Running head: REACTIVE ATTACHMENT DISORDER 1 Critically evaluate the characteristics of two overlapping clinical conditions justifying whether they should be considered separate or unique disorders in the next DSM. Reactive Attachment Disorder: Indiscriminately social disinhibited and emotionally withdrawn types. Word Count: 1998
REACTIVE ATTACHMENT DISORDER 2 Abstract Reactive Attachment Disorder (RAD) was classified as a single disorder with two subtypes in the Diagnostic and Statistical Manual of Mental Disorders, up until the release of the fifth edition of the manual (DSM 5, 2013). With the release of this edition, RAD: emotionally withdrawn type and RAD: disinhibited type became two separate disorders. They are now known as RAD (formally RAD: withdrawn type) and Disinhibited Social Engagement Disorder (DSED; formally RAD: disinhibited type). This review evaluates the decision to separate these two disorders, concluding that the majority of evidence is behind the change. Problems which remain in the DSM-5 criteria for these disorders are discussed, and improvements for subsequent editions of the DSM are proposed. Key Words: Attachment Disorders; Child Development; Child Neglect; Diagnostic Criteria; Institutionalised Children
REACTIVE ATTACHMENT DISORDER 3 Reactive Attachment Disorder: Indiscriminately social disinhibited and emotionally withdrawn types. Diagnostic criteria for Reactive Attachment Disorder (RAD) include: emotionally withdrawn behaviour; social emotional disturbance; and exposure to extremes of insufficient care. Diagnostic criteria for Disinhibited Social Engagement Disorder (DSED) include: reduced/absent reticence when interacting with unfamiliar adults; socially disinhibited behaviours; and exposure to extremes of insufficient care (Diagnostic and Statistical Manual of Mental Disorders (DSM-5), American Psychiatric Association (APA), 2013). Despite the very different symptoms, these two disorders were considered to be subtypes of a single construct; RAD: emotionally withdrawn type (now RAD), and RAD: disinhibited type (now DSED) (DSM III R, APA, 1987; DSM-IV, APA, 1994; DSM-IV-R, APA, 2000) until very recently. With the release of the DSM-5 in 2013 (APA), they now sit as separate disorders, bringing the DSM-V in line with both: the ICD-10 Classification of Mental and Behavioural Disorders: Clinical Descriptions and Diagnostic Guidelines (ICD-10; World Health Organization, 1992); and a vast body of research evidence (Zeanah & Gleason, 2010). The reasons for this decision, and why it should be maintained in the next DSM, will be discussed along with the relevant research evidence. Some key issues with the current diagnostic criteria will also be highlighted, in order to allow for further improvements to the next DSM. There is much research support for the greater separation of RAD and DSED in the DSM-5. For example, using factor analysis methods on attachment questionnaire items, Minnis et al (2007) found a distinct factor corresponding to each disorder, suggesting the two are in fact separate constructs. Similarly, O Connor, Bredenkamp & Rutter, (1999) found that on analysis of questionnaire responses,
REACTIVE ATTACHMENT DISORDER 4 disinhibited items were more closely associated with the other disinhibited items than they were with the inhibited item. This again supports a distinction between the two. There are a number of key differences between RAD and DSED; one of these is the prevalence following adoption. Whilst disinhibited social behaviour persists after adoption and can still be seen in children aged 11 (Rutter et al, 2007), this is not the case for the inhibited type. In the Bucharest Study (Nelson et al, 2007) prior to fostering 24 out of 56 children showed marked inhibited RAD; this figure reduced to just 1 case after fostering. Further, whilst the relationship between caregiving and RAD is well documented, the same cannot be said for DSED. Zeanah et al (2005) found moderate associations between caregiving and signs of RAD, but no association between caregiving and signs of DSED. Similarly, RAD responds well to enhanced caregiving, with symptoms reducing once children are placed in a more remedial environment; in contrast, enhanced caregiving is not as effective at reducing DSED (Rutter et al, 2009). These findings have implications for treatment; because DSED is very persistent and unresponsive to enhanced caregiving, it is difficult to provide intervention to these children. RAD shares some features with autistic spectrum disorders (Zeanah & Smyke, 2008), and also shows moderate convergence with depressed mood (Gleason et al, 2011), suggesting it might be described as an internalising disorder. In contrast, DSED is more similar to externalising disorders such as Attention Deficit Hyperactive Disorder (ADHD), as it shows moderate associations with measures of inattention and hyperactivity (Roy, Rutter & Pickles, 2004); this highlights a further distinction between the disorders. Finally, one of the most crucial differences between RAD and DSED is their relationship to attachment behaviour, as measured by the strange situation (SS) paradigm. RAD occurs when no selective attachment has been formed
