If It's Not RAD, What Is It?

What psychiatric diagnosis describes cases where children are aloof, irritable, rebellious, and given to rages? Hands up, everyone who says Reactive Attachment Disorder, or just plain “RAD”-- no, sorry, that’s not the right answer, no matter what you read on commercial Internet sites.

Reactive Attachment Disorder is defined by the most recent Diagnostic and Statistical Manual of the American Psychiatric Association (DSM-IV-TR) as involving markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5. Most children under the age of 5 are shy with strangers, although they are friendlier to unfamiliar children than to unfamiliar adults. They approach familiar people when frightened or hurt, and show distress when separated from them, although they tolerate this better and better and they get older. Disturbed social relatedness can involve a problem with any of these normal behaviors.

Children diagnosed with Reactive Attachment Disorder may be inhibited in their social behavior, shy and anxious with everyone-- or they may be disinhibited, overly friendly, and as inclined to approach strangers as familiar people. In either case, to be diagnosed with this disorder, a child must also have had problematic early care experiences, and must not be mentally retarded or have other cognitive or emotional problems like autism.

Although Reactive Attachment Disorder used to be defined differently in an earlier DSM (it was defined as a feeding problem of infancy), it has never been defined as involving irritability or “rages”. Although some Internet sites of groups who claim expertise on this topic provide “RAD checklists” including love of blood and gore, aggressiveness, and a “darkness behind the eyes” as symptoms of RAD, others of the same school of thought suggest that these symptoms do not indicate RAD, but another type of attachment disorder that they say DSM has not yet included.

If not RAD, what might be an appropriate diagnosis for irritable children? The pediatrician Daniel Dickstein has recently discussed this in an article entitled “DSM-5 and pediatric irritability: Acknowledging the elephant in the room”, in the Brown University Child and Adolescent Behavior Letter, October, 2010. Dickstein commented on the possible directions that will be taken on this by DSM-5, the new edition, forthcoming in 2013 and presently in development. He noted that in DSM-IV-TR, irritability is “everywhere and nowhere simultaneously”, without being treated as a distinct or well-described symptom. But this situation means that while irritable children do not get the RAD diagnosis, it’s not necessarily clear what they should get.

Dickstein gave several examples of children for whom irritability was an important part of the picture. In the case of one 9-year-old, Dickstein said, “his parents report that he becomes very irritable and angry, hitting them and throwing objects, not always in reaction to being asked to do something… they describe one week where he had several multihour ‘rages’ at home, had trouble falling asleep, could not focus on anything, was talking very loudly, and acted as though his parents had no authority over him” (pp. 6-7), but there were also days when he did well. (And it’s remarkable how many of these behaviors show up on the checklists that claim to evaluate children for attachment disorders.)

One possible diagnosis for this child would be bipolar disorder (BD), or a suggested related category, “severe mood dysregulation” (SMD), in which the child reacts intensely to negative emotional stimuli, as well as showing excitement (hyperarousal). Another possibility,proposed but not decided on for DSM-V, is called Temper Dysregulation Disorder with Dysphoria (TDDD). As the name says, one focus of this diagnosis is on developmentally inappropriate temper tantrums-- a 2-year-old, for whom the occasional tantrum is developmentally expectable, would not be likely to receive this diagnosis. Included among symptoms of TDDD would be an angry or irritable mood, in which the child “loses temper, is touchy/easily annoyed by others, and is angry/resentful”.

As Dickstein points out, committee members working on DSM-V have not yet decided how the symptom of irritability will be handled in the 2012 edition. However, it’s clearly not a part of Reactive Attachment Disorder, and concerned parents should be wary of web sites or therapists that suggest a RAD diagnosis for angry children.