Diagnostic Considerations
The diagnosis of an attachment disorder such as reactive attachment disorder (RAD) or disinhibited social engagement disorder (DSED) should be reserved for cases clearly related either to nonattachment (eg, gross neglect, separation, or loss of the caregiver) or to disinhibited superficial attachments (eg, multiple caregivers).
Some diagnose attachment disorders too freely, viewing practically any behavioral disturbance in a child as caused by disruptions in attachment. Such overdiagnosis may create problems for the parents’ clinician, in that the current definition of these disorders implies pathogenic care. [14]
Many children experience disruptions in their relationships with caregivers, and many children become aggressive, hypervigilant, or defiant. However, these children do not necessarily have attachment disorders. Aggressive behavior, explosions of temper, and defiance are characteristics of several disturbances in childhood and should not be automatically assumed to reflect an attachment disorder.
Many infants seem to pay little or no attention to their caregivers; they do not exhibit fear and are highly disinhibited. They may not have an attachment disorder but instead may be focused on a particular stimulus and unaware of their surroundings. This tendency to be impulsive, focused on a stimulus, and somewhat inattentive to potential danger is not necessarily a sign of an attachment disturbance; it is more likely to be a sign of attention deficit and impulsivity. The history of disruptions in relationships with caregivers guides the diagnosis.
In children who are unresponsive to others, it is important to rule out the presence of an autistic condition. The differential diagnoses are facilitated by the history of neglect or multiple caregivers and by the development of imaginative play and communicational intent (which are absent or grossly impaired in the child with a developmental disorder).
In addition to the conditions listed in the differential diagnosis, other problems to be considered include the following:
-
Growth retardation
-
Receptive language disorder
Differential Diagnoses
-
Child Abuse & Neglect: Posttraumatic Stress Disorder
