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Article Excerpt
Attachment is a critical issue among children in foster and adoptive settings. It is essential for mental health counselors who work with these children to develop appropriate appraisal skills for diagnosing Reactive Attachment Disorder (RAD), a syndrome associated with extreme attachment problems. However, there is no comprehensive procedure to assess a child for RAD. Thus, we propose a battery of semi-structured interviews, global assessment scales, attachment-specific scales, and behavioral observations to help mental health counselors identify the disorder We provide a case example to illustrate the utility of each assessment process.
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Reactive Attachment Disorder (RAD) is a developmental disorder resulting from either severe abuse and/or neglect of a child. Diagnosing RAD according to Diagnostic and Statistical Manual of Mental Disorders (4th ed. Text rev.; American Psychiatric Association, 2000) criteria is often a difficult process due to problems with differential diagnosis as well as disagreement among professionals regarding the etiology of RAD. In order to facilitate accurate diagnosis, an assessment protocol for RAD is necessary. While assessment protocols are controversial in nature, the difficulties faced by mental health counselors assessing children with RAD mandate accurate assessment protocols. We propose a battery of semi-structured interviews, global assessment scales, attachment-specific scales, and behavioral observations to identify attachment-related issues. We review the instruments used in our clinic and provide rationale for the application to RAD.
CURRENT CRITERIA AND COMORBIDITY
In efforts to simplify and create a quick reference, the DSM-IV-TR (2000) criteria for RAD as well as other related disorders are depicted in Table 1. Information provided on the etiology of this disorder is limited, and the prevalence of RAD is reported by the DSM-IV-TR as very uncommon. In fact, criteria and prevalence of RAD are areas of debate for many researchers. Boris, Zeanah, Larrieu, Scheeringa, and Heller (1998) noted that the DSM-IV-TR has been critiqued for its focusing of RAD as a "maltreatment syndrome" with emphasis on problematic parental care and overt social oddities, rather than a diagnostic focus of attachment issues. Consistent with this criticism, the DSM-IV-TR makes a distinction between two subtypes of RAD: (a) inhibited and (b) disinhibited types. The inhibited type focuses on social deficits that result in a child's inability to respond or initiate developmentally appropriate interactions. Disinhibited type describes a deficit in a child's ability to selectively choose an appropriate attachment individual.
Another important concern of the RAD diagnosis is its convenience to account for difficulties in children with maltreatment backgrounds. The diagnosis of RAD, while still considered uncommon, is gaining popularity in diagnosing children with neglectful and abusive histories. Hanson and Spratt (2000) noted that increasing use of this diagnosis among a particular population represents a possible danger of pigeonholing children into a diagnosis that is unwarranted or incomplete. Richters and Volkmar (1994) put forward the notion that the basis for the RAD diagnosis is twofold: (a) to conceptualize the deficits in social development, and (b) maintain a clinical awareness of the pathological familial background.
Conversely, prevalence and diagnosis has been called into question. In a recent article, Sheperis, Renfro-Michel, and Doggett (2003) noted that RAD symptomotology mimics that of many childhood disorders found in the DSM-IV-TR (2000). According to these researchers, not only can we attribute RAD's symptoms to another disorder, but RAD is often overlooked as a possible diagnosis for children who are potentially meeting its criteria. Hanson and Spratt (2000) cite misuse of defining terms such as bonding and attachment in creating diagnostic confusion, as the terms are being applied interchangeably by researchers and mental health counselors. The use of these terms synonymously implies the potential lack of conceptualization of the foundation of RAD that is imperative to its diagnosis.
The results of research conducted by Lynam (1996) supports the need for expansion of criteria for RAD and its potential relationship to other disorders such as conduct disorder, oppositional defiant disorder, ADD/ADHD, and the development of antisocial personality disorder. Lyman also examines the possible relationship between ADHD and conduct disorder as a possible basis for the development of a serious disorder he terms as "fledgling psychopath." Thus, RAD and other conduct-type disorders all reflect severe symptoms within children. These types of behaviors are potentially linked to the most resistant type of disorders to treat such as antisocial personality disorder. Therefore, there is added pressure for mental health counselors as well as researchers to determine adequate criteria so that these disorders can be diagnosed and treated closest to their onset.
In a study of 60 partially hospitalized adolescents, Rosenstein and Horowitz (1996) noted the many factors affecting diagnosis such as: (a) pathological or traumatic familial history, (b) low SES and economic conditions, (c) insecurity in attachment relationships, and (d) early onset of symptomology. All of these factors can contribute to the difficulty in adequately diagnosing and distinguishing RAD from a host of other psychiatric disorders. It can also account for the probability of the emergence of pathology.
DIFFERENTIAL DIAGNOSIS
Differential diagnosis is a critical area for any disorder; but due to the resemblance of other disorders, it is of particular importance to RAD (Muladdes, Bilge, Alyanak, & Kora, 2000). Many disorders are listed in the DSM-IV-TR (2000) that should be differentiated from RAD such as (a) mental retardation, (b) autism, and (c) pervasive developmental and attention-deficit disorders. Lynam (1996) provided other disorders to differentiate from RAD, including oppositional defiant disorder, conduct disorder, and the development of antisocial personality disorder. Lynam cited an overlap between conduct disorders and ADHD as well as concurrent and historical heterogeneity as potential variables maintaining diagnostic uncertainty.
Key components in adequately diagnosing RAD include: (a) differentiating the cognitive and lingual portion of the disorder adequately from other developmental disorders (such as those previously listed); (b) noting the behavioral portions, despite their tendencies to overlap other conduct type disorders; (c) paying particular attention to the assumed origin of the disorder as it relates to symptomotology; and (d) placing special emphasis on careful consideration of these criteria when making the diagnosis. With these considerations in mind, we developed an assessment protocol that aids in the identification of RAD. We provide a case example to illustrate the complex nature of RAD and the function of each instrument in the protocol. All of the identifying information related to the case has been changed to protect the confidentiality of the client.
CASE EXAMPLE
Reason for Referral
A state adoption specialist referred Joe Smith for a psychological evaluation. The evaluation was requested in order to determine the effect of physical and emotional factors on adoption placement. Prior to the assessment, Joe's adoptive parents reported that Joe demonstrated withdrawal, a high degree of fidgety behavior, difficulty sustaining attention, excessive talking, excessive distraction by extraneous stimuli, lack of boundary management, a degree of forgetfulness, and excessive daydreaming. He had formal diagnoses of Attention Deficit Hyperactivity Disorder (314.01) and Auditory Visual Processing Disorder (315.2) from a previous psychological evaluation conducted by an independent psychologist. Mental health medical interventions at the time of assessment included Adderall and Paxil.
Family History
Both the targeted adoptive parents and biological mother supplied psychosocial information prior to the date of assessment. The adoption specialist also supplied detailed information about Joe's history surrounding adoption placement. Joe, whose primary language was English, had some difficulty supplying historical information. He had problems recalling information about the reasons for his placement in foster care or details about his life with his birth parents. Joe had been in the custody of DHS for over 2 years at...
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