DSM-5: Rethinking Reactive Attachment Disorder

Melih Cevdet Teksen / Shutterstock.com

Melih Cevdet Teksen / Shutterstock.com

When I read through the new criteria for Reactive Attachment Disorder, I found myself hard pressed to think of any condition in which so great a disconnect exists between the way it is defined by academicians and community-based clinicians.

Beginning with the publication of the DSM-III-R in 1987, two subtypes of RAD have been recognized…an emotionally withdrawn, inhibited type and an indiscriminately social/disinhibited type. In the DSM-5, the term Reactive Attachment Disorder has been reserved for the emotionally withdrawn, inhibited type. The indiscriminately social/disinhibited type is now referred to as Disinhibited Social Engagement Disorder and considered a separate condition.

The new criteria for RAD are as follows…

A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:

  1. The child rarely or minimally seeks comfort when distressed.
  2. The child rarely or minimally responds to comfort when distressed.

B. A persistent social or emotional disturbance characterized by at least two of the following:

  1. Minimal social and emotional responsiveness to others
  2. Limited positive affect
  3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.

C. The child has experienced a pattern of of extremes of insufficient care as evidenced by at least one of the following:

  1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caring adults
  2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
  3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios)

D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).

E. The criteria are not met for autism spectrum disorder.

F. The disturbance is evident before age 5 years.

G. The child has a developmental age of at least nine months.

Specify if Persistent: The disorder has been present for more than 12 months.

Specify current severity: Reactive Attachment Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

What don’t you see in the criteria that you’d expect to see, based on the common understanding of RAD in the therapeutic community and the broader culture? Any description of the pathologic behaviors that generally lead adoptive and/or foster parents to seek out mental health services for children in their care!

When I’m asked to evaluate kids because a parent or professional suspects RAD, the child is usually exhibiting some combination of problematic behaviors from the following list:

  • Lack of conscience or empathy for others, manifesting in antisocial behavior
  • Severe aggression that (at times) may appear deliberate on the part of the child
  • Property destruction
  • Pathological lying
  • Stealing
  • Removing and hiding food from the family’s kitchen or refrigerator
  • Inappropriate sexual behavior
  • Manipulative behavior

Notice that none of these behaviors are included in the criteria for RAD. Allow me to quote from the American Academy of Child and Adolescent Psychiatry’s Practice Parameter on Reactive Attachment Disorder

The question of whether attachment disorders can reliably be diagnosed in older children and adults has not been resolved. It is clear that central attachment behaviors used for the diagnosis of RAD, such as proximity seeking, change markedly with development. Defining what behaviors in 12 year olds, for instance, are analogous to proximity seeking in toddlers is difficult. Even developmental attachment research has no substantially validated measures of attachment in middle childhood or early adolescence, leaving the question of what constitutes clinical disorders of attachment even less clear.

Nevertheless, there have been reports that many oppositional or aggressive older children, especially those who have been maltreated or raised in institutions, have RAD (Levy and Orlans, 2000). The diagnosis of RAD in these reports is based on an expanded set of diagnostic criteria for RAD; the additional criteria overlap with the disruptive behavior disorders, including conduct disorder (CD), oppositional defiant disorder (ODD), and attention-deficit disorder. Claims that many children with a diagnosis of attention-deficit/ hyperactivity disorder and bipolar disorder, in fact, have RAD highlight the problems with diagnostic precision in this area (Levy and Orlans, 2000). In effect, DSM-IV-TR criteria have been largely transformed by groups of clinicians such that psychopathic qualities such as shallow or fake emotions, superficial connections to others, lack of remorse, and failures of empathy are viewed as core features of RAD (Levy and Orlans, 1999, 2000). There is certainly evidence that some maltreated children exhibit both disruptive behavior disorders and disturbances in interpersonal relatedness. Historical accounts of so-called ‘‘affectionless psychopaths’’ detail the challenges that children deprived by institutionalization are alleged to present (Wolkind, 1974), although this construct was never validated. Furthermore, foster and adoptive parents who care for such children can become overwhelmed by managing remorseless aggression. Although some of these children may have met criteria for RAD as young children, few are described as either indiscriminate or inhibited in their social relationships.

There are two significant problems with the trend toward stretching the criteria for RAD to extend the diagnosis to older children. First, diagnostic precision is lost when signs such as oppositional behavior and aggression are viewed as aberrant attachment behaviors in older children. To say that these children do not have ODD or CD because their behavior is better explained by negative attachment experiences is to suggest an etiological pathway that can be neither proved nor disproved.

Second, untested alternative therapies, loosely based on the proposed etiological model for RAD in older children, have been developed and implemented, sometimes with tragic results.

So…what are we to make of the severe difficulties with emotional self-regulation and behavior common among foster and adopted kids if their difficulties aren’t because of attachment problems? Why might kids adopted from orphanages or placed in foster care exhibit severe behavior problems?

Genetic predisposition: Let’s consider why newborn babies are placed in orphanages or consider why children are placed in foster care. We know that women with ADHD engage in more risky sexual behavior. They’re more likely to be impregnated by men with ADHD. Impulsive sexual behavior is common among persons with Borderline Personality Disorder…we know that the complex patterns of behavior associated with borderline personality are strongly inherited. Parents with serious mental illness may have more difficulty appropriately caring for children.

Effects of trauma and neglect upon brain development: I would very much encourage our readers to download this excellent monograph from Harvard University… The Science of Neglect-The Persistent Absence of Responsive Care Disrupts the Developing Brain.

Abuse and neglect can contribute to the development of personality disorders in adults.

The child’s placement occurred because of their disability: In the case of Russian orphanages, a recent report in the Washington Post claimed that “Children in Russian orphanages are almost certain to have at least one disability.”

There are many reasons why children adopted from orphanages and children in foster care frequently exhibit severe problems with conduct and emotional self-regulation. Effects of trauma and neglect upon brain development combined with genetic and environmental influences appear to be responsible in most instances…as opposed to a primary attachment disorder.

Updated March 1, 2016