Myths and Facts About Reactive Attachment Disorder Part 2 - Symptoms

(Note: This is part 2 of a 3 part series. You can read part 1 here, or part 3 here.)

The second part of RAD diagnosis, of course, is the symptoms. In DSM-IV, these were phrased as two symptoms, with a wide range of presentation:

• persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness) 
• diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) 

In DSM-V, as well as splitting these two symptom categories into separate diagnoses, they also elaborated them quite a bit.
For RAD (formerly called inhibited RAD), they list the following as symptoms:

• The child rarely or minimally seeks comfort when distressed.
• The child rarely or minimally responds to comfort when distressed.
• Minimal social and emotional responsiveness to others
• Limited positive affect
• Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.

For DSED (formerly called disinhibited RAD), they list the following:

• Reduced or absent reticence in approaching and interacting with unfamiliar adults.
• Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
• Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
• Willingness to go off with an unfamiliar adult with minimal or no hesitation.

If you know a child with a mix of both features, by the way, you're not alone. I don't really understand why the DSM decided to split the two up, since many researchers have found that a significant subgroup of children with RAD show a mixture of both symptom types. If you're wondering how that works, keep in mind that inhibited RAD symptoms are usually most evident when the child is interacting with caregivers, while disinhibited RAD symptoms all refer to the child's behavior towards strangers. While the stereotype of disinhibited RAD is a child who is equally friendly towards caregivers and strangers, some research suggests that kids with particularly severe disinhibited behavior actually preferentially engage with strangers, while acting withdrawn towards their caregivers.

The Expanded List

Although the above symptoms (and ones thematically related to them) are the only ones that are used in clinically validated RAD/DSED diagnoses, many sources online provide an expanded list. For example, take a look at the Randolph Attachment Disorder Questionnaire, a favourite of quacks.

1. My child acts cute or charms others to get them to do what he/she wants.
2. My child has trouble making eye contact when adults want him/her to.
3. My child is overly friendly with strangers.
4. My child pushes me away or becomes stiff when try to hug him/her unless he/she wants something from me.
5. My child argues for long periods of time, often about ridiculous things.
6. My child has tremendous need to have control over everything, becoming very upset if things don't go his/her way.
7. My child acts amazingly innocent, or pretends that things aren't that bad when he/she is caught doing something wrong.
8. My child does very dangerous things, ignoring how he/she may be hurt while doing them.
9. My child deliberately breaks or ruins things.
10. My child doesn't seem to feel age- appropriate guilt for his/her actions.
11. My child teases, hurts or is cruel to other children.
12. My child seems unable to stop him/herself from doing things on impulse.
13. My child steals or shows up with things that belongs to others with unusual or suspicious reasons for how he/she got them.
14. My child demands things instead of asking for them.
15. My child doesn't seem to learn from his/her mistakes and misbehavior (no matter what the consequence, the child continues the behavior).
16. My child tries to get sympathy from others by telling them that "I" abuse and/or neglect him/her.
17. My child "shakes off" pain when he/she is hurt, refusing to let anyone comfort him/her.
18. My child likes to sneak things without permission, even though he/she could have had them if he/she asked.
19. My child lies, often about obvious or ridiculous things, or when it would have been easier to tell the truth.
20. My child is very bossy with other children and adults.
21. My child hoards or sneaks food, or has other unusual eating habits (eats paper, raw flour, package mixes, baker's chocolate, etc.)
22. My child can't keep friends for more than week.
23. My child throws temper tantrums (screaming fits) that last for hours.
24. My child chatters non-stop, ask repeated questions about things that make no sense, mutters or has other oddities in his/her speech.
25. My child is accident prone (gets hurt a lot) or complains lot about every little ache and pain (needs constant Band-Aids).
26. My child teases, hurts or is cruel to animals.
27. My child doesn't do as well in school as he/she could with even little more effort.
28. My child has set fires or is preoccupied with fire.
29. My child prefers to watch violent cartoons and/or TV shows or horror movies (regardless of whether or not you allow him/her to do this.
30. My child was abused/neglected during the first year of his/her life or had several changes of his/her primary caretaker.

