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Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Wednesday, February 17, 2016

Five Ways of Looking at "Attachment Disorders"

What is a syndrome of behavior and/or causes that leads to a mental health diagnosis? When we talk about mental health diagnoses, we are trying to use an analogy to diagnoses of physical illnesses and injuries. Like mental health diagnoses, classifications of physical health problems have to place people into categories for which they meet some, but not necessarily all, of the criteria. These diagnoses may in both cases also involve symptoms that can be found among the criteria for more than one category of problems. But--  there is one big difference between mental health and physical health diagnoses. For problems of physical health, there is a physical cause that may be hard to ascertain but is certainly there; without a specific physical cause, a specific diagnosis will not be made.

In the case of mental health diagnoses, physical causes are rarely present in detectable forms. Genetic factors may play important roles in causing mental illness, but although there is much ongoing research in this area, the complexity of the human genome makes it difficult to isolate genes and genetic events that may be at work. Occasionally criteria for mental health diagnoses  include  causes in the form of experiences (for example, post-traumatic stress disorders), but such causes have not been demonstrated for most mental health disorders, and it may be very difficult to trace histories of experience in early life. 

Our lack of understanding of causes of mental illness means that criteria for a diagnosis generally depend on systematic observation of many cases and the establishment of evidence that certain symptoms tend to be found together in ways that may overlap somewhat with other diagnostic categories but that can be regarded as having their own unique pattern. Our understanding of these patterns changes with new information, and that is why lists of diagnostic categories and their criteria change over time, and categories may be added or deleted.

In the 2013 edition of the American Psychiatric Association’s Diagnostic and statistical manual of mental disorders (DSM-5), changes were made in the description and criteria for Reactive Attachment Disorder, a diagnostic category that had been changing over the years since 1980, when it was classed as a disorder of feeding. This category had involved two potentially problematic patterns of social interaction by young children, one in which the child was anxious about separation and clung to caregivers, and one in which the child appeared interested in adults but indifferent to particular people, with no preference for familiar caregivers. In DSM-5, two separate categories were used. In one, Reactive Attachment Disorder, the child does not seek comfort from caregivers or respond to it when distressed; the child is not responsive to others and shows little positive emotion; the child may be irritable, sad, or fearful when interacting with an adult, even when there seems to be no evident threat to the child. For this diagnosis, there must also be a history of extremes of inadequate care, the child must be at least 9 months old because attachment does develop sufficiently before that age, and the child must be less than five years old when the problematic behavior begins.

The second DSM-5 category, Disinhibited Social Engagement Disorder, involves behavior rather different from the typical responses of young children to separation from familiar people or to the approach of strangers. Children with DSED readily approach strangers and are overly familiar with them in physical and verbal ways (as compared to what is typical of young children). They are less likely than typical children to “check back” by looking at or speaking to a familiar caregiver when exploring unfamiliar settings. They show little hesitation about going with an unfamiliar adult. To receive the DSED diagnosis, the child must also have experienced extremes of inadequate care and be at least 9 months old. There is no upper limit for when the  behavior begins, no doubt for the reason that such friendly, non-anxious behavior is much more typical of older children and should not be seen as problematic; what is “overly familiar” also changes with age.

DSM-5 is often treated as the “last word’ about mental health diagnoses, but in fact there are other sets of diagnostic categories. One of these is the one your insurance carrier is likely to use: the World Health Organization’s International classification of diseases and related health problems (ICD-10). ICD-10 includes the diagnostic category Reactive Attachment Disorder of Childhood and describes this as involving persistent abnormalities in the child’s pattern of social relationships, including fearfulness and hypervigilance, poor social interaction with peers, aggression toward self and others, misery, and possible growth reduction or growth failure. This syndrome is said probably to occur as a result of serious neglect, abuse, or mishandling, but unlike DSM-5, such a history is not required for the diagnosis. It’s notable that although the term “attachment” is found in the name of the diagnosis, the criteria do not particularly mention social interactions with adult caregivers.

ICD-10 also includes Disinhibited Attachment Disorder of Childhood, which is essential described in the same way as DSM-5 described DSED. The interesting difference is that ICD-10 says that depending on circumstances there may be associated emotional or behavioral disturbance.

ICD-10 dates back to an initial publication in 1992, and there is an ICD-11 in the works. Drafts of proposed material for ICD-11 are available. For Reactive Attachment Disorder, the draft proposes that the disorder occurs in cases of grossly negligent child care and involves grossly abnormal attachment behaviors. The child does not seek comfort from familiar caregivers or other adults and does not respond to offered comfort. The disorder cannot be diagnosed before one year of age or 9 months developmental age. The draft notes that there are normal variations in selective attachment behavior and these should not be confused with Disinhibited Attachment Disorder.

The ICD-11 draft uses the term Disinhibited  Social Engagement Disorder instead of Disinhibited Attachment Disorder, and again proposes that this problem must occur in the context of a history of inadequate care. The criteria are similar to the DSED criteria. The disorder is not to be diagnosed before age one year and must begin before age 5 years.

