Diagnosis

A pediatric psychiatrist or psychologist can conduct a thorough, in-depth examination to diagnose reactive attachment disorder.

Your child's evaluation may include:

  • Direct observation of interaction with parents or caregivers
  • Details about the pattern of behavior over time
  • Examples of the behavior in a variety of situations
  • Information about interactions with parents or caregivers and others
  • Questions about the home and living situation since birth
  • An evaluation of parenting and caregiving styles and abilities

Your child's doctor will also want to rule out other psychiatric disorders and determine if any other mental health conditions co-exist, such as:

  • Intellectual disability
  • Other adjustment disorders
  • Autism spectrum disorder
  • Depressive disorders

Diagnostic and Statistical Manual of Mental Disorders (DMS-5)

Your doctor may use the diagnostic criteria for reactive attachment disorder in the DSM-5, published by the American Psychiatric Association. Diagnosis isn't usually made before 9 months of age. Signs and symptoms appear before the age of 5 years.

Criteria include:

  • A consistent pattern of emotionally withdrawn behavior toward caregivers, shown by rarely seeking or not responding to comfort when distressed
  • Persistent social and emotional problems that include minimal responsiveness to others, no positive response to interactions, or unexplained irritability, sadness or fearfulness during interactions with caregivers
  • Persistent lack of having emotional needs for comfort, stimulation and affection met by caregivers, or repeated changes of primary caregivers that limit opportunities to form stable attachments, or care in a setting that severely limits opportunities to form attachments (such as an institution)
  • No diagnosis of autism spectrum disorder

Treatment

Children with reactive attachment disorder are believed to have the capacity to form attachments, but this ability has been hindered by their experiences.

Most children are naturally resilient. And even those who've been neglected, lived in a children's home or other institution, or had multiple caregivers can develop healthy relationships. Early intervention appears to improve outcomes.

There's no standard treatment for reactive attachment disorder, but it should involve both the child and parents or primary caregivers. Goals of treatment are to help ensure that the child:

  • Has a safe and stable living situation
  • Develops positive interactions and strengthens the attachment with parents and caregivers

Treatment strategies include:

  • Encouraging the child's development by being nurturing, responsive and caring
  • Providing consistent caregivers to encourage a stable attachment for the child
  • Providing a positive, stimulating and interactive environment for the child
  • Addressing the child's medical, safety and housing needs, as appropriate

Other services that may benefit the child and the family include:

  • Individual and family psychological counseling
  • Education of parents and caregivers about the condition
  • Parenting skills classes

Controversial and coercive techniques

The American Academy of Child and Adolescent Psychiatry and the American Psychiatric Association have criticized dangerous and unproven treatment techniques for reactive attachment disorder.

These techniques include any type of physical restraint or force to break down what's believed to be the child's resistance to attachments — an unproven theory of the cause of reactive attachment disorder. There is no scientific evidence to support these controversial practices, which can be psychologically and physically damaging and have led to accidental deaths.

If you're considering any kind of unconventional treatment, talk to your child's psychiatrist or psychologist first to make sure it's evidence based and not harmful.

Coping and support

If you're a parent or caregiver whose child has reactive attachment disorder, it's easy to become angry, frustrated and distressed. You may feel like your child doesn't love you — or that it's hard to like your child sometimes.

These actions may help:

  • Educate yourself and your family about reactive attachment disorder. Ask your pediatrician about resources or check trusted internet sites. If your child has a background that includes institutions or foster care, consider checking with relevant social service agencies for educational materials and resources.
  • Find someone who can give you a break from time to time. It can be exhausting caring for a child with reactive attachment disorder. You'll begin to burn out if you don't periodically have downtime. But avoid using multiple caregivers. Choose a caregiver who is nurturing and familiar with reactive attachment disorder or educate the caregiver about the disorder.
  • Practice stress management skills. For example, learning and practicing yoga or meditation may help you relax and not get overwhelmed.
  • Make time for yourself. Develop or maintain your hobbies, social engagements and exercise routine.
  • Acknowledge it's OK to feel frustrated or angry at times. The strong feelings you may have about your child are natural. But if needed, seek professional help.

Preparing for your appointment

You may start by visiting your child's pediatrician. However, you may be referred to a child psychiatrist or psychologist who specializes in the diagnosis and treatment of reactive attachment disorder or a pediatrician specializing in child development.

Here's some information to help you get ready and know what to expect from your doctor.

What you can do

Before your appointment, make a list of:

  • Any behavior problems or emotional issues you've noticed, and include any signs or symptoms that may seem unrelated to the reason for your child's appointment
  • Key personal information, including any major stresses or life changes that you or your child have been through
  • All medications, vitamins, herbal remedies or other supplements your child is taking, including the dosages
  • Questions to ask your child's doctor to make the most of your time together

Some basic questions to ask your doctor may include:

  • What is likely causing my child's behavior problems or emotional issues?
  • Are there other possible causes?
  • What kinds of tests does my child need?
  • What's the best treatment?
  • What are the alternatives to the primary approach that you're suggesting?
  • My child has these other mental or physical health conditions. How can I best manage them together?
  • Are there any restrictions that my child needs to follow?
  • Should I take my child to see other specialists?
  • Is there a generic alternative to the medicine you're prescribing for my child?
  • Are there any brochures or other printed material that I can have? What websites do you recommend?
  • Are there social services or support groups available to parents in my situation?

What to expect from your doctor

Your child's doctor or mental health provider is likely to ask you a number of questions. Be ready to answer them to reserve time to go over any points you want to spend more time on.

Some questions the doctor may ask include:

  • When did you first notice problems with your child's behavior or emotional responses?
  • Have your child's behavioral or emotional issues been continuous or occasional?
  • How are your child's behavioral or emotional issues interfering with his or her ability to function or interact with others?
  • Can you describe your child's and the family's home and living situation since birth?
  • Can you describe interactions with your child, both positive and negative?
July 13, 2017
References
  1. Reactive attachment disorder. In: Diagnostic and Statistical Manual of Mental Disorders DSM-5. 5th ed. Arlington, Va.: American Psychiatric Association; 2013. http://dsm.psychiatryonline.org. Accessed April 4, 2017.
  2. Facts for families: Attachment disorders. American Academy of Child and Adolescent Psychiatry. http://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/Attachment-Disorders-085.aspx. Accessed April 4, 2017.
  3. Dickerson Mayes S, et al. Reactive attachment/disinhibited social engagement disorders: Callous-unemotional traits and comorbid disorders. Research in Developmental Disabilities. 2017;63:28.
  4. Zeanah CH, et al. Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder and disinhibited social engagement disorder. Journal of the American Academy of Child & Adolescent Psychiatry. 2016;55:990.
  5. Coercive interventions for reactive attachment disorder. American Academy of Child & Adolescent Psychiatry. http://www.aacap.org/aacap/Policy_Statements/2003/Coercive_Interventions_for_Reactive_Attachment_Disorder.aspx. Accessed April 14, 2017.
  6. Hoecker JL (expert opinion). Mayo Clinic, Rochester, Minn. May 25, 2017.
  7. Position statement on reactive attachment disorder. American Psychiatric Association. Reaffirmed, 2007.

Reactive attachment disorder