1. REACTIVE ATTACHMENT DISORDER

2. 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.

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

4. 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.”

5. 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

6. 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

7. 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

8. 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

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

10. 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?

11. National Child Traumatic Stress Network Developmental Trauma Taskforce

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

13. 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

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

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

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

17. 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

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

19. 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)

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

21. 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

22. 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

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

24. Maslow’s Hierarchy