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Reactive Attachment Disorder:Assessment and Effective
Treatments for Foster and Adoptive Children
Reactive Attachment Disorder:Assessment and Effective
Treatments for Foster and Adoptive Children
Douglas Goldsmith, Ph.D.
Executive Director
The Children’s Center
What is Attachment?What is Attachment?
“To say of a child (or older person) that he is attached to , or has an attachment to, someone means that he is strongly disposed to seek proximity to and contact with that individual and to do so especially in certain specified conditions.” Bowlby (1988)
Attachment BehaviorsAttachment Behaviors
Approach the caregiver Crying Seeking contact Maintaining the contact The number of attachment behaviors
will vary with the degree of the perceived threat in the environment
Weinfield et al (1999)
Secure AttachmentSecure Attachment
The caregiver is perceived as a reliable source of protection and comfort
Secure Attachment Secure Attachment
When I am close to my loved one I feel good, when I am far away I am anxious, sad or lonely
Attachment is mediated by looking, hearing, and holding
When I’m held I feel warm, safe, and comforted
Results in a relaxed state so that one can, again, begin to explore
•Holmes (1993)
Secure AttachmentSecure Attachment
Promote exploration of the environment Expand mastery of the environment “I can explore with confidence because
I know my caregiver will be available if I become anxious.”
The infant gains confidence in his or her own interactions with the world
Weinfield et al (1999)
Disorganized vs. Attachment Disorder
Disorganized vs. Attachment Disorder
Disorganized Attachment: describes an insecure but selective attachment
Attachment Disorder: the failure to show selective attachment
– A pervasive disturbance
O’Connor & Zeanah (2003)
Developmental PerspectiveDevelopmental Perspective
“The quality of a young child’s attachment to a caregiver is a risk or protective factor for development of psychopathology.”
Zeanah & Smyke (2005)
Clinical PerspectiveClinical Perspective
“The attachment relationship may be so disturbed as to constitute an already established disorder.”
Zeanah & Smyke (2005)
Reactive Attachment Disorder
Reactive Attachment Disorder
DSM-IV The essential feature of Reactive
Attachment Disorder is markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 and is associated with grossly pathological care.
Core FeaturesCore Features
There must be evidence of grossly pathogenic care
The disturbance must be evident across situations and across relationships
O’Connor & Zeanah (2003)
Pathogenic CarePathogenic Care
Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection
Persistent disregard of the child’s basic physical needs
Repeated changes of primary caregiver that prevent formation of stable attachments
Disinhibited TypeDisinhibited Type
Predominate disturbance in social relatedness is indiscriminate sociability or a lack of selectivity in the choice of attachment figures.
Indiscriminate BehaviorIndiscriminate Behavior
“The terms ‘indiscriminately friendly’ and ‘indiscriminate sociability’ … imply more than is actually known about the nature of the child’s behavior”
O’Connor & Zeanah (2003)
Inhibited TypeInhibited Type
Persistent failure to initiate and to respond to most social interactions in a developmentally appropriate way.
What About Older Children?What About Older Children?
Defining attachment in older children. Age of onset must be 5 years of age or
younger. Multiple caregivers or pathogenic care
should be noted on axis IV. Relationship can still be focal point of
treatment.
ResearchResearch
RAD has been described formally in psychiatric nosology for 25 years
Fewer than one dozen studies involving only seven samples of young children
Zeanah & Smyke (2005)
AssessmentAssessment
“No ‘gold standard’ exists for assessing attachment disorders, and very little information is available on the convergence of information from alternative assessment methods.”
O’Connor & Zeanah, 2003
TreatmentTreatment
“No treatment has been shown to be effective for children with attachment disorders.”
O’Connor & Zeanah 2003
AssessmentAssessment
“The key to assessing attachment rests in determining how an infant organizes attachment behaviors to balance the need for protection and comfort with the desire to explore the environment.”
