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Reactive Attachment Disorder

Exploring symptoms, causes, theories, controversy, and therapeutic applications for children living with R.A.D.

Kristin Nelson

on 16 November 2012

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Transcript of Reactive Attachment Disorder

Root Causes of Reactive Attachment Disorder "Big Picture" Issues Allows a parent to:
share and reflect child's "inner experience"
instruct child in understanding, labeling, and managing emotions
Often shared non-verbally and kinesthetically

6-point scale to assess attunement Parental Depression (esp. Post-Partum) and anxiety

Unplanned Pregnancies

Significant marital discord and domestic violence

Parental Substance Abuse

Parental Incarceration

Culture of television dependence

Systemic problems in foster, adoption, and institutionalization structures Inhibited type Expressive Arts Therapies General R.A.D.
Symptoms Echo, Attune, and Unify: "Pathogenic Care" Abuse Neglect Persistent disregard for child's basic emotional needs for comfort, simulation, affection, and/or physical needs.

Repeated changes of primary caregiver that prevent formation of stable attachments (frequent changes in foster care). Physical
Emotional (DSM IV, 2004) Disinhibited type ignored cries as a ineffectivesurvival adaptation Sand Tray Therapy Music Therapy Play/Finial Therapy:
Dollhouse Signs , Symptoms, and Characteristics
Withdrawn, sad and listless appearance

Failure to smile

Lack of the normal tendency to follow others in the room with the eyes

Failure to reach out when picked up

No interest in playing peekaboo or other interactive games

No interest in playing with toys

Engaging in self-soothing behavior, such as rocking or self-stroking

Calm when left alone DSM-IV Diagnostic Criteria for R.A.D. Disturbed/developmentally inappropriate social relatedness beginning before age 5

Evidenced by:
1) Persistent failure to respond to social interactions in a developmentally appropriate way.
Responses are excessively inhibited, hypervigilant, contradictory, and ambivalent.
Mix of approach, avoidance, resistance to comforting, “frozen watchfulness.”
2) Diffuse attachments shown by indiscriminate sociability, inability to exhibit appropriate selective attachments.
Excessive familiarity and clinging to strangers, and lack of selectivity.

Behavior is not caused by or meet criteria for:
Mental retardation
Pervasive Development Disorder
ADHD Avoiding or dismissing comforting comments or gestures

Acting aggressively toward peers

Watching others closely but not engaging in social interaction

Failing to ask for support or assistance

Obvious and consistent awkwardness or discomfort

Masking feelings of anger or distress

Alcohol or drug abuse in adolescents Responding Compassionately to Reactive Attachment Disorder Kristin Nelson/ MCC 625: Psychopathology/ Nov 17, 2012 Developing
receptivity to child's emotional experience. Learning to adapt in tandem with therapist, parents, and child. Sharing subjective experience through
non-verbal communication play, and simulation. Trauma often takes place at a pre-verbal stage & can be dissociated from explicit memory Damage to brainstem

Overactive adrenaline system- aggression

Limbec system- managing emotions

Cortisol & Stress- destroy connections

Alteration of neurotransmitters- changes symptoms similar to adult depression. Theories... Erickson: Psychosocial

Bowlby: Attachment

Attunement that contribute to R.A.D. development Controversy So...what practical techniques
can foster connection with clients? Self Reflection:
My experience with
"Ashlyn" 1) gives thought to emotions & what she wants child to know.
2) empathizes with child's emotions
3) shows respect for experience of emotion
4) comforts child during emotion
5) talks about emotion when child is upset
6) wants to discuss emotions Parent... First Stage:
Trust vs. Mistrust Caregiver fails
to meet
infant's primary
needs... Basic
Mistrust Depression, withdrawal, and potentially paranoia later in life Warm, intimate, and continuous relationship with mother (or substitute)
Rejected Freud's oral fixation theory
Infants are social as an evolutionary function (protection) "Attachment Therapy" Interactive
Utilizes non-verbal reflections
Provides space for simulation, testing, and resolution towards trust. Cognitive Behavioral
Therapy Dyadic Developmental
Psychotherapy Strong metaphor for attunement

Creates "echo exchanges" that can be applied to parent-child play Echo: Attune: Unify: shun relationships and attachments to everyone
especially strong resistance towards adult authority figures
may happen when a baby never has the chance to develop an attachment to any caregiver seek attention from everyone (adult and peer) including strangers.
may happen when child has multiple caregivers or frequent changes in caregivers.
frequently show extreme dependence & ask for help doing simplistic tasks
inappropriately childish behavior
highly anxious (Becker-Weidman, 2006) Focus on caregivers' & therapists' attachment strategies

Both are attuned to child's subjective experience, share, and reflect back

Help child create "autobiographical narrative"

Address misattunements and conflicts

Incorporate cognitive- behavioral strategies

Multiple session rooms for caregivers to observe, work with therapist

"PACE" and "PLACE"
Targets symptoms stemming from abuse (fear, anxiety, post-traumatic stress)

Teaching child positive coping & anxiety management skills

Psychoeducation re: abuse and gradual exposure to reduce trauma related fear.

(Hanson and Spratt, 2000)

Assumption of "suppressed rage"

"Rage must be released for child to function normally"

Complete control of child's functioning and social environment WARNING: (Chaffin et al., 2006) Psychological, physical, or aggressive means to provoke, dominate, and coerce.

Holding, binding, "rib cage stimulation," forced into prolonged eye contact.


Death of 10 year old Candace Newmaker during therapy in 2000; child deaths caused by parents "following therapists' instructions."
Helps child express "inter-world" of experience; enables therapist/caregiver to "see" child's world

Metaphor for sorting/organizing thoughts and archetypes
(Carmichael, 1994) Can potentially be used as assessment tool

Child can act out fantasies and conflicts

Gradual exposure to triggers in safe space
(Courtney, 2006)
Full transcript