EMOTION REGULATION & EMOTION DYSREGULATION + CHILD-CAREGIVER ATTACHMENT & REACTIVE ATTACHMENT DISORDER. Diane Benoit, MD, FRCPC

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1 July 11, 2013 EMOTION REGULATION & EMOTION DYSREGULATION + CHILD-CAREGIVER ATTACHMENT & REACTIVE ATTACHMENT DISORDER Diane Benoit, MD, FRCPC (not supported by funding from an industry or pharmaceutical company; no conflict of interest to declare) OBJECTIVES Describe emotion regulation and emotion dysregulation Define child-parent attachment (types, assessment methods, antecedents, consequences) Describe Reactive Attachment Disorder of Infancy and Early Childhood and management (+ DSM-V changes) 1

2 EMOTIONAL DEVELOPMENT First 2 months distress contentment interest 2-7 months sadness disgust anger joy contentment interest surprise 4 mo. (can detect fear & express wariness) 7-18 months 9 mo. fear Smiling, pouting, and anger begin to be used instrumentally Relatively impervious to frustration Affective sharing Social referencing months after 18 mo. Moral emotions after 24 mo. embarrassment empathy envy guilt pride shame EMOTION REGULATION - Emotions may be positive (e.g., happy, proud) or negative (e.g., sad, anxious, angry) in valence and vary in intensity surprised afraid high arousal angry happy disgusted pleasant unpleasant sad Adapted from Adolphs (2002) neutral low arousal - 2 m.o. infants can discriminate among distinct human expressions, incl. intensity of some expression although does not yet understand others expressions 2

3 EMOTION REGULATION Emotion regulation: No universally accepted definition Likely involves a set of processes or systems: attentional cognitive behavioral social biological These processes act to modulate, manage, or organize emotions to help individuals meet the demands of the environment Source: Hilt LM, Hanson JL, & Pollak SD (2011). EMOTION REGULATION / DYSREGULATION Early development factors set the stage for later emotion regulation patterns Biology Exposure to alcohol and/or drugs during fetal development Temperament natural or inherited/biological predispositions Children with certain temperamental characteristics (e.g., proneness to negative affect, higher reactivity, poor attentional control) are more likely to have problems with regulating emotions later on Source: Hilt LM, Hanson JL, & Pollak SD (2011). 3

4 GENETICS Individual differences in infant temperament thought to originate in genetic variations underpinning behavioral, neuroendocrine, and physiological regulatory processes Genes/Receptors involved in approach behaviors and inhibition, attention and novelty seeking: Dopamine D4 receptor (DRD4) Serotonin transporter receptor (5-HTTLPR) Source: Rosenblum, Dayton & Muzik, 2009 GENETICS Infants with short (vs. long) allele of the DRD4 gene are rated by their mothers as higher in negative emotionality at 2 and 12 months old Infants with the short allele of the 5-HTLPR display heightened fear and behavioral inhibition Additive effect across DRD4 and 5-HTTLPR: Infants with short alleles on both genes display more negative emotion reactivity than infants who carry only one risk allele Source: Rosenblum, Dayton & Muzik,

5 EPIGENETICS Critical influence of early experience on gene functioning Children who are 5-HTTLPR risk carriers and experienced childhood abuse = more likely to develop depression later on, but only when their caregivers were under heightened stress Behaviorally inhibited infants who are carriers of the 5- HTTLPR risk allele = at increased risk for behavioral inhibition in middle childhood only when their caregivers report low social support In one study, although maternal insensitivity was associated with later externalizing behavior, this was only true in the presence of infant DRD4 genetic risk status. In one study, insensitive parenting coupled with infant genetic vulnerability led a sixfold increase in child aggressive behaviors in the preschool years EMOTION REGULATION / DYSREGULATION Social learning (+ social development) Interactions with caregiver 2-7 months:» Enhanced interest and ability to engage adults in synchronous and reciprocal social interchanges» Play periods alternate with time outs» Affective mismatches during interactions stimulate infant s coping capacities 7-18 months:» Preferred attachment to a small number of caregiving adults develops» Stranger wariness and separation protest appear» Social referencing to resolve uncertainty months:» Enhanced capacity to express needs and increased negotiations with caregivers» Increased interest in peer relatedness parallel play fleeting contact true interactive play» Concern with personal possessions and sensitive to being included/excluded» Relationships with others increasingly important as referents for selfappraisal 5

