Reactive Attachment Disorder

What is Reactive Attachment Disorder?

Reactive attachment disorder develops when infants and young children do not have their basic needs for comfort, affection and nurturing met, and are unable to establish loving and caring attachments with their parents/ caregivers. Instead of developing secure attachments, which form the foundation for healthy development, these children typically develop insecure attachments and see the world as a dangerous and frightening place in which they cannot depend on others. Reactive attachment disorder is therefore characterised by serious problems in emotional attachment to others and can result in impaired growth and development of the brain and body. Most children with reactive attachment disorder have experienced severe problems or disruptions in their early relationships including physical and emotional abuse or neglect and are significantly more likely to be uncomfortable with and reject affection, to lack internalized social rules and regulations, and to not feel the need to control their impulses to break rules or laws.

Signs and symptoms of Reactive Attachment Disorder 

  • An aversion to touch and physical affection. 
  • A desire to be in control and avoid feeling helpless.
  • Negative beliefs about the self, relationships and life in general.
  • Impulsive/hyperactive behaviour.
  • Disobedient/ defiant/argumentative behaviour.
  • Manipulative/aggressive /abusive behaviour.
  • Self –destructive behaviour.
  • Attention and learning difficulties.
  • Depression/anxiety/ mood swings.
  • Anger problems (which may be expressed directly, in tantrums or acting out, or through manipulative, passive-aggressive behaviour).
  • Difficulty giving/receiving genuine care and affection. 
  • An underdeveloped conscience with a failure to show guilt, regret, or remorse.

DSM-5 Criteria for Reactive Attachment Disorder 

A. A consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers, manifested by both of the following:
  1. The child rarely or minimally seeks comfort when distressed.
  2. The child rarely of minimally responds to comfort when distressed.
B. A persistent social and emotional disturbance characterised by at least two of the following:
  1. Minimal social and emotional responsiveness to others
  2. Limited positive affect
  3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during non- threatening interactions with adult caregivers
C.  The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
  1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults
  2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g. frequent changes in foster care)
  3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g. institutions with high child-to-caregiver ratios)
D. The care Criterion in C is presumed to be responsible for the disturbed behaviour in Criterion A (e.g. the disturbances in Criterion A began following the lack of adequate care in Criterion C)
E. The criteria are not met for autism spectrum disorder
F. The disturbance is evident before age 5 years
G.The child has a developmental age of at least 9 months 

Treatment

Reactive attachment disorder is a lifelong condition, but with treatment children can develop more stable and healthy relationships with caregivers and others. Treatment usually involves a combination of therapy, counselling, and parenting education, that aims to ensure safe living environments, positive interactions with caregivers, and positive peer relationships. Options for therapy include: family therapy, individual psychological counselling, play therapy, special education services and parenting skills classes.