An exploratory study of the association between reactive attachment disorder and attachment narratives in early school-age children

Preliminary Danish Norms for the Odense Child Trauma Screening (OCTS)

The Odense Child Trauma Screening (OCTS) is Danish story stem screening tool applicable for assessment of preschoolers and young children in risk of being traumatized. Having shown initial evidence of validation, Danish norms are needed to strengthen the clinical assessment with the OCTS by serving as a baseline comparison for assessment of potentially traumatized children. We tested 169 children from the Danish general population aged 4-8 with the OCTS and investigated sex and age differences in play-based behavior and narrative representations. Caregivers reported electronically on child demographic information, psychosocial functioning, and history of trauma exposure using The Strengths and Difficulties Questionnaire (SDQ) and The Diagnostic Infant and Preschool Assessment (DIPA) trauma list. Across the 145 scores of the OCTS coding scheme, significant sex and age differences were only found in five and sixteen scores respectively. In the five codes where significant sex differences were observed, boys' normative scores were higher. No significant sex differences were found in the partial story scores or the OCTS total score. Three significant age differences in partial story and OCTS total scores emerged with 4-year-olds scoring higher than 6-8-year-olds. We further found 13 significant age differences in code scores with higher scores among the youngest of the two groups in question suggesting that scores tend to decrease along older age. Few significant sex and age differences were found in children's OCTS play-based behavior and narrative representations. Indicative of few sex and age biases of the OCTS coding scheme and stories, results suggest that the OCTS can be applied across the intended target group of children aged 4 to 8 years. As higher scores were found in the younger age groups, clinicians should be attentive to age in certain codes of the OCTS coding scheme in their assessment of children in clinical practice. The preliminary normative scores must be interpreted and clinically applied with caution due to our non-representative sample and lack of analyses on factors potentially influencing children's responses to the OCTS (e.g., developmental, contextual, cultural factors).

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-024-00616-7.

Reactive attachment disorder, disinhibited social engagement disorder, adverse childhood experiences, and mental health in an imprisoned young offender population

BACKGROUND

A high proportion of young people in prison have a history of abuse and neglect, and/or of neurodevelopmental or psychiatric conditions.  Despite this, the only two conditions specifically associated with abuse and neglect, Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED), have never been included as part of a comprehensive prevalence study.

METHODS

A cross sectional study, in 110 male inmates aged 16 to 23, examined the prevalence of, and associations between, adverse childhood experiences (ACEs), neurodevelopmental and mental health conditions, including RAD and DSED.

OUTCOMES

Virtually all of the young men (96 %) had one or more lifetime neurodevelopmental or mental health conditions, 85.5 % had a current condition, yet less than 3 % reported having received a mental health assessment in prison. High rates of RAD and/or DSED symptoms were found (53.6 %) and 74.5 % had experienced some form of abuse or neglect.

INTERPRETATION

There is a high prevalence of ACEs, RAD/DSED, neurodevelopmental and other mental health conditions within this population. Comprehensive clinical assessments are required to ensure appropriate support and staff training is needed to ensure that the full implications of the high prevalence of neurodevelopmental and mental health conditions are understood as part of trauma informed care.

A Systematic Review on Assessing Assessments: Unveiling Psychometric Properties of Instruments for Reactive Attachment Disorder and Disinhibited Social Engagement Disorder in Minors under Protective Measures

BACKGROUND

Reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) manifest in individuals facing attachment system challenges, particularly observed in minors under protective measures. The lack of standardized tools for assessing these difficulties and uncertainty about the most effective instruments from a psychometric perspective prompted this study.

AIM

Using the COSMIN checklist, we systematically reviewed instruments assessing RAD, adhering to PRISMA.

METHODOLOGY

Examined tools included the Disturbance Attachment Interview, Preschool Age Psychiatric Assessment, Relationship Patterns Questionnaire, Assessment of RAD and DSED, Development and Well-Being Assessment, and Reactive Attachment Disorder Questionnaire.

RESULTS

Of the 10 articles analyzed, the results highlight a research emphasis on internal consistency and structural and construct validity, sidelining other properties.

CONCLUSION

Most articles review structural validity and internal consistency. These measures are satisfactory but insufficiently evaluated. It is necessary to evaluate these tools using other indicators such as cross-cultural validity, measurement error, or responsiveness in adolescents under protective measures.

Reactive Attachment Disorder and Its Relationship to Psychopathology: A Systematic Review

This study aimed to determine, through a systematic review, the relationship between Reactive Attachment Disorder (RAD) and the presence of psychopathology in children and adolescents, and to determine the existence of differences in terms of internalising and externalising psychological problems between the RAD group and groups with other disorders or with typical development. Following the PRISMA methodology, a search was carried out in the Web of Science, PubMed and Scopus databases. The search yielded 770 results, of which only 25 met the inclusion criteria. The results indicate a relationship between the presence of RAD and/or disinhibited social engagement disorder (DSED), with the presence of internalising and externalising problems. These difficulties are more present in children with RAD compared to children without personal difficulties, or children with DSED, children with autism, children with intellectual disabilities or children with hyperactivity. It can be concluded that the presence of RAD has negative consequences on the mental health of children and adolescents, with these being greater in the inhibited group than in the disinhibited group, and with respect to children with autism or hyperactivity.

The expected and the unexpected in recovery and development after abuse and neglect: The role of early foster carer commitment on young children's symptoms of attachment disorders and mental health problems over time

BACKGROUND

Whilst we know that foster care is better than institutional care for abused and neglected children, we know less about the specific qualities of foster care that are important for their development and recovery from maltreatment effects.

OBJECTIVE

This is the first study to investigate the effects of foster carer commitment on symptoms of Attachment Disorders (AD) and mental health problems in young children post-maltreatment.

PARTICIPANTS & SETTING

144 children, age 0-5, recently accommodated into foster care as part of an ongoing Randomised Controlled Trial.

METHODS

Children were assessed using the Disturbances of Attachment Interview and the Strengths and Difficulties Questionnaire, then followed up 15 months and 2.5 years thereafter. Commitment of the foster carer was measured by 'This Is My Baby' interview. Multiple regression was used to analyse the data.

RESULTS

Higher initial foster carer commitment, measured shortly after entry to care, was associated with a reduction in Reactive Attachment Disorder symptoms 15 months after placement, with a modest (non-significant) association persisting 2.5 years later. Initial commitment was not associated with symptoms of Disinhibited Social Engagement Disorder at any follow-up time point, nor with symptoms of mental health problems at 15 months. However, higher initial commitment was unexpectedly associated with higher mental health symptom scores at 2.5 years post-accommodation.

CONCLUSIONS

This study highlights the complex and non-linear development of children in committed foster care, underscoring the need to examine multiple time-points and to consider symptoms of Attachment Disorders separately from those of other mental health problems.

Differentiating "Attachment Difficulties" From Autism Spectrum Disorders and Attention Deficit Hyperactivity Disorder: Qualitative Interviews With Experienced Health Care Professionals

OBJECTIVES

"Attachment difficulties" is an umbrella term often used to describe various forms of non-secure attachment. Differentiating "attachment difficulties" from autism spectrum disorder (hereafter autism) and attention deficit hyperactivity disorder (ADHD) has been characterized as challenging. Few studies have explored how this happens in practice, from the perspective of professionals.

DESIGN

Qualitative study.