6 EMOTION REGULATION / DYSREGULATION Social learning...cont d Infants must rely on caregivers for much of their emotion regulation Children observe what their caregivers do to change negative emotional states e.g., distract, soothe, problem-solve Modeling of effective emotion regulation strategies by caregivers Children develop cognitive skills, incl. language to talk about emotions By age 3, children are typically able to mask negative emotions under some conditions, demonstrating increased emotion regulation capacities Source: Hilt LM, Hanson JL, & Pollak SD (2011). EMOTION REGULATION / DYSREGULATION Children whose parents are accepting and responsive to their emotions are often able to adaptively regulate their emotions Children whose parents punish or disregard their emotions often have more difficulty regulating their emotions Caregiver s unresponsiveness leads to child s emotion dysregulation Source: Hilt LM, Hanson JL, & Pollak SD (2011). 6

7 EMOTION REGULATION / DYSREGULATION Maltreatment, abuse, neglect Compared to adolescents who have not suffered early adversity, e.g., maltreatment, adolescents who have suffered early adversity are 3x more likely to suffer a mood disorder 4x more likely to show disruptive behavior 2-4x more likely to have an anxiety disorder Even if they might have no diagnosable disorder, children exposed to maltreatment are likely to have elevated symptoms of Depression Anxiety Posttraumatic stress Suicidal ideation Risk greater for females Girls vs. boys 7-10x more likely to suffer from affective psychopathology (depression, anxiety, posttraumatic stress-related symptoms) Source: Hilt LM, Hanson JL, & Pollak SD (2011). EMOTION REGULATION / DYSREGULATION Maltreatment, abuse, neglect cont d Adolescents maltreated as children (vs. nonmaltreated youth) have Greater risk of violent and nonviolent delinquency More often use threatening behaviors or physical abuse against their dating partners Have more arrests as a juvenile or adult Display poorer social competence Inaccurately infer emotional reactions Have trouble with interpersonal interactions involving peers and dating partners Source: Hilt LM, Hanson JL, & Pollak SD (2011). 7

8 Components of Emotion Regulation Cascade Emotion regulation involves numerous component processes including, at the most basic level: Reading or understanding emotional signals Sorting or categorizing the emotion signals as positive or negative to generate a response Enacting a behavior response Source: Hilt LM, Hanson JL, & Pollak SD (2011). Brain structures implicated & role Birth onwards (enables association learning) Intrinsic emotional arousal / response Amygdala: emotion recognition / directing eye gaze / reading emotions from faces Hippocampus: response to external context Rapid developments: 18 months 11 years old Sensory / spatial analysis Cortical subsystems (amygdala, orbitofrontal cortex) 3 confirming / modulating sources of information: face expression analysis vocal analysis eye configuration analysis Throughout childhood and adolescence: Increasing conscious control over regulating emotions Executive system synthesis Higher cortical processing (frontal / prefrontal cortex) The synthesis of emotion and cognition: Affect perception (reading emotions and empathizing) Executive functioning Emotion regulation / control Development of emotion recognition / processing abilities Adapted from Oliphant (2012) 8

