Saturday, May 30, 2015

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.

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