with peers, aggression towards self and others, misery, and growth failure in some cases (inhibited form only); evidence of capacity for social reciprocity and responsiveness as shown by elements of normal social relatedness in interactions with appropriately responsive, non-deviant adults (disinhibited form only). the first of these is somewhat controversial, being a commission rather than omission and because abuse in and of itself does not lead to attachment disorder. the inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is more enduring. icd-10 states the disinhibited form "tends to persist despite marked changes in environmental circumstances". disinhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same child. the question of whether there are two subtypes has been raised. the world health organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate subdivision. one reviewer has commented on the difficulty of clarifying the core characteristics of and differences between atypical attachment styles and ways of categorizing more severe disorders of attachment. as of 2010, the american psychiatric association has proposed to redefine rad into two distinct disorders in the dsm-v. corresponding with the inhibited type, one disorder will be reclassified as reactive attachment disorder of infancy and early childhood. in regards to pathogenic care, or the type of care in which these behaviors are present, a new criterion for disinhibited social engagement disorder now includes chronically harsh punishment or other types of severely inept caregiving. relating to pathogenic care for both proposed disorders, a new criterion is rearing in atypical environments such as institutions with high child/caregiver ratios that cut down on opportunities to form attachments with a caregiver. differential diagnosis the diagnostic complexities of rad mean that careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential. several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, post traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with rad, leading to over and under diagnosis. rad can also be confused with neuropsychiatric disorders such as autism, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. infants with this disorder can be distinguished from those with organic illness by their rapid physical improvement after hospitalization. autistic children are likely to be of normal size and weight and often exhibit a degree of intellectual disability. they are unlikely to improve upon being removed from the home. alternative diagnosis in the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the dsm and icd, were created out of clinical and parental experience within the field known as attachment therapy. these lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. many are found on the websites of attachment therapists. common elements of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either dsm-iv-tr or icd-10. many children are being diagnosed with rad because of behavioral problems that are outside the criteria. there is an emphasis within attachment therapy on aggressive behavior as a symptom of what they describe as attachment disorder whereas mainstream theorists view these behaviors as comorbid, externalizing behaviors requiring appropriate assessment and treatment rather than attachment disorders. however, knowledge of attachment relationships can contribute to the cause, maintenance and treatment of externalizing disorders. the randolph attachment disorder questionnaire or radq is one of the better known of these checklists and is used by attachment therapists and others. the checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment difficulties. critics assert that it is unvalidated and lacks specificity. treatment assessing the child's safety is an essential first step that determines whether future intervention can take place in the family unit or whether the child should be removed to a safe situation. interventions may include psychosocial support services for the family unit (including financial or domestic aid, housing and social work support), psychotherapeutic interventions (including treating parents for mental illness, family therapy, individual therapy), education (including training in basic parenting skills and child development), and monitoring of the child's safety within the family environment in 2005 the american academy of child and adolescent psychiatry laid down guidelines (devised by n.w. boris and c.h. zeanah) based on its published parameters for the diagnosis and treatment of rad. recommendations in the guidelines include the following: "the most important intervention for young children diagnosed with reactive attachment disorder and who lack an attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an emotionally available attachment figure." "although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child, assessing the caregiver's attitudes toward and perceptions about the child is important for treatment selection." "children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. after ensuring that the child is in a safe and stable placement, effective attachment treatment must focus on creating positive interactions with caregivers." "children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive (additional) treatments." mainstream prevention programs and treatment approaches for attachment difficulties or disorders for infants and younger children are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. these approaches are mostly in the process of being evaluated. the programs invariably include a detailed assessment of the attachment status or caregiving responses of the adult caregiver as attachment is a two-way process involving attachment behavior and caregiver response. some of these treatment or prevention programs are specifically aimed at foster carers rather than parents, as the attachment behaviors of infants or children with attachment difficulties often do not elicit appropriate caregiver responses. approaches include "watch, wait and wonder," manipulation of sensitive responsiveness, modified "interaction guidance", "clinician-assisted videofeedback exposure sessions (caves)", "preschool parent psychotherapy", "circle of security", "attachment and biobehavioral catch-up" (abc), the new orleans intervention, and parent–child psychotherapy. other treatment methods include developmental, individual-difference, and relationship-based therapy (dir, also referred