RAD vs. DSED: DSM-5 Changes Through a Humanistic Lens

The DSM-5 Change: RAD and DSED Diagnostic Criteria

In the DSM-5, RAD is diagnosed in children who are 9 months or older but under the age of 5. They must meet the criteria of failing to develop appropriate attachments to caregivers and failing to respond in an expected or appropriate way to comfort provided by caregivers. Children with RAD must also display at least two of the following characteristics: little to no social or emotional responsiveness to other people; little to no positive affect; and episodes of unexplainable irritation, sadness, fear, or anxiety that become apparent even when there is no threat from an adult care provider. At the same time, there must be an evident pattern of neglect, inadequate stimulation, or lack of affection from a caregiver; repeated rotation among care providers that prevents stable attachments from forming; or raising of the child in an environment that is unusual and prevents selective attachments from developing. Some examples of situations in which RAD can occur include a foster child who is frequently moved from one caregiver to another, and institutionalized care where there is no opportunity for the child to develop an attachment. Delays in cognitive and behavioral development often co-exist with RAD. Malnutrition and depression are also common co-occurring symptoms.

In the DSM-5, DSED is diagnosed in children who show little to no reticence in engaging adults who are unknown to them, or who act overly familiar with unfamiliar adults and demonstrate a willingness to wander away from caregivers without checking back with them—even to the point of going off with unfamiliar adults without hesitation. This kind of behavior should not be associated with impulsivity but rather should represent a consistent pattern of socially disinhibited behavior. The same pattern of neglect in terms of proper care must also be evident, as with cases of RAD. Children with DSED tend to have shallow relationships with peers and multiple conflicts with peers (American Psychiatric Association, 2013). However, DSED has not been identified in individuals who have experienced neglect from caregivers past the age of 2—and that is the main difference between it and RAD (Gleeson et al., 2011).

Literature Review

Both RAD and DSED are extremely rare occurrences among children who experience neglect from caregivers (Hornor, 2019; Mayes, Calhoun, Waschbusch, Breaux, & Baweja, 2017; Waschbusch, Mayes, Calhoun, & Baweja, 2018). Although both have been included in the DSM-5, neither occurred sufficiently in clinical settings to allow researchers to study the disorders adequately (Lehmann, Breivik, Heiervang, Havik, & Havik, 2016). Allen and Schuengel (2020) conducted an assessment of 100 maltreated foster children who presented for attachment disorder. Of the 100, only 3 were clinically diagnosed with DSED and none with RAD, according to DSM-5 criteria. The rarity of these disorders has thus been thoroughly established. That said, some researchers make the mistake of viewing RAD as a conduct disorder (CD) or as a callous/unemotional (CU) presentation (Allen, 2018). This is an error, as it contradicts the DSM-5 criteria for diagnosis.

There is also a considerable body of research focused on the overlap or co-occurrence of autism spectrum disorder (ASD) and RAD or DSED (Mayes, Calhoun, Waschbusch, & Baweja, 2017; Minnis et al., 2020). This research suggests that there may be some linkage between ASD and attachment disorders, though more research is needed to better understand the relationship. Currently, RAD and DSED are viewed as disorders caused by a lack of stable interaction with appropriately capable caregivers providing adequate care and nourishment. The development of RAD and DSED is consistent with Erikson's stages of psychosocial development, and this model has been applied to better understand how psychosocial obstacles can result in attachment disorder (Darling-Fisher, 2019). Healthy development consists of having the right supportive environment so that the child receives the necessary love, nourishment, and support.

According to Erikson, there are important stages of development that the child must pass through, each with its own central conflict. Other theories of development also exist, such as those of Piaget and Vygotsky. Vygotsky, for instance, argued that children learn by observing others. Since humans are social creatures, society is important for development—and for that development to proceed correctly, the social environment should be nurturing and stable. Social influences are particularly important in adolescent development, when emotions are felt intensely. Cold cognitive moments enable adolescents to think rationally, while hot cognitive moments make reasoning more difficult; adolescents constantly move between both states.

Additionally, Seim, Jozefiak, Wichstrøm, and Kayed (2019) researched the extent to which RAD and DSED can be validly diagnosed in adolescent children. They found that RAD and DSED can have latency in children and go undiagnosed into adolescence, where the disorders become more pronounced. Their conclusion was that both disorders may be rare in younger children but are more commonly found in adolescents: "RAD and DSED are not uncommon among adolescents in residential youth care and therefore warrant easy access to qualified health care and prevention in high-risk groups" (p. 1465). That finding suggests that RAD and DSED are disorders that become more pronounced over time and that stem from a lack of stable interaction with proper caregivers.

Conclusion

The separation of DSED from RAD in the DSM-5 has been shown to be logical on the basis that the two disorders are quite distinct from one another in clinical diagnosis and presentation, and that each develops through different factors arising during the developmental stages, as explained by humanistic psychology using Erikson's model of psychosocial development. For instance, the first stage of development—occurring between birth and 1.5 years—is where the conflict of trust vs. mistrust is encountered. It is likely that a person who later develops DSED would resolve this stage toward trust, while a person who develops RAD would resolve it toward mistrust. In the second stage, where autonomy vs. shame is the central conflict, the person who develops DSED would likely establish an extreme sense of autonomy, while the person with RAD would develop an extreme sense of shame causing avoidance of all adults. In the third stage of initiative vs. guilt, the same divergence would likely occur: the person with DSED developing extreme initiative, and the person with RAD experiencing a pervasive sense of guilt that prevents wanting to be around adults, who are perceived as censorious. Finally, neglect is associated more strongly with RAD than with DSED, which further supports the rationale for viewing these two disorders as separate diagnoses rather than as subtypes of a single condition.

References

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Lehmann, S., Breivik, K., Heiervang, E. R., Havik, T., & Havik, O. E. (2016). Reactive attachment disorder and disinhibited social engagement disorder in school-aged foster children—A confirmatory approach to dimensional measures. Journal of Abnormal Child Psychology, 44(3), 445–457.

Mayes, S. D., Calhoun, S. L., Waschbusch, D. A., Breaux, R. P., & Baweja, R. (2017). Reactive attachment/disinhibited social engagement disorders: Callous-unemotional traits and comorbid disorders. Research in Developmental Disabilities, 63, 28–37.

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Minnis, H., Messow, C. M., McConnachie, A., Bradshaw, P., Briggs, A., Wilson, P., & Gillberg, C. (2020). Autism and attachment disorder symptoms in the general population: Prevalence, overlap, and burden. Developmental Child Welfare, 2(1), 37–51.

Seim, A. R., Jozefiak, T., Wichstrøm, L., & Kayed, N. S. (2019). Validity of reactive attachment disorder and disinhibited social engagement disorder in adolescence. European Child & Adolescent Psychiatry, 1–12.

Waschbusch, D. A., Mayes, S. D., Calhoun, S. L., & Baweja, R. (2018). Response to Allen (2018): Points of agreement and disagreement on reactive attachment disorder. Research in Developmental Disabilities, 83, 190–193.