Editing Reactive attachment disorder (section)

==Signs and symptoms==
{{See also|Attachment theory| attachment disorder}}
[[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. [[Infant]]s up to about 18–24 months may present with [[Failure to thrive|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.<ref name=Sad04>{{cite book |title=Kaplan & Sadock's Concise Textbook of Clinical Psychiatry |last=Sadock |first=BJ |author2=Sadock VA |year=2004 |publisher=Lippincott Williams and Wilkins |location=Philadelphia |isbn=978-0-7817-5033-2 |pages=[https://archive.org/details/kaplansadockscon00sado/page/570 570–72] |url-access=registration |url=https://archive.org/details/kaplansadockscon00sado/page/570 }}</ref>

The core feature is severely inappropriate social relating by affected children. This can manifest itself in two 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 often 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.<ref name="Chaffin 2006, p. 80">Chaffin et al. (2006), p. 80. The APSAC Taskforce Report</ref>
#

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.<ref name="Rutter 2002">{{cite journal |author=Rutter M |title=Nature, nurture, and development: from evangelism through science toward policy and practice |journal=Child Dev |volume=73 |issue=1 |pages=1–21 |year=2002 |pmid=14717240 |doi=10.1111/1467-8624.00388 }}</ref>

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.<ref>{{Cite journal|last1=RICHTERS|first1=MARGOT MOSER|last2=VOLKMAR|first2=FRED R.|date=1 March 1994|title=Reactive Attachment Disorder of Infancy or Early Childhood|journal=Journal of the American Academy of Child & Adolescent Psychiatry|volume=33|issue=3|pages=328–332|doi=10.1097/00004583-199403000-00005|pmid=7513324|citeseerx=10.1.1.527.9988|s2cid=13058511 }}</ref>

===Assessment tools===
There is as yet no universally accepted diagnostic protocol for reactive attachment disorder. Often a range of measures are used in research and diagnosis. Recognized assessment methods of attachment styles, difficulties or disorders include the [[Strange Situation|Strange Situation Procedure]] (devised by [[developmental psychology|developmental psychologist]] [[Mary Ainsworth]]),<ref name="Ainsworth et al. (1979)"/><ref name="Main & Solomon (1986)"/><ref name= "Main &amp; Solomon 1990"/> the separation and reunion procedure and the Preschool Assessment of Attachment,<ref name= "Crittenden 1992">{{cite journal |author=Crittenden PM |title= Quality of attachment in the preschool years|journal= Development and Psychopathology |volume= 4 |issue=2 |pages= 209–41|year= 1992 |doi=10.1017/S0954579400000110|s2cid= 143894461}}</ref> the Observational Record of the Caregiving Environment,<ref name="NICHHD">{{cite journal |last1=National Institute of Child Health and Human Development |year=1996 |title=Characteristics of infant child care: Factors contributing to positive caregiving |journal=Early Childhood Research Quarterly |volume=11 |issue=3 |pages=269–306(38) |doi= 10.1016/S0885-2006(96)90009-5 |first1=D |url=https://zenodo.org/record/1260095 |author1-link=National Institute of Child Health and Human Development }}</ref> the [[Attachment measures#Developing methods for older toddlers and children|Attachment Q-sort]]<ref name="Waters &amp; Deane 1985">Waters E, Deane K (1985). "Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behavior in infancy and early childhood". In Bretherton I and Waters E (Eds.) ''Growing pains of attachment theory and research: Monographs of the Society for Research in Child Development'' 50, Serial No. 209 (1–2), pp. 41–65.</ref> and a variety of narrative techniques using [[attachment measures#Other approaches|stem stories]], puppets or pictures. For older children, actual interviews such as the [[Attachment measures#Other approaches|Child Attachment Interview]] and the Autobiographical Emotional Events Dialogue can be used. Caregivers may also be assessed using procedures such as the Working Model of the Child Interview.<ref name="Zeanah & Benoit 1995">{{cite journal |journal=Child and Adolescent Psychiatric Clinics of North America|vauthors=Zeanah CH, Benoit D | year= 1995 |title= Clinical applications of a parent perception interview in infant mental health |volume= 43|issue=3 | pages= 539–554 |doi=10.1016/S1056-4993(18)30418-8 }}</ref>

More recent research also uses the [[Attachment measures#Developing methods for older toddlers and children|Disturbances of Attachment Interview]] (DAI) developed by Smyke and [[Charles H. Zeanah|Zeanah]] (1999).<ref name="Smyke & Zeanah (1999)">Smyke A, Zeanah CH (1999). "Disturbances of Attachment Interview". Available on the ''Journal of the American Academy of Child and Adolescent Psychiatry'' website at www.jaacap.com via Article plus.[http://acs.tx.ovid.com/acs/.93554d254ce5ec50e95dc1edabf7938b1c449aa9b2907e89124e214976c8be5cd89fe896880c65062e4945ba06270e8ea898a69e2b2e5aa1286b97438aef50246f.doc] Retrieved on 3 March 2008.</ref> The DAI is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely "having a discriminated, preferred adult", "seeking comfort when distressed", "responding to comfort when offered", "social and emotional reciprocity", "emotional regulation", "checking back after venturing away from the care giver", "reticence with unfamiliar adults", "willingness to go off with relative strangers", "self-endangering behavior", "excessive clinging", "vigilance/hypercompliance" and "role reversal". This method is designed to pick up not only RAD but also the proposed new alternative categories of disorders of attachment.