METHODS

We conducted in-depth semi-structured interviews with (n = 17) healthcare professionals from five NHS Foundation Trusts in the United Kingdom. Participants were recruited using a combination of snowballing, convenience and purposive sampling. Data were analyzed using a thematic approach.

RESULTS

We identified six interrelated themes that might reflect difficulties with differential conceptualization. These include: a clinical lexicon of attachment; approaching attachment with caution; contextual factors; perceived characteristic behaviors; assessing attachment and adjacent supports; spotlighting intervention and dual conceptualization.

CONCLUSION

Our results indicate some of the ways suspicions around attachment are raised in practice. We advocate for more dialogue between research and practice communities on issues of differential conceptualization. We call for collaboration between a panel of experts consisting of attachment and neurodevelopmental orientated practitioners and researchers, to clarify issues around differentiating between attachment difficulties, ASD, and ADHD.

Reactive attachment disorder and disinhibited social engagement disorder in adolescence: co-occurring psychopathology and psychosocial problems

Insufficient care is associated with most psychiatric disorders and psychosocial problems, and is part of the etiology of reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED). To minimize the risk of misdiagnosis, and aid treatment and care, clinicians need to know to which degree RAD and DSED co-occur with other psychopathology and psychosocial problems, a topic little researched in adolescence. In a national study of all adolescents (N = 381; 67% consent; 12-20 years old; 58% girls) in Norwegian residential youth care, the Child and Adolescent Psychiatric Assessment interview yielded information about psychiatric diagnoses and psychosocial problems categorized as present/absent, and the Child Behavior Check List questionnaire was applied for dimensional measures of psychopathology. Most adolescents with a RAD or DSED diagnosis had several cooccurring psychiatric disorders and psychosocial problems. Prevalence rates of both emotional and behavioral disorders were high in adolescent RAD and DSED, as were rates of suicidality, self-harm, victimization from bullying, contact with police, risky sexual behavior and alcohol or drug misuse. Although categorical measures of co-occurring disorders and psychosocial problems revealed few and weak associations with RAD and DSED, dimensional measures uncovered associations between both emotional and behavioral problems and RAD/DSED symptom loads, as well as DSED diagnosis. Given the high degree of comorbidity, adolescents with RAD or DSED-or symptoms thereof-should be assessed for co-occurring psychopathology and related psychosocial problems. Treatment plans should be adjusted accordingly.

Mental health and use of health care services in opioid-exposed school-aged children compared to foster children

Given the concerns raised regarding the effects of prenatal exposure to methadone and buprenorphine on the developmental outcomes of the children, this study assessed mental health and use of services in a national sample of school-aged children (N = 78) born to women enrolled in opioid maintenance treatment during pregnancy, compared with a group of foster children (N = 140). The majority of the opioid-exposed children lived with their birth parent(s) at the time of assessment (N = 62), while 16 lived in foster homes. Caregivers completed the Strengths and Difficulties Questionnaire (SDQ) and the Reactive Attachment Disorder scale. Teachers completed the SDQ. Three kinds of services were included in measuring service use: school-based education services, child mental health services, and hospital-based habilitation services. The main finding of the study is that children prenatally exposed to methadone or buprenorphine living with their family of origin had significantly better mental health status than their foster-placed counterparts and that of the comparison group of foster children. In addition, the exposed children living at home had less child welfare involvement, and only half of them were using any of the three services measured. The odds for using services increased significantly in accordance with increasing mental health problems, independent of group affiliation, indicating a need-based access to services. In line with other studies, we found that the odds for using one or more services was 2.3 times greater for boys than for girls. Our results contribute to a more-nuanced understanding of the developmental outcomes of prenatal exposure to methadone and buprenorphine, and factors associated with increased service use in groups of at-risk children.

Meta-Analyses of the Associations Between Disinhibited Social Engagement Behaviors and Child Attachment Insecurity or Disorganization

Children with disinhibited social engagement disorder show reduced reticence with strangers, do not check back with their caregiver after venturing away, and may willingly leave with an unfamiliar adult. The recent DSM-5 has moved away from an attachment framework to understand disinhibited social engagement behavior (DSEB) due to studies indicating its presence in previously institutionalized children even after these children are adopted and show a selective, more secure attachment with their substitute caregiver (e.g. Chisholm et al., 1998). This meta-analysis aims to clarify the size of the associations between DSEB and attachment insecurity or disorganization. It also examines whether studies effect sizes differ according to various moderators (e.g., child age, type of attachment and DSEB measures). The results (k = 24) showed that the associations between DSEB and attachment insecurity (d = 0.48) or attachment disorganization (d = 0.47) were of small magnitude. There were no publication biases. As for moderator analyses on both attachment insecurity and disorganization, the effect sizes in studies using DSEB observational measures (respectively d = 0.63 and 0.57) were of moderate magnitude and stronger than those in studies not using an observational component (respectively d = 0.28 and 0.32). Given these small-to-moderate associations, attachment can be considered a relationship process associated with DSEB, and attachment-informed interventions could be potential tools to reduce DSEB in children. Nevertheless, given the sizable unshared portion of variance between DSEB and child attachment, future studies should examine other variables related to caregiving and noncaregiving contexts to further understand DSEB.

Development and Validation of a Measure of Attachment Disorders Based on DSM-5 Criteria: The Early TRAuma-Related Disorders Questionnaire (ETRADQ)

BACKGROUND

A review of the scientific literature showed few valid tools for assessing reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED), two diagnostic entities traditionally grouped under "attachment disorders." The Early TRAuma-related Disorders Questionnaire (ETRADQ), a caregiver report, was developed to assess attachment disorders in school-age children based on the Diagnostic and Statistical Manual of Mental Disorders-Fifth edition criteria. This study sought to validate this instrument.

METHOD

Caregivers of school-age children from the community (n = 578) and caregivers of at-risk children adopted or in out-of-home care (n = 245) completed a sociodemographic questionnaire, the ETRADQ, the Relationship Problem Questionnaire, the RADA (RAD and DSED Assessment) interview, and the Barkley Functional Impairment Scale for Children and Adolescents.

RESULTS

Confirmatory factor analysis of the ETRADQ items supported the expected organization of the measure, that is, two second-order factors and five subfactors: (1) RAD scale (three subscales: Low selective attachment, Low social and emotional responsiveness, Emotional unpredictability) and (2) DSED scale (two subscales: Interactions with unfamiliar adults, Social disinhibition). All scales showed excellent internal consistency, test-retest reliability, convergent validity, and known-group validity.

CONCLUSIONS

Results support the reliability and validity of the ETRADQ.

Current Perspectives on the Management of Reactive Attachment Disorder in Early Education

Children with Reactive Attachment Disorder (RAD) have special educational needs that are challenging for teachers in early education. In the current contribution, we will discuss a large body of research suggesting that stimulating these children's attachment development is feasible for teachers and potentially a successful strategy to ensure that these children thrive better in the classroom and socially. The current overview discusses research and theory on RAD and RAD treatment and results in the formulation of specific recommendations for the successful management of children with RAD in the classroom.

ADHD and Exposure to Maltreatment in Children and Youth: a Systematic Review of the Past 10 Years

PURPOSE OF THE REVIEW

The purpose of the current paper was to review and summarize the literature on ADHD and maltreatment over the past 10 years.

