Reactive attachment disorder of infancy or early childhood

Reactive attachment disorder is caused by abuse or neglect of an infant's needs for:

• Emotional bonds with a primary or secondary caretaker
• Food
• Physical safety
• Touching

An infant or child may be neglected when the:

• Caregiver is intellectually disabled
• Caregiver lacks parenting skills
• Parents are isolated
• Parents have a poorly controlled mental health condition
• Parents are teenagers

A frequent change in caregivers (for example, in orphanages or foster care) is another cause of reactive attachment disorder.

In a child, symptoms may include:

• Avoiding caregivers
• Avoiding physical contact
• Difficulty being comforted
• Not making distinctions when socializing with strangers
• Wanting to be alone rather than interacting with others

The caregiver will often neglect the child's:

• Needs for comfort, stimulation, and affection
• Needs like food, toileting, and play

This disorder is diagnosed with a:

• Complete history
• Physical exam
• Psychiatric evaluation

The treatment has two parts. The first goal is to make sure the child is in a safe environment where emotional and physical needs are met.

Once that has been established, the next step is to change the relationship between the caregiver and the child, if the caregiver is the problem. Parenting classes can help the caregiver meet the child's needs and bond with the child.

Counseling may help the caregiver work on problems, such as drug or alcohol use or family violence. Social Services should follow the family to make sure the child remains in a safe, stable environment.

The right intervention can improve the outcome.

If not treated, this condition can permanently affect the child's ability to interact with others. It can be connected with:

• Anxiety
• Depression
• Other psychological problems
• Post-traumatic stress disorder

This disorder is usually identified when a parent (or prospective parent) is at high risk for neglecting their child or when an adoptive parent has difficulty coping with a newly adopted child.

If you have recently adopted a child from a foreign orphanage or another situation where neglect may have occurred and your child shows these symptoms, contact your health care provider.

Early recognition is very important for the child. Parents who are at high risk for neglect should be taught parenting skills. The family should be followed by either a social worker or provider to make sure the child's needs are being met.

American Psychiatric Association website. Reactive attachment disorder. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). Washington, DC: American Psychiatric Association Publishing; 2022.

Milosavljevic N, Taylor JB, Brendel, RW. Psychiatric correlates and consequences of abuse and neglect. In: Stern TA, Wilens TE, Fava M, eds. Massachusetts General Hospital Comprehensive Clinical Psychiatry. 3rd ed. Philadelphia, PA: Elsevier; 2025:chap 62.

Walter HJ. Psychosocial assessment and psychiatric diagnostic evaluation. In: Kliegman RM, St. Geme JW, Blum NJ, et al, eds. Nelson Textbook of Pediatrics. 22nd ed. Philadelphia, PA: Elsevier; 2025:chap 32.

Zeanah CH, Chesher T, Boris NW; American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder and disinhibited social engagement disorder. J Am Acad Adolesc Psychiatry. 2016;55(11):990-1003. PMID: 27806867 pubmed.ncbi.nlm.nih.gov/27806867/.

Updated by: Charles I. Schwartz, MD, FAAP, Clinical Assistant Professor of Pediatrics, Regional Medical Director of Penn Medicine Primary and Specialty Care, Perelman School of Medicine at the University of Pennsylvania, General Pediatrician at PennCare for Kids, Phoenixville, PA. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.