to as floor time) by stanley greenspan, although dir is primarily directed to treatment of pervasive developmental disorders. the relevance of these approaches to intervention with fostered and adopted children with rad or older children with significant histories of maltreatment is unclear. attachment therapy the terms attachment disorder, attachment problems, and attachment therapy, although increasingly used, have no clear, specific, or consensus definitions. however, the terms and therapies often are applied to children who are maltreated, particularly those in the foster care, kinship care, or adoption systems, and related populations such as children adopted internationally from orphanages. outside the mainstream programs is a form of treatment generally known as attachment therapy, a subset of techniques (and accompanying novel diagnosis) for supposed attachment disorders including rad. these "attachment disorders" use diagnostic criteria or symptom lists different from criteria under icd-10 or dsm-iv-tr, or to attachment behaviors. those with "attachment disorder" are said to lack empathy and remorse. treatments of this pseudoscientific disorder are called "attachment therapy". in general, these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers. the theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasize obedience and parental control. there is considerable criticism of this form of treatment and diagnosis as it is largely unvalidated and has developed outside the scientific mainstream. there is little or no evidence base and techniques vary from non-coercive therapeutic work to more extreme forms of physical, confrontational and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the evergreen model. these forms of the therapy may well involve physical restraint, the deliberate provocation of rage and anger in the child by physical and verbal means including deep tissue massage, aversive tickling, enforced eye contact and verbal confrontation, and being pushed to revisit earlier trauma. critics maintain that these therapies are not within the attachment paradigm, are potentially abusive, and are antithetical to attachment theory. the apsac taskforce report of 2006 notes that many of these therapies concentrate on changing the child rather than the caregiver. children may be described as "rads", "radkids" or "radishes" and dire predictions may be made as to their supposedly violent futures if they are not treated with attachment therapy. the mayo clinic, a well known u.s. non-profit medical practice and medical research group, cautions against consulting with mental health providers who promote these types of methods and offer evidence to support their techniques; to date, this evidence base is not published within reputable medical or mental health journals. prognosis the aacap guidelines state that children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. however, the course of rad is not well studied and there have been few efforts to examine symptom patterns over time. the few existing longitudinal studies (dealing with developmental change with age over a period of time) involve only children from poorly run eastern european institutions. findings from the studies of children from eastern european orphanages indicate that persistence of the inhibited pattern of rad is rare in children adopted out of institutions into normative care-giving environments. however, there is a close association between duration of deprivation and severity of attachment disorder behaviors. the quality of attachments that these children form with subsequent care-givers may be compromised, but they probably no longer meet criteria for inhibited rad. the same group of studies suggests that a minority of adopted, institutionalized children exhibit persistent indiscriminate sociability even after more normative caregiving environments are provided. indiscriminate sociability may persist for years, even among children who subsequently exhibit preferred attachment to their new caregivers. some exhibit hyperactivity and attention problems as well as difficulties in peer relationships. in the only longitudinal study that has followed children with indiscriminate behavior into adolescence, these children were significantly more likely to exhibit poor peer relationships. studies of children who were reared in institutions have suggested that they are inattentive and overactive, no matter what quality of care they received. in one investigation, some institution-reared boys were reported to be inattentive, overactive, and markedly unselective in their social relationships, while girls, foster-reared children, and some institution-reared children were not. it is not yet clear whether these behaviors should be considered as part of disordered attachment. there is one case study on maltreated twins published in 1999 with a follow-up in 2006. this study assessed the twins between the ages of 19 and 36 months, during which time they had multiple moves and placements. the paper explores the similarities, differences and comorbidity of rad, disorganized attachment and post traumatic stress disorder. the girl showed signs of the inhibited form of rad while the boy showed signs of the indiscriminate form. it was noted that the diagnosis of rad ameliorated with better care but symptoms of post traumatic stress disorder and signs of disorganized attachment came and went as the infants progressed through multiple placement changes. at age three, some lasting relationship disturbance was evident. in the follow-up case study when the twins were aged three and eight years, the lack of longitudinal research on maltreated as opposed to institutionalized children was again highlighted. the girl's symptoms of disorganized attachment had developed into controlling behaviors—a well-documented outcome. the boy still exhibited self-endangering behaviors, not within rad criteria but possibly within "secure base distortion", (where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment). at age eight the children were assessed with a variety of measures including those designed to access representational systems, or the child's "internal working models". the twins' symptoms were indicative of different trajectories. the girl showed externalizing symptoms (particularly deceit), contradictory reports of current functioning, chaotic personal narratives, struggles with friendships, and emotional disengagement with her caregiver, resulting in a clinical picture