Markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before 5 years

Aetiology

• Associated with grossly pathological care
  • Persistent disregard for the child's emotional needs for comfort, stimulation and affection
  • Persistent disregard for the child's physical needs
  • Repeated changes of the primary caregivers
• As a result of this the child has difficulty forming lasting, loving, intimate relationships
• Accounts for 1% of all children under 5, about 20% of Looked After Children

Risk factors

• Adverse childhood experiences - abuse, neglect, household dysfunction
• Increased likelihood if child is orphaned at a young age

Pathophysiology

Subtypes of RAD

Inhibited

• Refers to children who continually fail to initiate and respond to social interactions in a developmentally appropriate way
• Interactions are often met with a variety of approaches - avoidance, resisting comfort, hypervigilant or highly ambivalent
• Example: a child or infant that does not seek comfort from a parent or caregiver during times of threat, alarm, or distress

Disinhibited

• Refers to a child who has an inability to display appropriate selective attachments
• Also known as Disinhibited Social Engagement Disorder (DSED)
• More enduring over time than inhibited subtype
• Example: a child who displays excessive familiarity with strangers, indiscriminate sociability or lack of selectivity in their choices of attachment figure

Neurobiology