RECENT FINDINGS

The majority of research on ADHD and exposure to maltreatment focuses on the high rates of comorbidity, including international studies from Asia, South America, North America, and Europe. Longitudinal studies showed that early exposure to maltreatment is a risk factor for ADHD symptoms later in development; however, this finding was not consistent. There were some preliminary studies on the neurological and genetic mechanisms underlying the link between ADHD and exposure to maltreatment. Finally, ADHD and exposure to maltreatment were found to have an additive effect on clinically salient outcomes (e.g., aggression, suicide attempts). Results from the review have direct clinical and future implications, including the need to understand the effect of comorbid ADHD and exposure to maltreatment in treatment studies.

Reactive attachment disorder symptoms and prosocial behavior in middle childhood: the role of Secure Base Script knowledge

BACKGROUND

Children with attachment disorder show prosocial behavior problems. Children with a reactive attachment disorder show inhibited and emotionally withdrawn behavior. Consequently, these children typically display prosocial behavior problems. However, the underlying mechanism between reactive attachment disorder and prosocial behavior problems is still unclear and findings in literature are mixed.

METHODS

The current study investigated the role of children's attachment representations in this association. Attachment representations reflect knowledge about a cognitive script regarding the attachment figure as a source for support (Secure Base Script). We tested whether secure base script knowledge 1) mediates or 2) moderates the link between reactive attachment disorder and prosocial behavior problems in 83 children (6-11 years; 83.1% boys) recruited from special education schools for children with behavioral problems. Children completed a pictorial Secure Base Script Test. Their reactive attachment disorder symptoms were assessed during an interview with the primary caregivers. Primary caregivers and teachers filled out a prosocial behavior questionnaire about the child.

RESULTS

Results did not support the mediation hypothesis, but evidence for the moderation hypothesis was found. Secure base script knowledge attenuated the negative association between attachment disorder symptoms and prosocial behavior.

CONCLUSIONS

These findings contribute to the discussion about the link between attachment representations and attachment disorders.

Development and Examination of the Reactive Attachment Disorder and Disinhibited Social Engagement Disorder Assessment Interview

The fifth edition of the Diagnostic and Statistical Manual (DSM) categorizes reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) as two separate disorders, and their criteria are revised. For DSED, the core symptoms focus on abnormal social disinhibition, and symptoms regarding lack of selective attachment have been removed. The core symptoms of RAD are the absence of attachment behaviors and emotional dysregulation. In this study, an international team of researchers modified the Child and Adolescent Psychiatric Assessment for RAD to update it from DSM-IV to DSM-5 criteria for RAD and DSED. We renamed the interview the reactive attachment disorder and disinhibited social engagement disorder assessment (RADA). Foster parents of 320 young people aged 11 to 17 years completed the RADA online. Confirmatory factor analysis of RADA items identified good fit for a three-factor model, with one factor comprising DSED items (indiscriminate behaviors with strangers) and two factors comprising RAD items (RAD1: failure to seek/accept comfort, and RAD2: withdrawal/hypervigilance). The three factors showed differential associations with clinical symptoms of emotional and social impairment. Time in foster care was not associated with scores on RAD1, RAD2, or DSED. Higher age was associated with lower scores on DSED, and higher scores on RAD1.

Potentially traumatic events in foster youth, and association with DSM-5 trauma- and stressor related symptoms

BACKGROUND

In DSM 5, three disorders are related to trauma and/or maltreatment: Post-traumatic Stress Disorder (PTSD), Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) but how these disorders relate to each other and to traumatic events is unknown.

OBJECTIVE

We examined 1. Prevalence of Potentially Traumatic Events (PTEs) and poly-victimization for youths in foster care. 2. Associations between single/multiple PTEs and PTSD, DSED, and the two symptom-clusters that constitute RAD: Failure to seek/accept comfort (RAD A), and Low social-emotional responsiveness/ emotion dysregulation (RAD B).

PARTICIPANTS, SETTING AND METHODS

Foster youth 11-17 years (N = 303) in Norway completed The Child and Adolescent Trauma Screen. Foster parents completed the RAD and DSED Assessment interview.

RESULTS

Foster youth reported experiencing, on average, 3.44 PTEs each (range 0-15, SD 3.33), and 52.9 % reported PTSD symptoms at or above clinical cut off. The PTE sum score was associated with the latent factors PTSD (r = .66, p < 0.001), RAD cluster B symptoms (Low social-emotional responsiveness / emotion dysregulation, r = .28, p < 0.001) and DSED (r = .11, p = 0.046), but not with RAD cluster A symptoms (Failure to seek/accept comfort).

CONCLUSIONS

These findings raise new questions about the nature, mechanisms and timing of development of RAD and DSED. Maltreatment assessment needs to encompass a wide range of PTEs, and consider poly-victimization.

Attachment disorder and attachment theory - Two sides of one medal or two different coins?

INTRODUCTION

Currently, attachment quality and attachment disorder exist in parallel, but the mutual association is still insufficiently clarified. For policy makers and clinical experts, it can be difficult to differentiate between these constructs, but the distinction is crucial to develop mental-health services and effective treatment concepts. We aimed to investigate the association between attachment representations (AR) and attachment disorders (AD), including Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) in children aged between 5 and 9.

METHODS

A total of 135 children aged between 5 and 9 years (M=7.17 years, SD=1.40, 63% male) and their primary caregivers participated in the study. Children were interviewed with the story stem method to assess AR, and the primary caregiver completed diagnostic interviews and questionnaires on mental disorders, AD, emotional and behavioral problems, and intelligence and development.

RESULTS

The prevalence of AR in children with AD was 28.6% for the 'secure' form of AR, 17.1% for the 'insecure-avoidant' form, 25.7% for the 'insecure-ambivalent' form, and 28.6% for the 'disorganized' form. Prevalences of the various AR forms did not differ statistically significantly, indicating that AR is conceptionally distinct from AD. Children with disorganized attachment scored significantly lower on language and intelligence skills than children with secure attachment. AD was significantly associated with a higher number of comorbidities, emotional and behavioral problems, and lower language skills.

CONCLUSIONS

Longitudinal studies using standardized assessment instruments are needed to systematically provide comparable and reliable empirical findings to improve current understanding of AR and AD as well as their etiological models.

Education and Attachment: Guidelines to Prevent School Failure

Portuguese schools have high student failure and early school leaving rates (Pordata, 2017) giving rise to a number of initiatives aimed at their reduction. The “Alternative Curricular Course” (ACC) promotes the learning of basic skills, specifically in Portuguese language and Mathematics, to support logical reasoning and artistic, vocational, and professional development. Its main goal is the fulfilment of compulsory schooling and the reduction of academic failure. Research based on attachment theory (Bowlby, 1969) suggests that different internal working models of attachment are associated with different characteristics of social, academic, emotional, and behavioural competencies that may interfere in the quality of relationships that young people establish in school, especially with teachers, and also influence their academic performance. This study evaluates the relationship between internal working models of students, their perceptions of the quality of their relationships with teachers, and their academic performance using three measures: (i) the “Inventory of Attachment in Childhood and Adolescence” (IACA) measure, (ii) the “Inventory of Parent and Peer Attachment” (IPPA) measure—concerning the attachment to teacher”, and (iii) a socio-demographic questionnaire on a sample of 305 students from the 8th grade of regular education (RE) and the ACC. The results reveal that students on the ACC exhibit a less secure internal working model than students in RE, and that the perception of the quality of the student-teacher relationship, regarding the dimension of acceptance and understanding by the teachers, is associated with a better academic performance. These results align with those of other recent studies in support of the conclusion that the process of attachment has a significant influence on educational contexts, consistent with attachment and related theories.

