Reactive Attachment Disorder is usually associated with some form of abuse or neglect in the first two to three years of life. This normally involves physical or emotional abuse, abandonment, a drug-addicted caregiver, a sequence of foster placements, or similar emotional trauma. In some cases, children may have symptoms of an attachment disorder if they have experienced divorce, long periods of hospitalization, a parent with chronic depression, or if their brains were altered by the mother's substance abuse. The most common factor for children with attachment disorders is that in the critical first years of life, either the child did not have the opportunity to bond emotionally with any single individual and maintain that bond, or the child did experience an emotional attachment and then was separated from the caregiver. ~ Strategies for Classroom Teachers of Students with Reactive Attachment DisorderAccording to the DSM IV-TR There are two types of Reactive Attachment Disorder:
- Being way too “cute” and charming, especially as a means to get what they want, whether it is attention or material objects/food.
- Acts like a baby/uses the “baby voice” and behaves inappropriately younger than their age.
- Exaggerates about everything, especially their “need” to be helped.
- Easily/readily goes off with strangers and/or seeks affection (i.e. hugs) from strangers.
- Makes friends with a lot of other children (usually younger than themselves), but is not very close to any one of them.
- Talks a lot – asks a lot of “crazy” questions
- Makes up stories – long, long, stories.
- Wants just about everything they see, and feels “unloved” when they do not get it.
- When they do get the item, pays attention to it for only a short while and then either breaks it or puts it away and ignores it/forgets about it.
- Avoids relationships and is in a constant pull-push mode with the people trying to be close to him, such as parents. (Gets close enough to get what he wants, then pushes away again.)
- Resists affection / stiffens when you try to hug them.
- Avoids eye contact (unless lying, then will look you straight in the eye and forcefully deny anything, even obvious things).
- Is always “on guard.” (Whenever you want to talk with them, they get defensive and think they’re in trouble.)
- Keeps score. Knows exactly what he “got” vs. what his brother got for birthdays, Christmas, etc.
- Has very few friends. The friends he does have are not all that close.
- Prefers to be alone.
- Lies a lot. “Crazy lies” about things that do not matter. Believes own lies.
- Engages in self-soothing behaviors rather than seek comfort from parents.
- May hoard food, trash.
- May steal.
- May argue about ev.ry.thing.
- May act completely different than the type they usually exhibit. (Ex. a disinhibited child may shut down and be surly from time to time, while an inhibited child may occasionally act silly and much younger than his/her age.)
A child whose past trauma is triggered will likely exhibit several of these signs at one time, and they may be even more exaggerated than usual. Kids can be triggered by sights (violent TV shows, for example), smells (fried potatoes), sounds (a full laundry basket falling to the ground, a siren, a fire alarm at school, or a loud/sharp yell), and sensory feelings (a certain touch, a particular fabric, cold weather). They can also be triggered by "traumaversaries" anniversaries of significant events (like entering foster care), birthdays, and holidays.
Changes from the DSM IV-TR to the DSM V - American Psychiatric Publishing
Reactive Attachment Disorder
The DSM-IV childhood diagnosis reactive attachment disorder had two subtypes: emotionally withdrawn/inhibited and indiscriminately social/disinhibited.
In DSM-5, these subtypes are defined as distinct disorders: reactive attachment disorder and disinhibited social engagement disorder. Both of these disorders are the result of social neglect or other situations that limit a young child’s opportunity to form selective attachments.
Although sharing this etiological pathway, the two disorders differ in important ways. Because of dampened positive affect, reactive attachment disorder more closely resembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults. In contrast, disinhibited social engagement disorder more closely resembles ADHD; it may occur in children who do not necessarily lack attachments and may have established or even secure attachments.
The two disorders differ in other important ways, including correlates, course, and response to intervention, and for these reasons are considered separate disorders.
Reactive Attachment Disorder - DSM V
Diagnostic criteria for reactive attachment disorder:
- 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
DSM-5 Criteria for Disinhibited Social Engagement Disorder
A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:
Reduced or absent reticence in approaching and interacting with unfamiliar adults.
Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
Willingness to go off with an unfamiliar adult with little or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.
C. The child has exhibited a pattern of extremes of insufficient care as evidenced by at least one of the following:
Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults.
Repeated changes of primary caregivers that limit ability to form stable attachments (e.g., frequent changes in foster care).
Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
E. The child has a developmental age of at least nine months.
Specify if Persistent: The disorder has been present for more than 12 months.
Specify current severity: Disinhibited Social Engagement Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.
Another post on RAD - Psychoses or Syndrome?
Online Support and Resources
What is Reactive Attachment Disorder?
Mayo Clinic definition
American Academy of Child & Adolescent Psychiatry
Where can I go for help, support, or to learn more about parenting a child with RAD?