Reactive attachment disorder (RAD) occurs when a person does not form a healthy attachment with their primary caregiver during childhood. It is a rare but serious condition that can affect people into adulthood.

RAD can occur as a result of childhood abuse, trauma, or neglect. Children with the disorder may have trouble forming relationships and feel threatened by physical or emotional closeness.

Treatment for RAD involves creating a safe and secure environment, then treating the condition via psychotherapy. There are various types of therapy that may help.

Read on to learn more about RAD treatment.

A hand casting a shadow against a grey wall.Share on Pinterest
Catherine Falls Commercial/Getty Images

In psychology, the term “attachment” refers to the bonds people form with each other. According to attachment theory, the bonds children form with their primary caregivers in early life go on to influence their mental health and future relationships.

Usually, primary caregivers are parents, but they can also be grandparents, foster parents, or other people responsible for the child’s care.

When adults respond with love and affection most of the time, children form healthy or secure attachments to them. This is important for their development. Challenges to attachment can occur due to:

  • a lack of love and affection
  • separation from caregivers
  • early trauma

The Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) specifically links RAD to neglect or abuse. When children do not receive the care and love they need, they do not learn how to form healthy attachments. They may find affection threatening.

In the general population, RAD is uncommon. In Canada, for example, the prevalence is around 1%. However, for children who have experienced abuse or institutionalization, the rate may be as high as 40%.

RAD is a serious condition, but it is responsive to treatment. Treating the condition involves several key things:

Establishing a healthy, safe environment

People cannot begin to recover from trauma until they feel safe. For this reason, a core component of RAD treatment is providing a safe, healthy environment.

For children, this may mean addressing the behavior of family members, parenting training, or family counseling. If the home environment is unlikely to become safe, they may stay with another caregiver.

For adults, establishing a healthy environment may involve ending harmful relationships, finding a safe place to live, or having a good support network of friends or family.

Compassionate care

If the person with RAD is a child or adolescent, their current caregivers need to treat them with compassion while they undergo treatment.

Children with RAD do not act out on purpose. Instead, the behavior comes from intense emotional distress, fears of abandonment, and difficulty feeling secure in relationships. Punishing them for their behavior will not help.

Instead, caregivers can learn positive or nonpunitive techniques for managing difficult behavior. This helps to reduce disruption without punishing the child.

Caregivers may also benefit from learning other techniques, including:

  • how to identify triggers, which are events that spark intense or overwhelming emotions
  • how to avoid triggers, or how to soothe the child when they occur
  • how to understand and respond to nonverbal communication

Similarly, for adults with RAD, their friends, family, or coworkers can be supportive by learning about the disorder and its impact. They may offer emotional support or, if a person feels more comfortable with it, practical help. For example, they could accompany the person to appointments.

Therapy

Therapy, specifically trauma-informed therapy, is the next step in RAD treatment.

There is no standardized approach to therapy for RAD, and researchers are still learning about what works best. A person may benefit from trauma therapy to address the impact of traumatic memories. Attachment therapy is also an option. This specifically aims to help people with attachment security.

Some may find it helpful to try different approaches or combine more than one. However, it is important to note that some once-popular interventions for RAD are very harmful and do not work. In fact, they may intensify symptoms or lead to serious consequences. These include:

  • physical restraint or coercion, such as “therapeutic holding”
  • attempting to “rework” the trauma via “rebirthing therapy” or similar approaches
  • regression therapy to promote “reattachment”

RAD is a clinical diagnosis. This means doctors diagnose the condition based on symptoms rather than physical tests.

Because of this, it can be difficult to diagnose RAD, as the symptoms can be similar to other conditions. For example, autistic people can have difficulty in social situations, and those with conduct disorder exhibit dysregulated behaviors.

Additionally, parenting practices vary according to culture. For example, in Hawaii, parts of Africa, and India, children often refer to people outside their family by familial terms, such as “auntie.” To an outsider, this may look as though the child is being overly familiar when it is actually typical.

For these reasons, children can only receive a RAD diagnosis if they have a known history of trauma or neglect, and another condition does not better explain the symptoms.

