Reactive Attachment Disorder 267
Development and Course
Conditions of social neglect are often present in the first months of life in children diag-
nosed with reactive attachment disorder, even before the disorder is diagnosed. The clin-
ical features of the disorder manifest in a similar fashion between the ages of 9 months and
5 years. That is, signs of absent-to-minima l attachment behaviors and associated emotion-
ally aberrant behaviors are evident in childre n throughout this age range, although differ-
ing cognitive and motor abilities may affect how these behaviors ar e expressed. Without
remediation and recovery through normative care giving environments, it appears that signs
of the disorder may persist, at least for several years.
It is unclear whether reactive attachment disorder occurs in older children and, if so, how
it differs from its presentation in young ch ildren. Because of this, the diagnosis should be
made with caution in children older than 5 years.
Risk and Prognostic Factors 
Environmental. Serious social neglect is a diagnost ic requirement for reactive attach-
ment disorder and is also the only known risk factor for the disorder. However, the ma-
jority of severely neglecte d children do not develop the disorder. Prognosis appears to
depend on the quality of the caregiving  environment following serious neglect. 
Culture-Related Diagnostic Issues
Similar attachment behaviors have been described in young children in many different
cultures around the world. Ho wever, caution should be exercised in making the diagnosis
of reactive attachment disorder in cultures  in which attachment has not been studied.
Functional Consequences of 
Reactive Attachment Disorder
Reactive attachment disorder significantly impairs young children’s abilities to relate in-
terpersonally to adults or peer s and is associated with functional impairment across many
domains of early childhood.
Differential Diagnosis