Rethinking RAD in 2008
Reactive Attachment Disorder Diagnosis DSM IV (1998)
- Markedly disturbed and developmentally inappropriate social relatedness in most contexts. Lack of a focused attachment relationship. Child experiences fear in relying on caregiver so much as to override normative need for others. Care feels “pathogenic”- causes such intense fear that all adults become suspect
- Distinct from Autism or Pervasive Development Disorder
- Must have experienced grossly pathogenic care and show symptoms before age 5
- Inhibited Type- Restricted feeling and behavior in situations that would normally activate seeking out one’s caregiver for comfort. Approach, then avoid caregiver Limited capacity for give and take in social exchanges. Problems with managing strong feelings. Seen primarily in neglected, maltreated or institutionalized children.
- Disinhibited Type- In new or stressful situation, tend to be overly familiar with strangers. Comfort seeking and proximity seeking are applied indiscriminately to anyone present. As opposed to “friendly”, interactions feel shallow or empty to other person.
- Being maltreated or institutionalized alone does not create conditions sufficient for RAD. Up to 70% of children post institutionalization may show no attachment disorder behaviors.
- Research has focused on early childhood. Little is known how RAD manifests in middle childhood and adolescence. Disorders of attachment will likely present differently across different developmental ages.
Zeanah and Colleagues alternative criteria for Assessing High Risk (2003)
Secure Base Distortions:
Child’s use of caregiver as an emotional secure base is distorted in one of four ways:
- Role reversal- child takes on directive, parent-like role in relationship with caregiver
- Provocative self endangering behaviors to get response from parent
- Excessive clinginess and restriction in exploration, as if not sure parent can protect him or her
- Excessive vigilance and hypercompliance in face of harsh parenting style
Complex Trauma-
Chronic trauma that begins in early childhood where child has caregiver who is supposed to be source of safety, yet child experiences emotional abuse and neglect, sexual abuse, physical abuse, or witnessing domestic violence. Chronic trauma impacts child functioning in seven ways:
- Attachment- trauma prevents development of attachment security
- Biology- trauma changes brain structure and function
- Affect Regulation- can’t learn to regulate feelings
- Dissociation- child splits off unbearable feelings
- Behavioral Control- strong feelings elicited by trauma make controlling
- behavior difficult or impossible
- Cognition- thinking is distorted as try to make sense of trauma
- Self-Concept- child assumes that she/he is cause of what happens to them
Developmental Trauma Disorder (being considered for DSM V, 2008)
- One or more interpersonal traumas which affect development
- Triggered pattern of repeated dysregulation in response to trauma cues
- Changed understandings and expectations for self and care-giving relationships
- Impairment in developmentally typical functioning in home and school
New Goal in Working with Traumatized Youth with Attachment Impairments-
Change Youth’s Expectancies and Strategies:
- Help child learn to manage own strong feelings without falling apart
- Help them learn to tolerate frustration long enough to learn new things
- Help them learn to “mentalize”, be aware of own thoughts, feelings in order to put wants and needs into words and reflect on what is happening
- Help them learn to organize painful life experiences into a workable “storyline” that helps memories and feelings make sense
- Help them learn how to do give and take in relationships
- Help them learn to seek out caregiver for comfort and use caregiver as a secure base from which to explore the world
“Children only learn self regulation as result of experiencing “co-regulation” of feelings with their parents when the parents are attuned to the child.”