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DSM-5 and School Psychology

Reactive Attachment Disorder and Disinhibited Social Engagement Disorder

By Madeleine Leveille

Contributing Editor’s Note: This series of articles on DSM-5 reviews changes made to specific diagnostic criteria, emphasizing changes that may be relevant in the school context. If any Communiqué reader is interested in contributing to this series, please contact Dr. Brock at brock@csus.edu.

Reactive attachment disorder of infancy or early childhood (RAD) was introduced as a psychiatric condition in DSM-III in 1980 (American Psychiatric Association; APA). Students who have this condition, which is associated with experiencing severe social neglect during early development (i.e., before the age of 5), have significant difficulties with social relationships DSM-III-TR (APA, 1987) divided RAD into two subtypes—inhibited and disinhibited. Youngsters who had the first subtype were described as displaying internalizing behaviors such as fear, avoidance, and withdrawal whereas youngsters who had the second type were described as displaying externalizing behaviors such as indiscriminate, superficial sociability. The criteria for RAD were relatively unchanged in DSM-IV (APA, 1994; 2000), but DSM-5 (APA, 2013) now has divided RAD into two separate and distinct conditions, reactive attachment disorder (RAD) and disinhibited social engagement syndrome (DSED). Despite the significant changes in DSM-5 regarding what was known previously as reactive attachment disorder of infancy or early childhood (RAD), there remains consistency regarding the prevalence of these disorders. The different editions of DSM consistently have described these disorders as rare and have suggested that they are more often seen in those who have been reared in deprived, institutional settings. DSM-5 (APA, 2013) notes that fewer than 10% of children who have been severely neglected develop RAD, and about 20% develop DSED (also see Gleason et al., 2011).

Changes From DSM-IV-TR

The changes in DSM-5 represent a reconceptualization of what DSM-IV-TR (APA, 2000) listed as reactive attachment disorder of infancy or early childhood (RAD). Table 1 identifies three of those changes. Individuals who had been diagnosed as having the Inhibited Type of RAD in DSM-IV-TR are now diagnosed as having reactive attachment disorder (note the shortened name) in DSM-5 (APA, 2013), whereas those who had been diagnosed as having the disinhibited type of RAD now receive a diagnosis of disinhibited social engagement disorder (DSED). Because RAD has been divided into two independent diagnostic categories, the criteria for each condition are now elaborated more extensively than were those of DSM-IV-TR (see Table 1 for details).

DSM-5 has eliminated the diagnostic group, Disorders Usually First Diagnosed In Infancy, Childhood, or Adolescence, in which RAD had been placed. Now RAD and DSED are part of a new group of diagnoses, Trauma and Stressor-Related Disorders. This new category includes post-traumatic stress disorder (PTSD), acute stress disorder, adjustment disorder, and other specified or unspecified trauma- or stressor-related disorders. Unlike the other stress disorders, which may arise at any age and may originate from a single event, RAD and DSED must originate during the early developmental period (i.e., prior to the age of 5) and must involve a pattern of social neglect, rather than a single traumatic incident. Like the trauma associated with PTSD, the stressors that precipitate RAD and DSED must be serious and extreme.

Table 1. DSM-5 Criteria for RAD and DSED and Their Relationship to DSM-IV-TR Reactive Attachment Disorder
DSM-IV TR (APA, 2000)DSM-5 (APA, 2013)
RAD — Inhibited Type (p. 118)

Predominant symptoms include persistent failure to initiate or respond in socially appropriate ways — excessively inhibited, hypervigilant, or highly ambivalent or contradictory responses to caregivers and others.

RAD (p.265)
  1. Consistent pattern of inhibited, emotionally withdrawn behavior toward caregivers — rarely or minimally seeks or responds to comfort when distressed
  2. Persistent social and emotional disturbance — minimal responsiveness to others socially or emotionally, limited positive affect or episodes of unexplained irritability, sadness or fearfulness even during nonthreatening interactions with adult caregivers (must have two of these behaviors)
RAD — Disinhibited Type (p. 118)

Predominant symptoms include diffuse attachments as manifested by indiscriminate sociability with marked inability to exhibit appropriate selective attachments

DSED (p. 268)

Actively approaches and interacts with unfamiliar adults, exhibiting two or more of the following: reduced reticence approaching and interacting with unfamiliar adults, overly familiar verbal or physical behavior in contrast ot age- and culturally appropriate behaviors, diminished checking back with caregivers, or willingness to go off with strangers

