ADHD/DAMP, attachment and reactive attachment disorder (RAD)

1. ADHD/DAMP, attachment and reactive attachment disorder (RAD) Penny Turton Helen Minnis Chris Gillberg

2. ADHD/DAMP, attachment and reactive attachment disorder (RAD) Are attachment problems important in understanding ADHD? Is RAD recognisable as a syndrome? Does RAD and ADHD overlap?

3. Infant Disorganised Attachment and ADHD A Prospective Study of Children Next-Born after Stillbirth

4. St George’s University of London Grant holder: Patricia Hughes Team: Penelope Turton, Carmen Pinto, Christopher Gillberg, Sarah White, Julia Ward, Samantha Riches, Patricia Hughes

5. Background • Neuroanatomical/ biochemical/ genetic factors can’t explain whole variance in presentation of ADHD • Environmental factors (e.g.maternal depression and social disadvantage) may be implicated in aetiology of ADHD • Some clinical reports suggest history of insecure attachment might also be implicated in ADHD

6. Disorganised attachment (D) is established marker of psychological vulnerability • Both attachment related factors and neurobiological factors reported as predisposing to disorganisation • D is associated with problematic stress management/ elevated risk of problem externalising behaviours at 6 years • Children with ADHD are usually disorganized, inattentive and impulsive from a very young age

7. Could infant D behaviors be an indication of incipient ADHD? AIMS: • to investigate any association between infant disorganised attachment behaviour and later ADHD • to identify factors explaining ADHD outcomes after controlling for mediating variables

8. Method • Subjects: Cohort of 104 children who had significant levels of disorganised attachment in infancy • Assessments: Mother / teacher rated ADHD symptoms* plus observer-rated hyperactivity, together with range of relevant maternal variables • *ADHD Rating Scale-IV (DuPaul, Power, Anastopoulos & Reid, 1998).

9. Results • 27 (26%) infants were classified as D • 8 children (7.8%) met ‘probable’ ADHD casecriteria • 11 children (10.7%) met ‘possible’ ADHD case criteria • 24 (23.1%) of mothers vs. 25 (24.3%) of teachers rated the child above cut-off score of 20 • Mother and teacher-rated ADHD scores were highly correlated

10. Did infant D predict ADHD? • No clear-cut association of infant disorganized attachment and later childhood ADHD caseness. • There was a significant correlation between infant D and teacher rated ADHD symptoms (more inattention than hyperactivity) • What are the attributes of D infants that teachers (but not mothers) observe several years later as ADHD symptoms?

11. Interpretation • D behaviours (freezing, stilling, sudden interruptions of intended actions) present as inattention? • Teachers more sensitive to inattention, while mothers become habituated? • Mothers have lower tolerance threshold for hyperactivity? (mother-rated hyperactivity was associated with lower SCID GAF score) • Maternal psychology/behaviour play a role in mild “ADHD-like” child problems?

12. Comorbidity in Reactive Attachment Disorder RAD diagnostic study funded by Chief Scientist Office of Scottish Executive Grantholders: Eric Taylor, Tom O’Connor, Anthony Pelosi, David Young, James Barnes Research Team: Julie Arthur, Michael Follan, Amanda Burston, Brenda Connolly Expert Panel: Jonathan Green, Danya Glaser (with Eric Taylor and Tom O’Connor) TEDS collaborators: Robert Plomin, Angelica Ronald

13. Comorbidity in RAD DSM-IV Diagnostic Criteria for Reactive Attachment Disorder Inhibited type excessively inhibited, hypervigilant or highly ambivalent and contradictory responses Disinhibited type indiscriminate sociability with marked inability to exhibit appropriate selective attachments

14. Comorbidity in RAD • The RPQ is an 18-item questionnaire for RAD symptoms. • Analysis of RPQ items from 13,472 8 year olds: • Inhibited and Disinhibited factors separate from each other in factor analysis but not in cluster analysis • In factor analysis, RAD factors are distinct from conduct problems, hyperactivity and emotional problems

15. Comorbidity in RAD Diagnostic research in RAD 40 “RAD” children aged 5-8 40 GP control children aged 5-8 Assessment for RAD, ADHD, ODD, CD, ASD

16. Comorbidity in RAD • Components of RAD assessment • Structured parental interview for RAD based on existing measures in CAPA/PAPA format • CAPA/PAPA modules for CD/ODD and ADHD and the 3-DI autism module. • Teacher questionnaire based on RPQ • Observational measure of child behaviour with parent and strangers • Diagnosis checked by panel of experts reviewing positive interview items and video material

17. Comorbidity in RAD • Of the first 53 children, (28 controls including 2 with other clinical diagnoses and 25 RAD cases): • 52% (13) RAD cases met criteria for ODD • 12% (3) RAD cases met criteria for Conduct Disorder • 12% (3) RAD cases met criteria for ASD • 2 children met criteria for ODD and ASD but not RAD

18. Comorbidity in RAD • 68% (17) RAD cases met criteria for ADHD • No children met criteria for ADHD but not RAD • Of the apparently comorbid RAD/ADHD cases, less than half (47%) were rated as abnormal (7%) or borderline (40%) for hyperactivity on the teacher SDQ

19. Comorbidity in RAD • Future research planned: • Use our RAD assessment package with children who have a clinical diagnosis of ADHD • Qualitative research to understand any differences in the nature of disinhibition in ADHD and RAD

20. Conclusions • Disorganised attachment in infancy does not predict clinical ADHD • Disorganised attachment in infancy predicts ADHD-like (mild) behaviours in early school age • There is a very high rate of comorbid ADHD in RAD • Future research (and clinical practice?) in ADHD and RAD needs to take both “conditions” into account