Core diagnostic features

• Onset in early childhood following grossly inadequate caregiving—persistent social and emotional disturbance.
• Two presentations recognised: inhibited type (emotionally withdrawn, limited seeking of comfort) and disinhibited social engagement (over‑familiar behaviour with strangers). Both reflect disrupted attachment, but are distinguished clinically.
• Symptoms should not be better explained by autism spectrum disorder or developmental delay; consider context of institutional care, neglect, frequent changes of caregivers or maltreatment.

When to suspect RAD

• Poor eye contact, lack of seeking comfort, flat affect toward caregivers, failure to form selective attachments, or indiscriminate friendliness with strangers.
• History of institutionalisation, multiple foster placements, severe neglect, or early separation from caregivers in critical developmental windows (first 2–3 years).

Assessment checklist

1. Detailed developmental and caregiving history: prenatal exposures, early deprivation, placement history, duration of institutional care and caregiver consistency.
2. Observe child–caregiver interactions: response to comfort, seeking behaviour, social referencing, play and reciprocity.
3. Screen for comorbidities: ASD, intellectual disability, PTSD, mood disorders, and conduct problems—use validated developmental and attachment assessments where available.
4. Collateral information: obtain records from social services, orphanage/foster records and prior medical notes to document caregiving history.

Differential diagnosis

• Autism spectrum disorder (look for restricted/repetitive behaviours and early social communication deficits), global developmental delay, selective mutism, and reactive behaviours secondary to trauma or neglect.
• Disinhibited Social Engagement Disorder (DSED) may co‑exist—distinguish by pattern of indiscriminate social approach vs inhibited withdrawal.

Treatment principles

• Early intervention prioritising stable, sensitive caregiving is central—improvements in caregiver responsiveness and consistency produce the best outcomes.
• Multidisciplinary approach: child psychiatry/psychology, paediatrics, social work, occupational therapy and family support services working together.
• Address safety, placement stability and caregiver capacity—reduce placement changes and support foster/adoptive families with training and respite.

Evidence‑based interventions

• Caregiver training & attachment‑based interventions: Parent–Child Interaction Therapy (PCIT) adapted for attachment, Video‑feedback Intervention to promote Positive Parenting (VIPP), and watchful coaching to increase sensitivity and contingency.
• Dyadic therapies: Theraplay, Child–Parent Psychotherapy (CPP) and therapeutic foster care programmes that strengthen secure attachment through structured interactions.
• Interventions for DSED: focus on reducing indiscriminate social approach by increasing caregiver supervision, educating carers on boundary setting, and improving social‑emotional skills.

Practical strategies for caregivers

1. Provide consistent routines, predictable responses to distress, and frequent, brief sensitive interactions (eye contact, affective mirroring, contingent responses).
2. Avoid punitive responses—use positive reinforcement for comfort‑seeking and prosocial play; model calm, attuned caregiving.
3. Support caregivers with education about attachment, access to respite, and clear behaviour plans—engage social services early to ensure placement stability.

When to involve specialists & red flags

• Severe neglect, signs of ongoing maltreatment, grooming or safety concerns—activate child protection and safeguarding procedures immediately.
• Persistent severe withdrawal, failure to thrive, aggressive or self‑injurious behaviour, or care setting instability—refer urgently to child psychiatry and multidisciplinary teams.

Outcomes & long‑term planning

• Early, stable caregiving and targeted therapeutic work improve attachment security, emotional regulation and social functioning—but persistent adversity and frequent placement changes worsen prognosis.
• Plan long‑term follow‑up for developmental, educational and mental health needs; involve schools and community services for integrated support.