Editing Reactive attachment disorder (section)

==Diagnosis==
{{See also|Attachment measures}}
RAD is one of the least researched and most poorly understood disorders in the DSM. There is little systematic epidemiologic information on RAD, its course is not well established and it appears difficult to diagnose accurately.<ref name="Chaffin 2006, p. 80"/> There is a lack of clarity about the presentation of attachment disorders over the age of five years and difficulty in distinguishing between aspects of attachment disorders, disorganized attachment or the consequences of maltreatment.<ref name="prior228"/>

According to the [[American Academy of Child and Adolescent Psychiatry]] (AACAP), children who exhibit signs of reactive attachment disorder need a comprehensive psychiatric assessment and individualized treatment plan. The signs or symptoms of RAD may also be found in other psychiatric disorders and AACAP advises against giving a child this label or diagnosis without a comprehensive evaluation.<ref name="AACAP">[http://www.aacap.org/cs/root/facts_for_families/reactive_attachment_disorder Reactive Attachment Disorder.] {{webarchive|url=https://web.archive.org/web/20080203213050/http://www.aacap.org/cs/root/facts_for_families/reactive_attachment_disorder |date=3 February 2008 }} American Academy of Child & Adolescent Psychiatry, Facts for Families, No. 85; Updated December 2002.  Retrieved on 13 February 2008.</ref> Their practice parameter states that the assessment of reactive attachment disorder requires evidence directly obtained from serial observations of the child interacting with their primary caregivers and history (as available) of the child's patterns of attachment behavior with these caregivers. It also requires observations of the child's behavior with unfamiliar adults and a comprehensive history of the child's early caregiving environment including, for example, pediatricians, teachers, or caseworkers.<ref name=AACAP-2005/> In the US, initial evaluations may be conducted by psychologists, psychiatrists, Licensed Marriage and Family Therapists, Licensed Professional Counselors, specialist Licensed Clinical Social Workers or psychiatric nurses.<ref>For examples see  [http://dcfswebresource.prairienet.org/resources/rad.php Reactive Attachment Disorder] {{webarchive|url=https://web.archive.org/web/20071228050441/http://dcfswebresource.prairienet.org/resources/rad.php |date=28 December 2007 }}, DCFS, State of Illinois and [http://www.azdhs.gov/bhs/guidance/attach.pdf DBHS Practice Protocol: Disturbances and Disorders of Attachment] (PDF), Arizona Department of Health Services, 2 October 2006. Retrieved on 23 February 2008.</ref>

In the UK, the [[British Association for Adoption and Fostering]] (BAAF) advise that only a psychiatrist can diagnose an attachment disorder and that any assessment must include a comprehensive evaluation of the child's individual and family history.<ref name="BAAF">[http://www.baaf.org.uk/about/believes/ps4.pdf Attachment Disorders, their Assessment and Intervention/Treatment] {{webarchive|url=https://web.archive.org/web/20081002051146/http://www.baaf.org.uk/about/believes/ps4.pdf |date=2 October 2008 }} (PDF). British Association for Adoption and Fostering, Position Statement 4, 2006. Retrieved on 23 February 2008</ref>

According to the AACAP Practice Parameter (2005) the question of whether attachment disorders can reliably be diagnosed in older children and adults has not been resolved. Attachment behaviors used for the diagnosis of RAD change markedly with development and defining analogous behaviors in older children is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence.<ref name=AACAP-2005/> Assessments of RAD past school age may not be possible at all as by this time children have developed along individual lines to such an extent that early attachment experiences are only one factor among many that determine emotion and behavior.<ref>Mercer (2006), p. 116.</ref>

===Criteria===
ICD-10 describes reactive attachment disorder of childhood, known as RAD, and [[disinhibited attachment disorder]], less well known as DAD. DSM-IV-TR also describes reactive attachment disorder of infancy or early childhood divided into two subtypes, inhibited type and disinhibited type, both known as RAD. The two classifications are similar and both include:
* markedly disturbed and developmentally inappropriate social relatedness in most contexts (e.g., the child is avoidant or unresponsive to care when offered by caregivers or is indiscriminately affectionate with strangers);<ref name=DSMIV />
* the disturbance is not accounted for solely by [[Child development|developmental]] delay and does not meet the criteria for [[pervasive developmental disorder]];
* onset before five years of age (there is no age specified before five years of age at which RAD cannot be diagnosed);<ref name=DSMIV>{{cite book|title=Diagnostic and Statistical Manual of Mental Disorders: Text Revision|url=https://archive.org/details/diagnosticstatis0ed4unse_y1p2|url-access=registration|year=2000|publisher=American Psychiatric Association|isbn=978-0-89042-025-6|pages=[https://archive.org/details/diagnosticstatis0ed4unse_y1p2/page/943 943]}}</ref>
* a history of significant neglect;
* an implicit lack of identifiable, preferred attachment figure.

