Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the disorder. The initial presentation varies according to the child’s developmental and chronological age, although it always involves a disturbance in social interaction. Infants up to about 18–24 months may present with non-organic failure to thrive and display abnormal responsiveness to stimuli. Laboratory investigations will be unremarkable barring possible findings consistent with malnutrition or dehydration, while serum growth hormone levels will be normal or elevated.
The core feature is severely inappropriate social relating by affected children. This can manifest itself in three ways:
- Indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers (older children and adolescents may also aim attempts at peers). This may oftentimes appear as denial of comfort from anyone as well.
- Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed.
- Actions that otherwise would be classified as conduct disorder, such as mutilating animals, harming siblings or other family, or harming themselves intentionally.
While RAD occurs in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect. However, the instances of that ability are rare.
The name of the disorder emphasizes problems with attachment but the criteria include symptoms such as failure to thrive, a lack of developmentally appropriate social responsiveness, apathy, and onset before 8 months.