The two types of reactive attachment disorder are the inhibited type and the disinhibited type. These were originally classified as subtypes of a single diagnosis, but in 2013, the DSM-5 split them into two fully separate conditions: reactive attachment disorder (RAD), which corresponds to the old inhibited type, and disinhibited social engagement disorder (DSED), which corresponds to the old disinhibited type. Both stem from early neglect or disrupted caregiving, but they look very different in how a child behaves.
How the Two Types Were Split Apart
The 1987 edition of the diagnostic manual first described the two subtypes. Children with the inhibited subtype showed internalizing behaviors like fear, avoidance, and withdrawal. Children with the disinhibited subtype showed the opposite pattern: indiscriminate, superficial friendliness toward anyone, including strangers. Over time, researchers recognized these weren’t just two flavors of the same problem. They followed different developmental paths, responded differently to treatment, and often appeared in different children rather than overlapping. That led to the 2013 decision to separate them into distinct diagnoses.
This distinction matters practically. A child who is emotionally shut down needs a different approach than a child who climbs into a stranger’s lap at the grocery store. Separating the diagnoses helps clinicians, parents, and foster families understand exactly what they’re dealing with.
Reactive Attachment Disorder (the Inhibited Type)
RAD is the withdrawn form. Children with this condition are less likely to interact with other people because of negative experiences with adults in their early years. When they’re upset or stressed, they don’t seek comfort from their caregivers the way most children instinctively do. They may seem to have little to no emotion during normal interactions, or they may appear unhappy, irritable, sad, or scared during activities that should be routine and safe.
This typically starts in infancy, and there’s limited research on what it looks like beyond early childhood. In fact, it remains uncertain whether RAD occurs in children older than five. The diagnosis is made when symptoms become chronic rather than situational.
RAD is relatively uncommon even in high-risk groups. In the general population, prevalence sits around 1%. Among foster children, studies find RAD symptoms in roughly 5% to 15%. In institutionalized children (those raised in orphanages or similar settings), rates are higher, ranging from about 5% in some studies to nearly 38% in others, depending on the severity of deprivation.
Disinhibited Social Engagement Disorder (the Disinhibited Type)
DSED looks almost like the opposite of RAD. Instead of withdrawing, these children approach unfamiliar adults with little or no hesitation. They may be willing to go off with a stranger, show excessive physical affection toward people they’ve just met, and fail to check back with their caregiver after wandering away, even in unfamiliar settings. The behavior isn’t simply the impulsiveness you’d see in a child with ADHD. It’s specifically social in nature: a pattern of overly familiar, boundary-less engagement with people the child doesn’t know.
DSED is more common than RAD among children who’ve experienced disrupted care. In foster care populations, DSED symptoms appear in 15% to 46% of children. Among institutionalized children, rates range from 19% to 42%. One study of foster children found that about 31% showed DSED symptoms during their first assessment after placement.
What Causes Both Conditions
The shared root is what clinicians call “pathogenic care,” meaning the child’s opportunity to form a secure bond with a consistent caregiver was severely limited. This includes extreme social neglect, repeated changes in primary caregivers, or being raised in an institution with high child-to-caregiver ratios where no adult is truly “theirs.”
Known risk factors include the length of time spent in institutional care, parental maltreatment, having a mother hospitalized for psychiatric illness, and extremely disrupted communication between parent and child. For institution-reared children, adoption itself can be a turning point, but the earlier the child leaves institutional care, the better the outcomes tend to be. Exactly why pathogenic care leads to the inhibited pattern in some children and the disinhibited pattern in others isn’t well understood.
How They Differ From Other Conditions
Both forms can be mistaken for other diagnoses. RAD’s emotional flatness and social withdrawal sometimes resemble autism spectrum disorder. However, structured observation typically reveals clear differences in the quality of social interactions. Children with RAD often show improvement in social engagement when placed in a stable, nurturing environment, while autism-related social differences persist regardless of caregiving quality.
DSED’s impulsivity and boundary-crossing behavior can look like ADHD. The key distinguishing feature is specificity: a child with DSED shows socially disinhibited behavior (being “too cuddly” with strangers, seeking comfort from unfamiliar adults), while a child with ADHD shows broader impulsiveness across many situations. Parent reports of comfort-seeking with strangers and clinician observation of the child’s behavior in a waiting room are often enough to tell the two apart.
Treatment and What to Expect
There’s no single standardized treatment for either condition, but both center on the same principle: giving the child a stable, consistent relationship with a caregiver. The goals are creating a safe living situation, building positive interactions, and strengthening the attachment between the child and the adults caring for them.
In practice, this means encouraging nurturing, responsive caregiving, keeping the child with consistent caregivers rather than cycling through placements, and creating a positive, interactive environment at home. Individual and family counseling can help, along with parenting skills education that gives caregivers concrete strategies for responding to the child’s specific behaviors. The emphasis is less on “fixing” the child and more on creating the conditions that allow attachment to develop naturally, sometimes for the first time.
For DSED in particular, improvement can be slower. Some research suggests that disinhibited social behavior persists longer than the withdrawn symptoms of RAD, even after a child is placed with a loving, stable family. That doesn’t mean progress is impossible, but families should expect the process to take time and patience.