Reactive Attachment Disorder (RAD) in childhood

Dr Minnis

Dr Minnis is a Senior Lecturer in Child and Adolescent Psychiatry. Her main research interest is in Reactive Attachment Disorder in childhood and her research has involved developing new assessment tools and increasing understanding of the aetiology of this serious disorder of social functioning.

She has also developed computerised assessment tools for aspects of child and adolescent mental health.

Background
Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children.

There is potentially a higher level of incidence in homes where the family is long-term unemployed and there is a history of social care provision but RAD can also occur in, what is believed to be, the best of family situations.

RAD is characterised by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts.

It can take the form of a persistent failure to initiate or respond to most social interactions in

• a developmentally appropriate way, known as the "inhibited form," (RAD) or
• an indiscriminate sociability, such as excessive familiarity with relative strangers known as the "disinhibited form" (DAD). 

The term is used in both the World Health Organization's International Statistical Classification of Diseases and Related Health Problems (ICD-10) and in the DSM-IV-TR, the revised fourth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

ICD-10 Definition
In ICD-10, the inhibited form is called RAD, and the disinhibited form is called "disinhibited attachment disorder", or "DAD".

DSM Definition
In the DSM, both forms are called RAD; for ease of reference, this article will follow that convention and refer to both forms as reactive attachment disorder.

RAD arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts. Not all, or even a majority of such experiences, result in the disorder.

The criteria for a diagnosis of a Reactive Attachment Disorder are very different from the criteria used in assessment or categorisation of attachment styles such as insecure or disorganised attachment, e.g. Pervasive Development Disorder (PDD).

PDD: Pervasive Development Disorder
It is differentiated and has a separate classification from Pervasive Developmental Disorder (PDD) or developmental delay and from possibly comorbid conditions such as mental retardation, all of which can affect attachment behaviour.

Dr Minnis appeared on BBC Radio 4's Women's hour program to discuss RAD with the presenter and families that had suffered from the experience of having a teenager with RAD.