Not counting item 30, which is a background item rather than a symptoms item, only items 3, 4, and maybe 24 are conceptually similar to the DSM criteria. The rest are a mishmash of symptoms under many different domains. And while these symptoms certainly are overrepresented in RAD children, they are also common in conduct disorder, oppositional defiant disorder, ADHD, disruptive mood dysregulation disorder, depression, and even autism spectrum conditions. Most children with these other conditions have not experienced pathogenic care, and do not show inhibited or disinhibited RAD symptoms.
Diagnosing RAD based on symptoms common to many disorders is like diagnosing chicken pox on the basis of fever and fatigue. Far better to use the highly specific skin sores, instead of symptoms present in pretty much any infectious disease. Incidentally, with the above checklist, each item is scored 1 to 5, and it says a child with a score of 50 or above might have RAD, and a child with 66 or above is highly likely to have RAD. Since only 3 out of 29 items actually relate to RAD specifically, it's pretty easy for a child to meet this cut-off without showing a single diagnostic symptom of RAD.
Some people have pointed out that parents and caregivers of RAD kids rarely seek help from psychiatric services because their child is overly friendly or doesn't accept affection. Instead, they seek help for aggressive, disruptive or disturbing behaviours, like the ones in the above list. But that changes nothing. A competent clinician looks at the full symptom picture, not just the presenting issue, when making a diagnosis. And misdiagnosing children with other conditions as having RAD is not going to lead to appropriate management of them or their parents. They should be treated for what they actually have.

RAD Versus Attachment Insecurity

Other times, when looking for stuff about RAD, you'll find descriptions of insecure attachment. For example, this blog entry seems to confuse adult RAD with adult insecure attachment, listing the following:

AVOIDANT

• Intense anger and loss
• Hostile
• Critical of others
• Sensitive to blame
• Lack of empathy
• Views others as untrustworthy
• Views others as undependable
• Views self as unlovable or "too good" for others
• Relationships feel either threatening to one's sense of control, not worth the effort, or both
• Compulsive self-reliance
• Passive withdrawal
• Low levels of perceived support
• Difficulty getting along with co-workers, often preferring to work alone
• Work may provide a good excuse to avoid personal relations
• Fear of closeness in relationships
• Avoidance of intimacy
• Unlikely to idealize the love relationship
• Tendency toward Introjective depression (self critical)

ANXIOUS/AMBIVALENT

• Compulsive Care giving
• Feel over involved and under appreciated
• Rapid relationship breakups
• Idealizing of others
• Strong desire for partner to reciprocate in relationship
• Desire for extensive contact and declarations of affections
• Over invests his/her emotions in a relationship
• Perceives relationships as imbalanced
• Relationship is idealized
• Preoccupation with relationship
• Dependence on relationship
• Heavy reliance on partner
• Views partner as desirable but unpredictable (sometimes available, sometimes not)
• Perceives others as difficult to understand
• Relationship is primary method by which one can experience a sense of security
• Unlikely to view others as altruistic
• Sensitive to rejection
• Discomfort with anger
• Extreme emotions
• Jealous
• Possessive
• Views self as unlovable
• Suicide attempts
• Mood swings
• Tendency toward anaclitic depression (dependent depression)

In fact, those two symptom lists refer to a different but conceptually related issue known as insecure attachment. Unlike RAD, an individual with an insecure attachment style is not necessarily impaired. In fact, since 40% of the general population has an insecure attachment style, it should be clear that you can be insecurely attached and function reasonably well. In contrast, RAD is a rare condition. (Incidentally, the more extreme symptoms on the above lists, such as suicide attempts, are relatively rare in insecure attachment.) There are two main types of insecure attachment - avoidant attachment, in which the person prefers keeping others at a distance; and ambivalent attachment, in which the person is needy but doesn't trust others.

Many RAD individuals show signs of insecure attachment, but not all do. Some appear securely attached (although I would argue that they are not truly secure). Others show too little attachment behaviour to be classified either way. In either case, RAD is assessed separately from attachment styles, and generally by using different measurements.

