1. RAD, Attachment Disorders, Complex Trauma, etc. What difference does the name make and who cares anyway? Todd Nichols ATTACh 2007 Conference

2. © 2007, Family Attachment Center Inc., www.familyattachment.com Overview  Attachment, Attachment Disorders, and Reactive Attachment Disorder  Alternative classifications Complex Posttraumatic Disorder Disorders of Nonattachment  DSM Process

3. © 2007, Family Attachment Center Inc., www.familyattachment.com Attachment Terminology Inconsistent  Names still evolving Academics Clinicians Parents  Effect of confusion Create terms to fill in Lots of inconsistent and inappropriate use

4. © 2007, Family Attachment Center Inc., www.familyattachment.com Literature Search Results Words in Article Title Reactive Attachment Attachment Disorder Disorder(s) 1900-1980 0 0 1981-1990 1 2 1990-200010 21 2001-200751 59 Databases searched: CINAHL Plus with Full Text, PsycARTICLES, PsycINFO, SocINDEX with Full Text

5. © 2007, Family Attachment Center Inc., www.familyattachment.com Literature Search Results Words in Article Title Reactive Attachment AttachmentPosttraumatic Disorder Disorder(s)Stress Disorder 1900-1980 0 0 1 1981-1990 1 2 406 1990-200010 21 1,778 2001-200751 59 2,311 Databases searched: CINAHL Plus with Full Text, PsycARTICLES, PsycINFO, SocINDEX with Full Text

6. © 2007, Family Attachment Center Inc., www.familyattachment.com Lack of clarity  Some names DO have clear definitions Important to know definitions that are established and accepted, particularly when communicating with various groups

7. © 2007, Family Attachment Center Inc., www.familyattachment.com Attachment  John Bowlby, Mary Ainsworth  Attachment theory articulated between 1940s and 1970s  Influenced by Freud and psychoanalysis Shift in emphasis from internal fantasy life and psychic processes (psychoanalytic) to real events-- nurture, sensitivity, and care

8. © 2007, Family Attachment Center Inc., www.familyattachment.com Disciplines that Influenced Attachment Theory  Psychoanalytic  Evolutionary  Ethology

9. © 2007, Family Attachment Center Inc., www.familyattachment.com Post-Attachment Fields That Continue Support  Developmental psychology  Trauma  Stress  Neuroscience

10. © 2007, Family Attachment Center Inc., www.familyattachment.com Attachment Classifications  Ainsworth-Strange Situation  Classifications based on response to stressful situations. Reunion episode especially important  Ainsworth classifications Secure Insecure  Avoidant  Ambivalent  Mary Main and Judith Solomon classification Insecure Disorganized

11. © 2007, Family Attachment Center Inc., www.familyattachment.com Important points about classifications  Attachment classifications are not clinical diagnoses 30% of “normal” population has an insecure attachment Potential exception is Disorganized Attachment  Classifications may differ depending on dyad Example  Child-mother insecure/ambivalent  Child-father secure So, attachment classification is relationship specific

12. © 2007, Family Attachment Center Inc., www.familyattachment.com Practical Implication 1 It is technically incorrect to say a child is “insecurely attached.”

13. © 2007, Family Attachment Center Inc., www.familyattachment.com Practical Implication 1 It is technically incorrect to say a child is “insecurely attached.” The correct phrasing would be to say the child has an insecure attachment with his (or her) mother, for example.

14. © 2007, Family Attachment Center Inc., www.familyattachment.com Attachment classifications  Insecure-Ambivalent  Insecure-Avoidant  Disorganized

15. © 2007, Family Attachment Center Inc., www.familyattachment.com Strange Situation Descriptions Source: Hesse, E. (1999). The adult attachment interview: Historical and current perspectives. In J. Cassidy and P. R. Shaver (Eds.), Handbook of Attachment: Theory, Research and Clinical Applications (pp. 395-433). New York: Guilford Press.

16. © 2007, Family Attachment Center Inc., www.familyattachment.com Reactive Attachment Disorder  Clear, but evolving, definition First appeared in DSM III 1980  Differentiate from nonorganic Failure to Thrive  Required condition of failure to thrive  Required inappropriate social relatedness in most contexts  Required onset prior to 8 months  inconsistent with developmental literature, which says kids form selective attachments between 6 and 12 months

17. © 2007, Family Attachment Center Inc., www.familyattachment.com Reactive Attachment Disorder  Major revision in DSM-III-R in 1987  Dropped failure to thrive requirement  Age of onset modified to first 5 years  Inhibited and disinhibited types added  Pathogenic care requirement  DSM IV 1994  Next DSM Revision expected 2011

18. © 2007, Family Attachment Center Inc., www.familyattachment.com Criticisms of R.A.D.  Not based on attachment (child-caregiver) relationship  Maltreatment syndrome  Requirement of inappropriate social relatedness in most contexts  Only appropriate for kids with NO selective attachment

19. © 2007, Family Attachment Center Inc., www.familyattachment.com Practical Implication 2

21. © 2007, Family Attachment Center Inc., www.familyattachment.com Attachment Disorders  There is a large group of children with significant clinical features related to disordered attachment relationships who are not captured by current diagnostic classifications  Attachment-exploration balance  Secure base and safe haven

22. © 2007, Family Attachment Center Inc., www.familyattachment.com Alternative Classification Systems  Lieberman, Zeanah, Boris, and others Disorders of nonattachment  With emotional withdrawal  With indiscriminate sociability Secure base distortions  With self-endangerment  With inhibition  With vigilance/hypercompliance  With role reversal Disrupted attachment Source: Zeanah, C. H. & Boris, N. W. Disturbances and disorders of attachment in early childhood. In C. H. Zeanah (Ed.), Handbook of Infant Mental Health, 2nd ed. (pp. 353-368). New York: Guilford.