9 SOME OF THE BRAIN REGIONS INVOLVED IN FACIAL AFFECT RECOGNITION Inferior occipital (visual system) Superior temporal sulcus Lateral fusiform gyrus Intraparietal sulcus Auditory cortex Limbic system (e.g., amygdala & insula) Parietal lobes Anterior temporal Somatosensory regions & Prefrontal regions Early feature perception Gaze, expression, lip movement Face identity Spatial attention Prelexical speech perception Supports attention to socially salient regions, esp. for complex emotions Support decoding of information from faces Identity, name, biography Associated with creating internal representations of the experiences of others, recognize emotion portrayed by their expressions EMOTION DYSREGULATION 1 st step in cascade (e.g., adolescent) Adolescent s perception of some change in the environment Sensory stimuli from the external environment are perceived, processed, categorized through the visual system & relayed to the central perceptual circuitry in the brain, incl. the occipital cortex, the superior temporal gyrus, and the fusiform gyrus Emotion dysregulation may occur during this step if adolescents are somehow biased in processing information, e.g., if can easily notice negative stimuli but has a harder time noticing positive stimuli. This, in turn, can affect categorization and behavioral responses (e.g., decision to avoid a situation b/c perception that it is negative rather than approach or vice versa) Source: Hilt LM, Hanson JL, & Pollak SD (2011). 9

10 EMOTION DYSREGULATION 2 nd step in cascade (after stimulus is processed): Generate an emotional response, attaching valence to stimuli (e.g., deciding if positive or negative) This is a complex step that involves aspects of emotional categorization, associative learning, memory, and reward processing Perceptual evaluations across development create an accumulation of stored associations and memories that impart meaning and motivate behavior (e.g., associating specific stimuli with specific outcomes) e.g., noticing a facial feature, such as a grimace, and immediately concluding that it is an indication of physical threat, without taking into account other contextual cues Source: Hilt LM, Hanson JL, & Pollak SD (2011). EMOTION DYSREGULATION 2 nd step in cascade (after stimulus is processed) cont d Associations become the background knowledge and beliefs that the adolescent holds about his/her emotional world, adding in the ability to predict others emotions in certain contexts Associative learning may be particularly important for the regulation of emotions, as children must learn to change their behavior in response to other people s negative emotional states such as anger or disapproval (or moderate behavior in response to feedback from parents, teachers or peers) With pleasurable and positively valenced stimuli, reward processing, in brain regions like the nucleus accumbens, elicits an appetitive (i.e., urge toward a stimulus) and emotional response Aberrant reward processing may be involved in some psychopathology; pediatric bipolar disorder may involve excessive pleasure seeking during mania or anhedonia during depression Source: Hilt LM, Hanson JL, & Pollak SD (2011). 10

11 EMOTION REGULATION 3 rd step in cascade: Generation of a behavioral response Requires mainly executive functions such as inhibitory control During adolescence, behavioral responses are changing, becoming increasingly flexible at both adapting and inhibiting prepotent responses based on changing environmental contingencies Memory processes influence this step (adol. relies on increasing knowledge of probability of success or failure of particular response options, based on previous experience) Source: Hilt LM, Hanson JL, & Pollak SD (2011). EMOTION REGULATION 3 rd step cont d Aggressive children are relatively inflexible in their ability to access behavioral responses tend to rely heavily on a single (dominant and often maladaptive) response rather than accessing less salient (but perhaps more prosocial) response options during ambiguous peer provocation, an aggressive child will infer hostile intent and respond aggressively have trouble changing to a new response if the one they use is not successful the rates of aggressive behavior are negatively associated with the number of responses generated Source: Hilt LM, Hanson JL, & Pollak SD (2011). 11

12 Amygdala: EMOTION REGULATION Responds to emotional stimuli (e.g., angry or fearful faces or upsetting pictures) Involved in other functions, e.g., memory, learning, attention Plays an integrative role: bringing together simple behaviors with more sophisticated ones esp. important when dealing with the interpretation of complex information and learning relative to previous exposure to similar events Greater activation in adolescents during processing of emotional stimuli such as fearful faces compared to children and adults EMOTION REGULATION Hippocampus: Implicated in memory functioning New memories processed in the hippocampus before being stored in the cortex as long-term memories Important for learning and remembering space (e.g., layout of city streets in the downtown area) Implicated in other functions: e.g., control of neuroendocrine functions and modulation of emotional behavior May be specifically involved with depression and anxiety 12

