REACTIVE ATTACHMENT DISORDER
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Transcript REACTIVE ATTACHMENT DISORDER
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
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
Subjective experience
Rage
Betrayal
Fear
Resignation
Shame
Developmental Trauma
Disorder
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
Maslow’s Hierarchy