REACTIVE ATTACHMENT DISORDER

CONTROVERSY-In General  Little evidence to support DX or TX.  Comorbidity with other Axis I & II is so significant that it gets lost.  DX may disappear in DSM V  Emerging info on genetic, neurophysiological and neuroanatomical data on early stress will shape our understanding of attachment disruption.

References  American Academy of Child and Adolescent Psychiatry  National Child Traumatic Stress Network – DSM V

RAD  “ is the clinical disorder that defines distinctive patterns of aberrant behavior in young children who have been maltreated or raised in environments that limit opportunities to form selective attachments.”

ACAP Practice Parameters (American Academy of Child and Adolescent Psychiatry)  Children with RAD  Extreme neglect  Abnormal social behaviors  Lack of responsiveness  Excessive inhibition  Hypervigilance  Indiscriminate sociability  Disorganized attachment behaviors

Etiology  Early Care – after 6 mos but before 3 yrs  Persistent disregard of child’s basic emotional needs for comfort, stimulation and affection  Persistent disregard of child’s basic physical needs  Repeated changes of primary caregiver

What is known  Attachment disturbance can occur in residential settings where infants must rely on a large number of caregivers  Lack of attachment is rare  Does not occur without serious neglect  Stressed kids seek comfort from caregiver  RAD kids resist comfort

What is known  Persistence over time unlikely  Attachments are compromised  Indiscriminate sociability  These kids a handful for adoptive parents  No validated measures for middle childhood, adolescence and adulthood  Dx relies on history

Problems with DX  No clinical data establishing Efficacy of Dx  Little TX research  Little longitudinal research  No solid outcome research

Problems with Dx –DSM V?  Is attachment a disorder of diagnosis? OR OR  Is RAD a symptom of neglect and trauma that fits into a Developmental Trauma Disorder?

National Child Traumatic Stress Network Developmental Trauma Taskforce

Developmental Trauma Disorder  Exposure  Multiple or chronic  Abandonment  Betrayal  Sexual assaults  Neglect  Coercive practices  Emotional abuse  Witnessing

Developmental Trauma Disorder SSSSubjective experience RRRRage BBBBetrayal FFFFear RRRResignation SSSShame

 Triggered pattern of repeated dysregulation in response to trauma cues  Some type of PTSD  Affect  Somatic  Behavioral  Cognitive  Relational  Self-care

Developmental Trauma Disorder  Regulation Strategy  Anticipation  Coping  Restorative  Disorganized

Developmental Trauma Disorder  Impact on other Disorders  Substance Abuse  Bipolar  Depression  Somatization

Developmental Trauma Disorder  Expectations  Negative self-attribution  Loss of protective caretaker  Loss of protection of others  Loss of trust in the system to protect  Expecting to be victimized in future

Developmental Trauma Disorder  Functional Impairment  Scholastic  Familial  Peer  Legal  Vocational

Attachment and Trauma  “The security of attachment bonds seems to be the most important mitigating factor against trauma-induced disorganization. In contrast, trauma that affects the safety of attachment bonds interferes with the capacity to integrate sensory, emotional and cognitive information into a cohesive whole and sets the stage for unfocused and irrelevant responses to subsequent stress.” (van der Kolk, 2003)

Core Features  Excessive attempts to receive comfort and affection OR  Extreme reluctance to initiate or accept comfort or affection

Additional Features  Disturbed and developmentally inappropriate social relatedness  Not as a result of a developmental delay  Onset before age five  Requires a history of significant neglect  Lack of identifiable, preferred attachment figures

AACAP Guidelines for TX  Provide an emotionally attachment figure  Assess caregivers attitude toward and perceptions about the kid  Creating positive interactions with caregivers  Kids with aggressive or oppositional behaviors will require other Tx

Trauma Processing  Safety  Stress Reducing Resources  Surface and Engage trauma  Transfer therapeutically (“Forget”)  Review child’s formulation of trauma

Maslow’s Hierarchy