Reactive attachment disorder

In Reactive AttachmentThe communication of emotion between an infant and their primary caregiver(s) is essential to shaping the developing mind. "Emotion serves as a central organizing process within the brain. In this way, an individual's abilities to organize emotions - a product in part, of early attachment relationships directly shapes the ability of the mind to integrate experience and to adapt to future stressors." {{Rp|9}} Interruption in the attachment pattern of young children with their caretaker(s) has been shown to be a primary precursor to Dissociative Disorder pathology. (see etiology) {{Rp|85}} {{Rp|97}} Disorder (RAD), attachment between a child and a parent is underdeveloped. They would be able to, but they do not have the opportunity in their environment to form selective attachment. Thus, the disorder develops as a result of maltreatment and/or neglect. Additionally, they do not seek protection from their parents or caretakers and have trouble regulating emotion. As a result, they display periods of unexplained negative emotions like fear, sadness and irritability (American Psychiatric Association [APA], 2013a).

Disinhibited social engagement disorder was a subtype of reactive attachment disorder, but the two disorders have been separated because they turned out to differ in important ways (APA, 2013b).

The APA states that "both of these disorders are the result of social neglect or other situations that limit a young child’s opportunity to form selective attachments." (APA, 2013b, p. 9) Both disorders are readily identifiable in maltreated children and some young children who have been raised in institutions, although disinhibited social engagement disorder may have a biological cause in some cases. Reactive attachment disorder is moderately related to depression and impairs social functioning. An attachment disorder is warranted when a child that is developmentally capable of forming attachments, does not because of an aberrant caregiving environment (Zeanah, 2010).

Reactive attachment disorder more closely resembles internalizing disorders; it is essentially equivalent to a lack of or incompletely formed preferred attachments to caregiving adults. (APA, 2013b, p. 9)

History, Diagnosis and Treatment of RAD

Reactive attachment disorder was first included as a diagnosis in the 1980 DSM III, and historically studies have concentrated on infants and young children brought up in an institutionalized environment (Zeanah, 2010). It is now recognized in the ICD10 as well as the DSM5. Reactive attachment disorder is present only in children that lack attachments, and is not present in young children who have been adopted out of institutions. Reactive attachment disorder responds well to enhanced caregiving, and is related to the quality of caregiving (Zeanah, 2010).

Split of the two subtypes in DSM-5

In the DSM-IV, reactive attachment disorder did have two subtypes, an inhibited and a disinhibited subtype. In the DSM-5, the disinhibited subtype was separated from reactive attachment disorder and made into a standalone diagnosis (disinhibited social engagement disorder). They were split because the two disorders turned out to differ in important ways.

• Reactive attachment disorder is now what was the emotionally withdrawn/inhibited subtype.
• Disinhibited social engagement disorder is what was the indiscriminately social subtype. It more closely resembles but differs from ADHD. It may occur in children that don't lack attachment or even have secure attachment (APA, 2013b).

ICD10 Criteria for reactive attachment disorder of Childhood

The ICD10 includes reactive attachment disorder within a group disorders of social functioning, with onset specific to childhood and adolescence and assigns the code F94.1.

The ICD10 states reactive attachment disorder:

Starts in the first five years of life and is characterized by persistent abnormalities in the child's pattern of social relationships that are associated with emotional disturbance and are reactive to changes in environmental circumstances (e.g. fearfulness and hypervigilance, poor social interaction with peers, aggression towards self and others, misery, and growth failure in some cases). The syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. (World Health Organization, 1990)

Exclusions include Asperger's Syndrome, disinhibited attachment disorder of childhood, maltreatment syndromes, normal variation in pattern of selective attachment and sexual or physical abuse in childhood, resulting in psychosocial problems.