Background: While considered a rare diagnosis, reactive attachment disorder (RAD) is simultaneously the subject of considerable debate. A recent report suggested that RAD is overdiagnosed in community settings and that conduct problems may be used to make a diagnosis of RAD (Woolgar & Baldock, Child and Adolescent Mental Health, 20, 2015, 34-40). This study seeks to replicate and extend these findings. Method: Clinical assessment data from 100 consecutive admissions of maltreated foster and adopted children (ages 3-17) to a specialty treatment clinic in the United States were reviewed. Measures included semi-structured interviews of RAD and disinhibited social engagement disorder (DSED) symptoms and caregiver-report questionnaires of emotional problems, conduct problems, and the quality of the parent-child relationship. Results: Of the 100 cases reviewed, 39 presented with a diagnostic history of RAD, DSED, or 'attachment disorder'. Of these cases, three were diagnosed in-clinic with DSED; no cases met diagnostic criteria for RAD according to DSM-5 criteria. However, analyses found that those diagnosed with RAD by community-based clinicians were significantly more likely to display conduct problems and to be adopted (as opposed to in foster care). Conclusions: These findings confirm those of Woolgar and Baldock (Child and Adolescent Mental Health, 20, 2015, 34-40). It appears that the diagnostic criteria of RAD are commonly being inaccurately applied in general communitybased practice. Clarification of diagnostic criteria for RAD in recent revisions of diagnostic taxonomies, the accumulation of empirical data on RAD, and improved instrumentation are either poorly disseminated or inadequately implemented in community-based practice settings.
Key Practitioner Message• Reactive attachment disorder (RAD) is considered a rare diagnosis, and the diagnostic criteria have undergone significant revisions in recent years with the release of the DSM-5 and ICD-11.• Previous research and anecdotal reports suggest that RAD may be overdiagnosed in community practice settings and that conduct problems may be commonly, and incorrectly, considered as primary symptoms of the condition.• Specialized in-clinic assessment only rarely concurred with community-based RAD diagnosis. Community mental health services showed strong overdiagnosis of RAD and underdiagnosis of disinhibited social engagement disorder (DSED).• Maltreated children with conduct problems and those who were adopted (as opposed to in foster care) were most likely to have been diagnosed with RAD in the community.• Efforts to improve the clarity of the diagnostic criteria for RAD, the increased empirical data on the condition, and improved instrumentation have either not been adequately disseminated to community practice settings or are poorly implemented.