German Version of the Relationship Problems Questionnaire: Effective Screening for Attachment Disorder

INTRODUCTION

Attachment disorder (AD), including reactive AD and disinhibited social engagement disorder, is a prevalent, yet underdiagnosed disorder in severely maltreated children. Because the condition is associated with significant psychiatric morbidity over the entire lifespan, a valid and economic screening tool to identify children with clinical symptoms of AD is needed to avoid unspecific or ineffective treatment. The present study aimed to assess the effectiveness and efficiency of the German version of the Relationship Problems Questionnaire (RPQ).

METHODS

With a total of 135 children (mean age = 7.17 years, SD = 1.40, 63% male) from both general (34 children) and high-risk populations (69 in- and outpatients, 32 foster children), we investigated the sensitivity and specificity of the RPQ. AD was diagnosed using a standardized clinical interview (K-DIPS). 35 out of 135 children fulfilled the criteria for AD.

RESULTS

The RPQ identified 74% of the children who fulfilled the criteria for AD in the standardized clinical interview. The optimal cut-off score of the RPQ for identifying AD was 4.5 with a moderate sensitivity of 0.74 and specificity of 0.68.

CONCLUSIONS

The German version of the RPQ proved useful as a diagnostic indicator of clinical symptoms of AD. The tool is economic and suitable for the screening of AD in the general population as well as high-risk populations. We recommend the use of the RPQ in clinical and research settings, adding multi-method approaches after a positive screening.

Response to Allen (2018): Points of agreement and disagreement on reactive attachment disorder

Reactive attachment disorder (RAD) is a very rare, understudied, and controversial disorder. Research in Developmental Disabilities (RIDD) recently published our research study, "Reactive attachment/disinhibited social engagement disorders: Callous-unemotional traits and comorbidity" (Mayes, Waschbusch, Calhoun, Breaux, & Baweja, 2017) investigating comorbidity in children with RAD and demonstrating a high prevalence of conduct disorder and callous-unemotional traits, consistent with previous research. Allen (2018) responded with a paper published in RIDD criticizing our study and offering his points of view. In our response to Allen, which follows, we discuss areas where we agree with Allen, as well as areas of disagreement, all presented within the context of scientific research. A point we assume we all agree on is the importance of continued empirical research to advance our knowledge and understanding of RAD.

Assessment of attachment disorder symptoms in foster children: comparing diagnostic assessment tools

BACKGROUND

Standardized methods for assessing attachment disorders are scarce but needed for research and practice.

METHODS

In the current study, several assessments for attachment disorder symptoms are used within a German sample of foster children after being exposed to neglect and maltreatment in their biological families. The symptoms were assessed with four established assessment methods based on both parents' report and behavioral observation: The Rating for Infant Stranger Engagement, the Stranger at the Door, the Disturbances of Attachment Interview and the Reactive Attachment Disorder Questionnaire.

RESULTS

The foster care sample showed symptoms of both the inhibited and the disinhibited attachment disorder. The degree of symptoms is comparable to previous findings. The results of the different tools investigating the disinhibited type of attachment disorder are correlated to each other, but do not overlap.

CONCLUSIONS

Although all approaches are based on the clinical criteria of the DSM-IV, the assessments do not coincide. Each tool provides a different point of view on the symptoms, so a multi methodical approach for assessing attachment disorder symptoms should be implemented. Furthermore, the inhibited and the disinhibited symptoms represent separate categories, as reflected in the DSM-5, requiring separate assessment.

Misperceptions of reactive attachment disorder persist: Poor methods and unsupported conclusions

Reactive Attachment Disorder (RAD) is an often discussed, but misunderstood, diagnostic presentation. A growing body of well-designed prospective studies is providing a wealth of information about the condition; however, misconceptions of RAD abound in both clinical and research arenas. As such, it can be difficult for reviewers to critically evaluate papers pertaining to RAD that are submitted to academic journals and even more difficult for practicing clinicians operating under the time constraints of community-based practice. Papers continue to appear that promote RAD as a form of conduct disorder (CD) or callous/unemotional (CU) presentation among maltreated children, although this conceptualization is directly at odds with the diagnostic criteria found in the DSM-5 and ICD-10 as well as a significant body of well-conducted research. Studies attempting to promote this understanding of RAD typically suffer from significant and multiple methodological flaws. This paper reviews these concerns and provides 5 questions that must be sufficiently answered when evaluating a paper purportedly examining RAD. A recently published paper promoting the CD/CU-conceptualization of RAD is critiqued as an exemplar of applying these 5 questions.

Assessing disorganized attachment representations: a systematic psychometric review and meta-analysis of the Manchester Child Attachment Story Task

Narrative story stem measures are increasingly popular for the assessment of attachment representations among early school-age children. Given their clinical and theoretical importance, disorganized representations are typically a focus of assessment procedures. The Manchester Child Attachment Story Task (MCAST) is one such measure. A systematic literature review and meta-analysis was conducted to evaluate the documented reliability and validity of the MCAST with a focus on assessing disorganized representations. Twenty-five studies were included in the review encompassing 1,876 children from nine countries. Results suggest that inter-rater reliability for the MCAST is acceptable and the prevalence of disorganization identified on the MCAST among various subgroups (e.g. community, clinical, adopted/maltreated) is comparable to prevalence estimates from other developmental periods using other assessment methods. In addition, prevalence of disorganization on the MCAST differed in hypothesized ways between the various subgroups. However, MCAST disorganization did not correlate in predictable ways with many constructs when relationships were examined within samples. Few studies examined the relationship of disorganization on the MCAST with parenting variables, aspects of adoption and maltreatment, and emotion regulation skills. Recommendations for further study of the MCAST and for how the tool might be integrated into clinical and developmental research are provided.

Autism and reactive attachment/disinhibited social engagement disorders: Co-occurrence and differentiation

DSM-5 ( Diagnostic and Statistical Manual of Mental Disorders, 5th edition) Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) are rare disorders sharing social difficulties with autism. The DSM-5 and ICD-10 (International Classification of Diseases, 10th revsion) state that RAD/DSED should not be diagnosed in children with autism. The purpose of our study is to determine whether children can meet criteria for both autism and RAD/DSED and to identify specific symptoms discriminating the disorders. Subjects were 486 children with autism and no RAD/DSED and 20 with RAD/DSED, 4-17 years of age. In total, 13 children with RAD/DSED met criteria for autism. Using the Checklist for Autism Spectrum Disorder (CASD), there was no overlap in total scores between the RAD/DSED with autism group (score range = 15-27) versus the RAD/DSED without autism group (range = 7-10 ). The autism with and without RAD/DSED groups did not differ in CASD scores. Nine of the CASD autism symptoms were found only in the autism with and without RAD/DSED groups. Our study demonstrates that children can meet criteria for both autism and RAD/DSED and that the disorders are easily differentiated by the presence of specific autism symptoms. Autism is a neurogenetic disorder, and RAD/DSED results from severe social-emotional maltreatment. Given the different etiologies, there is no reason why a child cannot have both disorders.

Convergence between observations and interviews in clinical diagnosis of reactive attachment disorder and disinhibited social engagement disorder

OBJECTIVE

A comprehensive approach is needed for diagnosing disordered attachment behavior due to the multifaceted nature of attachment. Differences between various indicators can pose a challenge for deciding on the proper diagnosis. This study assessed the convergence between clinical interview assessment and observation-based clinical diagnosis, and their linkages with inadequate care.

