An Overview

1. An Overview 921: Reactive Attachment Disorder (RAD):

2. Learning Objectives • Describe how healthy attachment occurs • Describe the effects of maltreatment and disordered attachment on brain development, self concept and behavior • Define risk factors for and symptoms of Reactive Attachment Disorder (RAD) and related disorders • List the recommended approaches for diagnosis and treatment of RAD and related disorders • Utilize attachment parenting principles when caring for a child with RAD The Pennsylvania Child Welfare Resource Center

3. Agenda • Introduction • Development of healthy attachment • Effects of unhealthy attachment • Symptoms, diagnosis and treatment of RAD and related disorders • Parenting principles that promote attachment • Closing

4. Healthy Attachment

5. Poll Think about your response to separating from the person(s) you are MOST attached to for 6 months. What would you want? • To feel secure, I would not need any contact. • To feel secure, I would want monthly contact. • To feel secure, I would want weekly contact. • To feel secure, I would want daily contact. • To feel secure, I would tell them don’t go!

6. How Does Healthy Attachment Occur? • Watch the First Years Last Forever clip • Can you identify the five main things parents are doing in the clip that facilitate parent/child attachment?

7. Normal Cycle of Attachment • Infant feels need (hunger, pain, attention) • Infant is aroused and expresses need (cry) • Response/gratification (need is promptly met in nurturing way) • Relief/relaxation (infant feels relief and relaxes, develops TRUST)

8. Normal Cycle of Attachment Need Relief Arousal Relaxation Expression Response Gratification

9. Disordered Cycle of Attachment • Infant feels need (hunger, pain, attention) • Infant is aroused and expresses need (cry) • There is no response, or response is angry/punitive • There is not relief/relaxation (infant develops anger/rage and learns not to depend on caregivers for need satisfaction)

10. Disordered Cycle of Attachment Need Discomfort/Fear/ Arousal Anxiety Expression Lack of Trust in Apathy Others & Lack of Empathy No Response -> Anger

11. Continuum of Attachment (From: Attachment, Trauma, and Healing, p. 94)

12. Effects of Unhealthy Attachment

13. Effect on the Brain • Frontal Lobes • Manages impulse control, social reasoning, organization and planning • Amygdala • Assesses threats and danger in the environment and results in fight, flight or freeze responses (Source: Dr. Bruce D. Perry, 2006, The Boy Who was Raised as a Dog)

14. Effect on the Brain: Hand Model Let’s watch Dr. Siegel’s hand model of the brain • http://www.youtube.com/watch?v=DD-lfP1FBFk • What does this mean for children who did not develop smooth regulation and impulse control as a result of disrupted attachment early in life? • What does this mean for us as parents when we respond to some of the extreme behaviors exhibited by children with disordered attachment? • How can you use this hand model with children who struggle with regulating their emotions, impulses and sensory responses?

15. Beliefs: About Self and the World • People are untrustworthy and inconsistent • The world is chaotic, unpredictable and unsafe • Nothing I say or do has an impact, not on others, myself or situations • My needs will only be met through my own efforts: I have to do it all myself (Source: Cross, 2003, Dyadic Developmental Psychotherapy)

16. Beliefs: About Self and the World (cont.) • I am worthless, unlovable and bad • I am unsafe and weak • Caretakers are unresponsive, unreliable and dangerous • The world is hostile and dangerous. (Source: Cross, 2003, Dyadic Developmental Psychotherapy)

17. Behavior: Attachment Disruption Signs

18. Symptoms, Diagnosis and Treatment of Reactive Attachment Disorder (RAD) and Related Disorders Symptoms of RAD Risk factors Diagnostic process Related disorders Recommended treatments

19. Symptoms of RAD • A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, evident before age 5, and manifested by both of the following: • Rarely or minimally seeks comfort when distressed • Rarely or minimally responds to comfort offered when distressed • A persistent social and emotional disturbance characterized by at least 2 of the following: • Minimal social and emotional responsiveness to others • Limited positive affect • Episodes of unexplained irritability, sadness, or fearfulness which are evident during nonthreatening interactions with adult caregivers (Source: DSM-5)

20. Symptoms of RAD • Child has experienced a pattern of extremes of insufficient care (pathogenic care) as evidenced by at least one of the following: • Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection (i.e., neglect) • Persistent disregard of the child’s basic physical needs. • Repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care) • Rearing in unusual settings such as institutions with high child/caregiver ratios that limit opportunities to form selective attachments • Not due to Autism Spectrum Disorder (Source: DSM-5)

21. Risk Factor for RAD:Social Neglect and Deprivation Due to One or More of the Following • Neglect • Abuse • Maternal postpartum depression • Parental mental illness • Substance abuse of parent • Inexperienced parent • Inconsistent care giving • Many different caregivers (Source: Mayo Clinic, 2013)

22. Case Vignette • Using HO#6 (RAD: Symptoms, Risk Factors and Treatment),please identify the possible indicators of RAD • Using HO#5 (Effects: Brain, Self-Concept and Behavior),please identify the possible beliefs this child might have based on the behavior Trisha exhibits

23. How Are Children Diagnosed? • Major focus of assessment is obtaining the most complete history of caregiving for the child and evaluating the attachment between parent and child • A full picture of the child’s behaviors is obtained • Psychiatric evaluation and/or psychological evaluation • Presenting problem • Child’s history (psychosocial, medical, school) • Family history • Interview with child • Interview with parents

