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Reactive Attachment Disorder

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Melissa Fernandez

on 12 November 2013

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Transcript of Reactive Attachment Disorder

Higher quality:
more likely to develop secure attachments
child is more like to have normal and positive psychological and physiological outcomes
Reactive Attachment Disorder
Poorer quality:
disorganized attachment appears when child is unable to elicit comfort from the caregiver
increased risk of psychopathology
often found in limited environments like institutions
multiple caregivers
poor stimulation
poor staff-child ratios
Play Therapy
Art Therapy
Parent-Child Interaction Therapy
Behavioral Management Training
Animal-Assisted Therapy
Attachment Theory
A child's attachment to the caregiver:
an attempt to limit pain, fear, cold or hunger
expectation to sooth the discomfort
begins to seek closeness at 7 to 9 months
across cultures a young child, when securely attached, is comforted & calmed by physical proximity to the parent
the goal of attachment is the protection the child receives from the caregiver
Bowlby (1988)
Melissa Fernandez
Socially Deprived Children
syndromes have been surfacing since the mid-century
clinical impairments in social interactions, growth, and affect
Tizard & Rees (1975)
most important & major longitudinal study
young institutionalized children
in London in 1960's
65 children placed a birth or soon after
received adequate nutrition and attention
still experiencing social deprivation
identified two types that make up RAD
socially indiscriminate/disinhibited type
children tend to be nonselective when seeking adult caregivers
exhibited social boundary violations
overly engaged with relative strangers
emotionally withdrawn/inhibited type
children showed little responsiveness
limited positive affect or emotion dysregulation
failed to seek comfort when distressed
Reactive Attachment Disorder
Diagnostic Criteria 313.89 (F94.1)
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
1. The child rarely or minimally seeks comfort when distressed.
2. The child rarely or minimally responds to comfort when distressed.

B. A persistent social and emotional disturbance characterized by at least two of the following:
1. Minimal social and emotional responsiveness to others.
2. Limited positive affect.
3. Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
DSM-V 313.89
C. The child has experienced a pattern of extremes of insufficient care as evidenced by 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 (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).
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 years.
G. The child has a developmental age of at least 9 months.

Controversial Interventions
Attachment Therapy
rage reduction
Behavioral Management Training
10-session manualized treatment
time limited, goal oriented, behaviorally oriented and concerned with parent participation
designed to address aggression, defiance, and problems with concentration or attention
provides caregivers with parenting skills to decrease these disruptive behaviors
problematic eating, hugging, self-touching
increase compliance through establishment of a disciplinary system-home based reward
lower drop-rates than other parent training
shown to have better outcomes than attachment therapy
Buckner, Lopez, Dunkel, & Joiner (2008)
No empirically supported treatments have been identified for RAD
Play Therapy for RAD
therapist takes a directive and active approach toward facilitating attachment between parent(s) and child
once parents learn & child is ready, parents join
structuring, challenging, engaging, and nurturing play activities are therapeutically implemented
theory is that healthy relationships will ameliorate behavioral problems
atmosphere is fun and playful
Weir (2007) Case Study
8 year old adoptive son
only adoptive son of five children
adopted at 3 years old
physically abused by his mother
behaviors: scream, throw tantrums, hit, swear, and express hatred toward adoptive mother
tried to bond at first
more she cuddled or showed affection, the worst his behavior became
ready to give up after 5 years of behaviors
found him irritating
felt guilty for her feelings
did not agree to give him up
able to bond more
Weir (2007) Case Study
Session 1:
parents only
acknowledging, recognizing, and demonstrating empathy for each person
Allow them to openly discuss their concerns without fear of hurting his feelings
Session 2:
noted that father was over-involved
Father did most of the nurturing and disciplining role
mother was under-involved
mother mirrored Aaron's detached posture
Middle Phase of Treatment
Aaron displayed willingness or openness to a better relationship with his mother
through reframing mother saw that Aaron's new behaviors and patterns were more open to attaching her
here-and-now focus enabled to forgive past patterns of hurt and embrace new relational opportunities
Treatment Techniques
break the ice
accept that level of touch
encourages engagement, structure, and some nurturing
Feeding each other
encouraged eye contact & nurturing
Rubbing lotion on Aaron's hands
paying attention to scratches, scrapes, and cuts
Red Balloon Volleyball
encouraging engagement and eye contact
"Mom" time
encouraged listening skills
forced parents to give careful, detailed and step-by-step instructions (therapist would highlight)
Happy Ball/Emotion Ball
take turns appreciating
Hop Puppet Story-telling
Final Phase & Treatment Outcomes
Aaron took competition seriously and personally
therapist had to work to help
parent set playful context
encourage Aaron when he was discouraged
celebrate his successes in a healthy way
Aaron asked to use emotion ball to express something other than appreciation
Experience of giving and receiving appreciation is difficult for child with RAD
if it become ritualized it is easier
saying what they appreciate about themselves can be very healing
self report-relationship much better
mom no longer exasperated
was able to play games and interact with him at home
Father felt deeper connection
Aaron able to accept and later want affection
smile bright versus flat affect
Full transcript