A related concept is disorganized attachment. This attachment style is somewhere in between insecure attachment and RAD in severity. A person with a disorganized attachment style may show traits of both types of insecure attachment, or a mix of secure and insecure behaviour, or they may show signs of dissociation or disorientation in attachment situations. Often, their attachment behaviour is markedly inconsistent.

Disorganized attachment is not currently considered a disorder, but it appears to be a stronger risk factor than insecure-organized attachment styles. It's associated with parental behaviour that is frightening or confusing to children. Common environmental causes include parental disorganized attachment or unresolved grief, parental mental illness, parental addiction, or physical or sexual abuse of the child. It is thought that disorganized attachment places individuals at particularly high risk of PTSD and dissociative disorders, although risks of many other conditions are also elevated.

Again, many RAD children show signs of disorganized attachment, but not all. Some children with RAD appear to show an organized attachment pattern instead, and some don't show enough attachment behaviour to be classified either way.

An interesting historical note - disorganized attachment was identified much later than the other attachment styles. In the 70s and 80s, most children who would now be classified as disorganized were instead assigned to the best-fitting organized attachment style, including some who were classified as 'secure'. This lead to some confusing findings, such as high rates of secure attachment in children abused by their primary attachment figure. However, some children could not be force-fit into any organized attachment pattern, and when two researchers (Main and Solomon) decided to take a closer look at these kids, they realized that these kids were best described by a fourth attachment style, one that also fit some children force-fit into other attachment styles.

Similarly, although some RAD children appear securely attached according to attachment style assessments (such as the Strange Situation), new evidence is starting to suggest that these kids aren't really securely attached. Instead, like disorganized-secure children, they simply don't fit into the existing attachment classification. For example, a child who, in the Strange Situation, behaves as though they were 'securely attached' to both their parent and a complete stranger would get classified as secure, because the assessment focuses mainly on interactions with the parent. However, when attachment behaviour towards strangers is assessed, this child clearly differs from true securely attached children.

Myths and Facts About Reactive Attachment Disorder Part 1 - Cause

(Note: this is part 1 of a 3 part series. You can read part 2 here, or part 3 here.)

Recently, I was taking a look at some of the information available online about Reactive Attachment Disorder, and it deeply concerned me. Unfortunately, there is a lot of misinformation out there. Although the official research base for RAD is reasonably good, many unofficial online sources present a very different picture of the causes and symptoms of RAD than the research does.

First of all, what is RAD? In the DSM-IV, Reactive Attachment Disorder is defined by both two sets of symptoms (defining two subtypes) and a form of environmental exposure presumed to cause those symptoms. In DSM-V, the two RAD subtypes have been split into two conditions, Reactive Attachment Disorder and Disinhibited Social Engagement Disorder, which are both diagnosed according to the same 'symptoms + cause' rule. They are part of only a small number of DSM diagnoses which include presumed cause in the criteria.

Cause: Pathogenic Care

So, what is the cause? The DSM-IV diagnosis of RAD requires:

"C. Pathogenic care as evidenced by at least one of the following:
(1) persistent disregard of the child's basic emotional needs for comfort, stimulation, and affection 
(2) persistent disregard of the child's basic physical needs 
(3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)
D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C)."

In the DSM-V, meanwhile, both RAD and DSED require that:

"C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
* Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults
* Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
* 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)."

Although the wording has changed, both criteria imply that RAD/DSED can result from either receiving inadequate care from one caregiver, or good quality care from too many caregivers. Of course, some children experience both inadequate care and too many caregivers, and they would presumably be at even higher risk.

The inadequate care criteria are pretty clearly implying serious child neglect. Note that in DSM-IV, either physical or emotional neglect could meet criteria, while in DSM-V, emotional neglect is needed. This reflects a greater understanding that a child who is malnourished or showing other signs of inadequate physical care can still be receiving good emotional care - for example, if the family is suffering from extreme poverty. Although many children do experience both kinds of neglect, emotional neglect is the really crucial one for RAD.

Note also that physical and sexual abuse are not included in either set of criteria. That's because, while those experiences certainly are damaging to children, they do not seem to cause RAD. Instead, they would be more likely to lead to a diagnosis of post-traumatic stress disorder, although the DSM V committee did consider adding a diagnosis known as Developmental Trauma Disorder, which would likely have covered the symptoms of abused children more specifically. Of course, many abused children also experience neglect, especially emotional neglect, and for those children RAD is a possibility.

