Here at RAD Advocates, we are asked one question often: “What causes reactive attachment disorder (RAD)?” As a mom to a child with severe reactive attachment disorder, I’ve also been asked this question repeatedly in my daily life. Many of our readers know that developmental trauma, commonly diagnosed as reactive attachment disorder (RAD), is induced by trauma during the first three years of life.
But how, specifically?
The answer to this simple question is more complex than you may think. Many misconceptions exist. It is incredibly important to address these matters to pave the way toward greater support for families of children struggling with the disorder.
Attachment Theory: How a Neurotypical Brain is Formed From Infancy
Before we dive into how the disorder is created, it’s helpful to first establish the circumstances that lead to healthy childhood development. We’ll cover some well-established psychological concepts to do so.
Attachment theory, developed by John Bowlby and Mary Ainsworth, explains the significance of early bonds between caregivers and children. Humans are born with an inherent need to form a close emotional bond with a primary caregiver. When caregivers consistently respond to an infant’s needs in the first six months of life, the child develops a secure attachment. This secure bond plays a critical role in brain development, influencing emotional regulation and social relationships throughout life.
Bowlby observed that infants separated from their caregivers will go to great lengths to reestablish a connection. When this connection is disrupted due to trauma, neglect, or inconsistent caregiving during critical stages of early brain development, it can lead to attachment trauma — a severe relational disruption that can result in reactive attachment disorder.
How the Attachment Cycle Works
A healthy attachment cycle consists of repeated interactions that teach a child to trust and develop security with their caregiver:
The child expresses a need (e.g., hunger, discomfort) through crying or other signals.
The caregiver responds promptly and appropriately to meet the child’s needs.
The child develops trust in the caregiver, forming a secure attachment.
When this cycle occurs consistently during critical brain development, the child learns that their needs matter and that they are safe. This foundation enables them to form healthy relationships throughout their lifetime (Simoes et al., 2024).
When the Attachment Cycle is Disrupted
The attachment cycle can be disrupted if the caregiver misinterprets or ignores the child's needs. It is critical to a child's social and emotional development in the first years of life and is an important early indicator of mental health (Simoes et al., 2024). It helps children learn that their needs matter and that they are safe.
Without a healthy attachment cycle, children can develop maladaptive strategies that can impact their relationships. A child’s early attachment experience determines their attachment style and whether or not they may develop reactive attachment disorder.
Four Basic Attachment Styles in Children, From Healthy to Impaired:
Secure
The most common style, and the goal, is for children to feel safe and loved by their caregivers. They are comfortable seeking reassurance from their caregivers when they feel scared or anxious.
Insecure-Avoidant
Children with this style feel they can't consistently count on their caregiver for comfort and care. They may not prefer their caregiver over a stranger.
Insecure-Anxious-Ambivalent
Children with this style experience inconsistent responses when they try to communicate their needs to their caregiver(s). They may receive the support they need sometimes but not others.
Insecure-Disorganized
This style is often a result of trauma, mistrust, or abuse. Children with this style may seek proximity but never feel safe with their primary caregiver. Children with RAD/DTD most often have a disorganized attachment style.
Causes, Risk Factors and Myths Surrounding Childhood Trauma
Much confusion exists surrounding childhood trauma and reactive attachment disorder for various reasons (read more here). The complexity and lack of education often creates hardship for parents struggling to understand their child’s needs. RAD Advocates is committed to dispelling these myths and promoting accurate assessments and treatment for RAD.
Myth #1: Attachment issues are the same thing as reactive attachment disorder.
To be clear, reactive attachment disorder is different from attachment issues. It takes extreme circumstances to develop moderate to severe RAD. That distinction can make all the difference in securing the right interventions. “Many people can struggle with attachment issues but, through traditional therapy and other supports, can lead pretty normal lives,” says RAD Advocates Executive Director Amy VanTine. “Reactive attachment disorder, on the other hand, is a serious brain disorder that requires extensive intervention not only for the child, but the entire family of that child. Unfortunately, many clinicians treat RAD in the same way they do attachment issues which often make matters worse.”
The origin and impact of a child’s early trauma determines how they struggle and what they need to heal. “Attachment problems are on a continuum of severity from attachment issues to mild, moderate, and severe reactive attachment disorder” according to Forrest Lien, a clinical social worker who has worked with children with RAD and their families for more than 40 years.
