Friday, April 12, 2013
Got RAD? DSM-V Rethinks the Diagnosis; Maybe You Should Too
As most readers will know, the American Psychiatric Association periodically publishes a new edition of the Diagnostic and statistical manual of mental disorders. Years of work between editions contribute to removal or addition of diagnostic categories, and revision of criteria for particular diagnoses. The differences between older and newer standards make it very clear that mental illnesses-- while very real-- are understood through construction and re-construction of ideas about mood and behavior. Childhood mental illness is particularly subject to construction, because most of our thoughts about it have to do with what we adults expect of children, not how children expect or want to feel.
There is now a new edition of the Diagnostic and statistical manual of mental disorders. Known as DSM-V, it differs in a number of ways from the previous edition, DSM-IV-TR, which came out in 2000. It’s especially interesting to see what changes have been made in the diagnosis of Reactive Attachment Disorder, a childhood emotional problem. DSM-IV-TR (and two editions before that) described two variations in which RAD could appear. One of them, the inhibited form, involved clinging to caregivers and being unusually shy with strangers. The other, disinhibited form, was one in which toddlers and preschoolers did not seem to have the usual strong preferences for familiar people that most children their age show. They did not seem especially interested in or dependent on familiar adults, and were quite happy to interact with unfamiliar people. Both forms were associated with neglectful or abusive early parenting and with frequent changes of caregivers. The problem behaviors appeared before the children were five years old.
How severe are the problem behaviors? There has been enough research to show that they are not very severe (although of course any child may have multiple disorders, some associated with severe mood and behavior problems). Basically, no significant association has been shown between the “clingy” type and externalizing problems like aggressive behavior. Neither has there been a significant association between the “too friendly” category and aggression. The “too friendly” category is moderately associated with inattention and hyperactivity (see http://sti.mimhtraining.com).
Thus, as is the case for some other difficulties of early development, these two versions of RAD were not so much problematic in themselves as in the developmental trajectories they shaped. That is, except for the possibility of abduction, there are no immediate dangers associated either with being “too friendly” or “too clingy”. However, the clingy child misses many opportunities to learn and develop through contacts with other people, and may find school too anxiety-producing to benefit from attendance, thus getting farther and farther behind in social and intellectual skills, compared to more typical children. The disinhibited, “too friendly” child may miss out on learning about family values and attitudes because of his or her willingness to pay as much attention to outsiders as to familiar caregivers. Over the years of development, either of these extremes will probably produce less than ideal social and intellectual development-- although it’s possible that new experiences may help an individual child move in the direction of typical development.
As DSM-V was prepared, committee members working on diagnostic categories consulted professional discussions of diagnostic approaches and examined empirical work-- in the case of RAD, research on the characteristics of children diagnosed with RAD. They received comments from interested members of the public as well as considering diagnostic categories used outside the U.S. The comments are interesting to examine, as in some cases they were concerned with issues outside the matters the DSM committees focused on. For example, at http://blog.radzebra.org/?p=12, the author Julie Beem stated her objection to a proposed change in the RAD category, the addition of a diagnosis called Disinihibited Social Engagement Disorder: “The criterion…’persistent harsh punishment or other types of grossly inept parenting’ is alarming… The danger of using ‘grossly inept parenting’ as a criterion is the blame it places on whoever is currently parenting the child. Grossly inept parenting is difficult to define and the words are emotionally loaded. This criterion could actually make it harder for children to be correctly treated, served, or diagnosed because of the stigma of bad parenting. It could lead to the removal of children from safe, loving homes where they are exhibiting these symptoms with their new, appropriate caregivers.” Ms. Beem, like a number of commenters, seems to have missed the point that DSM categories are supposed to be based on systematic research, rather than on the possible impact on caregivers of naïve application of these categories; she may also have been concerned about whether some of the methods encouraged by radzebra.org could themselves be classed as grossly inept parenting. Like some others (see http://center4familydevelopment.blogspot.com), Ms. Beem wanted the DSM committee to add a new category, Developmental Trauma Disorder, rather than altering the RAD criteria, but although this proposed diagnosis has received much discussion in certain quarters, the research evidence to support its inclusion does not exist.
What did DSM-V actually do in its construction of Reactive Attachment Disorder? The final decision was to split the previously-existing category into two separate diagnoses. Reactive Attachment Disorder is now defined as a lack of or incomplete formation of preferred attachments to familiar people, with a dampening of positive affect that resembles internalizing disorders (for example, anxiety). Disinhibited Social Engagement Disorder is more like ADHD and may occur in children who have clearly formed, even secure, attachments. This fact suggests strongly that treatment for the second disorder need not focus on attachment (although any mental health intervention has a basis in relationship-building).
Has your child been diagnosed with RAD by someone who claims that the untreated disorder will lead to serial killing? Do you have an inattentive child who has been said to have an attachment disorder? It’s time for a new diagnosis by someone who understands and uses evidence-based categories.