REACTIVE ATTACHMENT REACTIVE ATTACHMENT DISORDERDISORDER

CHILD PLACEMENT CHILD PLACEMENT CONFERENCECONFERENCE

NOV 2005NOV 2005

WELCOMEWELCOME

What we’ll cover this morningWhat we’ll cover this morning What is attachment?What is attachment? How does secure attachment develop?How does secure attachment develop? What are the types of attachment?What are the types of attachment? Difference between disordered attachment Difference between disordered attachment

and Reactive Attachment Disorder (RAD)and Reactive Attachment Disorder (RAD) RAD definedRAD defined What causes RAD and what does it look like?What causes RAD and what does it look like? What to do?What to do?

What is attachment?What is attachment?

Bond between Bond between primary caregiver and primary caregiver and childchild

Develops in first year Develops in first year of lifeof life

Basis for all other Basis for all other attachment attachment relationships relationships

Theories on attachmentTheories on attachment

Bowlby believed that Bowlby believed that attachment is what attachment is what allows children to allows children to develop a secure develop a secure base from which they base from which they can explore the worldcan explore the world

Harlow demonstrated Harlow demonstrated the importance of the importance of touch in attachment touch in attachment

Why is attachment important? Why is attachment important?

Essential foundation for healthy Essential foundation for healthy personality and functioning in societypersonality and functioning in society Influences:Influences:

Cognitive abilityCognitive ability

Development of conscienceDevelopment of conscience

Coping skills (frustration and stress)Coping skills (frustration and stress)

Relationship developmentRelationship development

Ability to handle perceived threatsAbility to handle perceived threats

Ability to handle negative emotions Ability to handle negative emotions

When does it happen?When does it happen?

Attachment bonds are Attachment bonds are formed in the first formed in the first year of lifeyear of life

Can be secure or Can be secure or insecureinsecure

Early development is Early development is critical for later critical for later development and development and functioningfunctioning

How does it happen?How does it happen?

How does healthy attachment develop?How does healthy attachment develop? Responsive parenting by stable caregiverResponsive parenting by stable caregiver

Eye contact, smiles, warmthEye contact, smiles, warmthEncourage reciprocityEncourage reciprocityTouchTouchMovementMovement

Doesn’t have to be biological parentDoesn’t have to be biological parentNot always best attachment figureNot always best attachment figure

Multiple attachments Multiple attachments Children can have multiple healthy attachmentsChildren can have multiple healthy attachments

Types of attachmentTypes of attachment

Derived from Derived from Ainsworth and her Ainsworth and her work with the Strange work with the Strange SituationSituation SecureSecure InsecureInsecure

Avoidant-stranger same Avoidant-stranger same as momas momAmbivalent-resist mom Ambivalent-resist mom leaving and contactleaving and contactDisorganized-Disorganized-pathogenic carepathogenic care

So What is Reactive Attachment So What is Reactive Attachment Disorder? Disorder?

RAD is not simply insecure attachment RAD is not simply insecure attachment patternspatterns

RAD is a diagnosable condition that has RAD is a diagnosable condition that has as a defining feature disruptions in as a defining feature disruptions in attachmentattachment

RAD defined by DSM-IVRAD defined by DSM-IV

A. Markedly disturbed and A. Markedly disturbed and developmentally inappropriate social developmentally inappropriate social relatedness in most contexts, beginning relatedness in most contexts, beginning before age 5, evidenced by (1) or (2)before age 5, evidenced by (1) or (2) (1) persistent failure to initiate or respond in (1) persistent failure to initiate or respond in

developmentally appropriate fashion to most developmentally appropriate fashion to most social interactions, manifested by excessively social interactions, manifested by excessively inhibited, hyper vigilant, or highly ambivalent inhibited, hyper vigilant, or highly ambivalent and contradictory responsesand contradictory responses

DSM-IVDSM-IV

(2) diffuse attachments as manifested by (2) diffuse attachments as manifested by indiscriminate sociability with marked inability indiscriminate sociability with marked inability to exhibit appropriate selective attachmentsto exhibit appropriate selective attachments

Inhibited type is A1 dominant featureInhibited type is A1 dominant feature Disinhibited type is A2 dominant featureDisinhibited type is A2 dominant feature

DSM-IVDSM-IV

B. The disturbance in Criterion A can’t be B. The disturbance in Criterion A can’t be accounted for by developmental delay (MR) or accounted for by developmental delay (MR) or PDDPDD

C. Pathogenic care as evidenced by at least one C. Pathogenic care as evidenced by at least one of the following:of the following: 1. persistent disregard of child’ basic emotional needs1. persistent disregard of child’ basic emotional needs 2. persistent disregard of child’s basic physical needs2. persistent disregard of child’s basic physical needs 3. repeated changes of primary caregiver that prevent 3. repeated changes of primary caregiver that prevent

formation of stable attachment formation of stable attachment

DSM-IVDSM-IV

D. There is a presumption that the care in D. There is a presumption that the care in Criterion C is responsible for the disturbed Criterion C is responsible for the disturbed behavior in Criteria Abehavior in Criteria A

In other words the behaviors did not begin In other words the behaviors did not begin until after the pathogenic care until after the pathogenic care

What causes RAD?What causes RAD?

