Reactive attachment disorder

Essential (Required) Features:

• A history of grossly insufficient care that may include:
• Persistent disregard for the child’s basic emotional needs for comfort, stimulation, and affection.
• Persistent disregard for the child’s basic physical needs.
• Repeated changes of primary caregivers (e.g., frequent changes in foster care providers).
• Rearing in unusual settings (e.g., institutions) that prevent formation of stable selective attachments.
• Maltreatment.
• Markedly abnormal attachment behaviours towards adult caregivers in a child, characterized by a persistent and pervasive pattern of inhibited, emotionally withdrawn behaviour including both of the following:
• Minimal seeking of comfort when distressed.
• Rare or minimal response to comfort when it is offered.
• The grossly insufficient care is presumed to be responsible for the persistent and pervasive pattern of inhibited, emotionally withdrawn behaviour.
• The symptoms are evident before the age of 5.
• The child has reached a developmental level by which the capacity to form selective attachments with caregivers normally develops, which typically occurs at a chronological age of 1 year or a developmental age of at least 9 months.
• The abnormal attachment behaviours are not better accounted for by Autism Spectrum Disorder.
• The abnormal attachment behaviours are not confined to a specific dyadic relationship.

Additional Clinical Features:

• Persistent disregard for the child’s basic needs may meet the definition for neglect: Egregious acts or omissions by a caregiver that deprive a child of needed age-appropriate care and that result, or have reasonable potential to result, in physical or psychological harm. Reactive Attachment Disorder is associated with persistent neglect rather than isolated incidents.
• Maltreatment is characterized by one or more of the following: 1) non-accidental acts of physical force that result, or have reasonable potential to result, in physical harm or that evoke significant fear; 2) sexual acts involving a child that are intended to provide sexual gratification to an adult; or 3) non-accidental verbal or symbolic acts that results in significant psychological harm. Reactive Attachment Disorder is typically associated with persistent maltreatment rather than isolated incidents.
• Children with Reactive Attachment Disorder related to repetitive maltreatment (e.g., chronic physical or sexual abuse) are at risk for developing co-occurring Post-Traumatic Stress Disorder or Complex Post-Traumatic Stress Disorder.
• Children with Reactive Attachment Disorder often exhibit more generalized persistent social and emotional disturbances including a relative lack of social and emotional responsiveness to others and limited positive affect. There may be episodes of unexplained irritability, sadness, or fearfulness that are evident during non-threatening interactions with adult caregivers.
• Children with a history of grossly insufficient care but who have nonetheless formed selective attachments do not appear to develop Reactive Attachment Disorder but may still be at risk of developing Disinhibited Social Engagement Disorder.

Boundary with Normality (Threshold):

• Many children without a diagnosis of Reactive Attachment Disorder show transient reductions of attachment behaviours towards a parent or caregiver as a normal part of development. In contrast, children with Reactive Attachment Disorder exhibit markedly atypical social responses toward caregivers that persist over time, extend across all social situations, and are not confined to a dyadic relationship with a particular caregiver.

Course Features:

• With the provision of adequate care, children with Reactive Attachment Disorder often experience a near or complete remission of symptoms. If appropriate caregiving is not provided, the disorder can persist for several years.
• Children with Reactive Attachment Disorder are at higher risk for developing Depressive Disorders and other internalizing disorders during adolescence and adulthood. They may also experience problems in developing and maintaining healthy interpersonal relationships.
• There is limited information about the course features of Reactive Attachment Disorder beyond the childhood years.
• Some adults with a history of Reactive Attachment Disorder may experience difficulty in developing interpersonal relationships.

Developmental Presentations:

• Caregiver neglect during the first 9 months of life is often an associated precursor to the onset of the disorder.
• The features of this disorder become noticeable in a similar fashion up to 5 years of age.
• It is currently unknown whether clinical features of the disorder vary among children older than 5 years of age.

Boundaries with Other Disorders and Conditions (Differential Diagnosis):

• Boundary with Autism Spectrum Disorder: In contrast to individuals with Autism Spectrum Disorder, children with Reactive Attachment Disorder have the capacity for initiating and sustaining social communication and reciprocal social interactions. Although some children with Reactive Attachment Disorder may show delays in language development due to a history of social neglect, they do not exhibit social communication deficits or the persistently restrictive, repetitive, and stereotyped patterns of behaviour, interests and activities characteristics of Autism Spectrum Disorder. Some individuals reared under conditions of severe deprivation in institutional settings exhibit autistic-like features including difficulties in social reciprocity and restricted, repetitive, and inflexible patterns of behaviour, interests, or activities. Also referred to as ‘quasi-autism’, affected individuals are differentiated from those with Autism Spectrum Disorder based on significant improvement of autism-like features when the child is moved to a more nurturing environment.
• Boundary with Disorders of Intellectual Development: Children with Disorders of Intellectual Development are able to form selective attachments to caregivers. Attachment usually develops consistent with the child’s general developmental level, and are typically evident by the time the child has reached a developmental age of at least 9 months. Reactive Attachment Disorder should only be diagnosed if it is clear that the characteristic problems in the formation of selective attachments are not a result of limitations in intellectual functioning.
• Boundary with Social Anxiety Disorder: Social Anxiety Disorder in children may include emotionally withdrawn behaviours in social situations or in anticipation of social encounters due to marked and excessive fear or anxiety. Unlike in Reactive Attachment Disorder, children with Social Anxiety Disorder exhibit appropriate attachment behaviours with parents or caregivers and seek comfort from them when distressed but are typically fearful of unfamiliar individuals. Children with Reactive Attachment Disorder exhibit emotionally withdrawn behaviours across all social contexts.
• Boundary with Depressive Disorders: Like Reactive Attachment Disorders, children with Depressive Disorders may exhibit emotionally withdrawn behaviour as well as associated features of lack of social and emotional responsiveness to others, limited positive affect, and/or episodes of unexplained irritability, sadness, or fearfulness. However, unlike Reactive Attachment Disorders, children with Depressive Disorders exhibit appropriate attachment behaviours with parents or caregivers and seek comfort from them when distressed.