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Reactive Attachment Disorder

Reactive Attachment Disorder. Causes Diagnosis Treatment. Basic Trust vs. Mistrust (Erikson). Infants are totally helpless and dependent on parents/caregivers. If needs are met consistently , the child learns to trust others, and the foundation for a secure attachment is laid .

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Reactive Attachment Disorder

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  1. Reactive Attachment Disorder Causes Diagnosis Treatment

  2. Basic Trust vs. Mistrust (Erikson) • Infants are totally helpless and dependent on parents/caregivers. • If needs are met consistently, the child learns to trust others, and the foundation for a secure attachment is laid. • If needs are not met consistently, the child becomes fearful and learns not to rely on others.

  3. The Attachment Cycle: First Year

  4. The Attachment Cycle: 2nd Year • The 2nd year attachment cycle cannot be started until the first year secure attachment cycle has been met. • Children with insecure attachment do not progress to this 2nd year cycle. • www.attachmentdisorder.net.

  5. Unhealthy Attachment & the Brain • Dr. Allan N. Schore’s 2001 article detailing the effects of traumatic attachment on the development of the right hemisphere changed the way RADis conceptualized and treated. • Traumatic attachment results in periods of “hyperarousal and dissociation,” which interferes with the developing autonomic nervous system & limbic system of the right brain. • The structural changes in the brain lead to ineffective stress coping mechanisms in the child. • What results is PTSD symptomatology. • Early intervention with neurofeedback programs is crucial to altering the process.

  6. RAD as a diagnosis • First talked about in 1980 as part of DSM- III • Considered a controversial diagnosis at the time • Some disagreement as to whether it is separate from Ainsworth’s disorganized attachment or basically the same thing. • Current thinking is that it is a subcategory of disorganized attachment • Disorganized attachment is also considered a risk factor for RAD.

  7. Changes from DSM IV to DSM 5 • DSM-IV listed RAD as having two subtypes: • --Emotionally withdrawn/inhibited • --Indiscriminately social/disinhibited • DSM 5 turned the two subtypes into separate disorders: • --Reactive Attachment Disorder (RAD) • --Disinhibited Social Engagement Disorder (DSED)

  8. Category placement of RAD/DSED • DSM 5 places both disorders in the general category of trauma & stress-related disorders. • Included in this group (besides RAD and DSED) are • PTSD • Adjustment disorders • Acute stress disorder

  9. RAD vs. DSED • Same etiological pathway for both • RAD has dampened positive affect (depressive symptoms) and is more internalized; equivalent to a lack of or improperly formed attachment to caregivers. • DSED resembles ADHD more closely. Marked by externalized behavior and disinhibition. • Social neglect during childhood is a diagnostic requirement for both conditions, but a child with DSED may have secure attachments. • Diagnoses differ in correlates, causes, and responses to intervention and are therefore considered separate disorders in DSM 5.

  10. DSM 5 criteria for RAD • A. Consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: • --Rarely/minimally seeks out comfort when distressed • --Rarely/minimally responds to comfort when distressed • B. A persistent social & emotional disturbance characterized by at least 2 of the following: --Minimal social & emotional responsiveness to others --Limited positive affect --Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with caregivers

  11. DSM Criteria (cont.) • C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least 1 of the following: • 1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection by caregiving adults. • 2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care). • 3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child-to-caregiver ratios).

  12. DSM criteria (cont.) • D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C). • E. The criteria are not met for autism spectrum disorder. • F. The disturbance is evident before age 5. • G. The child has a developmental age of at least 9 months.

  13. Specifications • Specify if: • Persistent: The disorder has been present for more than 12 months. • Specify current severity: • RAD is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.

  14. Key Diagnostic Features • Absent or extremely underdeveloped attachments between the child and caregiving adults. • No comfort-seeking behavior or responses to comfort when child is distressed. • Diminished or absent positive emotions when interacting with caregivers • Evidence that emotional regulation is compromised; negative emotions of fear, sadness, and irritability that are not easily explained.

  15. Older vs. Young Children • It is unclear whether older children show the same symptoms as younger children do or if the disorder even presents in older children. • Diagnosis should be made with caution in children older than age 5.

  16. Signs and Symptoms of RAD In Infants In Toddlers & Children Withdrawing from others Aggressive behavior Avoiding or dismissing comfort Watching others closely but not getting involved Obvious & consistent awkwardness or discomfort Failing to ask for assistance Masking feelings of anger or distress • Withdrawn, sad, listless appearance • Failure to smile • Failure to follow others with eyes • No interest in interactive games (peek-a-boo) or toys • Won’t hold out arms to be picked up • Self-soothing behavior • Calm when left alone

  17. Treatment of RAD • No standard treatment • Individual and family counseling is typical. • Behavior therapy is sometimes used. • No pharmacological treatment exists. • Neurofeedback is a promising new research & treatment area. • Three Crucial Ingredients by Caregivers: • Security • Stability • Sensitivity

  18. Beware of “Attachment Therapy” • Based on the idea that the child must release pent-up rage in order to become emotionally healthy • “Rebirthing”—has been linked to several deaths • Holding therapy • “Strong sitting” • Forced eye contact • Craniosacral therapy • Some attachment therapists are quick to diagnose RAD based on vague symptoms; they do not follow the DSM’s diagnostic criteria and charge thousands of dollars for their “therapy.” • http://www.youtube.com/watch?v=tNoIIwO3uIk

  19. BethThomas—original RAD kid (1989) http://www.youtube.com/watch?v=g2-Re_Fl_L4 HBO documentary Child of Rage.

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