Reactive Attachment Disorder: DSM-5 EPPP Lecture Video

The video below is the section for Reactive Attachment Disorder from Part 4 of TSM’s lecture series on DSM-5 and the EPPP, followed by a transcript. This lecture series aims to equip those preparing for the EPPP with everything you need to know about the impact DSM-5 will be having on the EPPP. To watch all of Part 4, click HERE. To watch earlier lectures in this series, or register for our webinar series on DSM-5 and the EPPP, click HERE.

Transcript of DSM-5 EPPP Lecture Video: Reactive Attachment Disorder


Reactive Attachment Disorder (RAD) occurs when a child demonstrates significantly disturbed and developmentally inappropriate social relatedness that is associated with grossly pathological care.

These disturbances are apparent before the age of 5 years in a child that has a developmental age of at least 9 months.

Pathogenic care in the form of serious social neglect is the only known risk factor as well as a diagnostic requirement for reactive attachment disorder. Pathogenic care during in fancy includes a failure to provide for the child’s basic emotional needs (e.g., comfort, affection, stimulation) or physical needs (e.g., food, shelter, safety, freedom from abuse).

Such care is, by definition, extreme in neglectfulness. Pathogenic care may also occur when there are frequent changes in primary caregivers such as through maladaptive foster care or institutional placement. These disturbances prevent the child from forming healthy selective attachments. This impairs the child’s ability to establish appropriate interpersonal relations with adults or peers.

Note that a majority of severely neglected children do not develop the disorder.

Symptoms of RAD are inhibition and emotional withdrawal from caregivers and persistent social and emotional disturbance. Emotional withdrawal is evidenced by the child rarely or minimally seeking comfort from a caregiver when distressed, with minimal response to comfort offered.

There is also minimal social and emotional responsiveness to others, little positive affect, and periods of unexplained irritability, sadness, or fearfulness that may occur even during pleasant interactions with adult caregivers.

Reactive Attachment Disorder may be associated with developmental delays, including cognitive and language delays, failure to thrive, stereotypies, and depressive symptoms. Medical conditions such as severe malnutrition may be present. Parents of children with RAD suffer from poverty, substance use problems, unmanageable personal stressors, and/or a history of childhood maltreatment and/or attachment difficulties themselves. Prognosis may be related to the quality of the caregiving environment following serious neglect.

Aberrant social behaviors, limited expression of positive emotions, cognitive and language delays, and impairments in social reciprocity may resemble autism spectrum disorder, and a differential diagnosis must be made.

Children with autism, however, rarely have a history of severe social neglect; and symptoms of autism include restricted interests or ritualized behaviors, which are not seen in RAD. Due to reduction in positive affect and what could be interpreted as social withdrawal, a child with RAD may appear to have a depressive disorder. However, depressed children usually exhibit impairments in attachment, and still seek and respond to comforting efforts by caregivers. And despite also having developmental delays, RAD should not be confused with intellectual Developmental Disorder (intellectual disability). Children with intellectual developmental disorder have social and emotional skills comparable to their cognitive skills, are generally able to develop selective attachments, and do not exhibit reduction in positive affect nor the emotion-regulation difficulties shown by children with RAD.

A DSM-5 disorder related to RAD that also results from severe social neglect is Disinhibited Social Engagement Disorder.  But symptoms are of disinhibition, with children exhibiting little hesitation in approaching and interacting with unfamiliar adults, with differing course of illness, prognosis and response to treatment.


Reactive Attachment Disorder (RAD)

  1. Marked by a child’s display of significantly disturbed and developmentally inappropriate social relatedness, linked directly to grossly pathological care (and not to Mental Retardation or Pervasive Developmental Disorders)
  2. Onset before the age of 5


  1. Symptoms are inhibition and emotional withdrawal from caregivers and emotional and social disturbance
  2. Developmental delays, failure to thrive, cognitive and language delays, depressive symptoms, and stereotypies
  3. Evidence of insufficient parental care and social neglect
  4. Symptoms develop before 5 years of age and has a developmental age of at least 9 months
  5. Specify if Persistent when the disorder is present for over 12 months


  1. Pathologenic care giving may be marked by continued and severe neglect (i.e., failure to provide for the basic emotional or physical needs or by frequent changes in primary caregivers such as foster care or institutional placement)
  2. Child prevented from forming healthy selective attachments
  3. Caregivers may have substance use problems, major life stressors, poverty, or histories of maltreatment themselves


  1.  Can be associated with developmental delays, Rumination Disorder, and Feeding Disorder of Infancy or Early Childhood, malnutrition
  2.  Not to be confused with Autism Spectrum Disorder where there is rarely pathogenic care and the child has restricted interests and repetitive behaviors


The form of poor caregiving most likely to be associated with Reactive Attachment Disorder is:


A. neglect

B. physical abuse.

C. sexual abuse.

D. authoritative parenting

RATIONALE: A is correct, as neglectful parenting (in terms of both emotional and physical needs) is often associated with Reactive Attachment Disorder, whereas there is no direct linkage with physical abuse or sexual abuse (although both of these are often associated with neglect). Authoritative parenting would have a protective effect against Reactive Attachment Disorder.


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