Reactive Attachment Disorder DSM-IV Diagnosis Problems

Reactive Attachment Disorder (RAD) as defined in the DSM-IV is misunderstood, under diagnosed and ignored by the adoption industry, the foster care system and orphanages. Attachment Disorder is diagnosed by similar internationally standardised diagnoses, in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th Edition) and the ICD-10 (International Statistical Classification of Diseases and Related Health Problems, 10th Revision)

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There are problems with the criteria, which must be fulfilled for an Attachment Disorder diagnosis, one of which is:

The behavior must be caused by the pathological care.

The problem here is that parents neglecting the child will not be willing to admit this, so there is a certain guesswork involved. Also two siblings, even twins, can react to the neglect in different ways because of their different personalities, making a connection bad parental care => bad behavior difficult in some cases. Emotional neglect can be the result of bad parenting and bad parenting attitudes.

This can result in social workers assuming neglect and/or abuse from the behavioural symptoms, when proven abuse should be a criterion to diagnose. One study showed that 20% of attachment disorder cases are not caused by abuse or neglect. Some more work needs to be done with the DSM diagnosis for Reactive Attachment Disorder.

One of the criteria for diagnosing Attachment Disorder is:

Repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care).

This definition of pathological care is a description of how children are cared for in an institutional orphanage system. The authorities are unlikely to focus on a disorder they themselves help to perpetuate. If the child already is suffering from one of the attachment disorder types, then placing that child in an orphanage stabilises the pathological inability to bond, preventing the child from developing in a healthy way.

In fact this is likely to be a criteria in the next version of the DSM, DSM-5, and is even more specific.

Rearing in unusual settings such as institutions with high child/caregiver ratios that limit opportunities to form selective attachments.

This is precisely what happens in the orphanage system. In other words the orphanage system’s institutionalised care creates and maintains an attachment problem. How can we expect an under resourced and under funded institution to take attachment disorder seriously when they cause it. Obviously, since the staff are human, they are forced into a state of denial for their own personal emotional survival. The politicians are unaware of the situation and anyway budgets are driven by votes, and the children in the orphanage system do not come high up on their priorities. Football stadiums yes, but not children that society has already written off as a loss.

Many Attachment Disorder children get misdiagnosed with some condition for which they can be medicate into compliant submission. There is no medication that cures Attachment Disorders, only patient behavioral therapy. Patience and perseverance with good professional guidance for the parent/carer is the key

The DSM-IV is a useful and valuable tool in diagnosing and understanding Reactive Attachment Disorder, but it is not a Bible written with the finger of God in stone. It is an ongoing attempt at classifying mental health conditions. The diagnosis needs to be interpreted in the context of real life situations with some common sense, not forcing people into a misdiagnosis.

One study of children abandoned at birth who did not get adequate attachment giving care, showed 38% of the children developed the Disinhibited Type, 31% developed the Inhibited Type and the other 31% formed preferred attachments to certain caregivers. This shows the role of personality in how we develop socially. There are many other factors involved in how we adapt and adjust to social relationships in life, among them is if the mother was abused or suffered high levels of stress during pregnancy, which causes the child to be less stress tolerant.

There is even less research conducted on children older than 6 years of age, but those studies confirm that the behavioral profile remains consistent, with dysfunctional behavior such as overfriendliness together with poor peer relationships and not being aware of boundaries with strangers.

A secure attachment leads to a socially healthy life, while a disorganized attachment, insecure attachment or an anxious attachment behavior leads to a traumatic, confused and unhappy life with conflicts and an inability to form a long-term relationship. At worst it can lead to the person developing a personality disorder as an adult.

There is not enough research on Attachment Disorder and the stages of its development especially as it affects adults. It is difficult to treat and there is not much money in treating the disorder, as the symptoms cannot be medicated away with drugs. However there is an indirect cost to every society from the social disruptions caused by this disorder, left untreated, as the children become adults.

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