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RAD, Attachment Disorders, Complex Trauma, etc. What difference does the name make and who cares anyway? Todd Nichols ATTACh 2007 Conference
© 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
© 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
© 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
© 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
© 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
© 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
© 2007, Family Attachment Center Inc., www.familyattachment.com Disciplines that Influenced Attachment Theory Psychoanalytic Evolutionary Ethology
© 2007, Family Attachment Center Inc., www.familyattachment.com Post-Attachment Fields That Continue Support Developmental psychology Trauma Stress Neuroscience
© 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
© 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
© 2007, Family Attachment Center Inc., www.familyattachment.com Practical Implication 1 It is technically incorrect to say a child is “insecurely attached.”
© 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.
© 2007, Family Attachment Center Inc., www.familyattachment.com Attachment classifications Insecure-Ambivalent Insecure-Avoidant Disorganized
© 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.
© 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
© 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
© 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
© 2007, Family Attachment Center Inc., www.familyattachment.com Practical Implication 2
© 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
© 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.
© 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.
© 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.
© 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
© 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
© 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
© 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
© 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.
© 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
© 2007, Family Attachment Center Inc., www.familyattachment.com Family Attachment Center 18322C Minnetonka Blvd Deephaven, MN 55391 952-475-2818 www.familyattachment.com
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