Repeated changes in caregiving, as well as institutional rearing, are both thought to contribute to RAD in a different way. Whereas emotionally neglected children have a caregiver who is consistently present but not engaged enough for the child to attach to them, children in foster care and institutions have many caregivers, most of whom would make perfectly fine caregivers on their own, but they are so transient in the child's life that the child cannot form an effective bond to any one person.

Note that, although the DSM doesn't mention it, there are also kids who experience placement changes outside of the child welfare system. My cousins first entered foster care at 11 and 14, but long before that, they had been passed around between their biological mother, biological father, stepmother and grandparents. My mother, as a family law lawyer, has also recounted tales of repeated placement changes in custody disputes. For example, in one case, a boy was living with his biological mother until she was found unfit due to drug abuse, at which point he went to live with his father and stepmother. Then, his biological mother cleaned up and regained custody. Just recently, she has suffered a relapse, so he's back with his father and stepmother again. Under the right circumstances, custody disputes or willingly passing custody off could place a child at risk for RAD as well.

Timing and Other Notes

Timing also matters. As quoted above, the DSM criteria require that the symptoms be present after the pathogenic care, not before. For example, if a child was observed to be showing symptoms suggestive of RAD at age two, and then at age 3 experienced a foster placement, the age 3 foster placement would not count towards the pathogenic care requirement. (However, if that child had been removed from the home due to neglect, and there was reason to believe the neglect started before age 2, that would count.)

In addition, while DSM-V DSED makes no mention of age of onset, both DSM-V RAD and DSM-IV RAD require symptoms to be evident before age 5. Which, by definition, requires that the pathogenic care occur before age 5. This is consistent with research data showing that placement changes in older children can trigger other psychiatric symptoms, but do not appear to cause symptoms of RAD. It's unclear why they left out the age of onset requirement for DSED, because in practice, both RAD and DSED symptoms appear equally age-dependent.

So, 5 or older is too late to develop RAD. But can pathogenic care occur too early, as well? The research says yes. In general, among children removed from pathogenic care environments and placed into healthy homes, children under 6 months old show no lasting effect, while children aged 6-12 months only show an effect if the deprivation was particularly severe (such as institutional care, where a child often experiences over 100 different caregivers in their first year as well as neglect due to high child-to-caregiver ratios).

In addition, some websites claim that RAD can be caused by prenatal or birth trauma. There is absolutely no evidence to support this claim. Certainly, such events can affect the mother's behaviour, and in some mothers this could be severe enough to cause them to provide pathogenic care, but in that case, it was the pathogenic care, not the prenatal or birth trauma, that caused the RAD. In addition, prenatal/birth trauma can sometimes cause a child to suffer a brain injury, which could affect the child's behaviour, but the symptoms of neonatal/prenatal brain injuries are distinct from RAD.

A special note about prenatal drug or alcohol exposure: parental addiction severely impacts on the quality of parenting. In fact, most if not all actively-addicted parents provide some sort of problematic caregiving, often of the type that can cause RAD. Since most drug or alcohol exposed children have experienced months or years of care by an addicted parent, and those that haven't have often experienced multiple foster care placements in their early years, it makes no sense to me why so many people think prenatal alcohol or drug exposure is a cause of RAD symptoms.

It is conceivably possible that such prenatal exposure could cause symptoms that resemble RAD in some ways (such as the hypersociability seen in Williams Syndrome, which has nothing to do with quality of care), but so far I have not seen any conclusive evidence for it. Instead, I've seen people claiming that their child adopted at 18 months, or 3 years, or even older, clearly has RAD because of their prenatal exposure, as if the child's postnatal experiences made no difference whatsoever. My best guess is that FASD or prenatal drug exposure has filled up the child's difference slot, and they can't conceive of the child having multiple separate disabilities. Or maybe it's less upsetting to think your child acts like that because their brain is damaged than to think they act like that because it helped them cope during their early years of life.