Attachment refers to the intimate bond formed between an infant or very young child and the primary caregiver. Research suggests that this bond, or attachment, is vital to the child’s emotional development. This relationship is important in  developing the child’s ability to establish other healthy social relationships.

When infants and children under the age of five show disturbed and developmentally inappropriate social relatedness and do not initiate or respond to most social interactions, a diagnosis of Reactive Attachment Disorder is considered.

The difficulties of children who develop this disorder are due primarily to a grossly deprived environment. There may be repeated changes of caregivers, or caregivers who persistently disregard the child’s physical needs or emotional needs for comfort, stimulation and affection.

Signs and Symptoms

The physical and emotional milestones of children with Reactive Attachment Disorder deviate from expected developmental norms.

  • Many of the children appear significantly malnourished.
  • They may show a patterns of interaction that are:
    • inhibited (frozen watchfulness)
    • hypervigilant(resistance to comfort)
    • ambivalent (a mixture of approach and avoidance)
  • Dullness, listlessness or apathy with a lack of spontaneous activity and reciprocity with the caregiver are often seen
  • Some children look sad, unhappy, joyless or miserable
  • Older infants show minimal curiosity about their surroundings and little exploratory behavior
  • They may show delayed responsiveness to a stimulus that might elicit fright or withdrawal in other children
  • Some may shrink from contact; others may exhibit indiscriminate attachments

Co-Occuring Disorders

  • Reactive Attachment Disorder may be associated with:
  • Developmental delays
  • Feeding Disorder of Infancy and Early Childhood
  • Pica or Rumination Disorder

Laboratory findings consistent with malnutrition may be present.

Physical examination may document medical conditions, such as growth delay or evidence of physical abuse, that might contribute to, or result from, difficulties in caring for the child.

Related Disorders

Reactive Attachment Disorder must be distinguished from:

  • Severe Mental Retardation
  • Autism Spectrum Disorder Disorders.

These disorders usually occur in the context of a reasonably supportive psychosocial environment whereas Reactive Attachment Disorder is due to a grossly deprived environment.

Autistic Disorder and Reactive Attachment Disorder may seem similar, but a child with autism has a neurologically based disability which impedes expected development in social relationships while  a child with Reactive Attachment Disorder has the capacity to comprehend social relationships, but does not function appropriately. In Reactive Attachment Disorder, neglect, not a neurological difficulty, is the causal factor.

Causes

Many factors can potentially interfere with the development of attachment between the mother or primary caregiver and the infant-curtailed mother/child interaction, including:

  • lack of holding
  • poor verbal and sensory stimulation
  • inadequate physical care and feeding
  • Alcohol and drug use by the caregiver may also affect parenting ability and interfere with the formation of an attachment relationship.
  • Certain situations, such as lack of a primary caregiver, prolonged hospital stay, extreme poverty, parental inexperience, and parental social isolation, may predispose a child to developing in a deprived environment that in turn may lead to a Reactive Attachment Disorder.

It must be noted that some children form stable attachments and social relationships despite marked neglect or abuse.

Diagnosis

Since it is believed that a strong attachment provides the basis for healthy emotional and social development, children who are deprived of the opportunity to form attachments, due to deprived environments and/or grossly inadequate caregiving, may develop a Reactive Attachment Disorder.

Although epidemiological data are limited, the disorder is uncommon. Because of its association with other disorders it may be underdiagnosed.

According to the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV) a child must show:

markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5, as shown by:

either 

  • persistent failure to initiate or respond to most social interactions, excessively inhibited, hypervigilant or ambivalent and contradictory responses, 

or

  • indiscriminate sociability or inability to exhibit appropriate selective attachments. 

