Attachment Disorders Clinical Presentation

Updated: Apr 22, 2019
  • Author: Roy H Lubit, MD, PhD; Chief Editor: Caroly Pataki, MD  more...
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Rene Spitz noted that children in orphanages were prone to physical illness and had decreased appetites. They exhibited some stereotyped movements, self-stimulation, and an empty look in the eyes. They lacked normal responses of interest when people came close. They cried vaguely or softly many times a day and seemed unhappy. Many of these children seemed depressed and unresponsive to initiatives for interaction, as if resigned to affective deprivation. They children also had a much higher mortality than noninstitutionalized peers.

For reactive attachment disorder (RAD), there must be a history of gross neglect, lack of contingent responses, and little or no attention, interaction, and affection. For disinhibited social engagement disorder (DSED), there must be a history of multiple caregivers, sequential changes in caregiver, disrupted relationships, and placement with different people for long periods. The child does not develop preferential attachments and secure base behavior toward 1 person but instead develops an undifferentiated closeness with anyone who approaches.

Symptoms of RAD may include the following:

  • Poor hygienic condition

  • Underdevelopment of motor coordination and a pattern of muscular hypertonicity because of diminished holding

  • Bewildered, unfocused, and understimulated appearance

  • Blank expression, with eyes lacking the usual luster and joy

  • No evidence of the usual responses to interpersonal exchanges - Appearance of not knowing body language; failure to pursue, initiate, or follow up on cues for an exchange or interaction; no exploration of another person’s face or facial expression; no approach to or withdrawal from another person; avoidance of eye contact and protesting or fussing if a person comes too close or attempts to touch or hold them

Symptoms of DSED may include the following:

  • Instead of caution, excessive familiarity or psychological promiscuousness with unknown persons

  • Readiness to give hugs to anyone who approaches and to go with that person if asked

  • Willingness to approach a complete stranger for comfort or food, to be picked up, or to receive a toy


Physical Examination

No specific physical signs of attachment disorder exist. Nevertheless, indirect indicators may be present, such as the following:

  • Signs of physical maltreatment, such as old fractures or bruises

  • Effects of undernutrition and rashes resulting from failure to change diapers frequently

  • A syndrome characterized by excessive appetite in children who have been in several foster homes

  • Excessive appetite and excessive thirst in children who experience severe stress

  • Flattened back of the head as a result of being left in bed much of the time

  • Growth retardation (in severe cases)



Children who have experienced multiple losses and who have developed attachment problems tend to engage in defiant behavior, to be uncooperative with adults, to experience pervasive anger and resentment, and to develop an exploitative attitude toward other people.

Persistence of the nonattachment or the superficial exploitation of people, commonly accompanied by fear of closeness and intimacy, is a major complication. When children become parents, they may transmit difficulties in attachment to their own children (eg, by being emotionally insensitive or unavailable) and thus perpetuate an intergenerational cycle of problems.

Children who have experienced multiple disruptions in placements and have witnessed violence may develop conduct disorder, experience difficulties in social settings, or be prone to antisocial behavior because they lack empathy and adequate exposure to appropriate models of coping and caring behavior.

Children who have experienced disrupted attachments face academic difficulties related to maltreatment and to mistrust of adults. Academic difficulties may also be related to attention problems and hyperarousal associated with posttraumatic stress. Additionally, the child may have learning disabilities and language difficulties as a consequence of genetic loading or exposure to drugs in utero. [12, 13] These disabilities may have led to the problems the parents had in caring for their child in the first place.

Even without all of those challenges, children with multiple placements and disruptions in their living situations are at risk for academic difficulties. A specific educational program designed to address those needs is necessary. If the child is a ward of the state and the school system does not promptly and appropriately respond, state-supported legal assistance is usually available to enforce compliance with federally mandated educational assessment and management.