REACTIVE ATTACHMENT DISORDER. Critical Analysis and Case Presentation Ashley Woods Community Health of Central Washington March 2, 2018

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1 REACTIVE ATTACHMENT DISORDER Critical Analysis and Case Presentation Ashley Woods Community Health of Central Washington March 2, 2018

2 WHAT IS ATTACHMENT? Developmental considerations 2-7 months; 7-9 months; 12 months. Attachment styles are relational as opposed to inherent concepts Secure, Anxious-Ambivalent, Avoidant, and Disorganized Strange Situation Procedure Validated research tool cross culturally Associated with different types of caregiving in infancy & different forms of adaptation/functioning throughout the lifespan (Zeanah, Chesher, Boris & the AACAP, 2016)

3 SPECIAL NOTE: Although many children raised in institutions, foster care, or maladaptive caregiving environments have disorganized or insecure attachments; they do not all develop symptoms of RAD. In fact, evidence indicates that RAD is not associated with any attachment style as there is so little attachment behavior, no pattern can be identified. (Zeanah & Smyke, 2005)

4 DIAGNOSIS: HISTORY AND EVIDENCE Two different clinical patterns of attachment disorders Reactive Attachment Disorder (RAD) known as the emotionally withdrawn/inhibited type Disinhibited Social Engagement Disorder (DSED) known as the indiscriminately social/disinhibited type (Oosterman & Schuengel study cited in Zeanah & Gleason, 2015)

5 DIAGNOSTIC CRITERIA A) A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both rare/ or minimal seeking and receiving of comfort when distressed B) persistent social and emotional disturbance characterized by minimal social and emotional responsiveness to others; limited positive affect; episodes of irritability, sadness, fearfulness that are evident even during non-threatening interactions with adult caregivers C) Child has experienced a pattern of extremes of insufficient care including at least one of the following: 1) social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults 2) Repeated changes of primary caregivers that limit opportunities to form stable attachments 3) Rearing in settings that severely limit opportunities to form selective attachments i.e. institutions with high caregiver to infant odds)

6 SPECIAL NOTE: Zeanah & Gleason (2015) To date, there are no case reports of young children exhibiting RAD without at least a reasonable inference of serious emotional neglect, and no cases from abuse without neglect (p.209).

7 WHAT THE RESEARCH TELLS US ABOUT RAD Most of the research is conducted with children aged 1 to 5 Common co-occurring disorders Emerging evidence these findings also apply to older children and adolescents Prevalence rates range <10% in high risk groups Community perceptions of RAD and its influence on assessment and treatment (Gleason et al., 2011; Rutter et al., 2007; Woolgar & Bladock, 2015; Zeanah & Gleason, 2015)

8 ASSESSMENT Behavioral observations: comforted by caregivers? Stranger wariness? Protest to separation from caregivers? Structured Clinical observations have been researched AACAP Clinical Observation of Attachment (not yet validated) RAD/DSED scale on the Developmental and Well-Being Assessment diagnostic interview (DAWBA) dawba.info RAD Questionnaire (cut off score of 33) (Lehmann, Breivik, Heiervang, Havik, & Havik, 2015; Minnis, Rabe-Hesketh, & Wolkin, 2002; Thrall, Hall, Golden, & Sheaffer, 2009; Zeanah, Chesher, Boris & the AACAP, 2016;)

9 TREATMENT Enhanced caregiving/attuned Responsiveness Zeanah and Gleason evidence based interventions aimed at these targets are reasonable starting points (p.217) Helping caregiver manage behaviors and own negative feelings in reaction to child through narrative sharing Dyadic interactive therapy approaches: Child-Parent Psychotherapy and Attachment and Bio-behavioral Catch Up Video-based intervention to promote positive parenting (VIPP) Circle of Security Smyke, Zeanah, Fox, Nelson, & Guthrie, 2010; Dozier, Stovall, Albus, & Bates, 2001; Steele et al., 2008; Zeanah & Gleason, 2015; Zeanah, Chesher, Boris & the AACAP, 2016)

10 CULTURAL AND ETHICAL CONSIDERATIONS Native American Psychology: Historical and Intergenerational Trauma through a Boarding School Generation Lens and the Indian Child Welfare Act (ICWA). (Bombay, Matheson, & Anisman, 2009; Braveheart, 2003)

11 Adoption has often been described as the most radical and powerful intervention we have to alter the course of the lives of traumatized children. Adoption provides in a child's world the chance for change from repeatedly making and breaking of affectional bonds to experiencing benign and, we hope, enduring permanent caregiving arrangements (p.427) (Steele et al., 2008)

12 REFERENCES Bombay, A., Matheson, K., Anisman, H., (2009). Intergenerational Trauma: Convergence of Multiple Processes among First Nations peoples in Canada. Journal of Aboriginal Health, 5(3), Brave Heart, M. H. (2003). The historical trauma response among natives and its relationship with substance abuse: A Lakota illustration. Journal Of Psychoactive Drugs, 35(1), doi: / Dozier, M., Stovall, K. C., Albus, K. E., & Bates, B. (2001). Attachment for infants in foster care: the role of caregiver state of mind. Child Development, 72(5), Gleason, M. M., Fox, N. A., Drury, S., Smyke, A., Egger, H. L., Nelson, C. 3., &... Zeanah, C. H. (2011). Validity of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types. Journal Of The American Academy Of Child And Adolescent Psychiatry, 50(3), e3. doi: /j.jaac Lehmann, S., Breivik, K., Heiervang, E. R., Havik, T., & Havik, O. E. (2016). Reactive attachment disorder and disinhibited social engagement disorder in school-aged foster children A confirmatory approach to dimensional measures. Journal Of Abnormal Child Psychology, 44(3), doi: /s Minnis, H., Rabe-Hesketh, S., & Wolkind, S. (2002). Development of a brief, clinically relevant, scale for measuring attachment disorders. International Journal Of Methods In Psychiatric Research, 11(2), Rutter, M., Kreppner, J., Croft, C., Murin, M., Colvert, E., Beckett, C., &... Sonuga-Barke, E. (2007). Early Adolescent Outcomes of Institutionally Deprived and Non-Deprived Adoptees. III. Quasi-Autism. Journal Of Child Psychology And Psychiatry, 48(12),

13 Smyke, A. T., Zeanah, C. H., Fox, N. A., Nelson, C. A., & Guthrie, D. (2010). Placement in foster care enhances quality of attachment among young institutionalized children. Child Development, 81(1), doi: /j x Steele, M., Hodges, J., Kaniuk, J., Steele, H., Hillman, S., & Asquith, K. (2008). Forecasting outcomes in previously maltreated children: The use of the AAI in a longitudinal adoption study. In H. Steele, M. Steele, H. Steele, M. Steele (Eds.), Clinical applications of the Adult Attachment Interview (pp ). New York, NY, US: Guilford Press. Thrall, E. E., Hall, C. W., Golden, J. A., & Sheaffer, B. L. (2009). Screening measures for children and adolescents with reactive attachment disorder. Behavioral Development Bulletin, 15(1), doi: /h Woolgar, M., & Baldock, E. (2015). Attachment disorders versus more common problems in looked after and adopted children: comparing community and expert assessments. Child & Adolescent Mental Health, 20(1), doi: /camh Zeanah, C. H., Chesher, T., & Boris, N. W. (2016). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. Journal Of The American Academy Of Child And Adolescent Psychiatry, 55(11), doi: /j.jaac Zeanah, C. H., & Smyke, A. T. (2005). Attachment in Institutionalized and Community Children in Romania. Child Development, 76(5),