24. Diagnosing Challenges and Debates Is it RAD or another disorder? • Disinhibited Social Engagement Disorder (due to pathogenic care) • Attachment may or may not be present • A pattern of behavior in which the child actively approaches and interacts with unfamiliar adults by exhibiting at least 2 of the following: • Reduced or absent reticence to approach and interact with unfamiliar adults • Overly familiar behavior (verbal or physical violation of culturally sanctioned social boundaries) • Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings • Willingness to go off with an unfamiliar adult with minimal or no hesitation (Source: DSM-5)

25. Diagnosing Challenges and Debates Is it RAD or another disorder? • Posttraumatic Stress Disorder (PTSD) • Symptoms of avoidance and emotional numbing • Symptoms of intrusive memories (flashbacks/nightmares) • Symptoms of alterations in cognitions and mood • Sensory Processing Disorder (SPD) • Difficulty processing sensory input • Hyper (over) or hypo (under) in one or more senses • Mood Dysregulation Disorder (MDD) • Severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation • Three or more times per week in more than one setting (Source: DSM-5)

26. Diagnosing Challenges and Debates Is it RAD and another disorder? • Posttraumatic Stress Disorder (PTSD) • Sensory Processing Disorder (SPD) • ADHD • Inattention and/or hyperactivity-impulsive behavior (Source: DSM-5)

27. Types of Treatment • RAD treatment must focus on supporting attachment • Many children diagnosed with RAD also experienced trauma due to neglect and/or abuse • History of controversy exists regarding treatments • Research continues to determine the most effective modes • Types of treatment available: • Attachment-based therapies • Trauma-informed therapies • Neurologically-based therapies • Ancillary therapies (OT, Speech/Language) • Medication to treat conditions such as sleep disturbances, anxiety, etc. No one medication for RAD

28. Types of Treatment Attachment-Based Trauma-Informed Psychotherapy Play therapy Art therapy Equine therapy • Facilitates attachment through nurturing, structure, attunement, empathy, support, positive affect, reciprocity, and sometimes holding to reduce “alarm” reaction • Example: Theraplay • Ann Jernberg in ‘60s • http://www.theraplay.org/

29. Types of Treatment Neurologically-Based OT and Meds Occupational therapy to address sensory integration issues No known “family” of medications for RAD Medications only used to treat specific issues such as sleep disturbances, anxiety, etc. • EMDR • Watch Colleen West and EMDR with children • http://www.emdrinaction.com/short-videos-introduction-emdr

30. Parenting Principles that Promote Attachment

31. Resource/Adoptive Parents Play a Critical Role in the Healing Process • Parenting with warmth and support • Disciplining to facilitate trust and safety • Collaborating with professionals and engaging in treatment approaches

32. Parenting Principles: Warmth and Support • Acknowledge mixed feelings of child • Allow expression of feelings • Let child know how much you care • Provide clear explanations for visitations and any moves • Dispel magical thinking common in young children

33. Parenting Principles: Warmth and Support • “Read” child’s cues to build trust • Reframe behaviors as grief/loss • Accept regression (feel safe to do so) • Allow mingling of scents between households and caregivers, especially for younger children

34. Parenting Principles: Discipline • Supervise, supervise, supervise for prevention • Create a low stress environment • Routines are KEY; use pictures or words to list sequence of routines

35. Parenting Principles: Discipline • Teach the child calming techniques (slow breathing, movement) and help the child calm down periodically throughout the day to minimize meltdowns • Use time IN not time out • Young child on your lap, facing outward • Older children in same room as you • Offer specific praise when child is calm • Give the child one concise direction at a time, monitor that it is followed, provide specific praise

36. Parenting Principles: Collaboration • Attend all team meetings to create a network of support • Follow guidelines recommended by caseworkers and therapists • Strive for consistency in all settings of the child’s life • Ensure that any school accommodations are followed • Birth parents are key members of the team

37. What Advice Would You Give These Resource/Adoptive Parents? • Divide into small groups and read the case vignette on HO# 8 (Parenting Principles that Promote Attachment) • Respond to the following questions : • How can these parents collaborate as a team with the child’s caseworker to move treatment toward a focus on attachment and addressing the trauma the child experienced? • What principles of parenting would you emphasize in this situation? • What discipline approaches would you emphasize?

38. What’s the #1 Take Away Message for You? • Healthy attachment • Effects of unhealthy attachment • Symptoms, diagnosis and treatment • Parenting principles

39. Useful Websites • Adverse Child Experiences Study • http://www.acestudy.org • The Institute for Attachment and Child Development • www.instituteforattachment.org • National Child Traumatic Stress Network • http://www.nctsn.org/ • Trauma Center • www.traumacenter.org

40. Additional Readings • Cline, F., & Fay, J. (2006). Parenting with Love and Logic. Colorado Springs, CO: NavPress. • Perry, B. D., & Szalavitz, M. (2006). The Boy Who Was Raised as a Dog: And Other Stories from a Child Psychiatrist's Notebook: What Traumatized Children Can Teach Us About Loss, Love and Healing. New York: Basic Books. • Siegel, D., & Hartzel, M. (2004). Parenting from the Inside Out: How a Deeper Self-Understanding Can Help You Raise Children Who Thrive. NY: Penguin Books. • Thomas, N. (1997). When Love Is Not Enough: A Guide to Parenting Children with RAD. Glenwood Springs, CO: Families by Design.