Other changes in DSM-5 concern the presumed causes of RAD and DSED, age of onset, and differential diagnosis. Disregard of the child's basic physical needs has been removed as a presumptive cause from DSM-5 and “rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios)” has been added as a cause of these stressor-related disorders (APA, 2013, p. 266, 268). In DSM-5, the list of the causal types of pathogenic care remains the same for both DSED and RAD (see Table 2). The earliest time period in which these disorders can be diagnosed is also the same for both disorders: DSM-5, unlike DSM-IV-TR, specifies that individuals must have “a developmental level of at least 9 months” to be diagnosed with these conditions (APA, 2013, p. 266, 269).

DSM-5 cautions that the indiscriminate sociability of youngsters who meet the criteria for DSED is not due primarily to impulsiveness (as is the case in attention deficit hyperactivity disorder), but is mainly a function of the child's socially disinhibited behavior. DSM-5 provides an expanded section on differentiating RAD from autism spectrum disorder, intellectual disability, and depressive disorders. DSM-5 added two specifiers for both RAD and DSED: the first regarding persistence of the condition (more than 12 months) and the second regarding severity (presence of all diagnostic symptoms at relatively high levels).

Table 2. DSM-5 Criteria and Specifiers for RAD and DSED and Their Relationship to DSM-IV-TR Reactive Attachment Disorder
RAD, DSM-IV TR (APA, 2000, p.118)RAD and DSED, DSM-5 (APA, 2013, pp. 265-266 and 268-269)
Pathogenic care - at least one of the following:
  1. persistent disregard of child's basic emotional needs for comfort, stimulation, and affection.
  2. persistent disregard of child's basic physical needs
  3. repeated changes of primary caregiver that prevent formation of stable attachments
Patterns of extremes of insufficient care - at least one of the following:
  1. social neglect or deprivation - persistent lack of having basic emotional needs for comfort, stimulation, and affection met by care-giving adults.
  2. repeated changes of primary caregivers, limiting opportunities to form stable attachments
  3. rearing in unusual settings that severely limit opportunities to form selective attachments
Specifiers: Type - Inhibited or Disinhibited Specifiers: Persistence (more than 12 months) Current severity (severe)

Rationale for the DSM-5 Changes

The rationale for separating RAD into two distinct disorders is based primarily on research regarding children and adolescents who display either the inhibited or disinhibited types of RAD. Zeanah and a research group who studied children reared in Romanian orphanages led the movement to parse RAD into two separate disorders. Zeanah and others found that a significant percentage of children who met the criteria for DSM-IV's RAD–disinhibited type demonstrated selective attachment to caregivers, whereas few children who met the criteria for RAD–inhibited type had formed an attachment to a caregiver in their early life (American Academy of Child and Adolescent Psychiatry [AACAP], 2005; Gleason et al., 2011; Minnis et al., 2009; Smyke et al., 2012; Zeanah & Gleason, 2010; Zeanah, Smyke, & Dumitrescu, 2002). In its practice parameters, the AACAP (2005) cited studies that found differences in the persistence of symptoms in children who had RAD–disinhibited type compared to those who had RAD–inhibited type. A significant minority of individuals diagnosed with the disinhibited type persisted in showing indiscriminate sociability into adolescence, even when they had established a preferred attachment with their new caregivers. When placed in more normative caregiving situations, children who had the inhibited type eventually became less inhibited and no longer met the criteria for a RAD diagnosis. These developmental differences support dividing RAD into two distinct conditions rather than two subtypes of one disorder and deleting the modifier “of infancy and early childhood” to the label. The division of RAD into two conditions is consistent with the categorization of these relationship disorders in the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD- 10; WHO, 1992) and further support APA's and WHO's attempts at aligning the two classification systems.

The changes in the types of “pathogenic care” infants and children who develop DSED and RAD have received emphasize that these are disorders of social relationships. They are caused by severely inadequate opportunities to form a selective attachment to a caregiver and result in marked deficiencies in relating to adults and peers. The shift in emphasis from attachment to social relatedness is based, in part, on current research and theory that suggests that the relatedness difficulties of individuals who have RAD or DSED are “quite distinct from attachment security or insecurity as conceptualized by Ainsworth, Bowlby, and others” (Minnis et al., 2009, p. 392; also see Minnis, Marwick, Arthur, & McLaughlin, 2006, and Rutter, Kreppner, & Snuga-Barke, 2009). Research supports the addition of unusual living situations as a causal criterion (e.g., Bruce, Tarullo, & Gunnar, 2009). The distinction between DSED and ADHD is supported by research conducted by Follan et al. (2011). The specification of the basal age at which a diagnosis can be made is based on the well-established developmental age in which preferred attachments start to become evident (cf. Marvin & Britner, 2008; Schaeffer & Emerson, 1964).

