Reactive attachment disorder

A pediatric psychiatrist or psychologist can conduct a thorough, in-depth examination to diagnose reactive attachment disorder.

Your child's evaluation may include:

• Direct observation of interaction with parents or caregivers
• Details about the pattern of behavior over time
• Examples of the behavior in a variety of situations
• Information about interactions with parents or caregivers and others
• Questions about the home and living situation since birth
• An evaluation of parenting and caregiving styles and abilities

Your child's mental health provider will also want to rule out other psychiatric disorders and determine if any other mental health conditions coexist, such as:

• Intellectual disability
• Adjustment disorders
• Autism spectrum disorder
• Depressive disorders
• Post-traumatic stress disorder

Your child's mental health provider may use the diagnostic criteria for reactive attachment disorder in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), published by the American Psychiatric Association. Diagnosis isn't usually made before 9 months of age. Signs and symptoms typically appear before the age of 5 years.

Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for diagnosis include:

• A consistent pattern of emotionally withdrawn behavior toward caregivers, shown by rarely seeking or not responding to comfort when distressed
• Persistent social and emotional problems that include minimal responsiveness to others, no positive response to interactions, or unexplained irritability, sadness or fearfulness during interactions with caregivers
• Persistent lack of having emotional needs for comfort, stimulation and affection met by caregivers, or repeated changes of primary caregivers that limit opportunities to form stable attachments, or care in a setting that severely limits opportunities to form attachments (such as an institution)
• No diagnosis of autism spectrum disorder

Children with reactive attachment disorder are believed to have the capacity to form attachments, but this ability has been hindered by their early developmental experiences.

Most children are naturally resilient. And even those who've been neglected, lived in a children's home or other institution, or had multiple caregivers can develop healthy relationships. Early intervention appears to improve outcomes.

There's no standard treatment for reactive attachment disorder, but it should involve both the child and parents or primary caregivers. Goals of treatment are to help ensure that the child:

• Has a safe and stable living situation
• Develops positive interactions and strengthens the attachment with parents and caregivers

A mental health professional can provide both education and coaching in skills that help improve signs and symptoms of reactive attachment disorder. Treatment strategies include:

• Encouraging the child's development by being nurturing, responsive and caring
• Providing consistent caregivers to encourage a stable attachment for the child
• Providing a positive, stimulating and interactive environment for the child
• Addressing the child's medical, safety and housing needs, as appropriate

Other services that may benefit the child and the family include:

• Individual and family psychological counseling
• Education of parents and caregivers about the condition
• Parenting skills classes

Controversial and coercive techniques

The American Academy of Child and Adolescent Psychiatry has criticized dangerous and unproven treatment techniques for reactive attachment disorder.

These techniques include any type of physical restraint or force to break down what's believed to be the child's resistance to attachments — an unproven theory of the cause of reactive attachment disorder. There is no scientific evidence to support these controversial practices, which can be psychologically and physically damaging and have led to accidental deaths.

If you're considering any kind of unconventional treatment, talk to your child's psychiatrist or psychologist first to make sure it's evidence based and not harmful.

If you're a parent or caregiver whose child has reactive attachment disorder, it's easy to become angry, frustrated, guilty and distressed. You may feel like your child doesn't love you — or that it's hard to like your child sometimes.

These actions may help:

• Educate yourself and your family about reactive attachment disorder. Ask your pediatrician or your child's mental health professional about resources or check trusted internet sites. If your child has a background that includes institutions or foster care, consider checking with relevant social service agencies for educational materials and resources.
• Find someone who can give you a break from time to time. It can be exhausting caring for a child with reactive attachment disorder. You'll begin to burn out if you don't periodically have downtime. But avoid using multiple caregivers. Choose a caregiver who is nurturing and familiar with reactive attachment disorder or educate the caregiver about the disorder.
• Practice stress management skills. For example, learning and practicing yoga or meditation may help you relax and not get overwhelmed.
• Make time for yourself. Develop or maintain your hobbies, social engagements and exercise routine.
• Acknowledge that it's OK to feel frustrated, angry or guilty at times. The strong feelings you may have about your child are natural. But if needed, seek professional help.

You may start by visiting your child's pediatrician. However, you may be referred to a child psychiatrist or psychologist who specializes in the diagnosis and treatment of reactive attachment disorder or a pediatrician specializing in child development.

Here's some information to help you get ready and know what to expect from your health care provider or mental health professional.

What you can do

Before your appointment, make a list of:

• Any behavior problems or emotional issues you've noticed, and include any signs or symptoms that may seem unrelated to the reason for your child's appointment
• Approaches or treatments you've tried, including how helpful or not helpful they have been.
• Key personal information, including any major stresses or life changes that you or your child have been through
• All medications, vitamins, herbal remedies or other supplements your child is taking, including the dosages
• Questions to ask your child's health care provider or mental health professional

Some basic questions to ask may include:

• What is likely causing my child's behavior problems or emotional issues?
• Are there other possible causes?
• What kinds of tests does my child need?
• What are the best treatments?
• What are the alternatives to the primary approach that you're suggesting?
• My child has these other mental or physical health conditions. How can I best manage them together?
• Are there any restrictions that my child needs to follow?
• Should I take my child to see other specialists?
• Are there any brochures or other printed material that I can have? What websites do you recommend?
• Are there social services or support groups available to parents in my situation?
• If medication is recommended, is there a generic alternative to the medicine you're prescribing for my child?

What to expect from your doctor

Your child's health care provider or mental health professional is likely to ask you a number of questions, such as:

• When did you first notice problems with your child's behavior or emotional responses?
• Have your child's behavioral or emotional issues been continuous or occasional?
• How are your child's behavioral or emotional issues interfering with his or her ability to function or interact with others?
• Can you describe your child's and the family's home and living situation since birth?
• Can you describe interactions with your child, both positive and negative?
• What approaches have you tried that have been helpful or unhelpful?

Your health care provider or mental health professional will ask additional questions based on your responses, symptoms and needs. Preparing and anticipating questions will help you make the most of your appointment time.