METHOD

Participating children ( N = 55) had intelligence quotients (IQs) between 50 and 85 and were referred for psychiatric consultation. Data were obtained by structured review of medical records, the Disturbances of Attachment Interview (DAI), and the Clinical Observation of Attachment (COA) procedure.

RESULTS

Of the 18 children identified using the DAI with Diagnostic and Statistical Manual of Mental Disorders-Fifth Edition (DSM-5) diagnosis of reactive attachment disorder (RAD) and/or disinhibited social engagement disorder (DSED), only 7 received a clinical DSM-5 diagnosis of RAD and/or DSED. Observed maladaptive attachment behavior in the COA was strongly associated with DAI scores and with clinical diagnosis of DSM-5 RAD and/or DSED. There was a significantly higher prevalence of extremes of insufficient care in children who were classified with RAD by DAI or DSM-5 and/or with DSED by DSM-5 compared to those with no attachment disorder.

CONCLUSIONS

Using structured observation and record assessment leads to more conservative identification of RAD or DSED than using the DAI.

Reactive attachment/disinhibited social engagement disorders: Callous-unemotional traits and comorbid disorders

BACKGROUND

DSM-5 Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) are rare, understudied, and controversial disorders.

METHODS

Comorbidity in children diagnosed with RAD or DSED was compared with comorbidity in ADHD and autism to determine if RAD/DSED comorbidity differed from that for the two most common disorders in child psychiatric clinics. Samples included 4-17-year-olds, 20 with RAD and/or DSED, 933 with autism, and 895 with ADHD. Children with RAD/DSED were removed from their neglectful environments at a mean of 4 years and were a mean 10 years when studied. Mothers rated the children on the Pediatric Behavior Scale assessing oppositional behavior, conduct problems, ADHD, anxiety, depression, and other symptoms.

RESULTS

Five of the 20 children with RAD/DSED had DSED without RAD, 15 had RAD with DSED, and none had RAD without DSED. All children with RAD had callous-unemotional traits (CU) and 73% had conduct disorder (CD). No children with DSED-no RAD had CU or CD. Children with RAD+DSED were considerably more impaired than children with DSED-no RAD, autism, and ADHD.

CONCLUSIONS

Findings are consistent with other studies indicating high CD/CU comorbidity in RAD and extreme rarity of RAD without DSED, findings which are not noted in the DSM-5.

Disinhibited Attachment Disorder in UK Adopted Children During Middle Childhood: Prevalence, Validity and Possible Developmental Origin

We investigate the prevalence, specificity and possible aetiology of Disinhibited Attachment Disorder (DAD) in adopted children without a history of institutional care. Sixty children adopted from UK out-of-home care (AD; mean age 102 months, 45 % male); 26 clinic-referred children with externalizing disorder (ED; mean age 104 months, 77 % male) but no history of maltreatment or disrupted care; and 55 matched low-risk comparison controls (LR; mean age 108 months, 49 % male) were assessed for DAD using a triangulation of parent, teacher, and research observations. Maltreatment history and child psychiatric symptoms were obtained from parent report and child language development was assessed. DAD was identified in 49 % of AD, 4 % of ED and 6 % of LR children. Seventy-two percent of AD children had suffered maltreatment. DAD was not associated with degree of risk exposure, demographics, or language. A significant association with ADHD did not explain variance in DAD prevalence across groups. DAD was significantly more common in children first admitted to out-of-home care between 7 and 24 months, independent of maltreatment severity, age at adoption and number of care placements. Implications for developmental theory, adoption policy and clinical application are discussed.

A study of Attachment Disorders in young offenders attending specialist services

Attachment disorders, specifically Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) are disorders associated with neglect and abuse in which people have significant difficulties relating to others. This study aims to explore Attachment Disorder symptoms and diagnoses in young offenders and factors that may be associated with them such as mental health problems. A cross-sectional design was used with 29 young people who were known to Intensive Services, aged 12-17 (M=16.2, SD=1.3), 29 carers and 20 teachers. They completed measures investigating symptoms of Attachment Disorders and psychopathology. Eighty-six percent of the young people had experienced some form of maltreatment and the rates of an actual or borderline Attachment Disorder was 52%. A positive correlation between Attachment Disorder symptoms and other mental health problems (as rated by carer-report Strengths and Difficulties Questionnaire Total Difficulties Score), accounting for 36% of the variance was found, with a large effect size (r_s=0.60). Attachment Disorder symptoms were associated with hyperactivity and peer relationship problems.

Reactive Attachment Disorder and Disinhibited Social Engagement Disorder in School-Aged Foster Children--A Confirmatory Approach to Dimensional Measures

This study aimed to investigate the factor structure and external correlates of the constructs Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) from the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The following were addressed: First, do our data support the DSM-5 conceptualization of RAD/DSED as two separate constructs? Second, are RAD and DSED distinct from other well-established dimensions of child psychopathology? Third, what are the external correlates of RAD/DSED in this sample? The study sample included 122 foster children aged 6–10 years. Foster parents completed the Strengths and Difficulties Questionnaire (SDQ), and the RAD/DSED-scale from the Developmental and Well-Being Assessment. Child protection caseworkers completed a questionnaire regarding exposure to maltreatment and placement history. Confirmatory factor analysis (CFA) of the RAD/DSED items identified a good fit for a model with a two-factor structure, which is congruent with the DSM-5 definition of RAD and DSED. A new CFA model, which included the RAD and DSED factors together with the four problem factors of the SDQ (emotional, conduct, hyperactivity-inattention, and peer problems), also demonstrated a good fit with our data. RAD and DSED were associated with the SDQ Impact scale and help seeking behavior. This was partly explained by the SDQ externalizing and peer problem subscales. Our findings lend support for the DSM-5 conceptualization of RAD and DSED as separate dimensions of child psychopathology. Thus, the assessment of RAD and DSED provides information beyond other mental health problems.

The socio-behavioral development of children with symptoms of attachment disorder: An observational study of teacher sensitivity in special education

BACKGROUND

Children with Reactive Attachment Disorder (RAD) have serious socio-behavioral problems and often rely on socially abnormal, aggressive, and manipulative forms of communication. Little is known, however, about the influence of teachers on the socio-behavioral development of children with symptoms of RAD.

AIMS

This longitudinal study examined the influence of teacher sensitivity on the socio-behavioral development of children with symptoms of RAD across one school year.

METHOD

The sample included 85 Belgian children and 70 teachers from special education schools. In the previous school year, teachers rated Inhibited and Disinhibited RAD symptoms. In the next school year, teacher Sensitivity was observed in interactions with individual children in the first trimester. Teacher-rated Overt aggression, Relational aggression, and Prosocial behavior was assessed in the first, second, and third trimester.

RESULTS

We found no effects of Sensitivity on Prosocial behavior. Also, no effects were found for children with Disinhibited RAD symptoms. For children with Inhibited RAD symptoms, increases in Overt and Relational aggression were observed when Sensitivity was low, whereas decreases were observed when Sensitivity was high.

CONCLUSIONS AND IMPLICATIONS

The results suggest that teacher sensitivity is associated with the socio-behavioral development of children with Inhibited RAD symptoms but not with the socio-behavioral development of children with Disinhibited RAD symptoms.