ICD-10 states in relation to the inhibited form only that the syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. DSM states in relation to both forms there must be a history of "[[pathogenic]] care" defined as persistent disregard of the child's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to account for the disorder. For this reason, part of the [[medical diagnosis|diagnosis]] is the child's history of care rather than observation of symptoms.

In DSM-IV-TR the ''inhibited'' form is described as 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", hypervigilance while keeping an impassive and still demeanour).<ref name= "DSM">{{cite book |title= Diagnostic and Statistical Manual of Mental Disorders |edition=4th ed., text revision ([[DSM-IV-TR]]) |author= American Psychiatric Association |year=2000 |isbn=978-0-89042-025-6 |chapter=Diagnostic criteria for 313.89 Reactive attachment disorder of infancy or early childhood  |publisher= AMERICAN PSYCHIATRIC PRESS INC (DC) |location= United States}}
</ref> Such infants do not seek or accept comfort at times of threat, alarm or distress, thus failing to maintain "proximity", an essential element of attachment behavior. The ''disinhibited'' form shows 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).<ref name ="DSM"/> There is therefore a lack of "specificity" of attachment figure, the second basic element of attachment behavior.

The ICD-10 descriptions are comparable save that ICD-10 includes in its description several elements not included in DSM-IV-TR as follows:
* [[Child abuse|abuse]], ([[Psychological abuse|psychological]] or physical), in addition to neglect;
* associated emotional disturbance;
* poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases (inhibited form only);
* evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness in interactions with appropriately responsive, non-deviant adults (disinhibited form only).

The first of these is somewhat controversial, being a commission rather than omission and because abuse in and of itself does not lead to attachment disorder.

The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is more enduring.<ref>Prior &amp; Glaser (2006), pp. 220–21.</ref> ICD-10 states the disinhibited form "tends to persist despite marked changes in environmental circumstances". Disinhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same child.<ref name="Zeanah et al. (2004)"/> The question of whether there are two subtypes has been raised. The World Health Organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate subdivision.<ref name="WHO1992">World Health Organisation (1992) ''International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10)''. Geneva: World health Organization.</ref> One reviewer has commented on the difficulty of clarifying the core characteristics of and differences between atypical attachment styles and ways of categorizing more severe disorders of attachment.<ref>{{cite journal | author = Zilberstein K | year = 2006 | title = Clarifying core characteristics of attachment disorders | journal = [[American Journal of Orthopsychiatry]] | volume = 76 | issue = 1| pages = 55–64 | doi=10.1037/0002-9432.76.1.55| pmid = 16569127 | s2cid = 25416390 }}</ref>

{{as of|2010}}, the American Psychiatric Association has proposed to redefine RAD into two distinct disorders in the DSM-V.<ref name=DSM-V>Proposed Revision Reactive Attachment Disorder, ''American Psychiatric Association'' (2012). Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=120</ref> Corresponding with the inhibited type, one disorder will be reclassified as ''Reactive Attachment Disorder of Infancy and Early Childhood''.<ref name=DSMIV />

In regards to pathogenic care, or the type of care in which these behaviors are present, a new criterion for Disinhibited Social Engagement Disorder now includes chronically harsh punishment or other types of severely inept caregiving. Relating to pathogenic care for both proposed disorders, a new criterion is rearing in atypical environments such as institutions with high child/caregiver ratios that cut down on opportunities to form attachments with a caregiver.<ref name=DSM-V />