Neglectful care can be shown by at least one of the following:

  • disregard for the child’s emotional needs for stimulation,comfort and affection
  • disregard of child’s physical needs
  • repeated changes of primary caregiver

Treatment

The severity and the course of the disorder vary, depending on individual factors in the child and the caregiver, the degree of the associated psychosocial deprivation, the length of time spent in the deprived environment, the nature and adequacy of the intervention, and the age of the child at the time of intervention. Considerable improvement or remission may occur if a disorder follows a continuous course. Possible interventions include, but are not limited to:

  1. Psychosocial support services, which can include providing homemakers, assessing the capacity of the caretakers, improving the physical condition of the home or obtaining more adequate housing, improving the financial status of the family, and decreasing the isolation of the family.
  2. Psychotherapeutic intervention, which can include family or marital counseling and medications for associated difficulties. Treatment should target the symptoms, not just the attachment problems.
  3. Educational/counseling services, which can include mother/infant groups and education to increase awareness and understanding of the child’s needs and improve parenting skills.
  4. Provisions for close monitoring of the progression of the infant’s physical and emotional well-being.
  5. Placement with relatives, foster care, or adoption may become alternatives should these interventions be unfeasible.

Resources

Adoption Learning Partners

The vision of Adoption Learning Partners is to make a positive measurable impact on adoption outcomes. They offer meaningful, timely, web-based educational adoption resources for professionals, parents, adopted individuals, and the families that love them. They provide support, a community forum, and are a resource for professionals and families.

Top Ten Tips for the First Year of Placement

What are reasonable things for parents to concentrate on during a child’s first year home? How can parents succeed in raising emotionally healthy children? WHen children arrive later in infancy or childhood, most parents are well-aware that they are doing more careful parenting. They must nurture not only to build a relationship but to help mitigate the impact of losses or maltreatment.  Deborah Gray, author of Attaching in Adoption offers ten tips on her website.

Center for Adoption Studies

The Center for Adoption Studies conduct research on families formed through adoption and systems through which families are created.  Their primary focus lies on children who are or have been in the child welfare system.

Child Welfare Information Gateway

Child Welfare Information Gateway connects child welfare and related professionals to comprehensive information and resources to help protect children and strengthen families. They feature the latest on topics from prevention to permanency, including child abuse and neglect, foster care, and adoption.

Frequently Asked Questions

What does attachment mean? Why is it so important?

Attachment is the gradually developing quality of a reciprocal affectionate relationship between the infant and parent(s), especially the mother or the primary caregiver, during the first year of life. It is believed that a strong attachment provides the basis for healthy emotional and social development, and children who are deprived of the opportunity to form attachments, due to deprived environments and/or grossly inadequate caregiving, will not be able to develop normally.

If a six-month-old infant is not gaining weight and seems listless, does that mean she has Reactive Attachment Disorder?

These symptoms alone do not point to Reactive Attachment Disorder. This disorder, by definition, must be caused by a gross lack of adequate care by the parents or other primary caregivers. Medical evaluation for other possible causes, such as inadequate nutrition, inappropriate levels of stimulation, or possible physical conditions is indicated.

Can Reactive Attachment Disorder be cured?

The sooner the problem is identified and the conditions contributing to the grossly inadequate care and poor environment are changed, the better the chances for a reversal of the disorder.

Do all children who are adopted have Reactive Attachment Disorder?

The majority of adopted children do not have Reactive Attachment Disorder. Children who have been in an institution or other environment in which the caregivers did not provide emotional and sensory stimulation, such as physical holding, talking and interaction with adults, do best when they are adopted as soon as possible. The younger the children are when they are removed from the deprived environment, the better their chances of following a normal developmental track.

Since children with autism often don’t respond to other people, do they also have Reactive Attachment Disorder?

Children with autism do show a lack of responsiveness to people, even to their parents, but most of these children are not apathetic or listless. They may show a preferential interest in inanimate objects and bizarre responses to environmental stimuli, but the deviant course of their development is not due to inadequate or pathological care-taking. A neurological basis for the lack of ability to comprehend normal social relationships is present in autism.