Weinfield et al (1999)
Assessment WorksheetAssessment Worksheet
Helps organize information obtained from observations and interviews
Helps determine treatment needs Assists with planning attachment based
interventions
Secure Base BehaviorsSecure Base Behaviors
Child explores the environment freely while checking in with the parents as necessary– Note child’s affect – Bright and engaged?
Anxious?
Hypervigilant?– Does child readily explore?– Does child make use of toys?– Does child share positive experiences with the
caregivers?
Secure BaseSecure Base
Child seeks contact with the parents for comfort when anxious, frightened, or hurt
– Who initiates the contact?
– Is the contact soothing?
– How long does it take for the child to soothe?
– Is the caregiver sensitive to child’s needs and cues?
Secure BaseSecure Base
Infants and Toddlers:
– Does the child visually check in with the parents to gain reassurance about contact with the examiner?
– Does the child demonstrate physical withdrawal at least momentarily when the examiner attempts outreach?
Secure BaseSecure Base
Do the caregivers demonstrate a sense of pride in the child’s exploration?
– Are they responsive to child’s delight in exploration?
– Are they facilitating play with an appropriate affect?
InsightfulnessInsightfulness
The parents are able to share examples suggesting insight into the child’s motives, thoughts, and feelings behind a range of behaviors– “ Can you give me an example of a time when
your child’s behavior was upsetting to you? What do you think might have been going on in his/her head?
– How did these behaviors make you feel?
InsightfulnessInsightfulness
The parents are able to appropriately reflect the child’s feelings:
– Watch for cues during your observation
– Ask how the caregivers responded the last time the child felt frightened, worried, or anxious
InsightfulnessInsightfulness
The parents show sensitivity to the child’s needs for affection and respond both to the child’s needs for comfort as well as to the child’s desire to terminate physical contact
Frightening BehaviorFrightening Behavior
The parents have protected the child from exposure to domestic violence or other environmental variables that would create fear or anxiety for the child
– Protection from violence and excessive arguing
– Protection from frightening movies
Frightening BehaviorFrightening Behavior
The parents avoid engaging in frightening behavior e.g. purposely scaring the child, physically harassing the child despite the child’s pleas to stop the behavior
– Parents avoid threatening to leave or abandon the child
ProtectionProtection
The parents establish appropriate boundaries with extended family members and strangers regarding contact with the child
– Supervision issues
– Parents exhibit an awareness of need for vigilance around unfamiliar people and situations
ProtectionProtection
The parents provide a sense of safety in the home by not allowing persistent physical or verbal attacks from siblings, peers, or other people present in the home– Caregivers establish and adhere to
limits on sibling rivalry behaviors– Caregivers process verbal attacks
between siblings
ProtectionProtection
Separations from the child for more than several days have been kept to a minimum
– Have the parent describe the child’s behavior upon their return home
Structure and Developmental Guidance
Structure and Developmental Guidance
The parents are aware of, and are responding to, the child’s current developmental needs
Structure and Developmental Guidance
Structure and Developmental Guidance
The parents expectations of the child are neither overwhelming or too restrictive
– Be particularly sensitive to children who appear older than their years
– Be aware of parental expectations of the oldest child
Structure and Developmental Guidance
Structure and Developmental Guidance
The parents are able to set and maintain appropriate limits during the session and report appropriate limits in the home
– Are the parents willing to assert their authority?
– Are caregiving decisions abdicated to the child?
Summarizing Your FindingsSummarizing Your Findings
Strengths of the parent-child interaction
Concerns about the parent-child interaction
Summarizing Your FindingsSummarizing Your Findings
What are the attachment/ relationship needs of this particular child?
What skills do the parents need to develop?
Attachment Based Interventions
Attachment Based Interventions
Secure Base– May need to address underlying issues
around parental unavailability to the child
Is the child’s behavior so out-of-control that the parent is unable to find enjoyable one-on-one moments?