Possible Consequences of the DSM-5 Changes

By separating these types of social engagement problems into two conditions and grouping them with trauma- and stressor-related disorders, DSM-5 has increased the specificity of these conditions and has emphasized that their cause is stressors that are severe and unusual. By reconceptualizing the former RAD–disinhibited type as DSED, DSM-5 clarifies that this condition is characterized by persistent, indiscriminate, and diffuse social relatedness and is not characterized by a total failure to form preferred attachments to adults during infancy or early childhood. This reconceptualization encourages the focus of treatment for students who have DSED on developing appropriate social skills, rather than establishing attachment to an adult caregiver. By elaborating the criteria for current behavior of individuals who have RAD and DSED and expanding sections regarding differential diagnosis, DSM-5 increases the likelihood of accurate diagnosis. These changes will assist clinicians in distinguishing the impulsivity associated with DSED from that of attention deficit hyperactivity disorder and the social skill deficits of RAD from those of autism spectrum disorder.

Critics of DSM-5 (e.g., Frances, 2013; Greenberg, 2013) fear that DSM-5 will lead to untoward increases in the frequency of psychiatric diagnosis in children and adolescents because of the addition of new diagnoses and the lowered threshold of some diagnoses. These concerns could be raised regarding RAD in that a new diagnosis was created—DSED—and an item was added to the list of situations associated with the etiology of these conditions (i.e., rearing in unusual settings that severely limit opportunities to form selective attachments). For instance, there might be increases in diagnosis, particularly for children and adolescents who were adopted from orphanages or foster care, because of the addition of rearing in institutional settings as a possible causal agent. The possible increase in diagnosis is not likely, however, to be inappropriate, because DSM-5, like DSM-IV-TR, requires that serious social neglect must have occurred and cannot simply be inferred to have occurred.

Caution should be exerted to avoid facile conclusions stemming from the new placement of RAD and DSED among the Trauma- and Stressor-Related Disorders. The difference between RAD and DSED on the one hand and other Trauma and Stressor-Related Disorders on the other hand in terms of treatment modalities has important therapeutic implications. Chaffin et al. (2006) pointed out the lack of scientific validity in attachment therapies involving interventions such as rebirthing or coercing children and adolescents with RAD to maintain eye contact with or hug their caregivers. The application of deconditioning or implosion techniques to the treatment of RAD and DSED should not be used to rationalize radical and unsound interventions with young people who have these disorders. The application of social skills training techniques to young people with such drastic social disadvantages will have to be closely tailored to their individual needs.

Implications for School Psychology

The changes in DSM-5 regarding what DSM-IV-TR had called reactive attachment disorder in infancy or early childhood should help school psychologists identify the service needs of students who are diagnosed with RAD or DSED. Infants and preschoolers who have RAD or DSED may meet criteria for services from Birth-to-Three and preschool programs because of their developmental delays in emotional regulation and their disturbed social behavior. Children and adolescents who have either of these conditions may meet criteria for special education eligibility as individuals who have an emotional disturbance. They would almost necessarily meet two of the requirements of “an inability to build or maintain satisfactory interpersonal relationships with peers and teachers.” Those two requirements are “over a long period of time” and “to a marked degree.” It is anticipated that they would meet the third requirement, which is that their relationship deficits “adversely affect” educational performance, because as Schwartz and Davis (2006) noted in their review article regarding the implications of RAD in school settings: “The ability to regulate emotions and behaviors in the context of developing relationships is an important prerequisite skill required for school readiness and academic success” (p. 475). Students who have RAD or DSED probably also meet the ED criterion of “inappropriate types of behavior or feelings under normal circumstances.”

The diagnostic descriptions of RAD and DSED in DSM-5 may help school psychologists to better identify interventions needed for students who have either of these conditions. These interventions will help these students develop both social skills and emotional regulation. The extended discussion in DSM-5 of the developmental course of these conditions reinforces the idea that they may continue into adolescence, especially if environments do not provide opportunities for stable attachments. This discussion also provides an impetus for school psychologists to structure academic environments to aid children and adolescents who have the internalizing disorder of RAD or the externalizing disorder of DSED.

