Reactive Attachment Disorder DSM-5 313.89 (F94.1)
DSM-5 Category: Trauma- and Stressor-Related Disorders
Introduction
An attachment disorder describes a problematic pattern of developmentally inappropriate moods, social behaviors, and relationships due to a failure in forming normal healthy attachments with primary care givers in early childhood. A child who experiences neglect, abuse, or separation during the critical stages of development of first three years of life is at risk of developing an attachment disorder. The two sub-types of attachment disorders - emotionally withdrawn/inhibited and indiscriminately disinhibited – are now defined separately in the DSM-V as the distinct disorders Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED).
RAD is diagnosed when a child’s social relations are inhibited and, as a result, he/she fails to engage in social interactions in a manner appropriate to his/her developmental age. The child may exercise avoidance, hyper-vigilance or resistance to social contact. The child may also avoid social reciprocity, fail to seek comfort when upset, become overly attached to one adult, and refuse to acknowledge a caregiver. Links have been shown between RAD and future behavioral and relationship problems.
In contrast, DSED is diagnosed when a child is excessively social with strangers and does not engage in selective attachments. A child with DSED will indiscriminately engage in social behavior.
DSM-5 Symptoms
The first indications of RAD or DSED are a child’s abnormal social interactions. The child may avoid initiating social interaction or responding to social stimuli even from family members and other intimates. Alternatively, under DSED he/she may indiscriminately seek excessive social interaction with strangers. The symptoms according to the DSM-V are as follows (American Psychiatric Association, 2013):
Symptoms of Reactive Attachment Disorder (RAD):
- Failure to develop normally
- Poor hygiene
- Underdevelopment of motor coordination and a pattern of muscular hypertonicity
- Bewildered, unfocused, and under-stimulated appearance
- Blank expression, with eyes lacking the usual luster and joy
- Fails to respond appropriately to interpersonal exchanges
Symptoms of Disinhibited Social Engagement Disorder (DSED):
- Excessive social interaction with unknown persons
- Readiness to give hugs to anyone who approaches and to go with that person if asked
- Willingness to approach a complete stranger for comfort or food, to be picked up, or to receive a toy
The disorder must be present for 12 months. Under DSM-V, if the symptoms of both RAD and DSED are present at high levels, the disorder is specified as severe.
Reactive Attachment Disorder in Daily Life
Attachment disorders present various difficulties in a family environment. A child who is overly attached to his/her mother experiences the distress of separation on a regular basis and can make it difficult for the mother (or primary caregiver) to attend to other daily responsibilities such as caring for and engaging in social and emotional interactions with other children. A pregnant mother may seek extra caregiving assistance to deal with the excessive demands of the child with RAD. The need of the parents to seek caregiving assistance can result in negative emotions in the child, including feelings of anger, rejection and neglect. The child may express his or her frustration by acting out towards others. Parents need to be mindful that frequent changes in caregivers can be a contributing factor to RAD, according to DSM-V.
Many individuals with RAD have suffered psychological and/or physical abuse. The DSM-V cites social neglect, isolation, and unmet emotional needs as examples of insufficient care that can lead to RAD. RAD symptoms can isolate a child from siblings and peers, resulting in a child’s over-reliance on parents. Initial symptoms may be revealed during play time among peers. The child will appear more isolated and fail to make eye contact with other children, and may exhibit aggressive or manipulative behavior. Attachment disturbances from early life can manifest in a variety of ways, including aggressive behavior, uncooperativeness, anger, avoidance of intimacy, social awkwardness, mistrust of adults, and academic difficulties.
Parents and caregivers play an important role in therapy, including modeling and guiding children to make good social judgments. Children with disinhibited social engagement disorder are more likely to trust a stranger’s face and therefore often make poor, indiscriminate social judgments (Miellet et al., 2014).
Reactive Attachment Disorder Therapy
Attachment disturbances in early development can have severe detachment effects later in life. The earlier the treatment starts, the better the potential treatment outcome.
Adopted children have a higher incidence of reactive attachment disorder, and may have more trouble bonding with new parental figures. As many as 25% may experience adoption disruption. Attachment therapy, the conventional treatment, has reduced attachment symptoms in adopted children. It has also shown to have a positive impact on the family unit by supporting family functioning and structure (Wimmer, Vonk, & Bordnick, 2009).
Attachment disorder symptoms often overlap with other disorders, posing challenges to effective treatment. Therefore, individualized, multimodal treatment options are recommended. Many behavioral therapies, such as those widely used to treat autism, do not address psychological trauma. Trauma-focused cognitive behavioral therapy (TF-CBT), when applied to attachment disorders, treats the underlying attachment disruptions and promotes emotion regulation, producing positive therapeutic outcomes (Michelson, 2010). Trauma therapy addresses the mechanisms of complex trauma that shift the brain into survival mode. Specifically, it recognizes that complex trauma leads to the development of brain networks influenced by the stress response mechanism. Motivated by harm avoidance, maladaptive emotion regulation arises and the child dissociates with any potential threats in his/her environment. This process explains the child’s avoidance strategies. The behavioral therapy component, meanwhile, can identify the triggers underlying the disassociation, as well as model and reinforce healthy adaptive behavior.
Emotion regulation is important in any treatment approach. The parent/teacher/caregiver plays an important role in ensuring a safe and supportive environment to teach, model and encourage emotion regulation.
Integrative play therapy (IPT) and social learning provide creative channels through which children can learn social behavior and explore the underlying causes of their detachment disorder. Social learning stories demonstrate model behavior in a context familiar to the child. Like behavioral theory, the desired behavior can be modeled through these modalities. Cognitive-behavioral therapy (CBT) is often applied simultaneously with IPT.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Michelson, S. E. (2010). Treating complex trauma: therapists' perspectives on the effectiveness of the trauma focused-cognitive behavioral therapy clinical approach to treat traumatized children: a project based upon an independent investigation (Doctoral dissertation).
Miellet, S., Caldara, R., Raju, M., Gillberg, C., & Minnis, H. (2014). Disinhibited Reactive Attachment Disorder symptoms impair social judgements from faces. Psychiatry Research.
Wimmer, J. S., Vonk, M. E., & Bordnick, P. (2009). A preliminary investigation of the effectiveness of attachment therapy for adopted children with reactive attachment disorder. Child and Adolescent Social Work Journal, 26(4), 351-360.
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