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Reactive attachment disorder of infancy or early childhood

Reactive attachment disorder is a problem in which a child is not able to easily form a normal or loving relationship with others. It is considered to be a result of not forming an attachment to any specific caregiver when very young.

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Causes

Reactive attachment disorder is caused by abuse or neglect of an infant's needs for:

• Emotional bonds with a primary or secondary caretaker
• Food
• Physical safety
• Touching

An infant or child may be neglected when the:

• Caregiver is intellectually disabled
• Caregiver lacks parenting skills
• Parents are isolated
• Parents have a poorly controlled mental health condition
• Parents are teenagers

A frequent change in caregivers (for example, in orphanages or foster care) is another cause of reactive attachment disorder.

Symptoms

In a child, symptoms may include:

• Avoiding caregiver
• Avoiding physical contact
• Difficulty being comforted
• Not making distinctions when socializing with strangers
• Wanting to be alone rather than interacting with others

The caregiver will often neglect the child's:

• Needs for comfort, stimulation, and affection
• Needs like food, toileting, and play

Exams and Tests

This disorder is diagnosed with a:

• Complete history
• Physical examination
• Psychiatric evaluation

Treatment

Treatment has two parts. The first goal is to make sure the child is in a safe environment where emotional and physical needs are met.

Once that has been established, the next step is to change the relationship between the caregiver and the child, if the caregiver is the problem. Parenting classes can help the caregiver meet the child's needs and bond with the child.

Counseling may help the caregiver work on problems, such as drug abuse or family violence. Social Services should follow the family to make sure the child remains in a safe, stable environment.

Outlook (Prognosis)

The right intervention can improve the outcome.

Possible Complications

If not treated, this condition can permanently affect the child's ability to interact with others. It can be connected with:

• Anxiety
• Depression
• Other psychological problems
• Post-traumatic stress disorder

When to Contact a Medical Professional

This disorder is usually identified when a parent (or prospective parent) is at high risk for neglecting their child or when an adoptive parent has difficulty coping with a newly adopted child.

If you have recently adopted a child from a foreign orphanage or another situation where neglect may have occurred and your child shows these symptoms, contact your health care provider.

Prevention

Early recognition is very important for the child. Parents who are at high risk for neglect should be taught parenting skills. The family should be followed by either a social worker or provider to make sure the child's needs are being met.

References

American Psychiatric Association website. Reactive attachment disorder. In: American Psychiatric Association, ed. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013:265-268.

Milosavljevic N, Taylor JB, Brendel RW. Psychiatric correlates and consequences of abuse and neglect. In: Stern TA, Wilens TE, Fava M, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 3rd ed. Philadelphia, PA: Elsevier; 2025:chap 62.

Zeanah CH, Chesher T, Boris NW; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder and disinhibited social engagement disorder. J Am Acad Adolesc Psychiatry. 2016;55(11):990-1003. PMID: 27806867 pubmed.ncbi.nlm.nih.gov/27806867/.

Review Date: 4/17/2024  

Reviewed By: Neil K. Kaneshiro, MD, MHA, Clinical Professor of Pediatrics, University of Washington School of Medicine, Seattle, WA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.

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