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.

"Chronic Biting Extinguished": Some Useful Ideas About Toddler Aggression

I want to comment today on a most interesting presentation I attended at a meeting of the Delaware Valley Group chapter of the World Association for Infant Mental Health. Lisa Poelle, author of The Biting Solution (see www.stopthefightingandbiting.com) discussed the complexities of toddler biting and offered some approaches to solving this often-difficult problem. Biting is a behavior that deeply distresses parents and caregivers of toddlers . It can be medically dangerous to the bitee, but even beyond that it has an out-of-control, “animal-like” vibe that causes some degree of panic--  and if it can’t be stopped, children are often kicked out of child care programs when care is essential to the family’s working hours and income.

Lisa differentiated between “garden variety biting”--  the occasional chomp that any infant or toddler may take when teething or just experimenting--  and the chronic biting in anger or frustration that may occur many times a day and that gets children thrown out of child care programs. The first will probably resolve by itself; the second needs help and guidance to help the child get back on track developmentally and to prevent either chronic aggressive behavior or other problems that can stem from constant disapproval and punishment.

Why do children bite, not just once but chronically? It’s all too easy for adults asking this question to fall into the “fundamental attribution error”--  the belief that people do things because of their own internal characteristics. They want to bite! They like to hurt people! They want to control everybody and everything! If we think that these are the reasons why toddlers bite, we probably won’t be able to think of any solution except to make them not want to bite, and to accomplish this by punishing them--  even, classically, by “biting them back”.

The title of Lisa Poelle’s talk, “Chronic Biting Extinguished”, immediately puts a very different spin on the biting problem. By talking about extinction of a behavior (the reduction in its frequency when it is not reinforced), she positions problem biting as a learned behavior. From that point she is able to consider not only how a child has learned to bite, but how he or she can be helped to learn not to bite, but to use more mature social skills instead.

Thinking about chronic biting as learned (rather than something fundamental to a child) also opens up the option of considering the difference between learning and performance. There are many things each of us has learned to do, but we don’t do them all the time. We can perform an action under the right circumstances or refrain from performing it under the wrong circumstances, and all this without having to forget how to do it. If the circumstances--  the environmental characteristics—are altered, our learned behavior can become more or less likely to occur. In driving a car, we ordinarily apply the brake only when we want to slow or stop, but if the rear-view mirror shows a truck barreling down on us, we may tap the brake several times to get the attention of the truck driver.  

Because children too perform in different ways in response to the environment, Lisa Poelle discussed many factors that influence the performance of a learned behavior, over and above the fact that it was learned rather than innate. Her handout (and her book) provided an action plan worksheet that guides caregivers to observe multiple factors that can influence the occurrence of biting--- factors that may not be easily observed by busy adults who are responsible for a number of children. Lisa suggested that only by careful observation of contributing factors can anyone create an action plan that will help a child not only stop biting, but start using more appropriate behaviors when frustrated.

Lisa’s action plan worksheet begins with examining the child’s developmental status. Does he  know how to share or take turns? Was the child premature, or is she tall, giving the impression of being more mature than she really is? Do adults expect too much of the child, and do they need to offer guidance in social skills?

A second issue is the child’s recent experience of changes and previous experiences in general. Are the parents either excessively strict or very lax at setting limits? Have they moved to a new house, had Grandma come to live with them, had a new baby, had parent conflict rise to high levels? Has there been a change in child care providers?

What are the child’s verbal skills like? There may be good receptive language but limited expressive language, and there may also be facial expressions that are hard for other children to read.

The child’s physical condition may be an important factor that increases or decreases biting. Toddlers need plenty of sleep and may not get it for various reasons. They may be hungry or thirsty more frequently than many day care centers plan for.

Temperamental differences can make some children need extra guidance with respect to biting. Children who are low in adaptability can be easily frustrated and need extra help around transitions or other challenging situations. Low thresholds of sensory responsiveness can make children generally irritable, as they quickly notice small differences in temperature or taste and are bothered by constricting clothing or tags on clothes. Those with negative mood quality may have blank or sulky expressions that discourage other children (and some adults) from approaching them in friendly ways.

The physical environment of the day care center may create problems for children and make biting more likely. Overcrowding, colors and sounds that are too stimulating, a lack of novelty or challenge in the toys available, a lack of soft things to sit on or play with, too few play spaces--  all of these may cause a vulnerable child to respond with biting to another child who is too close or who interferes with play.

Finally, the child care setting and the parents may be using ineffective practices for limit-setting. Forcing children to apologize may simply lead to continued biting followed by “sorry”. Time-outs may be ineffective and may simply raise the child’s frustration level. Lisa suggested “instructive intervention” both at the time of a bite and planfully at other times, with much emphasis on the child’s understanding how he feels himself--  not so much on the “how did you make Tommy feel?”--  and what he can do to express this without biting or other aggression. (One very practical idea was to provide a damp washcloth or teether that the child can bit on when tense.)

Just a couple of comments from me about the limit-setting issue: one point is that it’s much easier to get someone to do something different than to “just stop”. What do you do when you’ve stopped? That question is more than a toddler can answer. A second point is that when setting limits for toddlers, we need to go to the toddler and get down face-to-face with him or her. Calling from across the room, or looming over the child, is likely to have a frightening and frustrating impact if it has any impact at all. Finally, a little more about “how you feel” rather than “how he feels”: toddlers show the beginnings of empathy and of Theory of Mind, the understanding that other people think, feel, or know things other than what the toddler thinks, feels, or knows--  but they are not very good at this, and months and years will have to pass before they get much better. They cannot effectively perform the mental gymnastics of thinking, “I don’t like to be bitten. Tommy is like me. Therefore, Tommy also does not like to be bitten”. In any case, it doesn’t really matter whether they know how Tommy feels, if the issue is development of their own impulse control and social skills. Those are abilities they can develop best if they are aware of--  and have words to describe and talk about—their own feelings. They didn’t bite Tommy because Tommy felt good or bad, they did it because they themselves were  angry and frustrated. While “thinking how he feels” can be an excellent learning device for 6-year-olds, “thinking how you feel”—and knowing what you can do about it--  is developmentally appropriate for toddlers.

The late, great Sally Provence used to say “Don’t just do something; stand there and watch”. Unless we stand and watch in the ways Lisa Poelle has suggested, chances are that we will not be able to figure out what factors are encouraging a child to bite. And, by the way, unless parents and child care providers can work together cooperatively, and be candid and open about the situations at home and in child care, they will not be able to put together all the information that’s needed to solve the problem of chronic biting.

N.B. I hope everyone has noticed that there is no mention here of “therapeutic restraint” as a solution for toddler aggression.