Reactive attachment disorder (RAD) is characterized by inhibited or emotionally withdrawn behavior toward caregivers manifested as rarely seeking or responding to comfort when distressed. It results from extreme neglect such as lack of emotional nurturing or repeated changes in caregivers. Children with RAD show minimal social/emotional responsiveness, limited positive affect, and irritability. Treatment focuses on forming secure attachments through individual, family, and play therapy. RAD significantly impairs social relationships and is associated with developmental delays. It is differentiated from autism by histories of neglect rather than social communication deficits.

1. Reactive
Attachment
Disorder
Presented by Glenford M. Fiecas

2. What is Attachment?
 Attachment itself is a predisposition rather than
behaviour
 Selective interest in an individual with whom we
share new experiences with implicit references to
the past together, and whom we will miss if
unable to communicate about our responses with
something new

3. Diagnostic Criteria
(DSM-5)
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withdrawn behaviour toward adult caregivers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

4. Diagnostic Criteria
(DSM-5)
B. A persistent social and emotional disturbances
characterized 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-
threathening interactions with adult caregivers

5. Diagnostic Criteria
(DSM-5)
C. The child has experienced a pattern of extremes
of insufficient cares as evidence 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 care
giving adults
2. Repeated changes of primary care givers
3. Rearing in unusual setting

6. Diagnostic Criteria
(DSM-5)
D. The care in criterion C is presumed to be
responsible for the disturbance of behaviour in
criterion A (e.g, the disturbance 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 of 5 years
G. The child has a developmental age of at least 9
months

7. Two Specifiers
 Persistent – the disorder has been present for
more than 12 months
 Severe – when the child exhibits all symptoms of
the disorder manifesting at relatively higher level

8. Diagnostic Features
 - Characterized by a pattern of markedly disturbed
and developmentally inappropriate attachment
behaviour in which child rarely or minimally turns
preferentially to an attachment figure for comfort,
support protection and nurturance
 - Essential features is absent or grossly
underdeveloped attachment
 - Has the capacity to form selective attachment

9. Associated Features
Supporting Diagnosis
 Because of the shared etiological association with
social neglect, reactive attachment disorder often
co-occurs with developmental delays, especially in
delays in cognition and language
 Other associated features include stereotypes and
other signs of severe neglect

10. Prevalence
 Prevalence is unknown, but the disorder is seen
rarely in clinical setting. However, even in
population of severely neglected children, the
disorder is uncommon occuring in less than 10 %
of such children

11. Children with Reactive Attachment Disorder are
more likely to have unpleasant facial expression

12. Reactive Attachment Disorder

13. Development and Course
 Conditions of social neglect are often present in
the first months of life in children diagnosed with
reactive attachment disorder, even before the
disorder is diagnosed
 Manifest in similar fashion between the age of 9
months and 5 years
 Without remediation and recovery through
normative care giving environments, it appears
that signs of the disorder may persist at least for
several years.

14. Development and Course
 It is unclear wither reactive attachment disorder
occurs in older children and if so, how it differs
from its presentation in young children
 The diagnosis should be made with caution in
children older than 5 years

15. Risk and Prognostic Factors
Environmental
- Serious social neglect is a diagnostic
requirements for reactive attachment disorder and
is also the only known risk factors for the disorder

16. Culture Related Diagnostic Issues
 Similar attachment behaviours has been described
in young children in many different cultures around
the world. However, caution should be exercised
in making the diagnosis of the reactive attachment
disorder in cultures in which attachments has not
been studied

17. Functional Consequences of
Reactive Attachment Disorder
 Reactive attachment disorder significantly impairs
young children’s abilities to relate interpersonally
to adults or peers and is associated with functional
impairment across many domains of early
childhood

18. Differential Diagnosis
Autism Spectrum Disorder
- the two disorders can be distinguished based on
the different histories of neglect and the presence
of restricted interests or ritualized behaviours
specific deficit in social communication and
selective attachment behaviours
- Only children with autism spectrum disorder exhibit
selective impairments in social communicative
behaviours such as intentional communication

19. Differential Diagnosis
Autism Spectrum Disorder
- Children with reactive attachment disorder show
social communications functioning comparable to
their overall level of intellectual functioning
- Children with autistic spectrum disorder regularly
show attachment behaviour typical for their
developmental level
- In contrast, children with reactive attachment
disorder do so only, rarely or inconsistently, if at
all.

20. Differential Diagnosis
Intellectual Disability
- Children with Intellectual Disabilities should exhibit
social and emotional skills comparable to their
cognitive skills and do not demonstrate the
profound reduction in positive affect and emotion
regulation difficulties evident in children with
reactive attachment disorder
- Developmentally delayed children who have
reached a cognitive age of 7-9 months should
demonstrate selective attachments regardless of
their chronological ages

21. Differential Diagnosis
Intellectual Disability
- In contrast, children with reactive attachment
disorder show lack of preferred attachments
despite of having attained developmental age of at
least 9 months

22. Differential Diagnosis
Depressive Disorder
- children who has been diagnosed with depressive
disorders still should seek and respond to
comforting efforts by care givers

23. Comorbidity
Conditions associated with neglects includes:
1. Cognitive delays
2. Language delays
3. Stereotypes
Medical conditions such as:
1. Severe malnutrition
2. Depressive symptoms

24. Treatment Options
1. Holding Therapy
2. Individual Therapy/ Play Therapy
3. Family Therapy