Reactive attachment disorder

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.

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

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.

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.

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.

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.

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.

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 mental health provider will also want to rule out other psychiatric disorders and determine if any other mental health conditions coexist, such as:

• Intellectual disability
• Adjustment disorders
• Autism spectrum disorder
• Depressive disorders
• Post-traumatic stress disorder

Your child's mental health provider may use the diagnostic criteria for reactive attachment disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. Diagnosis isn't usually made before 9 months of age. Signs and symptoms typically appear before the age of 5 years.

DSM-5 criteria for diagnosis 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

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

A mental health professional can provide both education and coaching in skills that help improve signs and symptoms of reactive attachment disorder. 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 has 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.

If you're a parent or caregiver whose child has reactive attachment disorder, it's easy to become angry, frustrated, guilty 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 or your child's mental health professional 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 that it's OK to feel frustrated, angry or guilty at times. The strong feelings you may have about your child are natural. But if needed, seek professional help.

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 health care provider or mental health professional.

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
• Approaches or treatments you've tried, including how helpful or not helpful they have been.
• 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 health care provider or mental health professional

Some basic questions to ask 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 are the best treatments?
• 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?
• 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?
• If medication is recommended, is there a generic alternative to the medicine you're prescribing for my child?

What to expect from your doctor

Your child's health care provider or mental health professional is likely to ask you a number of questions, such as:

• 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?
• What approaches have you tried that have been helpful or unhelpful?

Your health care provider or mental health professional will ask additional questions based on your responses, symptoms and needs. Preparing and anticipating questions will help you make the most of your appointment time.