Several different factors or a combination Several different factors or a combination of them put a child at high risk for the of them put a child at high risk for the development of RADdevelopment of RADCritical period is from conception to twenty Critical period is from conception to twenty six months of agesix months of age Frequent moves or placements (foster care Frequent moves or placements (foster care

failed adoptions)failed adoptions) Sudden separation from primary caregiverSudden separation from primary caregiver Abuse (physical, emotional, sexual) Abuse (physical, emotional, sexual)

What causes RAD?What causes RAD?

Traumatic prenatal experienceTraumatic prenatal experienceMaternal ambivalence toward pregnancyMaternal ambivalence toward pregnancyNeglectNeglectUndiagnosed and/or painful illness (ear Undiagnosed and/or painful illness (ear infections)infections)Inconsistent day careInconsistent day careUnprepared mothers-poor parenting skillsUnprepared mothers-poor parenting skillsBirth trauma Birth trauma

High Risk Signs in Infants High Risk Signs in Infants

Weak crying responseWeak crying response

Extreme resistance to Extreme resistance to cuddlingcuddling

Poor sucking responsePoor sucking response

No reciprocal smile No reciprocal smile responseresponse

Failure to respond with Failure to respond with recognition to primary recognition to primary caregivercaregiver

Delay in developmental Delay in developmental milestonesmilestones

What RAD looks likeWhat RAD looks like

Superficially engaging and charmingSuperficially engaging and charmingIndiscriminately affectionateIndiscriminately affectionateDestruction of self, others, or thingsDestruction of self, others, or thingsDevelopmental lagsDevelopmental lagsNo eye contactNo eye contactCruel to animals or siblingsCruel to animals or siblingsPoor peer relationshipsPoor peer relationshipsInappropriately demanding and clingy Inappropriately demanding and clingy

What RAD looks likeWhat RAD looks like

Stealing or lyingStealing or lying

No conscienceNo conscience

Poor impulse controlPoor impulse control

Persistent nonsense questionsPersistent nonsense questions

Hoarding or gorging on foodHoarding or gorging on food

Preoccupation with fire, blood, or gorePreoccupation with fire, blood, or gore

Abnormal speech patternsAbnormal speech patterns

What RAD looks likeWhat RAD looks like

What gun? I don’t see a gun

Can look like other things tooCan look like other things too

RAD can look like Oppositional Defiant RAD can look like Oppositional Defiant Disorder or Conduct DisorderDisorder or Conduct Disorder

Characterized by many of the same Characterized by many of the same behaviorsbehaviors

However, RAD is characterized by early However, RAD is characterized by early disruptions in attachment disruptions in attachment This is the distinguishing featureThis is the distinguishing feature

What about placement of a child What about placement of a child with RAD with RAD

Placement is tough and often times Placement is tough and often times disrupteddisrupted

Disrupted placements further exacerbate Disrupted placements further exacerbate the issuethe issue

RAD has an impact on the family that can’t RAD has an impact on the family that can’t be ignoredbe ignored

Training is important for these adoptive or Training is important for these adoptive or foster familiesfoster families

Impact on FamilyImpact on Family

Dreams of solving all Dreams of solving all the problems with the problems with love nurturing are love nurturing are quickly squashedquickly squashedParents become Parents become frustrated as they try frustrated as they try to receive reciprocal to receive reciprocal loveloveSchool and family can School and family can become critical of become critical of family family

Impact on FamilyImpact on Family

Siblings are threatened and targetedSiblings are threatened and targeted

Family pets are targetedFamily pets are targeted

Family becomes controlled by the child, Family becomes controlled by the child, often withdrawing family from normal often withdrawing family from normal social functionssocial functions

Automatic parenting won’t work, no logic Automatic parenting won’t work, no logic to how to deal with behaviorto how to deal with behavior

Can you form attachments with Can you form attachments with these children?these children?

Yes, with time and time and more timeYes, with time and time and more timeHow:How: Eye contactEye contact TouchTouch SmileSmile Parenting encourages reciprocity on parent’s Parenting encourages reciprocity on parent’s

termsterms Working together in reciprocal wayWorking together in reciprocal way Demonstrate affection regardless of responseDemonstrate affection regardless of response

More….More….

Be tough!Be tough!No control battlesNo control battlesListening actively to behavior (encourage Listening actively to behavior (encourage feelings expression)feelings expression)Remove control from childRemove control from childSchedules and consistency are keySchedules and consistency are key

These parents often times need a respiteThese parents often times need a respite