be described as an "in-your-face" child. This is the child who is angry, oppositional, and who can be violent. The anxious sub-type is clingy, anxious, shows separation anxieties, among other symptoms. The avoidant sub-type is often overlooked. This child is very compliant, agreeable, and superficially engaging. This child often has a lack of depth to his emotions and functions as an "as-if" child; meaning that he tries to do and say what you want, but is not genuine, authentic, or real in emotional engagement. Finally, there is the disorganized subtype, this child often presents with bizarre symptoms.

The words 'attachment' and 'bonding' are now used interchangeably. Children with Reactive Attachment Disorder exhibit many of the following symptoms:


  • Weak Crying Response.
  • Rage.
  • Constant Whining.
  • Sensitivity to Touch/Cuddling.
  • Poor Sucking Response.
  • Poor Eye Contact.
  • No Reciprocal Smile Response.
  • Indifference to Others


  • Lack of Conscience Development.
  • Superficially Charming.
  • Lack of Eye Contact (except when lying).
  • Inability to give and Receive Affection.
  • Extreme Control Issues.
  • Destructive to Self, Others, Animals and Property.
  • No Impulse Control.
  • Unusual Eating Patterns (hoarding, gorging, or refusal to eat).
  • Unsuccessful Peer Relationships.
  • Incessant Chatter in Order to Control.
  • Very Demanding.
  • Unusual speech patterns, mumbling, robotic speech, talking very softly except when raging.

Associated Features

Learning Delays and Disorders.
Depressed I.Q. scores.

Differential Diagnosis:

Some disorders have similar symptoms. The clinician, therefore, in his diagnostic attempt, has to differentiate against the following disorders which need to be ruled out to establish a precise diagnosis.


From conception through approximately the third year of life the child needs to bond in order to develop physical, psychological and emotional health. This early attachment is the foundation for the child's ability to feel empathy, compassion, trust and love.

Children with attachment issues and those with Reactive Attachment Disorder have experienced a break in this bonding cycle. This break can be the result of:

  • Genetic Predisposition.
  • Maternal Ambivalence Toward the Pregnancy.
  • Traumatic Prenatal Experience.
  • In-Utero Exposure to Alcohol and/or Drugs.
  • Birth Trauma.
  • Neglect.
  • Abuse.
  • Abandonment.
  • Separation from Birth Parents.
  • Inconsistent or Inadequate Day Care.
  • Divorce.
  • Multiple Moves and/or Placements.
  • Institutionalization (e.g. children adopted from orphanages).
  • Undiagnosed or Untreated painful illness (e.g. untreated ear infections).
  • Medical Conditions which Prohibit Adequate Touch (e.g. child who is in an incubator or body cast).


Traditional 'talk' or 'play' therapies do not work with these children because such therapies depend upon the child's ability to develop a trusting relationship with the therapist. Children with Reactive Attachment Disorder are unable to form any genuine relationships.

Therefore parenting must be very structured and very nurturing. Natural consequences, not lectures work best. If the child does not want to eat and you've put a meal in front of them which they will not eat, If the child complains and begins to ruin the mealtime, remove them from the table. The key is to not let such a child make everyone feel like she does. Such children are very good at externalizing their feelings and getting everyone else to feel as miserable as the child does.

Counseling and Psychotherapy [ See Therapy Section ]:

Many therapeutic methods are employed: re-parenting, role-playing, therapist-supervised parent holdings, modeling of behaviors, behavioral shaping, cognitive restructuring, Gestalt Therapy, family therapy and general psychotherapy.

Effective therapy requires a team approach which must always include the child's parents.


brilliant article Lana,
lots of food for thought for any parent.
presumably children who remain untreated carry these traits in adult life.
has me thinking about my own kids, who i "took" from their father at early ages.

thank you for posting this.


Great information Lana,
Thank you for posting this article also, in respect to reactive attachment disorder.

One question with children who may have been abused to do think the anxious, separation anxieties would be part of the symptoms.
I was just wondering, it may seem possible, most children who been abused do have different behaviours?
Thanks Lana. I know if may be a question for Dr. Baxter.
Take care :)
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