Reactive attachment disorder in children

Babies normally form a specific bond with a main caregiver, who becomes a safe base to explore from and a source of comfort when they are upset. Patient's professional reference says clear attachment bonds normally appear between 6 and 9 months. Attachment difficulties arise mainly when a child has not had a normal connection with a parent figure because of neglect, abuse, institutionalisation or disrupted care.

RAD is the most severe, specifically defined end of this spectrum. The same source says it occurs in the context of grossly inadequate childcare and is characterised by grossly abnormal attachment behaviours in early childhood. It is rare in the general population but more common among children in the care system or on the edge of care.

Disinhibited social engagement disorder (DSED) was once seen as a subtype of RAD. Patient says it is now recognised as a separate disorder by both ICD-11 and DSM-5. Like RAD it arises from grossly inadequate care, but the child approaches adults indiscriminately, goes off with unfamiliar adults and is overly familiar with strangers.

Attachment difficulties in a broad sense are much more common than either diagnosis. The professional reference describes insecure avoidant, insecure resistant and disorganised patterns that may be associated with difficulties but are not themselves attachment disorders. NICE guideline NG26 is written for children and young people who are adopted from care, in care or at high risk of going into care, and uses the term attachment difficulties.

Patient's professional reference lists signs that may be seen from about 6 to 9 months of age. A child may not seek attention or comfort, reject comfort when offered, avoid touch or affection, show no distress in situations that would normally cause it, or be inconsolable. Some children show indiscriminate, excessive friendliness towards strangers.

Emotional and behavioural difficulties such as anxiety, low mood, social withdrawal, aggression and challenging behaviour can accompany these signs. Many of these also occur in autism, ADHD, trauma reactions or simply a child who has had a very difficult start, which is why a careful assessment matters before any label is applied.

• Not seeking or accepting comfort when upset or hurt

• Little response to affection, or avoidance of touch

• Wary, watchful behaviour, or excessive friendliness to strangers

• Lack of smiling or responsiveness in an infant

• Anxiety, withdrawal or aggression alongside these signs

The professional reference states that attachment disorders arise almost exclusively where there has been pathogenic care. Causes listed include child maltreatment such as neglect or abuse, multiple care placements, institutionalisation, separation from the primary caregiver through illness, death or war, parental drug and alcohol misuse, and the circumstances of children seeking asylum.

It says the evidence suggests genetic factors do not play a role and that attachment disorders arise primarily from the care environment. NICE advises against genetic screening to predict or identify attachment difficulties. In practice this means the focus of help is on the child's relationships and environment, and that no parent should be blamed for a difficult history that predates their care.

NICE guideline NG26 says to diagnose an attachment disorder only if the child's difficulties meet defined criteria in DSM-5 (reactive attachment disorder and disinhibited social engagement disorder) or ICD-10. Assessment is carried out by child and adolescent mental health professionals, often with input from social care, education and health visiting.

The professional reference describes age-specific assessment tools, including structured observation of a child with their caregiver for toddlers, story-based tasks for school-age children and interviews for older children and young people. It notes RAD cannot be diagnosed before age 1 or in the context of autism, so developmental conditions are considered as part of the assessment.

NICE says children and young people should have equal access to interventions regardless of placement type or background, and that surrounding health, education and social care should be stable and consistent, with the same key worker where possible. The stability of a placement should not decide whether services are offered.

For preschool-age children with or at risk of attachment difficulties, NICE recommends a video feedback programme for parents, foster carers, special guardians and adoptive parents. It is delivered at home by a trained worker and consists of 10 sessions of at least 60 minutes over 3 to 4 months, including filming the carer with the child and watching it together to highlight sensitivity and strengths. If it is not wanted, parental sensitivity and behaviour training is offered.

The professional reference says the most important part of management is improving the child-carer relationship where possible, that parenting programmes can improve attachment security, and that there is no evidence for individual psychological therapy for the child. Therapies used for associated behaviours, such as CBT or family therapy, may still help, though research in this group is limited.

Outlook varies. The professional reference notes that for children who have been in abusive situations and then moved to stable foster homes, abnormal attachment behaviours can resolve, with around half of such adolescents showing secure attachment to their foster parents. It stresses the importance of finding and supporting stable placements, often within the extended family when circumstances allow.

NICE emphasises ongoing support for carers, training for school staff about how attachment difficulties present and affect learning, and support at school during interventions. Caring for a child with these difficulties is demanding, so carers should ask for support early rather than waiting for a crisis.