REACTIVE ATTACHMENT DISORDER 5 (Gleason et al, 2011), thus when measured using the SS, children with RAD are often rated as unclassified due to not displaying any attachment behaviours (Zeanah et al, 2005). In contrast, those with DSED may or may not have selective attachments, and even those who are classified as secure on the SS can still display indiscriminate behaviour (Chisholm, 1998; O Connor et al, 2003). Further, Zeanah et al (2005) found moderate associations between RAD and SS ratings of attachment behaviour, but no relationship between DSED and these ratings. Findings such as these have led to debate about what the core deficit of DSED actually is. One interesting question raised by the relationship of DSED to ADHD is whether the two disorders form a unitary post institutional syndrome, or if they are just commonly comorbid (Zeanah & Smyke, 2008). Further, some have argued that DSED should be seen as something other than an attachment disorder (Gleason et al, 2011). In fact, the new name disinhibited social engagement disorder is intended to reflect that it is not necessarily attachment behaviours that are disinhibited, but social behaviours more generally (Zeanah & Gleason, 2010). If the core of this disorder is not attachment behaviour, DSED is even more distinct from RAD than was previously thought. Due to this uncertainty, it makes sense for the two to stand as separate disorders. In summary, evidence is completely against the view that the two disorders are part of the same construct (Rutter, Kreppner & Sonuga-Barke, 2009). Compared to this vast number of differences, the similarities between the two disorders are few and far between. One similarity is the aetiology; it is specified in the DSM criteria that both disorders are a result of pathological care. Even this is problematic, however. The disorders are rare, even among maltreated children (Zeanah & Smyke, 2008); if not all children faced with pathological care develop them, there must be additional risk factors (Hanson & Spratt, 2010). Current research
REACTIVE ATTACHMENT DISORDER 6 is examining the role of genetics (Minnis et al, 2007); in particular, a potential role for 5HTT (Kumsta et al, 2010; Bakermans-Kranenburg, Dobrova-Krol & van IJzendoorn, 2012). It has also been questioned how two disorders with such different characteristics can develop from the same early environment (Zeanah & Smyke, 2008). Hinshaw-Fusilier, Boris and Zeanah (1999), for example, report a case study of two dizygotic twins, who grew up in the same family home and were placed in foster care at 18 months. Despite the shared early environment, one twin displayed symptoms of RAD, the other one displayed symptoms of DSED. Zeanah and Fox (2004) suggest that temperamental dispositions (e.g. withdrawn inhibited behaviour/ negative emotionality or exuberance/impulsivity) may interact with a neglectful caregiving environment and explain the development of the different disorders. Thus, it is likely that there are different risk factors for both RAD and DSED, leaving them with only a partly shared aetiology. There is one key argument for RAD and DSED being returned to subtypes of the same construct: the potential of a mixed subtype. An alternative classification system for RAD exists; this appears in the Research Diagnostic Criteria - Preschool Age (RDC-PA; AACAP, 2002) and the Diagnostic Criteria 0-3R (DC: 0-3R; Zero to Three, 2005). These alternative criteria still consider RAD as one disorder; however, they include three separate subtypes: Inhibited, disinhibited, and a mixed type which shares features of both inhibited and disinhibited. These criteria are based on studies showing moderate intercorrelations between RAD and DSED; these same studies also used cluster analyses which suggested a mixed type of RAD (Zeanah et al, 2004). However, there are a number of reasons why including a mixed subtype in the next DSM would be a premature decision. Firstly, there has never been a case report of a child with features of both the types (Zeanah & Gleason, 2010). In addition, when the