But ICD-10 and ICD-11 are not the “last words” either. Because diagnosis of early childhood mental health problems may be quite a different task than diagnosis of adults, the Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood (Revised edition; DC:0-3R) has been developed. DC:0-3R has dropped the term Reactive Attachment Disorder and instead refers to Deprivation or Maltreatment Disorder of Infancy. This may appear in three patterns. The first, an emotionally withdrawn or inhibited pattern, may be characterized by failing to seek comfort when stressed, showing few attachment behaviors (cooperating, seeking help from others), appearing emotionally blunted, showing frozen watchfulness, avoiding and failing to initiate social interactions, or actively resisting comforting. The second pattern, an  indiscriminate or disinhibited pattern, involves a lack of the usual shyness about interacting with strangers, seeking comfort and proximity even with strangers, and even resisting comforting by familiar people. In a third pattern, there may be a combination of features from the first two. As its title suggest, DC:0-3R is a classification system for infants, toddlers, and preschoolers, and would not be used for older children.

What’s the fifth way of looking at ‘attachment disorders”? I’m only mentioning this one because I want readers to compare it to the legitimate attempts to define the diagnosis. Here’s part of a list of symptoms given by Nancy Thomas, the well-known proponent of  an alternative theory of child development,  at www.attachment.org/reactive-attachment-disorder/ : superficially engaging and charming, lack of eye contact on parents’ terms, indiscriminately affectionate with strangers, cruel to animals, etc. etc. If anyone reading this has been exposed to this view of “attachment disorders”, let me suggest that you compare it carefully to the DSM-5, ICD-10/11, and DC:0-3R efforts. Keep in mind that that the first four were based on careful observation and ongoing discussion by people trained in research methodology. The last one was borrowed from the old Hare Psychopathy Checklist, slightly revised to bring in some alternative beliefs about eye contact and some behaviors related to conduct disorders—also, to give parents a good scare.

It’s evident that professionals are still refining their formulations of “attachment disorders”. However, none of these efforts so far have included the list at www.attachment.org, and I am quite certain that they never will.


6 comments:

  1. Excellent article. I just attended a "training" that was supposed to be on RAD and it was a trainwreck. I will have to do some clean-up in our community from that experience. I will probably point people here, thank you!

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    1. I'd really like to no more details of what you attended and where it was, if you can give them. Were there psychologists involved? A complaint to the state licensing board might be in order.

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  2. Hi,my baby is 2 months old and still don't make eye contact and rarely smiles.sometimes I also see her eyes are not alligned.for few seconds she track objects..please help me

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  3. Dear Pratima-- your baby is still very young and may not be quite ready to do these things. I would bet that she will smile and make eye contact more by the time she is 3 months. However, please understand that even then her eye contact will probably be quite brief-- they do not gaze into your eyes as adults do.

    If you are very worried and sad about this, it might be a good idea for you to ask your doctor about depression. Sometimes mood problems following childbirth make mothers worry when there is really nothing to worry about.

    Berst of luck to you and your family!

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  4. My daughter has RAD, she is adopted from foster care due to neglect. She would not look back to make sure I was still there, she would talk "at" me not to me, she would make sit on strangers laps, she is overly controlling basically has 90% of the symptoms of the classic check list, except the most extreme. I've been to a therapist that recommended what would be termed moderately nutty. I've been to ones that don't believe it is real. Based on what I've seen it is very real and not at all rare like is claimed. Perhaps the extreme cases are rare but I see mild versions in children of divorce, children with mentally absent parents, children who are just plain without a support system. Where emotional ends and true physical illness begins with this I do not know. However, I do believe that anything that causes a child to doubt their personal security at an early age causes this in various degrees and is often mistaken for something else like ADHD and chemical imbalances. Perhaps there are parts of the brain that are less developed because of the separation. I don't know but I know it is not at all rare, all too often the approach is drugs that never address the underlying issues. Our society is full of detached adults, we are a transient disposable society. We divorce, move, use social media in place of personal contact, children have brothers, sisters, half brothers, half sisters, step sisters, step brothers, these siblings have half siblings etc. and lets not forget the same chain of siblings, aunts, grandmothers, of just plain live ins that come and go in their lives. If you have to really think about where you are going on Christmas and when, you have an issue. The basis of sexual harassment, bullying, oppositional defiant disorder, even depression is a feeling of lack of control. That feeling is the core of reactive attachment disorder and it is a common condition that is the basis of many other conditions. Perhaps more effort should be put on knowing what it takes to make a child feel in control and secure to begin with, instead of trying to fix the various problems that comes after the damage is done.

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  5. I would certainly agree with your conclusion, that prevention would be a much better idea than attempts at treatment.

    But I have to point out that while psychologists and psychiatrists certainly recognize the problematic behaviors you describe, they do not refer to them as reactive attachment disorder, a diagnosis that has a quite different description.

    All the experiences you describe, like not knowing where you will go for Christmas, certainly cause a preoccupation with control. (And strangely enough, some who claim to treat attachment disorders make a point of withholding information from children!) However, I think the emphasis you are putting on experiences can make people forget some other factors that can affect adopted children perhaps more than they affect most children. There are genetic factors that help to determine personality and behavior, and these can influence tendencies to ADHD , depression, and other mental health problems. Although some adopted children lost their biological parents through accident or illness, most children adopted from within the U.S. have been placed for adoption after parental rights were terminated as a result of abuse or neglect of the specific child or other children. Abuse and neglect are associated with addictions and with mental health problems (as well as with poverty and other risk factors), and these have genetic components. This means that adopted children MAY be more likely to carry genetic factors that make them more vulnerable to development of behavior problems. This unfortunately means that some adoptees are more likely to develop behavior problems even if their care has been ideal. It would be a good thing if adoptive parents could be educated about this and prepared to use some evidence-based methods that can help guide development along the best possible trajectories. This could solve part of the problem you describe, even in cases where poor early nurture has created poor foundations for development.

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