13 EMOTION REGULATION Pre-frontal cortex: Central to top-down control of attention, inhibition, emotion regulation, complex learning, and theory-of-mind processing Of critical note for understanding emotion dysregulation are Dorsolateral prefrontal cortex Crucial in attention, working memory, cognitive control processes If damaged: impairments in planning, goal attainment, problemsolving ability Role in exerting top-down control in emotion regulation (such as reappraising negative stimuli) Involved in visuo-spatial working memory of salient stimuli Is activated during successful inhibition of irrelevant stimuli Orbito-frontal cortex Primarily involved in valuation of stimuli and aspects of emotion recognition Activated by emotional stimuli such as faces and pleasurable and painful touch If damaged: deficits in socioemotional regulation Supports behaviors such as inhibition, appropriate responses to other people s moods, self-regulation of social-emotional behavior EMOTION REGULATION The dorsolateral prefrontal cortex & orbitofrontal cortex two of the last regions in the brain to fully develop in humans changes are seen until 20 years of age or later 13

14 EMOTION REGULATION Nucleus accumbens: the reward and positive-affect center of the brain involved with approach-related behavior such as reward and positive emotion Anterior cingulate cortex Involved with conflict monitoring and/or error detection in relation to an emotional state May be especially important for adolescent socioemotional regulation (may be activated in response to social conflict or peer rejection) Adolescents show activity when examining angry faces, but less activity than adults when viewing happy faces EMOTION DYSREGULATION A maladaptive pattern of regulating emotions that may involved a failure of regulation or interference in adaptive functioning Occurs if emotion-regulation strategies are not learned, well practiced, are overly rigid, overused, or fail Source: Hilt LM, Hanson JL, & Pollak SD (2011). 14

15 EMOTION DYSREGULATION Involves attempts at regulation, but the process leads to maladjustment rather than adjustment, e.g., may result in or be associated with poor interpersonal relationships difficulty concentrating feeling overwhelmed by emotions inability to inhibit destructive behaviors unhappiness in severe cases, the development of psychopathology (e.g., depression, anxiety, substance abuse) Source: Hilt LM, Hanson JL, & Pollak SD (2011). CHILD-CAREGIVER ATTACHMENT Attachment = organization of behaviors in a young child that are designed to achieve physical proximity to a preferred caregiver at times when the child is distressed (physically hurt, ill, frightened) and/or seeks comfort, support, nurturance, or protection Source: AACAP Practice Parameters,

16 CHILD-CAREGIVER ATTACHMENT Newborns recognize their mother s smell & sound at birth, but express no preference for a particular person to provide comfort for distress Between 2-7 months: may be more readily comforted by a familiar caregiver, although can be soothed by unfamiliar adults as well Around 7-9 months: reticence around unfamiliar adults (stranger wariness) and protest around separations from familiar caregivers (separation protest) Once stranger wariness and separation protest have appeared, infant is said to be attached Source: AACAP Practice Parameters, 2005 CHILD-CAREGIVER ATTACHMENT By 12 months: can assess quality of infant s attachment to a discriminated attachment figure Strange Situation Procedure 4 patterns of attachment Associated with different types of caregiving in the first year of life Associated with different outcomes/adaptation in the preschool years and beyond Source: AACAP Practice Parameters,

17 4 TYPES OF ATTACHMENT Quality Strange Situation Procedure classification or Type of of caregiving Attachment Loving Secure (~55%) Rejecting Avoidant (~23%) Inconsistent Resistant (~8%) Atypical Disorganized (15%) SECURE ATTACHMENT (~55%) During the Strange Situation Procedure: Seek proximity to caregiver Establish physical contact Show little/no avoidance toward caregiver May seek interaction from a distance rather than physical proximity/contact Settle quickly when the caregiver is present and are able to explore Loving caregiving Secure attachment 17

