How to distinguish between reactive attachment and autism

Background: Autism Spectrum Disorder (ASD) versus Reactive Attachment Disorder (RAD) is a common diagnostic challenge for clinicians due to overlapping difficulties with social relationships. RAD is associated with neglect or maltreatment whereas ASD is not: accurate differential diagnosis is therefore critical. Very little research has investigated the relationship between the two, and it is unknown if standardised measures are able to discriminate between ASD and RAD. The current study aimed to address these issues.

Methods: Fifty eight children with ASD, and no history of maltreatment, were group matched on age with 67 children with RAD. Group profiles on multi-informant measures of RAD were investigated and group differences explored. Discriminant function analysis determined assessment features that best discriminated between the two groups.

Results: Although, according to parent report, children with ASD presented with significantly fewer indiscriminate friendliness behaviours compared to the RAD group (p<0.001), 36 children with ASD appeared to meet core RAD criteria. However, structured observation clearly demonstrated that features were indicative of ASD and not RAD for all but 1 of these 36 children.

Conclusions: Children with RAD and children with ASD may demonstrate similar social relationship difficulties but there appears to be a difference in the social quality of the interactions between the groups. In most cases it was possible to differentiate between children with ASD and children with RAD via structured observation. Nevertheless, for a small proportion of children with ASD, particularly those whose difficulties may be more subtle, our current standardised measures, including structured observation, may not be effective in differentiating RAD from ASD.

Keywords: Autism spectrum disorder; Differential diagnosis; Indiscriminate friendliness; Observation; Reactive attachment disorder; Social relationships.

Children with ASD and children with RAD may appear to present with similar social relationship difficulties.

Accurate diagnosis is of the essence; ASD is a heritable neurodevelopmental disorder whereas RAD is caused by maltreatment.

The ASD group had significantly less indiscriminate friendliness symptoms than the RAD group, on parent report.

There was a difference in the quality of the social interaction difficulties between groups.

Structured observation was the best discriminatory tool; some misclassifications highlight need to develop tools further.

Abstract

Background

Autism Spectrum Disorder (ASD) versus Reactive Attachment Disorder (RAD) is a common diagnostic challenge for clinicians due to overlapping difficulties with social relationships. RAD is associated with neglect or maltreatment whereas ASD is not: accurate differential diagnosis is therefore critical. Very little research has investigated the relationship between the two, and it is unknown if standardised measures are able to discriminate between ASD and RAD. The current study aimed to address these issues.

Methods

Fifty eight children with ASD, and no history of maltreatment, were group matched on age with 67 children with RAD. Group profiles on multi-informant measures of RAD were investigated and group differences explored. Discriminant function analysis determined assessment features that best discriminated between the two groups.

Results

Although, according to parent report, children with ASD presented with significantly fewer indiscriminate friendliness behaviours compared to the RAD group (p < 0.001), 36 children with ASD appeared to meet core RAD criteria. However, structured observation clearly demonstrated that features were indicative of ASD and not RAD for all but 1 of these 36 children.

Conclusions

Children with RAD and children with ASD may demonstrate similar social relationship difficulties but there appears to be a difference in the social quality of the interactions between the groups. In most cases it was possible to differentiate between children with ASD and children with RAD via structured observation. Nevertheless, for a small proportion of children with ASD, particularly those whose difficulties may be more subtle, our current standardised measures, including structured observation, may not be effective in differentiating RAD from ASD.

Susan Dickerson Mayes, Department of Psychiatry (H073), Penn State College of Medicine, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA. Email: [email protected]

Abstract

DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) are rare disorders sharing social difficulties with autism. The DSM-5 and ICD-10 (International Classification of Diseases, 10th revsion) state that RAD/DSED should not be diagnosed in children with autism. The purpose of our study is to determine whether children can meet criteria for both autism and RAD/DSED and to identify specific symptoms discriminating the disorders. Subjects were 486 children with autism and no RAD/DSED and 20 with RAD/DSED, 4–17 years of age. In total, 13 children with RAD/DSED met criteria for autism. Using the Checklist for Autism Spectrum Disorder (CASD), there was no overlap in total scores between the RAD/DSED with autism group (score range = 15–27) versus the RAD/DSED without autism group (range = 7–10 ). The autism with and without RAD/DSED groups did not differ in CASD scores. Nine of the CASD autism symptoms were found only in the autism with and without RAD/DSED groups. Our study demonstrates that children can meet criteria for both autism and RAD/DSED and that the disorders are easily differentiated by the presence of specific autism symptoms. Autism is a neurogenetic disorder, and RAD/DSED results from severe social–emotional maltreatment. Given the different etiologies, there is no reason why a child cannot have both disorders.