===Differential diagnosis===
The diagnostic complexities of RAD mean that careful diagnostic evaluation by a trained [[mental health]] expert with particular expertise in [[differential diagnosis]] is considered essential.<ref name="Hanson&Spratt2000">{{cite journal |vauthors=Hanson RF, Spratt EG |title=Reactive Attachment Disorder: what we know about the disorder and implications for treatment |journal=Child Maltreat |volume=5 |issue=2 |pages=137–45 |year=2000 |pmid=11232086 |doi=10.1177/1077559500005002005 |s2cid=21497329 }}</ref><ref name="Wilson (2001)">{{cite journal |doi=10.1080/00223980109603678 |author=Wilson SL |title=Attachment disorders: review and current status |journal=J Psychol |volume=135 |issue=1 |pages=37–51 |year=2001 |pmid=11235838 |s2cid=7226465 }}</ref><ref name="taskforce"/> Several other disorders, such as [[conduct disorder]]s, [[oppositional defiant disorder]], [[anxiety disorder]]s, [[post traumatic stress disorder]] and [[social anxiety disorder|social phobia]] share many symptoms and are often comorbid with or confused with RAD, leading to over and under diagnosis. RAD can also be confused with neuropsychiatric disorders such as [[autism spectrum|autism]], [[pervasive developmental disorder]], [[pediatric schizophrenia|childhood schizophrenia]] and some genetic syndromes. Infants with this disorder can be distinguished from those with organic illness by their rapid physical improvement after hospitalization.<ref name=Sad04/> Autistic children are likely to be of normal size and weight and often exhibit a degree of intellectual disability. They are unlikely to improve upon being removed from the home.<ref name=Sad04/><ref name="Hanson&Spratt2000"/><ref name="Wilson (2001)"/><ref name="taskforce"/>

===Alternative diagnosis===
In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the [[Diagnostic and Statistical Manual of Mental Disorders|DSM]] and [[ICD]], were created out of clinical and parental experience within the field known as [[attachment therapy]]. These lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common elements of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either DSM-IV-TR or ICD-10.<ref>Chaffin et al. (2006), pp. 82–83. The APSAC Taskforce Report</ref> Many children are being diagnosed with RAD because of behavioral problems that are outside the criteria.<ref name="Hanson&Spratt2000"/> There is an emphasis within attachment therapy on aggressive behavior as a symptom of what they describe as attachment disorder whereas mainstream theorists view these behaviors as comorbid, [[Externalization (psychology)|externalizing]] behaviors requiring appropriate assessment and treatment rather than attachment disorders. However, knowledge of attachment relationships can contribute to the cause, maintenance and treatment of externalizing disorders.<ref name="Gutman-Steinmetz &amp; Crowell (2006)">{{cite journal |vauthors=Guttmann-Steinmetz S, Crowell JA |title=Attachment and externalizing disorders: a developmental psychopathology perspective |journal=J Am Acad Child Adolesc Psychiatry |volume=45 |issue=4 |pages=440–51 |year=2006 |pmid=16601649 |doi=10.1097/01.chi.0000196422.42599.63 }}</ref>

The Randolph Attachment Disorder Questionnaire or RADQ is one of the better known of these checklists and is used by attachment therapists and others.<ref name="Randolph 1996">Randolph, Elizabeth Marie. (1996). ''Randolph Attachment Disorder Questionnaire''. Institute for Attachment, Evergreen CO.</ref> The checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment difficulties. Critics assert that it is unvalidated<ref name="Mercer J.">{{cite journal |author=Mercer J |title=Coercive restraint therapies: a dangerous alternative mental health intervention |journal=MedGenMed |volume=7 |issue=3 |pages=6 |year=2005 |pmid=16369232 |url=http://www.medscape.com/viewarticle/508956 |pmc=1681667 }}</ref> and lacks [[Specificity (tests)|specificity]].<ref name="Cappelletty et al. (2005)">{{cite journal |title= Correlates of the Randolph Attachment Disorder Questionnaire (RADQ) in a Sample of Children in Foster Placement |year=2005 |journal=Child and Adolescent Social Work Journal |volume=22 |issue=1 |pages=71–84 |doi=10.1007/s10560-005-2556-2 |quote=The findings showed that children in foster care have reported symptoms within the range typical of children not involved in foster care. The conclusion is that the RADQ has limited usefulness due to its lack of specificity with implications for treatment of children in foster care |vauthors=Cappelletty G, Brown M, Shumate S |s2cid=143743052 }}</ref>