9 Child and adolescent psychiatry9.7 Disorders in childhood and adolescence
9.7.7 Attachment disorders
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Written by Resident Doctor Committee · Published
Classification
Reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) are uncommon disorders that follow grossly inadequate early care.
Both differ from insecure attachment, which is common and is not a disorder.
ICD-11 (International Classification of Diseases, 11th revision) classes both with disorders specifically associated with stress.
Diagnosis needs a history of pathogenic care, because unusual social behaviour alone is not enough.
RAD and DSED compared
Both arise from pathogenic care but differ in direction: RAD is inhibited withdrawal and DSED is indiscriminate sociability.
Feature | Reactive attachment disorder | Disinhibited social engagement disorder |
|---|---|---|
Core behaviour | Inhibited, withdrawn, comfort-avoiding | Indiscriminate, over-familiar approach to unfamiliar adults |
Signs | Absent comfort seeking, restricted affect, unexplained fearfulness with carers | Little wariness, failure to check back with the carer, leaving with a stranger |
Resembles | Autism or depression | Attention deficit hyperactivity disorder (ADHD) |
With good later care | Usually improves | Often persists, even alongside secure attachment |
Age limits
Onset is before age 5 in both disorders.
RAD is not diagnosed before a developmental age of about 9 months (ICD-11: not before the first birthday), because selective attachment must exist before its absence is disordered.
DSED also needs a developmental age of generally at least 9 months.
Differential diagnosis
Condition | How it differs |
|---|---|
Autism spectrum disorder | Persistent social-communication differences and restricted, repetitive behaviour; a history of inadequate care is not required |
ADHD | Broader inattention, hyperactivity and impulsivity; may coexist with DSED |
Post-traumatic stress disorder (PTSD) and complex PTSD | Re-experiencing, avoidance and threat symptoms; may coexist |
In ICD-11, RAD is not diagnosed when autism spectrum disorder accounts for the presentation.
Severe deprivation can itself cause language delay and autism-like features (quasi-autism), so assess autism directly.
Evidence from deprivation
RAD affects fewer than 1% of community children, with far higher rates in institutional and care populations.
The Bucharest Early Intervention Project randomised institutionalised children to foster care or care as usual: foster care improved attachment and cognition, most with earlier placement, but indiscriminate sociability improved less.
The English and Romanian Adoptees study linked longer deprivation to disinhibited behaviour, autism-like features, cognitive difficulty and inattention-overactivity, though many children recovered substantially.
Treatment
The main treatment is safe, stable, sensitive caregiving, with support for carers to prevent placement breakdown.
For children under 5 with RAD and no other mental health condition, the National Institute for Health and Care Excellence (NICE) recommends first a home-based video feedback programme to improve carer sensitivity.
Medication does not treat attachment difficulties, so treat any coexisting disorder on its own evidence.
Coercive holding and rebirthing therapies are dangerous and must not be used.
Outcome
RAD outcome depends chiefly on later care: a consistent, sensitive, emotionally available carer predicts recovery, and institutional care predicts the opposite.
DSED may persist into adolescence despite a secure relationship with an adoptive parent, and persistence does not by itself mean poor current parenting.
Anorexia nervosa
Anaemia from chronic undernutrition in anorexia nervosa is typically normocytic and normochromic, because the marrow is hypoproliferative.
Anorexia nervosa was wrongly labelled a disease of affluence because early case series drew on wealthy patients with access to specialist care (sampling bias). Review evidence shows no link with higher socioeconomic status.