WHAT THIS PAPER ADDS

Children with Reactive Attachment Disorder (RAD) exhibit socio-behavioral problems that hinder their school adjustment. These socio-behavioral problems appear relatively stable and it is not known what influence special education teachers might have on the development of these problems across a school year. This study suggests that teacher sensitivity is associated with changes in the socio-behavioral development of children with Inhibited RAD symptoms. Whereas high sensitivity was associated with improvements, low sensitivity appeared to exaggerate the socio-behavioral problems of these children. As children with Inhibited RAD symptoms have difficulties communicating their needs and wishes in socially adaptive ways, it may not be easy for teachers to understand these children. Teachers may misinterpret a child's behavior and consequently will fail to respond to the child's underlying needs. This may reinforce the child's socio-behavioral problems and increase the child's reliance on egocentric and aggressive means in interactions with others. This study therefore highlights the need to support teachers in interactions with children with Inhibited RAD symptoms in order to help them understand how the children's observable behaviors in the classroom may convey their underlying socio-emotional needs and how they can respond to these needs. Importantly, teacher sensitivity was not associated with the socio-behavioral development of children with Disinhibited RAD symptoms (e.g., indiscriminate friendliness). Consistent with previous research, this study suggests that children with Inhibited RAD symptoms are more susceptible to the quality of the caregiving environment than children with Disinhibited RAD symptoms and extends this finding to the school context.

Association between Reactive Attachment Disorder/Disinhibited Social Engagement Disorder and Emerging Personality Disorder: A Feasibility Study

A systematic review of reactive attachment disorder (RAD)/disinhibited social engagement disorder (DSED) in adolescence highlighted that young people with the disorder had indiscriminate friendliness with difficulties in establishing and maintaining stable relationships. Most reported experiences of rejection. We were struck by similarities between the above and features of emergence of personality disorders (EPD). This feasibility study aimed to determine best ways of recruiting and retaining vulnerable young people and the proportion of participants with RAD/DSED who might have emerging borderline personality disorder (EBPD). Participants were referred to the study by their treating clinicians from local mental health teams. Results showed strong association between RAD/DSED and EBPD. Participant characteristics showed high levels of out of home placements, early termination of school careers, suicide attempts, quasipsychotic symptoms, and multiagency involvements. They experienced the project as an opportunity to talk about relationships and reported that they would like more of this in usual clinical contacts. They all agreed to be contacted for future studies. Previous studies have shown that early detection and treatment of emergent personality traits can alter trajectory. Future research will continue to explore these trajectories, explore detection of vulnerability factors, and evaluate interventions.

Clinical effectiveness and cost-effectiveness of parenting interventions for children with severe attachment problems: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Services have variable practices for identifying and providing interventions for 'severe attachment problems' (disorganised attachment patterns and attachment disorders). Several government reports have highlighted the need for better parenting interventions in at-risk groups. This report was commissioned to evaluate the clinical effectiveness and cost-effectiveness of parenting interventions for children with severe attachment problems (the main review). One supplementary review explored the evaluation of assessment tools and a second reviewed 10-year outcome data to better inform health economic aspects of the main review.

DATA SOURCES

A total of 29 electronic databases were searched with additional mechanisms for identifying a wide pool of references using the Cochrane methodology. Examples of databases searched include PsycINFO (1806 to January week 1, 2012), MEDLINE and MEDLINE In-Process & Other Non-Indexed Citations (1946 to December week 4, 2011) and EMBASE (1974 to week 1, 2012). Searches were carried out between 6 and 12 January 2012.

REVIEW METHODS

Papers identified were screened and data were extracted by two independent reviewers, with disagreements arbitrated by a third independent reviewer. Quality assessment tools were used, including quality assessment of diagnostic accuracy studies - version 2 and the Cochrane risk of bias tool. Meta-analysis of randomised controlled trials (RCTs) of parenting interventions was undertaken. A health economics analysis was conducted.

RESULTS

The initial search returned 10,167 citations. This yielded 29 RCTs in the main review of parenting interventions to improve attachment patterns, and one involving children with reactive attachment disorder. A meta-analysis of eight studies seeking to improve outcome in at-risk populations showed statistically significant improvement in disorganised attachment. The interventions saw less disorganised attachment at outcome than the control (odds ratio 0.47, 95% confidence interval 0.34 to 0.65; p < 0.00001). Much of this focused around interventions improving maternal sensitivity, with or without video feedback. In our first supplementary review, 35 papers evaluated an attachment assessment tool demonstrating validity or psychometric data. Only five reported test-retest data. Twenty-six studies reported inter-rater reliability, with 24 reporting a level of 0.7 or above. Cronbach's alphas were reported in 12 studies for the comparative tests (11 with α > 0.7) and four studies for the reference tests (four with α > 0.7). Three carried out concurrent validity comparing the Strange Situation Procedure (SSP) with another assessment tool. These had good sensitivity but poor specificity. The Disturbances of Attachment Interview had good sensitivity and specificity with the research diagnostic criteria (RDC) for attachment disorders. In our supplementary review of 10-year outcomes in cohorts using a baseline reference standard, two studies were found with disorganised attachment at baseline, with one finding raised psychopathology in adolescence. Budget impact analysis of costs was estimated because a decision model could not be justifiably populated. This, alongside other findings, informed research priorities.

LIMITATIONS

There are relatively few UK-based clinical trials. A 10-year follow-up, while necessary for our health economists for long-term sequelae, yielded a limited number of papers.

CONCLUSIONS

Maternal sensitivity interventions show good outcomes in at-risk populations, but require further research with complex children. The SSP and RDC for attachment disorders remain the reference standards for identification until more concurrent and predictive validity research is conducted. A birth cohort with sequential attachment measures and outcomes across different domains is recommended with further, methodologically sound randomised controlled intervention trials. The main area identified for future work was a need for good-quality RCTs in at-risk groups such as those entering foster care or adoption.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42011001395.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

[Accessing Disturbances of Attachment Symptoms Using Interview Technique]

Disturbances of attachment represent a clinically significant disorder and seriously impair social behavioural functioning. To date there has been little research and valid diagnostic methods are lacking. In the present study a German Version of the Disturbances of Attachment Interview developed by Smyke and Zeanah (1999) was used to assess disturbances of attachment in a sample of foster children and the validity of the translation is investigated. Furthermore, the Strengths and Difficulties Questionnaire (Goodman, 1997) was used to examine the discriminative validity. The results show a satisfying reliability and the scales of attachment disorders declare the main of the variance. There is a weak association between the disinhibited scale and hyperactivity in the SDQ. Overall the disinhibited disorder can be distinguished from other behaviour patterns. Regarding the inhibited scale there are associations with all SDQ scales and the inhibited category seems harder to distinguish from other deviant developmental issues. The method is evaluated as a qualified approach to the diagnosis of attachment disorders in the context of a multimethodical approach. Furthermore, the findings suggest further examination of the construct of attachment disturbances.

[The Relationship Between Attachment Representations of Foster Parents and Foster Children and the Role of the Child's Sex]

Children who have been placed in foster care after having experienced difficult family situations need to experience secure relationships. The development of a secure attachment model is regarded as a key protective factor for a healthy development. The present study examines predictors of attachment representations in a sample of 37 foster children aged three to eight years. Children's attachment representations were assessed using the Attachment Story Completion Task, and foster parents' attachment representations with the Adult Attachment Interview. Female foster children scored higher in secure attachment representations than males. Attachment representations of male foster children were positively influenced by a secure attachment representation of their primary foster parent and slightly by the duration of placement in the foster family as well as their age of placement but differently than expected. These results suggest that male foster children may be more vulnerable in their development of attachment representations and that foster parents' state of mind regarding attachment as well as the duration of the placement seem to have an impact on the development of attachment patterns in their foster children. This should be considered in the choice and counseling of foster parents.