Certain factors and combinations of factors increase the risk of developing the disorder. For example, children who have experienced extremely adverse, neglectful caregiving environments have demonstrated clear increased risk for RAD compared to children who are not exposed to adverse caregiving environments (Boris et al., 2004; Bruce et al., 2009; Chisholm, 1998; Gleason et al., 2011; O'Connor & Rutter, 2000; Oosterman & Schuengel, 2007; Pears et al., 2010; Smyke et al., 2002; Van Den Dries et al., 2012; Zeanah et al., 2004, 2005; Zeanah & Gleason, 2014).
Reactive attachment disorder is different from attachment issues. It takes extreme circumstances to develop moderate to severe RAD. That distinction can make all the difference in securing the right interventions.
RAD Advocates recommends a thorough evaluation for RAD from a specialist to determine appropriate next steps for a child who experienced early trauma. “Unfortunately, most college students who aspire to work with children, from teachers to pediatricians and therapists, aren’t taught about disrupted attachment. They learn about healthy attachment but not what to look for or what to do when that cycle is broken, resulting in a disorder,” says Lien. "It is important for parents to look for professionals who pursued further education about RAD, oftentimes extensively after graduate school, and who specialize in the disorder.”
Myth #2: Only children who have been in the foster care system or have been adopted can develop reactive attachment disorder.
Insecure-disorganized attachment is the most common attachment style in institutionalized children. However, there is a common misconception that only fostered and institutionalized children can develop RAD/DTD (Dobrova-Krol et al., 2010; Vorria et al., 2003; Zeanah et al., 2005; Zeanah & Gleason, 2014).
While the disorder is common in foster and adoption communities, there are other factors that increase the risk of developing attachment issues and reactive attachment disorder for kids who do not come from this background, including the following situations:
Babies who stayed in a neonatal intensive care unit (NICU)
Certainly not all babies in NICU environments will develop RAD/DTD, but they are at greater risk. The attachment cycle between an infant and primary caregiver is disrupted after preterm birth during a critical time in the infant’s brain development. Emotional and physical detachment, limited social interaction, and a medically traumatic environment in a neonatal intensive care unit may result in impaired attachment or bonding (Kim et al., 2019).
Illness, hospitalization, postpartum depression (PPD) and multiple children
The attachment process can be disrupted when a primary caregiver experiences a severe illness, hospitalization, mental illness such as postpartum depression (PPD), or the birth of multiple children. There is substantial evidence that PPD is associated with a poor mother-infant bond (Handelzalts et al., 2021). Some studies have proposed that a primary caregiver can only attach to one infant at a time, suggesting that discrepancies in attachment styles between multiples might be common (Simoes et al., 2024; Wenze et al., 2024). Since attachment is not a static process, early intervention within these vulnerable groups is crucial (Simoes et al., 2024).
Children of dual households, divorce or separation
Infants and toddlers who are passed back and forth between primary caregivers during the critical years of brain development are at greater risk of insecure attachment as these circumstances disrupt the attachment cycle. Parental divorce or separation can significantly contribute to attachment issues in children, as it disrupts the possibility to securely bond with their parents, potentially leading to feelings of insecurity, anxiety about abandonment and difficulty forming healthy relationships later in life.
Children experiencing divorce may develop insecure attachment styles, such as anxious or avoidant, where they worry about abandonment or struggle to trust others in relationships (D’Rozario & Pilkington, 2021). Numerous studies confirm that a history of parental separation or divorce is positively associated with anxious and avoidant attachment styles in adult children (Rozario & Pilkinton, 2021; D’Onofrio & Emery, 2019; Smith-Etxeberria et al., 2022).
Addiction, substance abuse, physical abuse, sexual abuse or emotional abuse
These are more obvious causes. Children who experience ongoing neglect or abuse from a primary caregiver will likely develop a disordered attachment with that caregiver. Likewise, caregivers who suffer from addiction and/or substance abuse and mental illness are more prone to neglecting their child’s needs, which increases the risk.
The results of one study on addicted parents emphasize the lack of warmth, love and high responsiveness in the parent-child relationship (Bahmani et al., 2022). Further indirect evidence comes from the host of studies in samples of substance-abusing parents. These parents are hardly able to establish secure attachment relationships with their offspring (Suchman & DeCoste, 2018). Such is the case for parents who struggle with mental illness such as bipolar disorder according to Dr. John F. Alston (read more here).