References

American Academy of Child and Adolescent Psychiatry. (2005). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy or early childhood. Journal of the American Academy of Child and Adolescent Psychiatry, 44, 1206–1219. doi:10.1097/01 .chi.0000177056.41655.ce

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American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Bruce, J., Tarullo, A. R., & Gunnar, M. (2009). Disinhibited social behavior among internationally adopted children. Development and Psychopathology, 21, 157–171. doi:10.1017/ S0954579409000108

Chaffin, M. Hanson, R. Saunders, B. E., Nichols, T., Barnett, D., Zeanah, C., … Miller- Perrin, C. (2006). Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems. Child Maltreatment, 11, 76–89. doi:10.1177/1077559505283699

Follan, M., Anderson, S., Huline-Dickens, S. Lidstone, E., Young, D., Brown, G., & Minnis, H. (2011). Discrimination between attention deficit hyperactivity disorder and reactive attachment disorder in school-age children. Research in Developmental Disabilities, 32, 520–526. doi:10.1016/j.ridd.2010.12.031

Frances, A. (2013). Saving normal: An insider's revolt against out-of-control psychiatric diagnosis, DSM-5, Big Pharma, and the medicalization of ordinary life. New York, NY: William Morrow.

Gleason, M. M., Fox, N. A., Drury, S., Smyke, A., Egger, H. L., Nelson, C. A., … Zeanah, C. H. (2011). Validity of evidence-derived criteria for reactive attachment disorder: Indiscriminately social/disinhibited and emotionally withdrawn/ inhibited types. Journal of The American Academy of Child and Adolescent Psychiatry, 50, 216–231. doi:10.1016/j.jaac.2010.12.012

Greenberg, G. (2013). The book of woe: The DSM and the unmaking of psychiatry. New York, NY: Blue Rider Press.

Marvin, R. S., & Britner, P. A. (2008). Normative development: The ontogeny of attachment. In J. Cassidy & P. R. Shaver, Eds., Handbook of attachment: Theory, research and clinical applications, 2nd ed., (pp. 269–294). New York, NY: Guilford Press.

Minnis, H., Green, J., O'Connor, T. G., Liew, A., Glaser, D. Taylor, E., … Sadiq, F. A. (2009). An exploratory study of the association between reactive attachment disorder and attachment narratives in early school-age children. Journal of Child Psychology and Psychiatry, 50, 931–942. doi:10.1111/j.1469-7610.2009.02075.x

Minnis, H., Marwick, H., Arthur, J., & McLaughlin, A. (2006). Reactive attachment disorder: A theoretical model beyond attachment. European Child and Adolescent Psychiatry, 15, 336–342. doi:10.1007/s00787-006-0539-2

Rutter, M., Kreppner, J., & Sonuga-Barke, E. (2009). Emanuel Miller Lecture: Attachment insecurity, disinhibited attachment, and attachment disorders: Where do research findings leave the concepts? Journal of Child Psychology and Psychiatry, 50, 529–543. doi:10.1111/j.1469-7610.2009.02042.x

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Smyke, A. T., Zeanah, C. H., Gleason, M. M. Drury, S. S., Fox, N. A., Nelson, C. A., & Guthrie, D. (2012). A randomized controlled trial comparing foster care and institutional care for children with signs of reactive attachment disorder. American Journal of Psychiatry, 169, 508–514. doi:10.1176/appi.ajp.2011.11050748

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Zeanah, C. H., & Gleason, M. M. (2010). Reactive attachment disorder: A review for DSM-5. Washington, DC: American Psychiatric Association. Retrieved from http://www.nrvcs.org/nrvattachmentresources/documents/APA%20DSM-5%20Reactive%20Attachment%20Disorder%20Review%5B1%5D.pdf

Zeanah, C. H., Smyke, A. T., & Dumitrescu, A. (2002). Attachment disturbances in young children. II: Indiscriminate behavior and institutional care. Journal of the American Academy of Child and Adolescent Psychiatry, 41, 983–989. doi:10.1097/00004583-200208000-00017


Madeleine Leveille, PhD, NCSP, has a forensic psychology practice in Waterford, Connecticut.