Reactive Attachment Disorder and Attachment Disorder: Compare and Contrast

My colleague Linda Rosa recently sent me a link to an apparently highly commercialized organization called “The Adoption Exchange”. At https://www.adoptex.org/events/understanding-attachment-2016-april-18/, The Adoption Exchange announced a class that purported to explain the difference between Reactive Attachment Disorder and Attachment Disorder, as well as informing students about parenting methods that “heal attachment issues” in adopted children. The instructor was a licensed professional counselor. Nevada social work education units were said to have been requested for this class. A list of learning objectives was provided, but these were puzzling to me because rather than stating some active performance demonstrating mastery (such as being able to define certain terms or differentiate between two conditions), as such objectives ordinarily do, they simply referred to understanding as an objective. (But this is a problem for the Nevada social work association, not for the rest of us.)

I don’t know what the instructor said about differences between Reactive Attachment Disorder and Attachment Disorder, but I think I can guess, because of the very fact that she proposed to discuss a difference between one well-established diagnosis, and another that is essentially the invention of a group who are confused about the nature of attachment and of any problems that may result from a poor attachment history. The title of the course, “Understanding Attachment”, might be better stated as “Completely Misunderstanding Attachment.”

The term Reactive Attachment Disorder has been in the Diagnostic and Statistical Manual of the American Psychiatric Association since about 1980. It’s a term that has gone through various changes over the years, as has indeed been the case for a lot of other diagnoses as well. RAD was initially a term that shared much with nonorganic failure to thrive (NOFTT) as a description of poor weight gain and physical development in the first year or so of life. Because poor development can and does often result from physical disease processes (referred to as failure to thrive, FTT), RAD/NOFTT was a relatively new concept, suggesting as it did that poor growth and development might also result from disturbances of relationships with caregivers, such that a baby did not ingest enough food or was unable to digests and use what was provided. (I remember a lecture on this topic in the ’70s that gave as an example a mother who was so anxious that her baby would not eat enough that she attempted to entertain him after every bite by putting an umbrella up and taking it down again, which amused the baby but distracted him from eating.)  By the 1980s and ‘90s, the failure-to-thrive aspects of RAD had disappeared from DSM, and the term focused entirely on behavioral indications of infant-caregiver relationships. At that point, a spectrum of attachment relationships was envisioned, with normal attachment behavior in the “Goldilocks” position, and aspects of RAD on either side of that--  one side involving children who were did not seem to prefer one adult to another, and the other side including those who were excessively clingy and afraid of separation. The current, DSM-5, position has divided these possibilities into two separate categories, Reactive Attachment Disorder (involving aloofness, unresponsiveness, difficulty in engaging in relationships,  and difficulty in receiving comfort), and Disinihibited Social Engagement Disorder (lack of preference for familiar people, exploring without normal “checking back”, and willingness to go with strangers). Both of these begin before age 5 years (but after 9 months) and are preceded by poor caregiving experiences.

You can see that those two diagnoses, as currently defined, are based on different kinds of behavior . So, how are they different from attachment disorders? Given that the term “attachment disorder” is written all lower-case, they are not entirely different. “Attachment disorder” (all l-c) is a general term that can be applied to either RAD or DSED, and has been applied to disorganized/disoriented attachment behavior in toddlers.  “Attachment disorder” (all l-c) is not meant to indicate a particular kind of problem, any more than “childhood rashes” necessarily means rubella.

However, when people capitalize those words--  Attachment Disorder—they think they mean something specific. Even in the 1990s, proponents of Holding Therapy/Attachment Therapy, who claimed that childhood aggressive or noncompliant behavior resulted from attachment problems, had been told frequently that the things they were talking about were not Reactive Attachment Disorder. As a result, they proposed a new term, Attachment Disorder (with caps) that they claimed was characterized by failure to make eye contact on a parent’s terms, love of blood and gore, aggression toward small children and pets, etc. Elizabeth Randolph, a psychologist whose license had been revoked in California, self-published a test she called the RADQ (not Reactive Attachment Disorder, but Randolph Attachment Disorder Questionnaire [Randolph, 2000]). Randolph, felt that she could validate this questionnaire against her own diagnosis, because she was able, she said, accurately to determine which children had Attachment Disorder—for example, Randolph stated, they were unable to crawl backward on command. Randolph clearly stated that the RADQ did not diagnose RAD, but instead tested for  Attachment Disorder, a diagnosis that was “not yet” in DSM. Sixteen years later, AD is still not in DSM, and the reason is that no one has done any of the substantiating work to show that such a diagnosis differentiates reliably between a specific problem and other problems a child may have.

No one would deny that there are children who are highly (and dangerously) noncompliant, or who seem fascinated by aggressive acts, or who attack both adults and younger or weaker beings. What would be denied is that there is any evidence that such problems are associated with attachment history, or that they can be cured by treatments that focus on attachment. What would also be denied is that there is a need for an additional diagnosis to replace disorders like Obsessive Compulsive Disorder, Oppositional Defiant Disorder, early onset schizophrenia, and so on.

The Attachment Disorder (with caps) concept has been a money-spinner for a shadowy world of practitioners who have little training in either established theory or research facts about attachment. They have sold their views to adoption organizations, who in turn market them to confused and overwhelmed adoptive parents, for whom the idea of fixing previously-damaged attachment is most attractive.

I doubt very much that the instructor of “Understanding Attachment” made any of these points.