Reactive Attachment Disorder DSM-5 Symptoms
Reactive Attachment Disorder is defined in the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th Edition) and the ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10thRevision)
There are a number of ways to classify Attachment Disorder over the years, since John Bowlby and Mary Ainsworth developed the Attachment Theory. Today, both the DSM-IV and the ICD-10 have two forms. There is a more difficult attachment form, and a relatively milder, yet still very serious form.
Reactive Attachment Disorder was first included in the DSM system in 1980 in the DSM-III. In this version the lack of social response to a caregiver as a central characteristic, and also specified it had to be evident by eight months’ age and caused by physical and emotional neglect of the baby’s needs.
Today’s version, the DSM-IV calls both types as Reactive Attachment Disorder of Infancy or Early Childhood (RAD) with two subtypes:
- The Inhibited Type which is the more serious subtype.
- The Disinhibited Type is relatively milder, but still a very serious subtype.
The ICD-10 calls these two types as separate disorders:
- Reactive Attachment Disorder of childhood (RAD), which corresponds with the DSM-5 Inhibited Type.
- Disinhibited Attachment Disorder (DAD), which corresponds with the DSM-5 Disinhibited Type.
Children with both types of Attachment Disorder show clearly disturbed and developmentally inappropriate social behavior in most contexts, beginning before the age of 5 years.
Firstly there is a condition that the child does not have a developmental delay due to mentally retardation or has an Autism Spectrum Disorder.
Secondly the disturbed behavior is a result of pathological care, which includes one or more of these: physical abuse, emotional abuse, physical neglect, emotional neglect and frequent changes of primary carer.
Specifically in the DSM-5 this pathological care is due to at least one of the following:
- Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection.
- Persistent disregard of the child’s basic physical needs.
Repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care).
The two types are defined in the DSM-5 by the way the children interact socially or are unable to interact socially, especially when in need of comfort.
This is characterised by a persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as evident by excessively inhibited, hyper-vigilant, or highly ambivalent and contradictory responses. For example, the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness.
This type is characterised by random attachments as evident by indiscriminate sociability with marked inability to exhibit appropriate selective attachments. For example they show a lack of selectivity in choice of attachment figures with primary caregivers or excessive familiarity with relative strangers, such as being clingy with everyone, including adults they have never met before.
Interpreting the DSM-5 Diagnosis
These diagnostic criteria are guides to help us understand our children. They are not absolute truth, but ongoing revisions. There are some problems with the DSM-5 diagnistic criterea for Attachment Disorder.
As an example of ongoing revisions is the age when it should be evident. The DSM-III had 8 months as the age when the behavior should be evident. The DSM-IV has 5 years as that age.
The DSM-III had a failure to thrive as one of the indicators of Attachment Disorder. The DSM-IV does not. While there are children who both fail to thrive and have Attachment Disorder, these two are separate disorders as most children with either of these two disorders have only one of them, either failure to thrive or an Attachment Disorder.
The DSM-IV puts the emphasis on a dysfunctional social behaviour, while it should emphasise dysfunctional attachment behaviour. It mixes the two as well, even in the same sentence. For example in the Disinhibited Type the DSM-IV describes an attachment behaviour, “lack of selectivity in choice of attachment figures” followed by a social behaviour, “excessive familiarity with relative strangers.”
The diagnosis of Reactive Attachment Disorder is evolving. Emotional and psychological conditions cannot be adequately described in a manual, as they are extremely complex, dynamic and variable. A diagnosis is a guide to help us understand our loved ones and ourselves. No diagnosis is absolute and we should not expect anyone to fit into a categorical definition that will change with time.
A secure attachment leads to a socially healthy and balanced life, while an insecure, disorganized attachment or an anxious attachment behavior leads to a traumatic, confused and unhappy life with conflicts and an inability to have a long-term relationship. At worst it can lead to the person developing a personality disorder as an adult. There is not enough research in Attachment Disorder. It is difficult to treat and there is not much money in treating the disorder, as the symptoms cannot be medicated away with drugs. However there is an indirect cost to every society from the social disruptions caused by this disorder left untreated, as the children become adults.
Agape Trust needs support to be able to help young people who have been raised in the orphanage system to adjust to a life outside the institution and lead meaningful lives in their communities.