Overview

Reactive attachment disorder is a rare but serious condition in which an infant or young child doesn't establish healthy attachments with parents or caregivers. Reactive attachment disorder may develop if the child's basic needs for comfort, affection and nurturing aren't met and loving, caring, stable attachments with others are not established.

With appropriate treatment, children who have reactive attachment disorder may develop more stable and healthy relationships with caregivers and others. Treatments for reactive attachment disorder include learning how to create a stable, nurturing environment and providing positive child and caregiver interactions. Parent or caregiver counseling and education can help.

Symptoms

Reactive attachment disorder usually starts in infancy. There's little research on signs and symptoms of reactive attachment disorder beyond early childhood, and it remains uncertain whether it occurs in children older than 5 years.

Signs and symptoms may include:

  • Unexplained withdrawal, fear, sadness or irritability
  • Sad and listless appearance
  • Not seeking comfort or showing no response when comfort is given
  • Failure to smile
  • Watching others closely but not engaging in social interaction
  • Failure to reach out when picked up
  • No interest in playing peekaboo or other interactive games
  • Behavior problems
  • Failing to seek support or assistance

When to see a doctor

Consider getting an evaluation if your child shows any concerning signs that persist across time. Some signs can occur in children who don't have reactive attachment disorder or who have another disorder, such as autism spectrum disorder. Sometimes young children may display some temporary signs and symptoms, but they tend to be brief, minor or don't cause developmental problems. It's important to have your child evaluated by a pediatric psychiatrist or psychologist who can determine whether behaviors indicate a more serious problem.

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Causes

To feel safe and develop trust, infants and young children need a stable, caring environment. Their basic emotional and physical needs must be consistently met by caregivers. For instance, when a baby cries, the need for comfort, a meal or a diaper change must be met with a shared emotional exchange that may include eye contact, smiling and caressing.

A child whose needs are ignored or who is met with a lack of emotional response from caregivers does not come to expect care or comfort or form a stable attachment to caregivers.

It's not clear why some babies and children develop reactive attachment disorder and others don't. Various theories about reactive attachment disorder and its causes exist, and more research is needed to develop a better understanding and improve diagnosis and treatment options.

Risk factors

The risk of developing reactive attachment disorder from severe social and emotional neglect or the lack of opportunity to develop stable attachments may increase in children who, for example:

  • Live in a children's home or other institution
  • Frequently change foster homes or caregivers
  • Have parents who have severe mental health problems, criminal behavior or substance abuse that impairs their parenting
  • Have prolonged separation from parents or other caregivers due to repeated out-of-home placement, hospitalization or death of a primary caregiver

However, most children who are severely neglected don't develop reactive attachment disorder.

Complications

Without proper treatment, reactive attachment disorder can continue for several years and may have lifelong consequences. These can include problems with relationships, social interactions, mental and physical health, behavior, intellectual development, and substance abuse.

More research is needed to determine if problems in older children and adults are related to experiences of reactive attachment disorder in early childhood.

Prevention

While it's not known with certainty if reactive attachment disorder can be prevented, there may be ways to reduce the risk of its development. Infants and young children need a stable, caring environment and their basic emotional and physical needs must be consistently met. The following parenting suggestions may help.

  • Be actively engaged with your child by lots of playing, talking to him or her, making eye contact, and smiling.
  • Learn to interpret your baby's cues, such as different types of cries, so that you can meet his or her needs quickly and effectively.
  • Provide warm, nurturing interaction with your child, such as during feeding, bathing or changing diapers.
  • Offer both verbal and nonverbal responses to the child's feelings through touch, facial expressions and tone of voice.
  • Take classes or volunteer with children if you lack experience or skill with babies or children. This will help you learn how to interact in a nurturing manner.

May 12, 2022
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  4. Hornor G. Attachment disorders. Journal of Pediatric Health Care. 2019; doi:10.1016/j.pedhc.2019.04.017.
  5. Zimmermann P, et al. Recent contributions for understanding inhibited reactive attachment disorder. Attachment & Human Development. 2019; doi:10.1080/14616734.2018.1499207.
  6. Vega H, et al. Interventions for children with reactive attachment disorder. Nursing. 2019; doi:10.1097/01.NURSE.0000554615.92598.b2.
  7. Dickerson Mayes S, et al. Reactive attachment/disinhibited social engagement disorders: Callous-unemotional traits and comorbid disorders. Research in Developmental Disabilities. 2017; doi:10.1016/j.ridd.2017.02.012.
  8. Coercive interventions for reactive attachment disorder. American Academy of Child & Adolescent Psychiatry. https://www.aacap.org/aacap/Policy_Statements/2003/Coercive_Interventions_for_Reactive_Attachment_Disorder.aspx. Accessed July 28, 2021.
  9. Sawchuk, CN (expert opinion). Mayo Clinic. Sept. 2, 2021.

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