Recently on Quora, a user asked the following question: “What are the two types of Reactive Attachment Disorder?” I answered with the following explanation of Reactive Attachment Disorder and Disinhibited Social Engagement Disorder.
Prior to the DSM-V, there were two types of reactive attachment disorder listed in the manual (Reactive Attachment Disorder – Inhibited Type and Reactive Attachment Disorder – Disinhibited Type). They’re now broken up into two separate diagnoses (Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED)).
In RAD, the kiddo is more likely to withdraw and blatantly refuse to attach to her caregivers. A child who has this diagnosis does not seek comfort from adults when hurt or upset, exhibits a low response when comforted by caregivers, has a low positive affect and often looks sad, irritated or fearful when interacting with caregivers during routine or even enjoyable interactions with adults.
Middle retains her initial diagnosis of RAD and she’s suspicious of adults, especially me. I’ll ask her a seemingly innocuous question such as, “How are you doing?” and she will freeze up like a deer in headlights – she’s afraid I’m going to attack her when she answers the question.
She refuses to let us take care of her – and I’m not talking typical kid, “I’ll test boundaries and assert my independence.” She doesn’t trust me to take care of her BIG pain (emotional or physical) and resists being comforted. She has an attitude of, “I have to take care of myself – adults just let me down and hurt me so why bother with them?”
At the same time, she NEEDS love and care so she’ll sometimes manufacture reasons for me to give her nurturing, but it’s all wonky. For instance, she often claims that one of her siblings wronged her in some fashion and she’ll then put on a huge display of anger and sadness until we’re convinced she’s been hurt or harassed by Little or Oldest… and a few hours later we’ll find evidence that she was pretneding, that the wrong never occurred, that she’d made it all up (this still happens regularly at age 8). Or maybe she’ll get a hangnail which obviously means the world must stop until I’ve bandaged her up and spent at least five minutes making a big to-do over the admittedly-irritating-but-not-super-painful flap of stinging skin on her finger stop but when she breaks her elbow she says nothing, she’ll pretend she can’t do something she very well can do.
Or maybe she’ll get a hangnail which obviously means the world must stop until I’ve bandaged her up and spent at least five minutes making a big to-do over the admittedly-irritating-but-not-super-painful flap of stinging skin on her finger… But when she wakes in the middle of the night with a nose-bleed or, you know, breaks her elbow, she tries to take care of the pain and fear she feels on her own. She might even lie when asked if she’s in pain!
She might pretend she can’t do something she very well can do, like read the word “of” or “happy” and beg me to help her read the word. I’ll help her sound it out against the protestations of, “She can read it don’t you help her!” (because seriously, she’s in second grade, in the accelerated learning magnet and just started attending the gifted program at her school). She’ll then deliberately mispronounce the word even after pronouncing each letter separately (ex: “Ffff-uhhhhhh-nnnnn… Free?”), only to beg me for more help.
All of this “pretending” can drive any caregiver nuts if you stick with the idea that she’s deliberately acting out to draw attention to herself for ridiculous reasons. But I no longer believe that she’s doing this stuff on purpose. If you share my outlook, you know she isn’t pretending in the traditional sense of the word – instead, you recognize that this behavior is a product of her early trauma. Even though she’s healed a lot since moving in with us in 2013, she’s still in survival mode. I see this behavior as her sort testing us (still!) to see if we can handle all of the little stuff, stuff that doesn’t really matter, before she risks trusting us with bigger issues.
In DSED, the kiddo approaches strangers as though he’s known them his entire life and usually engages in overly familiar behavior with unfamiliar adults – this means that the kid APPEARS to attach to people immediately, often at the expense of his primary caretaker. A kiddo with this disorder is more likely to use the skill of “superficial charm and engagement” to get his needs met than to try to meet their own and reject adults as is more common in RAD.
As an example, when my I met my husband’s kids for the first time after he got custody of them, the kids hadn’t seen their dad in months. I just showed up and they didn’t question my presence, but my son (who was age 3 at the time), spent only a few moments with his dad with whom he should have had an attachment. Unfortunately, my husband’s two deployments, an “overseas” duty station, and the multiple, sustained traumas (mostly neglect and being in an unsafe environment) my son’s mom put the kids through while my husband was gone led to his development of an attachment disorder.
After his initial greeting, my son came over to me and crawled on my lap. We sat there for about 30 minutes and I put on a little puppet show for him with a Winnie-the-Pooh plush toy (I’ll never forget when he, at age three, remember, looked at me and said, “You know that’s not real you know. That bear isn’t really talking to me, that’s all you”).
After 30 minutes my husband wanted some snuggles with his son whom he hadn’t seen in so long so my husband tried to call him over. When that failed to catch the attention of the little boy on my lap my husband came over and plucked him off my lap and all hell broke loose. He burst into tears, his arms outstretched and grasping for me. He yelled he wanted to stay with me and that he didn’t want to sit with Daddy.
At the time, I was flattered and thought it was a good sign that he liked me. But my son likes EVERYONE he meets and instantly prefers them over his parents – EVERY TIME. He (and his sister) even started trying to call me mom within a week (and remember they were three and four years old!), even before we announced that my husband and I were dating (boyfriend at the time).
About a year later, I saw this play out again – we were at a friend’s house we’d never brought the kids to before. When we walked in, my son waltzed right up to the “woman of the house,” climbed on her lap (even pushed something she was working on out of her lap), and refused to listen to me whenever I spoke to him… In fact, actively turning his back to me and arguing about staying with this new lady (he was four at the time). We ended up staying the night.
When he woke up in the middle of the night, instead of calling out for us as most 4-year-olds would do when waking up in the middle of the night and especially in an unfamiliar place, he left the room we all were staying in, found the hosting couple’s bedroom, walked in and stood by our friend’s bed until she woke up. She took him to the bathroom; he came back trying to get in her bed, then he asked her to make him breakfast.
Remember – he’d never met this woman before and had only spent about two hours with her that day but he went to her in the middle of the night instead of either one of his primary caretakers – and he was four.
That’s not typical behavior.
My kids seem to have a mixture of both disorders but are diagnosed by their most prominent reactions to caregivers (for instance, my daughter will sometimes “attach” quickly to another adult in a way that’s not typical or appropriate which is more associated with DSED and my son sometimes refuses to seek comfort when scared or hurt which is behavior more associated with RAD).
DSED seems harder to handle to me than RAD – because in DSED, the coping mechanisms they use to avoid attaching aren’t drastically out of the ordinary when they first start presenting (this happened to us – we noticed my daughter’s issues immediately but it was about six months before we caught on that my son was having issues) so a lot of kids’ problems will go unnoticed until that method of coping is firmly entrenched in their little brains and bodies.
Both of these diagnoses depend on an age of at least nine months, a history of maltreatment and the development of behavioral symptoms before the age of five, the behavior presenting for at least twelve months, and the absence of other diagnoses that may cause these behaviors (genetic disorders or autism, for example).
Personally, I’m glad the DSM-V changed RAD into two different diagnoses… My kids are so different from each other that it made little sense for them to have the same diagnosis attached to their medical charts.