I did this presentation my junior year in college for my advanced child psychology class.

1. Reactive Attachment Disorder Shayna Ross Advanced Child Psychology 11-20-08

2. History of the attachment theory John Bowlby developed the attachment theory in the 1960s Focused on the early relationship the child has with their primary caregiver Infants are vulnerable and depend on adults for care which ensures the bond will be formed Attempt to maintain physical proximity to attachment figure and will go to the attachment figure for support when doing an individual task Four types: secure, avoidant, resistant-ambivalent, and disorganized Lyons, H. (2007).

3. Clinical Literature Definition of Reactive Attachment Disorder (RAD) Severe and relatively uncommon attachment disorder that can affect children Children do not form a bond with parent or caregiver Lyons, H. (2007).

4. DSM IV Definition of RAD Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2):(1) persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness) (2) diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) (Source: DSM IV)

5. Signs and Symptoms of RAD Pediatricians are usually the first professional to raise suspicion of RAD Infants 18-24 months may show non-organic failure to thrive or they may have abnormal responses to stimuli The child will look for attention and comfort from any available adult, even strangers The child will not initiate or accept comfort and attention from familiar people especially when the child is in distress Hall, S. and Geher, G. (2003)

6. Signs and Symptoms of RAD RAD is likely to occur with children who are neglected or abused, but just because the child is abused/neglected doesn’t mean they will be diagnosed with RAD without other symptoms or signs. The reason for this is children can still develop stable attachment and relationships regardless of neglect/abuse. Hall, S. and Geher, G. (2003)

7. Causes of RAD Failure to form normal attachments to primary caregivers in early childhood Neglect, abuse, sudden separation, frequent change of caregiver, lack of responsiveness from caregiver Not every child who experiences these will be diagnosed with RAD Also you need to take into consideration children are able to form stable attachment and social relationships even if they were abused/neglected Chapman, Sue. (2002).

8. Causes Continued… Based on problematic history of care and social relationships Abnormal parenting Traumatic experiences Temperament of the child may cause unstable relationships with caregivers Chapman, Sue. (2002).

9. Assessment Tools There is no universal diagnostic measure used for RAD yet A range of different measures are used The strange situation (Mary Ainsworth) Preschool Assessment of Attachment Observational Record of the Caregiving Environment Stem stories, puppets, pictures Interviews: Child Attachment Interview and the Autobiographical Emotional Events Dialogue Recently the Disturbances of Attachment Interview has been used. It was developed by Smyke and Zeanah in 1999. Hall, S. and Geher, G. (2003).

10. Diagnosis of RAD RAD is one of the least researched disorders It is very poorly understood It is difficult to diagnose because there is no specific course the disorder takes. There are no stages. Initial evaluations can be conducted by psychiatrists, specialist Licensed Clinical Social Workers, psychiatric nurses, and psychologists. Hall, S. and Geher, G. (2003).

11. AACAP’s Opinion on Diagnosing Children With RAD The American Academy of Child and Adolescent Psychiatry (AACAP) states each child who exhibits symptoms of RAD or are diagnosed with RAD need an individualized plan of action The AACAP also suggests against labeling the child with RAD without comprehensive evaluations. They feel there needs to be several tests done and several observations before stating the child has RAD. The child’s relationship with it’s caregiver/parent needs to be looked at numerous times before making a diagnosis. Also a diagnosis needs to see the child’s attachment patterns Requires observation of how the child reacts with unfamiliar adults A comprehensive history of the child’s caregiving environment from a very young age (Pediatricians, teachers, caseworkers, daycares) The AACAP hasn’t resolved the question – can attachment disorders reliably be diagnosed in older children and adults Lyons, H. (2007).

12. Diagnostic Criteria There are two classifications of RAD; inhibited and disinhibited. Both types include: Disturbed and inappropriate social relatedness Disturbance isn’t accounted for by developmental delay or a developmental disorder Onset before 5 years old History of significant neglect Lack of identifiable preferred attachment figure Lyons, H. (2007).