Diagnostic criteria

The DSM-5 states that for a person to receive a RAD diagnosis, they must:

  • be withdrawn and highly inhibited, and have trouble finding comfort when they are distressed
  • have a history of abuse, neglect, maltreatment, or deprivation
  • have at least two of the following symptoms:
  • be at least 9 months old, with symptoms that appear before the age of 5
  • not qualify for a diagnosis of autism

Part of this process involves a child or adult telling a doctor about the trauma history. This can be difficult. In some cases, there may be abuse that the child’s caregivers do not know about, such as from a grandparent or foster parent.

Uncovering whether abuse has taken place can be hard and, in some cases, may not be possible. If a person has the symptoms of RAD, but the cause is unclear, they should not try to diagnose themselves.

Only a medical professional can diagnose RAD, and self-diagnosing may mean a person does not get the care they need if they are incorrect.

If possible, speak with a healthcare professional with a background in attachment disorders or who works with children who have experienced trauma for expert help and advice.

It is important to find a mental health professional who understands RAD and attachment theory specifically. A therapist with a more generalized background may not have the right skill set to treat it.

Try asking for a referral or recommendation from:

  • child care agencies or authorities
  • a doctor or pediatrician
  • other therapists

Building a positive relationship with a therapist is an important part of psychotherapy. However, as attachment is hard for people with RAD, this may be a difficult process. A person with RAD may not feel they get on well with their therapist.

An indicator that the therapist is a good fit despite this is the progress the person makes during the course of treatment. If they do not make progress over time, they may benefit from changing to another.

Treatment for RAD may involve exploring the root causes and experiences that led to disruptions in attachment. As RAD has strong links to neglect and abuse, this can be a tough process.

Sometimes, neglect occurs when caregivers are not available to care for the child or when severe pressures prevent them from doing so. These pressures include:

  • poverty
  • difficulty accessing child care
  • substance misuse
  • mental health conditions
  • incarceration

Institutions, foster homes, and group homes can also be problematic. In crowded facilities, it is not always possible for children to get the care and attention they need.

It may be common practice in some orphanages to leave babies in cribs and not hold them much. Isolation and a lack of contact with loving caregivers may raise the risk of RAD.

A 2019 study found a lower rate of RAD among children living with their families in a community setting than children living in foster care or clinical settings, such as a psychiatric hospital.

Some other examples of situations in which RAD may develop include:

  • Instability: Children may have an attachment to one caregiver but then experience disruption to the relationship. For example, authorities may move a child through several foster homes during infancy, preventing them from forming any deep attachments.
  • Forced separation: Conscription, imprisonment, and other events can forcibly separate caregivers from children. The United States government separating parents and children attempting to enter the country is an example.
  • Bereavement: The death of a parent or primary caregiver may elevate the risk of RAD if there is no other loving caregiver who can raise the child.

People who are concerned about their mental health or the well-being of a child can seek help at any time.

For a child or adolescent who may have RAD, speak with a child psychologist or other mental health professional to get an assessment. It is especially important to do this if the person:

  • has a history of trauma or abuse and is not currently receiving support
  • finds it difficult to form relationships with others
  • experiences severe distress that is disproportionate to the situation they are in
  • engages in antisocial or high risk behavior, such as substance misuse or crime

Adults who think they may have RAD can also speak with a therapist. Family therapy or couples counseling may also be helpful since it can help people who love the person to understand their attachment challenges.

Suicide prevention

If you know someone at immediate risk of self-harm, suicide, or hurting another person:

  • Ask the tough question: “Are you considering suicide?”
  • Listen to the person without judgment.
  • Call 911 or the local emergency number, or text TALK to 741741 to communicate with a trained crisis counselor.
  • Stay with the person until professional help arrives.
  • Try to remove any weapons, medications, or other potentially harmful objects.

If you or someone you know is having thoughts of suicide, a prevention hotline can help. The National Suicide Prevention Lifeline is available 24 hours per day at 800-273-8255. During a crisis, people who are hard of hearing can use their preferred relay service or dial 711 then 800-273-8255.

Click here for more links and local resources.

Reactive attachment disorder (RAD) happens when a child experiences severe maltreatment or disruptions in their attachment to a primary caregiver. While the effects tend to be most apparent in childhood, they can have consequences for the rest of a person’s life.

It is impossible to change the circumstances that led to RAD, and it is a very serious condition with numerous long-term ramifications. A loving environment alone cannot cure it. However, with compassionate support, a safe environment, and psychotherapy, a person may be able to develop a healthier attachment style.

Learn more about the symptoms, impact, and complications of RAD here.