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christian counseling today
Vol. 20 no. 2
One of the most frequently asked questions I receive from
counselors, parents and staff in child and adolescent settings
is my understanding of, and advice on, Reactive Attachment
Disorder (RAD). The growing interest in the understanding
of RAD is due, in part, to the numbers of children in foster
care placement
1
and children adopted to America from
international orphanages.
2
Studies have, indeed, shown
significantly higher rates of mental health problems in chil-
dren within residential care settings as opposed to those not in
placements.
3
However, misperceptions and preconceived notions exist
concerning the theoretical and etiological factors with this
relatively new disorder. I have also seen confusion in the field,
and even among mental health professionals, between the
recognized
DSM
diagnosis of RAD and the more generally
familiar “attachment disorder,” a term child and adolescent
researchers use to describe a broader symptomology that
combines elements of oppositional defiant disorder, Attention
Deficit Hyperactivity Disorder (ADHD), conduct disorder,
anxiety disorders and even Post-traumatic Stress Disorder
(PTSD).
4
In fact, in older children and adolescents, attach-
ment disturbances may better be accounted for by any of the
aforementioned disorders.
5
I hope to dispel some of these misperceptions and clearly
explain RAD and its most recent corresponding diagnosis,
disinhibited social engagement disorder.
Changes from
DSM IV-TR
to
DSM-5
In addition to moving to a brand-new category called
“Trauma and Stressor-Related Disorders” (along with disin-
hibited social engagement disorder, PTSD, acute stress
disorder and adjustment disorders), one of the most signifi-
cant changes of reactive attachment disorder in the recently
released
DSM-5
, was the separation of its previously recog-
nized subtypes (inhibited and disinhibited) into two separate
disorders.
Signs and Symptoms
Reactive Attachment Disorder now consists primarily of the
previously titled inhibited type. It is described as “a pattern
of markedly disturbed and developmentally inappropriate
attachment behaviors, in which a child rarely or minimally
turns preferentially to an attachment figure for comfort,
support, protection, and nurturance.”
6
Children with RAD
have extreme difficulty self-soothing, being comforted by
others, and show minimal, if any, positive emotions. For no
apparent reason, they can become irritable, sad, or fearful.
The primary diagnostic feature “is absent or grossly underde-
veloped attachment between the child and putative caregiving
adults.”
7
The disinhibited type is now known as disinhibited
social engagement disorder and is different from RAD in
that the child’s attachments to primary caregivers can range
from neglectful to disturbed, but also be secure. The primary
diagnostic feature “is a pattern of behavior that involves
Reactive
Attachment
Disorder &
Disinhibited
Social
Engagement
Disorder
Joshua Straub