Impaired neural reward processing in children and adolescents with reactive attachment disorder: A pilot study

Reactive attachment disorder (RAD) is characterized by markedly disturbed and developmentally inappropriate social relatedness due to parental maltreatment. RAD patients often display a high number of comorbid attention deficit/hyperactivity disorder (ADHD) symptoms, and certain RAD symptoms are difficult to discriminate from ADHD. One of the core characteristics of ADHD is a decrease in neural reward processing due to dopamine dysfunction. The aim of the present study was to determine whether the brain activity involved in reward processing in RAD patients is impaired in comparison with ADHD patients and typically developed controls. Five RAD patients, 17 typically developed (TD) controls and 17 ADHD patients aged 10-16 years performed tasks with high and low monetary reward while undergoing functional magnetic resonance imaging. ADHD patients were tested before and after 3 months treatment with osmotic release oral system-methylphenidate. Before treatment, ADHD patients showed that striatal and thalamus activities only in the tasks with low monetary reward were lower than TD controls. RAD patients showed decrease in activity of the caudate, putamen and thalamus during both the high and low monetary reward conditions in comparison with all the other groups. In RAD patients, the activity of the putamen was associated with the severity of posttraumatic stress and overt dissociation. Reward sensitivity was markedly decreased in children and adolescents with RAD, as evidenced by a diminished neural response during reward perception. This suggests that dopaminergic dysfunction exists in these patients, and may inform future dopaminergic treatment strategies for RAD.

Reduced visual cortex grey matter volume in children and adolescents with reactive attachment disorder

Child maltreatment increases the risk for psychiatric disorders throughout childhood and into adulthood. One negative outcome of child maltreatment can be a disorder of emotional functioning, reactive attachment disorder (RAD), where the child displays wary, watchful, and emotionally withdrawn behaviours. Despite its clinical importance, little is known about the potential neurobiological consequences of RAD. The aim of this study was to elucidate whether RAD was associated with alterations in grey matter volume (GMV). High-resolution magnetic resonance imaging datasets were obtained for children and adolescents with RAD (n = 21; mean age = 12.76 years) and typically developing (TD) control subjects (n = 22; mean age = 12.95 years). Using a whole-brain voxel-based morphometry approach, structural images were analysed controlling for age, gender, full scale intelligence quotient, and total brain volume. The GMV was significantly reduced by 20.6% in the left primary visual cortex (Brodmann area 17) of the RAD group compared to the TD group (p = .038, family-wise error-corrected cluster level). This GMV reduction was related to an internalising problem measure of the Strength and Difficulties Questionnaire. The visual cortex has been viewed as part of the neurocircuit regulating the stress response to emotional visual images. Combined with previous studies of adults with childhood maltreatment, early adverse experience (e.g. sensory deprivation) may affect the development of the primary visual system, reflecting in the size of the visual cortex in children and adolescents with RAD. These visual cortex GMV abnormalities may also be associated with the visual emotion regulation impairments of RAD, leading to an increased risk for later psychopathology.

Social relationship difficulties in autism and reactive attachment disorder: Improving diagnostic validity through structured assessment

BACKGROUND

Autism Spectrum Disorder (ASD) versus Reactive Attachment Disorder (RAD) is a common diagnostic challenge for clinicians due to overlapping difficulties with social relationships. RAD is associated with neglect or maltreatment whereas ASD is not: accurate differential diagnosis is therefore critical. Very little research has investigated the relationship between the two, and it is unknown if standardised measures are able to discriminate between ASD and RAD. The current study aimed to address these issues.

METHODS

Fifty eight children with ASD, and no history of maltreatment, were group matched on age with 67 children with RAD. Group profiles on multi-informant measures of RAD were investigated and group differences explored. Discriminant function analysis determined assessment features that best discriminated between the two groups.

RESULTS

Although, according to parent report, children with ASD presented with significantly fewer indiscriminate friendliness behaviours compared to the RAD group (p<0.001), 36 children with ASD appeared to meet core RAD criteria. However, structured observation clearly demonstrated that features were indicative of ASD and not RAD for all but 1 of these 36 children.

CONCLUSIONS

Children with RAD and children with ASD may demonstrate similar social relationship difficulties but there appears to be a difference in the social quality of the interactions between the groups. In most cases it was possible to differentiate between children with ASD and children with RAD via structured observation. Nevertheless, for a small proportion of children with ASD, particularly those whose difficulties may be more subtle, our current standardised measures, including structured observation, may not be effective in differentiating RAD from ASD.

Social cognitive deficits and biases in maltreated adolescents in UK out-of-home care: Relation to disinhibited attachment disorder and psychopathology

Children entering out-of-home (OoH) care have often experienced multiple forms of maltreatment and are at risk of psychiatric disorder and poor long-term outcome. Recent evidence shows high rates of disinhibited attachment disorder (DAD) among maltreated adolescents in UK OoH care (Kay & Green, 2013). This study aimed to further understand the mechanisms of outcome in this group through investigation of social cognitive functioning. Patterns of theory of mind (ToM) and social information processing were assessed alongside DAD behavior and psychopathology in 63 adolescents in UK OoH care (mean age = 176 months, SD = 22; 48% male; 89% White British) and 69 low-risk comparison adolescents (mean age = 171 months, SD = 17; 46% male; 87% White British). Compared to low risk, OoH adolescents showed a hostile attribution bias and ToM deficit, but this was confounded by language ability. ToM was associated with reduced hostile attribution and responding biases and increased social competence, which was further associated with lower levels of externalizing psychopathology. There was no association between social cognition and core features of DAD. Social cognitive deficits and biases may play a role in the high rates of externalizing psychopathology and relationship functioning difficulties in maltreated samples. Future research should assess alternative cognitive mechanisms for DAD.

Annual research review: Attachment disorders in early childhood--clinical presentation, causes, correlates, and treatment

BACKGROUND

Though noted in the clinical literature for more than 50 years, attachment disorders have been studied systematically only recently. In part because of the ubiquity of attachments in humans, determining when aberrant behavior is best explained as an attachment disorder as opposed to insecure attachment has led to some confusion. In this selective review, we consider the literature on reactive attachment disorder and disinhibited social engagement disorder and describe an emerging consensus about a number of issues, while also noting some areas of controversy and others where we lack clear answers. We include a brief history of the classification of the disorders, as well as measurement issues. We describe their clinical presentation, causes and vulnerability factors, and clinical correlates, including the relation of disorders to secure and insecure attachment classifications. We also review what little is known and what more we need to learn about interventions.

METHODS

We conducted a literature search using PubMed, PsycINFO, and Cochrane Library databases, using search terms 'reactive attachment disorder,' 'attachment disorder,' 'indiscriminate behavior,' 'indiscriminate friendliness,' 'indiscriminate socially disinhibited reactive attachment disorder,' 'disinhibited social engagement disorder,' and 'disinhibited social behavior.' We also contacted investigators who have published on these topics.