This section is meant to be an informative guide only. It is not intended for self-diagnosis. These diagnostic summaries are only meant for educational purposes, not diagnostic ones. If you believe that these patterns of symptoms describe you or someone you love, seek out a professional opinion by a treatment provider who understands trauma.

Reactive Attachment Disorder & Disinhibited Social Engagement Disorder

The absence of adequate caregiving during childhood is a diagnostic requirement of both the reactive attachment disorder and disinhibited social engagement disorder. Because there are many similarities between these two diagnoses, they will be described here together:

  • Both are diagnoses intended for children under the age of 18. To qualify for either diagnosis in the DSM-5, there must be an attachment-related trauma that occurred before the age of 5.
  • Social neglect or deprivation in the form of persistent lack of care for basic emotional needs such as comfort, stimulation, and affection;
  • Repeated changes in primary caregivers that limit opportunities to form stable attachments;
  • Rearing in institutional or other unusual settings that severely limit opportunities to form close attachments.

Children with reactive attachment disorder demonstrate limited emotional responsiveness. Some examples include a lack of remorse, or an inability to register any emotion in situations that might usually elicit an emotional response. For instance, if I suddenly snatch a favorite toy from a child, most children would minimally express some form of protest. However, a child with reactive attachment disorder may simply stare blankly, and pick up another nearby toy to play with. While their range of emotion is limited, they sometimes experience episodes of irritability, sadness, and fearfulness even when there is no apparent reason for these reactions. A child with reactive attachment disorder may be unable to form close attachments with others. They do not appear to want or need comfort or support from caregivers. Other examples of how trauma-related emotional distress may manifest in children are covered in the previous sections describing trauma symptom clusters.

Children with disinhibited social engagement disorder are quite the opposite. They may be over-zealousness in their efforts to form attachment to others. They may willingly, and without question, wander off with strangers. They may behave in an overly familiar manner with unfamiliar adults, such as lavishing them with hugs and other forms of physical or verbal affection. Clearly this places them at greater risk for victimization. Impulsive or acting out behaviors can show up as symptoms in this diagnosis, in addition to the overly needy or clingy behaviors that are not better explained by culturally appropriate norms.

DSM-5 (APA 2013) indicates that some behaviors we may normally associate with the hyperactivity component of ADHD may be better categorized as disinhibited social engagement disorder. This is particularly true if there is a history of inadequate caregiving and social neglect. Likewise, some of the social awkwardness or inability to read social cues that we might associate with the autism spectrum disorder may be better explained by this diagnosis, especially if there is evidence of inadequate care or other trauma.

So far, we have reviewed the major diagnoses covered in the DSM-5 (APA 2013) chapter of Trauma and Stressor Related Disorders. It is important to note that other diagnostic categories, covered in other chapters of the DSM, may have trauma, abuse, neglect, or other adverse life experiences as causal, or exacerbating factors. Some examples are: mood disorders such as depressive disorders and bipolar disorder; anxiety disorders and phobias; dissociative disorders; and personality disorders. As we’ve emphasized throughout, if these patterns of symptoms resonate with you, we recommend consultation with a mental health professional.

Keep in mind, when we read articles and descriptions online, it may seem like everything applies to us. This is a common phenomenon with trauma survivors because unhealed trauma can affect nearly every aspect of life.

Children with ASD and children with RAD may appear to present with similar social relationship difficulties.

Accurate diagnosis is of the essence; ASD is a heritable neurodevelopmental disorder whereas RAD is caused by maltreatment.

The ASD group had significantly less indiscriminate friendliness symptoms than the RAD group, on parent report.

There was a difference in the quality of the social interaction difficulties between groups.

Structured observation was the best discriminatory tool; some misclassifications highlight need to develop tools further.

Abstract

Background

Autism Spectrum Disorder (ASD) versus Reactive Attachment Disorder (RAD) is a common diagnostic challenge for clinicians due to overlapping difficulties with social relationships. RAD is associated with neglect or maltreatment whereas ASD is not: accurate differential diagnosis is therefore critical. Very little research has investigated the relationship between the two, and it is unknown if standardised measures are able to discriminate between ASD and RAD. The current study aimed to address these issues.

Methods

Fifty eight children with ASD, and no history of maltreatment, were group matched on age with 67 children with RAD. Group profiles on multi-informant measures of RAD were investigated and group differences explored. Discriminant function analysis determined assessment features that best discriminated between the two groups.