– Plan behavioral interventions to increase cooperation to parental requests
Does the parent find parent-child time enjoyable?
Attachment Based InterventionsAttachment Based Interventions
Secure Base– Use precision commands to help the
parent develop positive behavioral control
Stop the coercive cycleUse time-limited time-outs to gain complianceReinforce all compliant behaviorsPositive practiceEncourage the parent not to give up positive
reinforcers prematurely
Attachment Based InterventionsAttachment Based Interventions
Secure Base
– Decrease oppositional battles around: Toileting
– Assist with toilet training or encourage the parent to relax anxiety around toileting accidents
Eating– Stop discussions about quantity of food or insisting
that the child increase their food repertoire Sleeping
– Encourage the parent to help the child regulate anxiety around sleep. Develop a bedtime routine
Attachment Based InterventionsAttachment Based Interventions
Secure Base– Help parent learn to give warnings around
transitions and brief separations– Increase predictability of the environment– Increase reliability of parental availability
This is important particularly for the non-custodial parent
Evaluate the possibility of telephonic or electronic communication
Attachment Based InterventionsAttachment Based Interventions
Secure Base
– Develop nurturing skills
– Help the parent learn to be an “ideal grandparent”
Anticipate the child’s needsProvide physical comfortsPlan surprises so the child knows s/he is
thought about even when absentIncrease sensitivity to cues
Attachment Based InterventionsAttachment Based Interventions
Exploration
– Help the parent develop age appropriate expectations
– Carefully evaluate and develop appropriate parental supervision
– Assess joint pleasurable activities and develop a list of pleasant activities
Attachment Based InterventionsAttachment Based Interventions
Exploration
– Examine the parent’s ability to “let go”
– Develop plans and support the parent in managing “conflict free” separations by waiting until the child is comfortable in a new environment
Attachment Based InterventionsAttachment Based Interventions
Exploration
– Teach the child “checking in” behaviorsAlways keep the caregiver in viewUse a timer to help the child
develop checking-in skills
Attachment Based InterventionsAttachment Based Interventions
Emotional Regulation– Teach the parent to use “Time-in”
Remain available during emotional outburstsOnly move away if child attempts physical attacksConstantly reassure child that, “As soon as you
calm down, I’ll help you fix it/ figure it out”If attacks persist state, “I’ll be in the next room so
I can stay safe but as soon as I hear you calm I’ll be right back”
Develop deep breathing and self-soothing skills
Attachment Based InterventionsAttachment Based Interventions
Emotional Regulation– Work on acceptance of physical contact
Help child make self-contact rather than other-contact to soothe self
– Avoid direct “no” and instead fantasize what it would be like if the child could get all of his/her needs met
– Write down and post the desire to be satisfied at a later date/ time
– Model self-soothing cognitive strategies– Teach empathic listening skills– Use transitional objects
Attachment Based InterventionsAttachment Based Interventions
Safe Harbor
– Assess use of negative projections
– Assess parent’s past trauma’s that may be interfering with an “objective” view of the child
– Assess parent’s ability to benefit from an insight-oriented approach
Attachment Based InterventionsAttachment Based Interventions
Safe Harbor
– Help parent utilize respite services to be more emotionally available
– Help parent utilize support system more effectively
Attachment Based InterventionsAttachment Based Interventions
Safe Harbor– Use insightfulness strategies to help the parent look
at negative projections and learn to reframe the child’s behaviors
“What do you think was going on in your child’s head when that happened?”
Listen empathically to gain an understanding of what it is like to walk in this parent’s shoes
Agitation toward the parent indicates that the therapist is not understanding the parent’s stress
Attachment Based InterventionsAttachment Based Interventions
Safe Harbor
– Conflicts don’t need to be addressed right away! Encourage the parent to wait until both are feeling calmer to process.
– Help parents focus on providing the child with new coping strategies and ideas for solving conflicts
– Practice positive solutions!