Reactive attachment disorder (RAD) was first introduced as a diagnosis to the DSM-3 in 1980. Unlike many of the other vaguely supported conditions in the manual, RAD has a stable scientific foundation. That said, there is a lot of controversy over exactly how to define it.
RAD is often confused with Conduct Disorder (CD), but whereas children with CD are able to form some satisfying relationships with adults, RAD children struggle with this. However, if you look at kids with CD or oppositional defiant disorder (ODD), you’ll often find that a majority of them have a history of attachment traumas. So it seems to me a rather dubious distinction. If you have a child with attachment trauma who’s acting out, chances are pretty good that their behavior is related to the attachment trauma.
Criteria for diagnosis
In order to be diagnosed with RAD, a child must meet 4 sets of criteria:
- They exhibit “markedly disturbed and developmentally inappropriate” behavior in social interactions, beginning before age 5. This is evidenced by either inhibited or disinhibited behaviors, as discussed in the Signs & Symptoms section
- The aforementioned disturbance cannot be explained by a developmental delay or other developmental disorder.
- A history of pathological care that predates the disturbance, as evidenced by one or more of the following:
A) Persistent disregard for the child’s basic emotional needs in terms of comfort, stimulation and affection
B) A similar persistent disregard for the child’s physical needs.
C) Disruptive changes in the primary caregiver that prevent the formation of stable attachments.
- The presumption that the child’s behavior as outlined in A is directly related to the criteria in C (i.e., the attachment problems are causing or contributing to the behavior).
For a diagnosis of RAD, this unhealthy way of relating must extend to all adults. (Hanson & Spratt, 2000) In other words, it can’t just be a problem of a child not getting along well with a particularly bad or marginal parent. There are no reliable or validated tests to assess or diagnose RAD. (Minde, 2003) A diagnosis is typically made based on child observations, interviews with the child and his or her parents or caregivers, and a child’s reaction to the Strange Situation protocol, which assesses how children act during a brief separation from caregivers that places them with strangers.
One quarrel I have with this diagnostic criteria is the under 5 age requirement. There’s plenty of case studies out there that suggest children much older can develop the same type of psychopathology when subjected to abrupt attachment injuries or separations from their primary caregivers.
For example, an 8-year-old girl might suddenly develop uncontrollable fits of rage and behavior problems fitting RAD when her father suddenly abandons the family, or children placed in foster care at later ages might do the same. To place an age limit on the same set of symptoms caused by the same type of injury seems silly.
Some suggest that RAD should only be diagnosed if children have an inability to form any secure attachments, and suggest that because many institutionalized children will exhibit behaviors that suggest attachment to a particular adult, such as seeking out that person for affection, this means they couldn’t have RAD. (Zeanah, Smyke & Dumitrescu, 2002) But I think this seriously misses the point and misrepresents the underlying issue. RAD should not be understood as a child’s lack of desire for love – this is something all children desire. The problem is that their previous experiences make it much harder for them to feel secure in their attachments, which in turn leads to maladaptive behavior.