18 INSECURE/AVOIDANT ATTACHMENT (~23%) During the Strange Situation Procedure: Rarely distressed by the separation Show strong avoidance Do not seek proximity to the caregiver Do not maintain contact Show little/no resistance Focus attention away from the caregiver Rejecting caregiving Avoidant attachment INSECURE/AMBIVALENT- RESISTANT ATTACHMENT (~8%) During the Strange Situation Procedure: Show no avoidance Seek proximity to caregiver or may be so upset that they only signal desire for contact Show high levels of distress Cannot be comforted during the reunion Maintain contact that fails to soothe them Inconsistent caregiving Ambivalent/Resistant attachment 18

19 INSECURE/DISORGANIZED ATTACHMENT (~15%) During the Strange Situation Procedure: Exhibit behaviors suggesting that they are frightened, confused and unable to use of coherent strategy for dealing with the stress of the Strange Situation (e.g., cover eyes/face when caregiver returns, hides behind furniture, confuses stranger and caregiver, approaches a wall rather than caregiver when distressed, freezes, cries and laughs at the same time) Frightening caregiving Disorganized attachment CHILD-CAREGIVER ATTACHMENT Strange Situation Procedure Classifications are neither clinical diagnoses nor indicators of psychopathology Classifications represent protective (secure) or risk (insecure, disorganized) factors e.g., poor socio-emotional outcome associated with disorganized attachment: aggression, social incompetence, vulnerability to stress, low self-esteem, problems with regulation and control of negative emotions, dissociation, oppositional defiant, hostile, coercive behavior, problems at school Conducted in many cultures around the world Limited clinical utility e.g., months old Patterns of attachment are relationship specific rather than within-the-child traits 19

20 CHILD-CAREGIVER ATTACHMENT Capacity for attachment is innate - infants become attached to any caregiver with whom they have had significant amounts of interaction regardless of the quality of caregiving Hierarchy of attachment figures (in terms of strength of preference) Preferred attachments to caregivers can develop any time after infant reaches developmental age of 7 to 9 months, provided the new caregivers have sufficient involvement with the child Lack of attachment to a specific attachment figure is exceedingly rare in reasonably responsive caregiving environments Source: AACAP Practice Parameters, 2005 INTERVENTIONS (Attachment) Caregiver sensitivity // Organized attachment - secure/avoidant/resistant Disorganized attachment Atypical caregiver behavior // Organized attachment - secure/avoidant/resistant Disorganized attachment 20

21 REACTIVE ATTACHMENT DISORDER Distinction between classifications of attachment in the Strange Situation Procedure and disorders of attachment Disorganized attachment IS NOT equivalent to a disorder Disorganized attachment IS NOT SYNONYMOUS with Reactive Attachment Disorder REACTIVE ATTACHMENT DISORDER Clinical descriptions of disordered attachment in infancy and early childhood (Levy, 1937; Bowlby, 1944; Spitz, 1950) Tizard & Rees (1975), Tizard et al. (1977) N = 26 children raised in residential nurseries in London; children had adequate books, toys & instruction available so the usual confound of material privation in previous studies of institutionalized children was eliminated and the variable of most interest, caregiver-child relationship, was isolated for study 8/26: emotionally withdrawn & unresponsive to anyone DSM inhibited type 10/26: indiscriminately social, attention seeking and clingy with everyone, including unfamiliar adults DSM disinhibited type 8/26: formed preferred attachments to caregivers 21