23. © 2007, Family Attachment Center Inc., www.familyattachment.com Continuum of attachment levels Source: Boris, N. W. & Zeanah, C. H. (1999). Disturbances and disorders of attachment in infancy: An overview. Infant Mental Health Journal, 20, 1-9.

24. © 2007, Family Attachment Center Inc., www.familyattachment.com Alternative Classification Systems  Complex Trauma-dual problem Children’s exposure to traumatic events  Multiple traumatic events that occur within caregiving system, which is supposed to be the source of safety and stability  Simultaneous or sequential occurrences of maltreatment-- emotional abuse and neglect, sexual abuse, physical abuse, witness domestic violence--that are chronic and begin in early childhood  Initial exposure puts individual at elevated risk for subsequent exposure Source: Cook, A., Blaustein, M.. Spinazzola, J., & van der Kolk, B. (Eds.). (2003). Complex Trauma in Children and Adolescents: White Paper from the National Child Traumatic Stress Network Complex Trauma Task Force. National Child Traumatic Stress Network: Los Angeles.

25. © 2007, Family Attachment Center Inc., www.familyattachment.com Alternative Classification Systems  Complex Trauma-dual problem (cont.) Impact of exposure on long term outcomes  Range of clinical symptomatology after such exposure Multiple domains of impairment  Attachment  Biology  Affect Regulation  Dissociation  Behavioral Control  Cognition  Self-Concept

26. © 2007, Family Attachment Center Inc., www.familyattachment.com DSM Focii  Unite DSM and ICD classifications  6 initial focus area-White papers Basic nomenclature issues Basic and clinical neuroscience and genetics Advances in developmental science Personality and relational disorders Mental disorders and disability Cross-cultural issues  3 additional focus areas added Gender Geriatric Infants and young childrenSource: dsm5.org

27. © 2007, Family Attachment Center Inc., www.familyattachment.com DSM V Timeline-Publication 2011 19992000200120022003200420052006200720082009 White papers Publish Research Agenda Conferences Workgroups Begin Task Force Appts. Planning Stage Formal Revision

28. © 2007, Family Attachment Center Inc., www.familyattachment.com DSM Task Force  David J. Kupfer, M.D. chair  Darrel A. Regier, M.D., M.P.H. vice chair  Chairs of 20-25 work groups plus others

29. © 2007, Family Attachment Center Inc., www.familyattachment.com Task Force Members  William Narrow, M.D., M.P.H., research director, DSM-V Task Force  Maritza Rubio-Stipec, Sc.D., statistics and methods director  William T. Carpenter Jr., M.D., chair, Psychosis Work Group  Francisco Xavier Castellanos, M.D., chair, Externalizing Disorders  Wilson M. Compton, M.D., M.P.E.  Joel E. Dimsdale, M.D., chair, Somatoform Disorders Work Group  Javier Escobar, M.D., M. Sc.  Jan Fawcett, M.D., chair, Mood Disorders Work Group  Steven E. Hyman, M.D., rapporteur, Spectra Study Group  Dilip Jeste, M.D., chair, Dementia, Delirium, Amnestic & Other Cognitive Disorders Work Group  Helena C. Kraemer, Ph.D.  Daniel T. Mamah, M.D., M.P.E.  James McNulty, A.B., Sc.B.

30. © 2007, Family Attachment Center Inc., www.familyattachment.com Task Force Members  Howard B. Moss, M.D.  Charles O'Brien, M.D., Ph.D., chair, Substance-Related Disorders Work Group  Roger Peele, M.D.  Katherine A. Phillips, M.D., chair, Anxiety Disorders Work Group  Daniel Pine, M.D., chair, Childhood/Adolescent Disorders Work Group  Charles F. Reynolds III, M.D., Ph.D., chair, Sleep Disorders Work Group  Andrew E. Skodol II, M.D., chair, Personality Disorders Work Group  Susan Swedo, M.D., chair, Autism & Other PDD Work Group  B. Timothy Walsh, M.D., chair, Eating Disorders Work Group  Philip Wang, M.D., Dr. P.H.  William Womack, M.D.  Kimberly A. Yonkers, M.D., rapporteur, Gender & Cross-Cultural Study Group

31. © 2007, Family Attachment Center Inc., www.familyattachment.com Family Attachment Center 18322C Minnetonka Blvd Deephaven, MN 55391 952-475-2818 www.familyattachment.com