2 ADHD/DAMP, attachment and reactive attachment disorder (RAD) Are attachment problems important in understanding ADHD?Is RAD recognisable as a syndrome?Does RAD and ADHD overlap?
3 Infant Disorganised Attachment and ADHD A Prospective Study of Children Next-Born after Stillbirth
4 St George’s University of London Grant holder:Patricia HughesTeam:Penelope Turton, Carmen Pinto, Christopher Gillberg, Sarah White, Julia Ward, Samantha Riches, Patricia Hughes
5 BackgroundNeuroanatomical/ biochemical/ genetic factors can’t explain whole variance in presentation of ADHDEnvironmental factors (e.g.maternal depression and social disadvantage) may be implicated in aetiology of ADHDSome clinical reports suggest history of insecure attachment might also be implicated in ADHD
6 Disorganised attachment (D) is established marker of psychological vulnerability Both attachment related factors and neurobiological factors reported as predisposing to disorganisationD is associated with problematic stress management/ elevated risk of problem externalising behaviours at 6 yearsChildren with ADHD are usually disorganized, inattentive and impulsive from a very young age
7 Could infant D behaviors be an indication of incipient ADHD? AIMS:to investigate any association between infant disorganised attachment behaviour and later ADHDto identify factors explaining ADHD outcomes after controlling for mediating variables
8 MethodSubjects: Cohort of 104 children who had significant levels of disorganised attachment in infancyAssessments: Mother / teacher rated ADHD symptoms* plus observer-rated hyperactivity, together with range of relevant maternal variables*ADHD Rating Scale-IV (DuPaul, Power, Anastopoulos & Reid, 1998).
9 Results 27 (26%) infants were classified as D 8 children (7.8%) met ‘probable’ ADHD case criteria11 children (10.7%) met ‘possible’ ADHD case criteria24 (23.1%) of mothers vs. 25 (24.3%) of teachers rated the child above cut-off score of 20Mother and teacher-rated ADHD scores were highly correlated
10 Did infant D predict ADHD? No clear-cut association of infant disorganized attachment and later childhood ADHD caseness.There was a significant correlation between infant D and teacher rated ADHD symptoms (more inattention than hyperactivity)What are the attributes of D infants that teachers (but not mothers) observe several years later as ADHD symptoms?
11 InterpretationD behaviours (freezing, stilling, sudden interruptions of intended actions) present as inattention?Teachers more sensitive to inattention, while mothers become habituated?Mothers have lower tolerance threshold for hyperactivity? (mother-rated hyperactivity was associated with lower SCID GAF score)Maternal psychology/behaviour play a role in mild “ADHD-like” child problems?
12 Comorbidity in Reactive Attachment Disorder RAD diagnostic study funded by Chief Scientist Office of Scottish ExecutiveGrantholders: Eric Taylor, Tom O’Connor, Anthony Pelosi, David Young, James BarnesResearch Team: Julie Arthur, Michael Follan, Amanda Burston, Brenda ConnollyExpert Panel: Jonathan Green, Danya Glaser (with Eric Taylor and Tom O’Connor)TEDS collaborators: Robert Plomin, Angelica Ronald
13 DSM-IV Diagnostic Criteria for Reactive Attachment Disorder Comorbidity in RADDSM-IV Diagnostic Criteria for Reactive Attachment DisorderInhibited typeexcessively inhibited, hypervigilant or highly ambivalent and contradictory responsesDisinhibited typeindiscriminate sociability with marked inability to exhibit appropriate selective attachments
14 Comorbidity in RADThe RPQ is an 18-item questionnaire for RAD symptoms.Analysis of RPQ items from 13,472 8 year olds:Inhibited and Disinhibited factors separate from each other in factor analysis but not in cluster analysisIn factor analysis, RAD factors are distinct from conduct problems, hyperactivity and emotional problems
15 Assessment for RAD, ADHD, ODD, CD, ASD Comorbidity in RADDiagnostic research in RAD40 “RAD”childrenaged 5-840 GP controlchildrenaged 5-8Assessment for RAD, ADHD, ODD, CD, ASD
16 Comorbidity in RAD Components of RAD assessment Structured parental interview for RAD based on existing measures in CAPA/PAPA formatCAPA/PAPA modules for CD/ODD and ADHD and the 3-DI autism module.Teacher questionnaire based on RPQObservational measure of child behaviour with parent and strangersDiagnosis checked by panel of experts reviewing positive interview items and video material
17 Comorbidity in RADOf the first 53 children, (28 controls including 2 with other clinical diagnoses and 25 RAD cases):52% (13) RAD cases met criteria for ODD12% (3) RAD cases met criteria for Conduct Disorder12% (3) RAD cases met criteria for ASD2 children met criteria for ODD and ASD but not RAD
18 Comorbidity in RAD 68% (17) RAD cases met criteria for ADHD No children met criteria for ADHD but not RADOf the apparently comorbid RAD/ADHD cases, less than half (47%) were rated as abnormal (7%) or borderline (40%) for hyperactivity on the teacher SDQ
19 Comorbidity in RAD Future research planned: Use our RAD assessment package with children who have a clinical diagnosis of ADHDQualitative research to understand any differences in the nature of disinhibition in ADHD and RAD
20 ConclusionsDisorganised attachment in infancy does not predict clinical ADHDDisorganised attachment in infancy predicts ADHD-like (mild) behaviours in early school ageThere is a very high rate of comorbid ADHD in RADFuture research (and clinical practice?) in ADHD and RAD needs to take both “conditions” into account