22 REACTIVE ATTACHMENT DISORDER DSM-IV-TR CRITERIA A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2): (1) persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness) (2) diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) B. The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for Pervasive Developmental Disorder. C. Pathogenic care as evidenced by at least one of the following: (1) persistent disregard of the child s basic emotional needs for comfort, stimulation, and affection (2) persistent disregard of the child s basic physical needs (3) repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care). D. There is a presumption that the care in Criterion C is responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C. Specify type: Inhibited Type: If Criterion A1 predominates in the clinical presentation Disinhibited Type: If Criterion A2 predominates in the clinical presentation REACTIVE ATTACHMENT DISORDER A minimum cognitive age of 9 months is necessary for a diagnosis of RAD to be made Only a minority of young children who are abused and neglected develop attachment disorders Most institutionalized children do not develop attachment disorders Individual differences in caregiving quality among institutionalized children have been related to signs of the emotionally withdrawn/inhibited type but not to the indiscriminately social/disinhibited type of RAD (challenging pathogenic care) 22

23 REACTIVE ATTACHMENT DISORDER Natural course: No data compatible with the idea that there is a critical period for attachment formation Persistence of the inhibited pattern RAD is exceedingly rare in children adopted out of institutions into more normative caregiving environments Although the quality of attachments that these children form with subsequent caregivers may be compromised, they probably no longer meet criteria for inhibited RAD Source: AACAP Practice Parameters, 2005 REACTIVE ATTACHMENT DISORDER Indiscriminate behavior Stable from 4 to 8 y.o. even after more normative caregiving environments are provided Overfriendly behavior especially resistant to change At age 16: Indiscriminate behavior less evident with caregivers but evident with peers Relations with peers conflicted and superficial Likely to name a recent acquaintance as close friend 23

24 REACTIVE ATTACHMENT DISORDER The question of whether attachment disorders can reliably be diagnosed in older children and adults has not been resolved Some have stretched criteria for RAD to expend the diagnosis to older children problems: Diagnostic precision is lost when signs such as oppositional behavior and aggression are viewed as aberrant attachment behavior Untested alternative therapies, loosely based on the proposed etiological model of RAD in older children, have been developed and implemented, sometimes with tragic results Source: AACAP Practice Parameters, 2005 REACTIVE ATTACHMENT DISORDER Differential diagnosis & comorbidity: Few direct data A number of problems documented to arise from the same risk conditions (institutional rearing or maltreatment) that give rise to RAD: Mental retardation (developmental delays are often reversible, much like the signs of RAD, when normative caregiving environment is provided Language disorders PDD Posttraumatic Stress Disorder Maltreatment associated with problems with regulation of emotions, hypervigilance, withdrawal Source: AACAP Practice Parameters,

25 REACTIVE ATTACHMENT DISORDER DSM-V (APA, 2013) Two distinct disorders Reactive Attachment Disorder - RAD Disinhibited Social Engagement Disorder - DSED Differences in phenomenology, correlates, and responses to intervention of RAD and DSED REACTIVE ATTACHMENT DISORDER DSM-V (APA, 2013) Reactive Attachment Disorder Limited or absent initiation or response to social interactions with caregivers and aberrant social behaviors When distressed, the child fails to seek or respond consistently to comfort from caregivers and exhibits emotion dysregulation Disinhibited Social Engagement Disorder Lack of social reticence with unfamiliar adults, failure to check back with caregivers in unfamiliar settings and a willingness to go off with strangers In somewhat older children, intrusive and overly familiar behavior with strangers, including asking overly personal questions, violating personal space, or initiating physical contact without hesitation Rare to non-existent in low risk samples; rare in higherrisk samples; readily identifiable in maltreated and institutionalized samples 25