Results

Although, according to parent report, children with ASD presented with significantly fewer indiscriminate friendliness behaviours compared to the RAD group (p < 0.001), 36 children with ASD appeared to meet core RAD criteria. However, structured observation clearly demonstrated that features were indicative of ASD and not RAD for all but 1 of these 36 children.

Conclusions

Children with RAD and children with ASD may demonstrate similar social relationship difficulties but there appears to be a difference in the social quality of the interactions between the groups. In most cases it was possible to differentiate between children with ASD and children with RAD via structured observation. Nevertheless, for a small proportion of children with ASD, particularly those whose difficulties may be more subtle, our current standardised measures, including structured observation, may not be effective in differentiating RAD from ASD.

Children with ASD are capable of forming selective, secure attachments.

In seven samples using the Strange Situation procedure, 47% of children with ASD were classified as secure (n = 186).

Risk and protective factors range from child to caregiving environment factors.

Evidence for attachment-based therapies are mixed.

Further work is needed investigating the clinical application of attachment theory.

Abstract

This paper aims to synthesise the literature on attachment in children with Autism Spectrum Disorder (ASD), highlighting gaps in current research and applications for clinical practice. The research databases PsycINFO, Ovid Medline, and the Cochrane Library were searched for the terms “autism” and “attachment”. Forty papers investigating attachment in children with ASD were identified and narratively reviewed. Seven samples were identified that reported attachment classifications using the Strange Situation Paradigm, with an average of 47% of children with ASD classified as secure (n = 186). With research to date concluding that children with ASD can form secure attachments, studies are now looking at risk and protective factors in the development of attachment, correlates of attachment, attachment disorders in children with ASD, and attachment-based interventions for children with ASD. Many of these studies are preliminary investigations with contradictory findings reported, highlighting important directions for future research.

We aimed to determine whether it is possible to discriminate between children with attention deficit hyperactivity disorder (ADHD) and children with reactive attachment disorder (RAD) using standardized assessment tools for RAD. The study involved 107 children: 38 with a diagnosis of RAD and 30 with ADHD were recruited through community child and adolescent mental health services (CAMHS) and specialist ADHD clinics. In addition, 39 typically developing children were recruited through family practice. Clinicians were trained to use a standardized assessment package for RAD using a DVD with brief follow-up support. Discriminant function analysis was used to identify the items in the standardized assessment package that best discriminated between children with ADHD and children with RAD. Clinicians’ ratings of RAD symptoms were reliable, particularly when focusing on eight core DSM-IV symptoms of RAD. Certain parent-report symptoms were highly discriminatory between children with ADHD and children with RAD. These symptoms included “cuddliness with strangers” and “comfort-seeking with strangers”. A semi-structured interview with parents, observation of the child in the waiting room and teacher report of RAD symptoms aided diagnostic discrimination between the groups. Clinical diagnosis of RAD can be made reliably by clinicians, especially when focusing on eight core RAD symptoms. Clear discrimination can be made between children with RAD and children with ADHD.

Susan Dickerson Mayes, Department of Psychiatry (H073), Penn State College of Medicine, Penn State Health Milton S. Hershey Medical Center, 500 University Drive, Hershey, PA 17033, USA. Email: [email protected]

Abstract

DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, 5th edition) Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) are rare disorders sharing social difficulties with autism. The DSM-5 and ICD-10 (International Classification of Diseases, 10th revsion) state that RAD/DSED should not be diagnosed in children with autism. The purpose of our study is to determine whether children can meet criteria for both autism and RAD/DSED and to identify specific symptoms discriminating the disorders. Subjects were 486 children with autism and no RAD/DSED and 20 with RAD/DSED, 4–17 years of age. In total, 13 children with RAD/DSED met criteria for autism. Using the Checklist for Autism Spectrum Disorder (CASD), there was no overlap in total scores between the RAD/DSED with autism group (score range = 15–27) versus the RAD/DSED without autism group (range = 7–10 ). The autism with and without RAD/DSED groups did not differ in CASD scores. Nine of the CASD autism symptoms were found only in the autism with and without RAD/DSED groups. Our study demonstrates that children can meet criteria for both autism and RAD/DSED and that the disorders are easily differentiated by the presence of specific autism symptoms. Autism is a neurogenetic disorder, and RAD/DSED results from severe social–emotional maltreatment. Given the different etiologies, there is no reason why a child cannot have both disorders.