Neglectful caregiving environments
We often think of institutions as neglectful environments, but other lesser-known environments can increase attachment risk. Neglect is characterized by the ongoing failure to meet a child's basic needs, including physical and emotional needs. For example, a primary caregiver who works outside the home excessively often cannot spend enough time with the child to engage in a consistent attachment cycle. Thus, the odds of a secure attachment forming between that child and caregiver aren’t as high. Another example is a child who is left to cry it out sleep training (CIO) for prolonged periods. This inhibits steps 2 and 3 of the attachment cycle. These are not situations of extreme neglect and likely won’t result in reactive attachment disorder, but could result in insecure attachment. A threshold of neglect may be necessary for signs of the disorder to appear (Zeanah & Gleason, 2014). A study of two groups of institutionalized children showed that the children with a restricted number of caregivers showed significantly fewer signs of RAD than those with the standard number of caregivers (Zeanah & Gleason, 2014; Smyke et al., 2002).
Myth #3: Babies adopted at a young age won’t develop RAD.
There is another common misconception that a child who is placed with a family early enough, at birth or during infancy, won’t develop RAD/DTD. Factors such as in-utero trauma, post-partum depression, newborn colic, prenatal drug and alcohol exposure, and more can have a significant impact on the bond between the infant and primary caregiver. It is widely accepted in psychological research that the earliest connection does not begin at birth and that the infant-mother bond starts developing in utero (Alhusen, 2008; Cranley, 1981; Deutsch, 1945; DiPietro, 2010).
"Reactive attachment disorder is a serious brain disorder that requires extensive intervention not only for the child, but the entire family of that child," says RAD Advocates CEO Amy VanTine. "Unfortunately, many clinicians treat RAD in the same way they do attachment issues which often make matters worse.”
A newborn separated from its biological mother at birth is susceptible to a primal wounding. According to Carlis (2015), “this construct describes the deep psychic scarring and lasting emotional impact of adoption caused by the sudden severing of the in-utero bond with the biological mother. The results of this trauma are substantial and carry major long-term developmental effects.” The loss of the biological mother leaves an impact on the infant’s brain.
Why Some Children Develop Reactive Attachment Disorder and Others Don’t
The human brain is a complicated system built on a network of billions of interconnected neurons, each communicating with thousands of others through synapses. This complex web of electrical signals enables thought, emotion and behavior (Tompa, 2022). Resilience is the brain’s ability to respond to stressors in a way that sustains well-being, resists behavioral modification, and adapts to adversity, trauma, and threats.
While the disorder is common in foster and adoption communities, there are other factors that increase the risk of developing attachment issues and reactive attachment disorder for kids who do not come from this background.
Research suggests that some people's brains are more resilient than others, meaning they can bounce back from stress and trauma. Genetic factors, personal experiences and brain circuitry influence brain resilience. Brain resilience is a complex trait that varies widely between individuals. Resiliency could explain the difference between two children who experience the same neglectful caregiving conditions, but one child develops moderate to severe RAD, and the other develops only mild attachment issues.
The brain is also highly malleable, allowing it to adapt continually to changes in the environment throughout a person’s lifespan. This malleability is called neuroplasticity. For our children with RAD who experienced developmental trauma, the brain adapted for survival to protect them during adversity. Once placed in a stable, loving home, many of our kids become maladaptive; their brains are still “stuck” in survival mode, and they are not able to adjust appropriately to the environment or situation. Reactive attachment disorder is an extremely complex disorder, and the path to which it develops is equally complex. Often, there are many risk factors that converge, creating the perfect storm for RAD to strike.
Finding Support for Children with Reactive Attachment Disorder
Although securing proper support for children with reactive attachment disorder can be challenging, it is possible.
RAD Advocates recommends that parents:
Vet professionals to ensure they specialize in developmental trauma and RAD.
Secure an accurate assessment from a specialist.
Build a support team for the entire family — not just the child with RAD.
“Reactive attachment disorder is serious and complex,” says VanTine. “You need specialists who understand its nuances as well as the impact it has on everyone in the family.”
✔️ Article content verified by RAD Advocates Approved Professional Forrest Lien, LCSW
References
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