26 REACTIVE ATTACHMENT DISORDER DSM-V (APA, 2013) Reactive Attachment Disorder - RAD More closely linked to internalizing disorders Converges modestly with depression Essentially equivalent to lack of or incompletely formed preferred attachments (disordered attachment) More responsive to intervention; disappears after institutionalized child is placed in a family REACTIVE ATTACHMENT DISORDER DSM-V (APA, 2013) Disinhibited Social Engagement Disorder - DSED More closely linked to ADHD & disruptive disorders, but not synonymous Converges modestly with ADHD & disruptive disorders Child has established attachment, and even secure attachment (disinhibited social engagement) More resistant to intervention; shown to persist into adolescence (even after placement in adequate caregiving environments) and to be associated with peer relational difficulties 26

27 AACAP Practice Parameters, 2005 revisions underway Recommendation 1. The assessment of RAD requires evidence directly obtained from serial observations of the child interacting with his or her primary caregivers and history (as available) of the child s patterns of attachment behavior with these caregivers. Observations of the child s behavior with unfamiliar adults are also necessary for diagnosis. Given the association between a diagnosis of RAD and a history of maltreatment, the clinician should also gather a comprehensive history of the child s early caregiving environment, including from collateral sources (e.g., pediatricians, teachers, or caseworkers familiar with the child). AACAP Practice Parameters, 2005 revisions underway Recommendation 2. A relatively structured observational paradigm should be conducted so that comparable behavioral observations can be established across relationships. Recommendation 3. After assessment, any suspicion of previously unreported or current maltreatment requires reporting to the appropriate law enforcement and protective services authorities. 27

28 AACAP Practice Parameters, 2005 revisions underway Recommendation 4. Maltreated children are at high risk of developmental delays, speech and language deficits or disorders, and untreated medical conditions. Referral for developmental, speech, and medical screening may be indicated. Recommendation 5. The most important intervention for young children diagnosed with RAD and who lack an attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an emotionally available attachment figure. AACAP Practice Parameters, 2005 revisions underway Recommendation 6. Although the diagnosis of RAD is based on symptoms displayed by the child, assessing the caregiver s attitudes toward and perceptions about the child is important for treatment selection. Recommendation 7. Children with RAD are presumed to have grossly disturbed internal models for relating to others. After ensuring that the child is in a safe and stable placement, effective attachment treatment must focus on creating positive interactions with caregivers. 28

29 AACAP Practice Parameters, 2005 revisions underway Recommendation 8. Children who meet criteria for RAD and who display aggressive and oppositional behavior require adjunctive treatments. Recommendation 9. Interventions designed to enhance attachment that involve noncontingent physical restraint or coercion (e.g., Therapeutic Holding or Compression Holding ), Reworking of trauma (e.g., Rebirthing Therapy ), or promotion of regression for reattachment have no empirical support and have been associated with serious harm, including death. REFERENCES 1. Adolphs R (2002). Recognizing emotion from facial expressions: Psychological and neurological mechanisms. Behavioral and Cognitive Neurosciences Reviews, 1(1), Benoit D (2000). Attachment and parent-infant relationships A review of attachment theory and research. Ontario Association of Children s Aid Societies Journal, 44(1), Available at April/Attachment.pdf 3. Benoit, D. (2004). Infant-parent attachment: Definition, types, antecedents, measurement and outcome. Paediatrics and Child Health, 9(8), Hilt LM, Hanson JL, & Pollak SD (2011). Emotion dysregulation. Encyclopedia of Adolescence, 3,

30 REFERENCES 4. Oliphant J (2012). Emotional processing from faces following childhood brain injury: A literature review. Dissertation. University of Exeter. (substantive literature review). 5. Rosenblum KL, Dayton CJ, & Muzik M (2009). Infant social and emotional development. In C. H. Zeanah (Ed.), Handbook of Infant Mental Health (Third Edition, pp ). New York: Guilford Press. 6. Zeanah CH & Gleason MM (2010). Reactive Attachment Disorder: A review for DSM-V. American Psychiatric Association. 7. Zeanah CH & Smyke AT (2009). Attachment disorders. In C. H. Zeanah (Ed.), Handbook of Infant Mental Health (Third Edition, pp ). New York: Guilford Press. 30