It would appear that children in institutions like these are unable to form selective attachments to their caregivers. The difference between the institutionalized children and the control group had lessened in the follow-up study three years later, although the institutionalized children continued to show significantly higher levels of indiscriminate friendliness. However, even among children raised in the most deprived institutional conditions the majority did not show symptoms of this disorder.A 2002 study of children in residential nurseries in Bucharest, in which the DAI was used, challenged the current DSM and ICD conceptualizations of disordered attachment and showed that inhibited and disinhibited disorders could coexist in the same child.There are two studies on the incidence of RAD relating to high risk and maltreated children in the U.S. Both used ICD, DSM and the DAI. The first, in 2004, reported that children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups, however this was mainly the proposed new classification of disrupted attachment disorder rather than the DSM or ICD classified RAD or DAD. The second study, also in 2004, attempted to ascertain the prevalence of RAD and whether it could be reliably identified in maltreated rather than neglected toddlers. Of the 94 maltreated toddlers in foster care, 35% were identified as having ICD RAD and 22% as having ICD DAD, and 38% fulfilled the DSM criteria for RAD.
A range of treatment approaches are used in attachment therapy, some of which are physically and psychologically coercive, and considered to be antithetical to attachment theory. Signs and symptoms
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 childs 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.