Convergence between observations and interviews in clinical diagnosis of reactive attachment disorder and disinhibited social engagement disorder

Objective: A comprehensive approach is needed for diagnosing disordered attachment behavior due to the multifaceted nature of attachment. Differences between various indicators can pose a challenge for deciding on the proper diagnosis. This study assessed the convergence between clinical interview assessment and observation-based clinical diagnosis, and their linkages with inadequate care. Method: Participating children (N=55) had intelligence quotients (IQs) between 50 and 85 and were referred for psychiatric consultation. Data were obtained by structured review of medical records, the Disturbances of Attachment Interview (DAI), and the Clinical Observation of Attachment (COA) procedure. Results: Of the 18 children identified using the DAI with Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) diagnosis of reactive attachment disorder (RAD) and/or disinhibited social engagement disorder (DSED), only 7 received a clinical DSM-5 diagnosis of RAD and/or DSED. Observed maladaptive attachment behavior in the COA was strongly associated with DAI scores and with clinical diagnosis of DSM-5 RAD and/or DSED. There was a significantly higher prevalence of extremes of insufficient care in children who were classified with RAD by DAI or DSM-5 and/or with DSED by DSM-5 compared to those with no attachment disorder. Conclusions: Using structured observation and record assessment leads to more conservative identification of RAD or DSED than using the DAI.