REACTIVE ATTACHMENT DISORDER 7 data from the studies was subjected to closer inspection, it was found that the items most used to code indiscriminate behaviour (for example, willingness to go off with a stranger, failure to check back with caregivers in unfamiliar settings) can also be applied to children with emotionally withdrawn behaviour. What is important in distinguishing between the two is the passivity of the behaviour; those with indiscriminate behaviour will seek interaction with other adults, whilst those with withdrawn behaviour may simply act in these ways due to a lack of regard for any particular caregiver (Zeanah & Gleason, 2010). Therefore, before any changes are made to the DSM based on the possibility of a mixed type, controlled studies with coding taking into account not only the types of behaviours, but also the passivity with which they are performed are needed. As of yet, there is insufficient validity data for a mixed type of RAD. Therefore, the majority of evidence suggests that the DSM 5 is an improvement on previous versions. However, there are other problems that remain to be addressed relating to the disorders. This is hardly surprising, as the DSM criteria have largely been developed without research evidence (Zeanah & Gleason, 2010); RAD was first included in the DSM III in 1980 (APA), but the first study addressing the validity of the criteria was not until 1998 (Boris, Zeanah, Larrieu, Scheeringa & Heller). This has left some areas in desperate need of research attention. One issue is the rate of diagnosis, with concerns that children are being over-diagnosed in institutions (Hanson & Spratt, 2000), and under-diagnosed in the general population (e.g. Pritchett, Pritchett, Marshall, Davidson & Minnis, 2013). Research that tried to address RAD/DSED in the general population faces a number of problems, such as poor response rate. Minnis et al, (2013) only received a 67.5% parental response rate in their study of RAD in a deprived population. Additionally, diagnosis of this
REACTIVE ATTACHMENT DISORDER 8 disorder is a sensitive issue. Due to the requirement of pathological care, this would be a difficult diagnosis for parents to deal with, and for psychologists to give. For these reasons, it is believed RAD/DSED often goes undetected in this population. On the other hand, researchers have expressed concern that within children with a history of maltreatment (e.g. neglect; sexual abuse) the disorder is over-diagnosed. In these cases, it is assumed that any behavioural problems observed are a result of the maladaptive relationships with their caregivers, with other possible causes not being considered, leading to a diagnosis of RAD/DSED (Hanson & Spratt, 2000). A further issue is that little is known about the developmental course. The current cut off age of 5 is arbitrary (Hanson & Spratt, 2000). This age is not based on any form of research evidence, and due to this, cases of RAD/DSED which are not identified until after the age of 5 could miss out on a diagnosis, affecting their chances of treatment. To conclude, it is clear that despite having some degree of shared cause, these two disorders are very different, and should remain separate in the next DSM. The vast number of differences between the disorders, shown in the majority of research, completely nullifies the idea they belong to the same construct. The only reason for this decision to be reconsidered in the future would be if evidence for a mixed subtype was found. This evidence would need to be methodologically sound and replicable in order to counter the existing support for the separation of the disorders. The main problem with RAD at present is not the issue of whether the two types are distinct; this issue has received plenty of research attention, whilst issues with the diagnostic criteria in general have received comparatively little. It is important that we consider how to identify and treat hidden cases of RAD/DSED in the general population, without causing more cases of over-diagnosis in institutionalised children. Due to the rarity of the disorders, and the criteria changing often, some clinicians may not be
REACTIVE ATTACHMENT DISORDER 9 very familiar with them (Hanson & Spratt, 2010); therefore raising awareness of RAD and DSED could be a solution to the problems with diagnosis. Further, the validity of the current age of onset requirement of 5 years needs to be looked into. In summary, the RAD criteria are still a work in progress, but they are improving with each edition of the DSM and have come a long way since their first appearance in 1980. The decision to separate them in the DSM 5 has only improved the criteria further. Hopefully by the next edition of the DSM there will be more research on the areas outlined, allowing for further improvements.
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