13. Inhibited RAD Failure to initiate or respond to social interactions, in developmentally appropriate ways Child may respond to caregiver in very undecided ways. Very indecisive on how to react to caregiver Infants not seeking comfort when in danger, alarm or upset Don’t feel a need to maintain proximity to caregiver Hall, S. and Geher, G. (2003).

14. Disinhibited RAD Child does not exhibit appropriate selective attachments Child develops close relationships with strangers Child doesn’t develop relationships with caregivers Hall, S. and Geher, G. (2003).

15. Treatment Treating parents for mental illness, family therapy, individual therapy Should the child be removed and placed in a safe situation Help for the family such as financial aid, housing aid, social work Training for parenting skills and child development Monitoring the child’s safety within their home/family environment Therapy which increases the responsiveness of the child to their caregivers Hall, S. and Geher, G. (2003).

16. Hall and Geher Study Participants: Caregivers of children with RAD, caregivers of non-RAD children, children with RAD. The parents provided information about the behavior and personality characteristics of their children measured by the RAD scale Hall, S. and Geher, G. (2003).

17. Results Showed children with RAD display more violent and detrimental behavior than those children without RAD Children with RAD have more general behavior problems , social problems, withdrawal, anxiety, depression, attention problems, delinquent behavior. Hall, S. and Geher, G. (2003).

18. Tobin, Wardi-Zonna, Yezzi-Shareef Study Interviews with children and adolescents diagnosed with RAD, about their earliest recollections The children and adolescents were audio taped Tobin, D., Wardi-Zonna, K., Yezzi-Shareef A. (2007).

19. Results Found all the recollections were negative about the caregiver None of the children or adolescents felt they were loved Some examples of the early recollections: We had fun finger-painting at school; I got grounded for four days because I got paint on my white shirt I did not get up. I wet the bed, and my mom was mad at me We got taken away from the babysitter because my mom didn’t come home that night Tobin, D., Wardi-Zonna, K., Yezzi-Shareef A. (2007).

20. References Chapman, Sue. (2002). Reactive Attachment Disorder. British Journal of Special Education. Volume 29, No.2. Hall, S. and Geher, G. (2003). Behavioral and Personality Characteristics of Children with Reactive Attachment Disorder. The Journal of Psychology. 137(2), 145-162. Lyons, H. (2007). Attachment Theory and Reactive Attachment Disorder: Theoretical Perspectives and Treatment Implications. Journal of Child and Adolescent Psychiatric Nursing. Volume 20, No. 1, Page 27039. Minnis, H. and Keck, G. (2003). A clinical/research dialogue on Reactive Attachment Disorder. Attachment & Human Development. Volume 5, No. 3, 297-301. Minnis, H., Marwick, H., Arthur, J., and McLaughlin, A. (2006). Reactive attachment disorder- a theoretical model beyond attachment. Child Adolescent Psychology. Page 336-341. Schwartz, E., Reed, S., Davis, A. (2006). Reactive Attachment Disorder: Implications for School Readiness and School Functioning. Psychology in the Schools. Volume 43(4). Shaw, S. and Paez, D. (2007).Reactive Attachment Disorder: Recognition, Action, and Considerations for School Social Workers. National Association of Social Workers. Page 69-95. Tibbits-Kleber, L. and Howell, R. (1985). Reactive Attachment Disorder of Infancy (RAD). Journal of Clinical Child Psychology. Volume 14, No. 4, Page 304-310. Tobin, D., Wardi-Zonna, K., Yezzi-Shareef A. (2007). Early Recollections of Children and Adolescents Diagnosed with Reactive Attachment Disorder. The Journal of Individual Psychology. Volume 63, No. 1. Weir, Kyle N. (2007) Using Integrative Play Therapy with Adoptive Families to Treat Reactive Attachment Disorder: A Case Example. Journal of Family Psychotherapy. Volume 18. Wingert, P. and Nemtsova A. (2007). When Adoption Goes Wrong. Newsweek. Volume 150, Issue 25.