미국 정신장애 진단 분류지침서(DSM-III)가 1980년에 소개된 이래, 반응성 애착장애(RAD)는 오로지 유아들을 진단하기 위한 것이며 구체적인 병인이 제시 되어야 한다는 두 가지 이유로 딴 진단들로 부터 구분되어 왔다. 따라서 본 연구의 저자는 다음의 연구질문을 가지고 반응성 애착장애에 관해서 폭넓게 문헌조사를 하였다. 첫째, RAD의 정의는 한 가지 장애로 명시하기에 구체적이고 적절한가? 둘째, RAD는 과연 애착장애 인가? 셋째, 병원성 케어가 RAD를 유발하는 유일한 선행 조건인가?; 넷째, RAD를 진단하는데 있어서 단일 사정도구만으로도 가능한가? 다섯째, RAD를 가지고 있는 어린이들을 위한 가장 성공적인 치료법은 무엇인가? 이상의 질문에 관한 해답을 찾기 위해 1998년 이후에 발간된 책들과 전문지(애착장애 이론을 소개한 초기 논문들은 예외)를 Google Scholar, Psychological Abstracts, Social Work Abstracts 데이터 베이스 검색을 통해서 추출한 자료들을 문헌조사 범위로 삼았다. 반응성 애착장애는 인간애착에 관한 연구와, 병적 케어로 인해 발생 하는 것으로 여겨지는 애착장애에 관한 연구에서 파생 되었는데, 이 분야의 많은 전문가들은 반응성 애착장애는 애착장애와 근본적으로 다르다고 지적하고 있다. 즉, 반응성 애착장애를 가진 아이들은 애착의 질을 개선할 필요가 없으며, 반면에 애착관계를 형성할 수 있도록 이미 손상을 입은 그들의 애착 능력을 교정 해 줄 필요가 있다는 주장이다. 반응성 애착장애는 애착장애로 분류되어 있지만, 애착보다는 부적응 사회행동에 중점을 두고 있어서 그 분류 기준이 적절하지 못하다는 비난과, 몇 연구들에서 병적 케어가 반응성 애착장애의 원인이라는 증거를 찾지 못했으며, 반응성 애착장애를 애착장애의 하나로 보는 진단 타당성에 의문을 나타내고 있다.

Since its introduction into DSM-III in 1980, reactive attachment disorder (RAD) hasnstood curiously apart from other diagnoses for two reasons: it remains the only diagnosisndesigned for infants, and it requires the presence of a specific etiology. With the followingnquestions about RAD an extensive literature review was conducted: 1) Is the definition ofnRAD specific enough to specify one disorder?; 2) Is RAD really a disorder of attachment?;n3) Is pathogenic care the only possible antecedent of RAD?; 4) Is it possible to come upnwith a single assessment instrument in diagnosing RAD?; 5) What treatments are mostnsuccessful in treating children with RAD? A list of references for the review parameter wasndeveloped by search of book chapters and articles published since 1998 except for thenseminal works of leading theorists and listed in the database of Google Scholar,nPsychological Abstracts, and Social Work Abstracts.nThe RAD diagnosis was born out of research on human attachment and disorders ofnattachment thought to be caused by pathogenic care. Many experts in field do not alwaysnagree on the definition, symptomatology and etiology of RAD. RAD is still fundamentallyndifferent from disordered attachment as children with RAD don’t need to improve thenquality of their attachments, but need to repair their ability to form attachments. AlthoughnRAD is classified as a disorder of attachment by its title, the criteria for diagnosis hasnbeen heavily criticized as they focus more on maladaptive social behaviors than onnattachment. While these behavior problems do not have to be present for diagnosis, theynare usually the very reasons parents and caregivers seek professional help for thesenchildren. Different from the theoretical assertion that pathogenic care is the antecedent ofnRAD, evidences found in several studies show that pathogenic care does not implicitlyncause RAD nor is it always necessary for RAD to develop, and the validity of a RAD diagnosis as an attachment disorder is currently questioned and challenged. To this date,nthere is no single, comprehensive tool to assess children for RAD. This absence of anstandard assessment protocol has sometimes led to substantial variations in clinician’snpractice and has become one of the contributing factors in the over diagnosis of RAD.nIn spite of a few disagreements as addressed, RAD is still classified as a disorder ofnattachment, and most treatments applied are grounded in attachment theory. A fewntreatments proven to be effective include therapeutic parenting, rebirthing, dyadicnrelationship-focused infant-parent psychotherapy, internal working models (IWM), eyenmovement desensitization and reprocessing (EMDR), individual psychotherapy such asncognitive behavioral management, behavioral modification therapy, psycho-education aboutnissues surrounding abuse and sexual abuse, anxiety management skills, techniques tonreduce trauma-related fear and anxiety, the learning of new coping strategies, andneducation and coaching surrounding socially appropriate behaviors. Holding Therapy,nhowever, is a highly controversial therapy which utilizes behaviors that do not reallynpromote attachment and are unrelated to attachment theory.

• Kim, Joon-Kyoung(Professor, Dept, of Child Welfare, NamSeoul University) | 김준경 Corresponding Author