Reactive attachment disorder: an evolving entity.

g t l n T o put into deserved perspective the contribution that Gleason and colleagues make in this issue of the Journal, theirs is one of the most extensive validation studies to date of reactive attachment disorder (RAD). The investigators sought to validate RAD with approaches derived from the classic 1970 article by Robins and Guze. The study focused primarily on four complementary aspects of validity: construct validity (i.e., is the current description of RAD valid?), discriminant validity (i.e., is RAD different from other disorders?), longitudinal stability (i.e., is RAD stable across time?), and functional impairment (i.e., does RAD impair function as other serious psychiatric disorders do?). This multifaceted validation attempt is a major step forward. A synthesis of phenomenologic and theoretical perspectives led to the 1980 introduction of RAD in the DSM-III. Clinical descriptions of infants and toddlers exposed to severely deviant rearing environments had long converged to recognize their high risk for certain patterns of emotional-behavioral outcomes, specifically a socially disinhibited/indiscriminate pattern, an inhibited/emotionally withdrawn pattern, and a pattern combining features of social disinhibition and inhibition. RAD subtypes were first described in the DSM-III-R in 1987. By examining the validity of RAD, the study by Gleason and colleagues tackles several enduring controversies: the postulation that a failure and/or absence of a normative attachment process is the core etiologic agent for RAD; that its core dysfunction centers around attachment, which is more theoretical than empirical at this time and thus controversial; the conjectural status of RAD as a bona fide psychiatric disorder; and whether RAD should be separated into two distinct subtypes, which has remained preliminary. The study uses data from the groundbreaking Bucharest Early Intervention Project (BEIP). Together with other famous studies such as the St. Petersburg Orphanage Study, the BEIP has ushered in an era of serious research on the sequelae of severe deprivation and its mediators and moderators. Orphanages are