FINDINGS

A growing literature has assessed behaviors in children who have experienced various types of adverse caregiving environments reflecting signs of putative attachment disorders, though fewer studies have investigated categorically defined attachment disorders. The evidence for two separate disorders is considerable, with reactive attachment disorder indicating children who lack attachments despite the developmental capacity to form them, and disinhibited social engagement disorder indicating children who lack developmentally appropriate reticence with unfamiliar adults and who violate socially sanctioned boundaries.

CONCLUSIONS

Although many questions remain to be answered, especially regarding appropriate interventions, we know considerably more about attachment disorders than we did only a decade ago.

Secure attachment promotes the development of effortful control in boys

Although effortful control (EC), a regulatory aspect of temperament, is associated with a wide range of developmental outcomes, knowledge about EC promoters is scarce. This study explored whether secure attachment promoted the development of EC from preschool to school age in a community sample of 903 Norwegian children. EC was measured using the parent-reported Children's Behavior Questionnaire at four (T1) and six (T2) years of age, and attachment was measured using the Manchester Child Attachment Story Task at T1. Previous research has indicated that a child's gender and socioeconomic status are possible covariates of EC; hence, these factors were included in the analyses. Despite considerable rank-order stability in EC, secure attachment contributed to an increase in EC. Furthermore, gender moderated the effect of attachment: secure attachment promoted EC in boys only. These findings emphasize preschool boys' need for emotional security to facilitate effortful capacities in their transition to school.

Psychiatric diagnostic screening of social maladaptive behaviour in children with mild intellectual disability: differentiating disordered attachment and pervasive developmental disorder behaviour

BACKGROUND

Children with intellectual disability (ID) are at risk for maladaptive development of social relatedness. Controversy exists whether Pervasive Developmental Disorder (PDD) takes precedence over disordered attachment for describing maladaptive social behaviour. The aim of this study was to assess the prevalence of disordered attachment symptoms in children with ID referred for mental health diagnosis, and to study the potential diagnostic overlap between symptoms of disordered attachment and PDD symptoms.

METHOD

Children (n = 102) in the age of 5-11 with IDs (borderline or mild; IQ 50-85) referred for psychiatric consultation were recruited. Parents were administered a screening interview for disturbances of attachment and teachers were administered a screening questionnaire for PDD.

RESULTS

Behavioural symptoms of disordered attachment were reported for 42%* of the children, with 16%* showing symptoms of inhibited and 37%* showing symptoms of disinhibited attachment disorder. In 11% both types of symptoms were noted. Attachment disorder symptoms were not significantly associated with gender, ethnic background or age. Positive screening for PDD occurred for 27%. Positive screening for PDD was not significantly associated with symptoms of attachment disorder.

CONCLUSIONS

Among children with ID referred for psychiatric consultation, Reactive Attachment Disorder (RAD) and PDD symptoms were both highly prevalent. RAD and PDD symptoms appear as distinct, but sometimes comorbid, forms of aberrant social relatedness.

The feasibility of a randomised controlled trial of Dyadic Developmental Psychotherapy

BACKGROUND

Maltreated children have significant and complex problems which clinicians find difficult to diagnose and treat. Previous US pilot work suggests that Dyadic Developmental Psychotherapy (DDP) may be effective; however, rigorous evidence from a randomised controlled trial (RCT) is lacking. The purpose of this study is to establish the feasibility of an RCT of DDP by exploring the ways that DDP is operating across different UK sites and the impacts of current practice on the potential set-up of an RCT.

METHODS

Qualitative methods (interviews, focus groups and teleconferences) were used to explore trial feasibility with therapists and service managers from teams implementing both DDP and possible control interventions. Data were analysed thematically and related to various aspects of trial design.

RESULTS

DDP was commonly regarded as having a particular congruence with the complexity of maltreatment-associated problems and a common operating model of DDP was evident across sites. A single control therapy was harder to establish, however, and it is likely to be a non-specific and context-dependent intervention/s offered within mainstream Child and Adolescent Mental Health Services (CAMHS). Because a 'gold standard' Treatment as Usual (TAU) does not currently exist, randomisation between DDP and TAU (CAMHS) therefore looks feasible and ethical. The nature of family change during DDP was regarded as multi-faceted, non-linear and relationship-based. Assessment tools need to be carefully considered in terms of their ability to capture change that covers both individual child and family-based functioning.

CONCLUSIONS

An RCT of DDP is feasible and timely. This study has demonstrated widespread interest, support and engagement regarding an RCT and permissions have been gained from sites that have shown readiness to participate. As maltreated children are among the most vulnerable in society, and as there are currently no treatments with RCT evidence, such a trial would be a major advance in the field.

Perceptions of self, significant others, and teacher-child relationships in indiscriminately friendly children

OBJECTIVE

Despite increasing research on indiscriminate friendliness in children, almost no research exists on social-cognitive deficits that are supposed to underlie indiscriminately friendly behavior. In this study, we compared indiscriminately friendly children with controls regarding their perceptions of self, reliability trust in significant others, and perceptions of the teacher-child relationship.

METHOD

Children's perceptions were compared in two samples: a sample of 33 likely cases for disinhibited reactive attachment disorder (RAD) from special education for children with emotional and behavioral disorders (75.76% boys, Mage=8.52, 96.9% Caucasian, 33.3% and 45.5% of their mothers completed primary or secondary education, respectively) was matched on sex, age, and socio-economic status with a sample of 33 controls from general education. Children participated individually in several interviews assessing global and social self-concept, reliability trust in significant others, teacher-child relationship perceptions, and vocabulary. Parents and teachers completed a screening questionnaire for RAD and the Strengths and Difficulties Questionnaire.

RESULTS

Likely disinhibited RAD-cases showed more indiscriminate friendliness and more problem behavior in general according to their parents and teachers than controls. Furthermore, likely RAD-cases reported a more positive global self-concept, more reliability trust in significant others, and more dependency in the teacher-child relationship than controls.

CONCLUSIONS

The results are in line with clinical observations of indiscriminately friendly children and findings in clinical samples of maltreated or attachment disrupted children but contrast hypotheses from developmental attachment research. Further research is needed to explain the more positive perceptions of indiscriminately friendly children.

Narrative responses as an aid to understanding the presentation of maltreated children who meet criteria for autistic spectrum disorder and reactive attachment disorder: a case series study

This paper offers research case studies of four severely maltreated children who had received a diagnosis of autistic spectrum disorder. A range of measures were employed to explore the children's psychological and emotional functioning, including Theory of Mind assessment (Sally-Anne Test), attachment measures (Story Stems Assessment Profile and Relationship Problems Questionnaire), along with measures to assess general psychological and emotional well-being. Contrary to the diagnosis, the children did not reveal a theory of mind deficit. However, they did indicate a profile of difficulties in mentalisation on the Story Stems. The findings are discussed in terms of the extent to which mentalisation and theory of mind are influenced by situational factors, especially the anxiety evoked by the Story Stem attachment scenarios. Clinical implications regarding mentalisation as a state vs. trait phenomenon are discussed.

Feeding forward to a 'miracle day' – a pilot study of video feedforward in reactive attachment disorder

Video feedforward is a solution-focused intervention used to improve desired behaviour. We present two case studies of using video feedforward in reactive attachment disorder. Children with reactive attachment disorder, their caregivers and their clinician completed storyboards of behaviours desired during a 'miracle day' and filmed the individual scenes. These scenes were edited to a prolonged sequence of successful behaviour which was fed back to the child and their caregiver using principles of video interaction guidance. Families reported major improvements in the targeted behaviours, usually within a week of filming the 'miracle day'.