Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder.

This Practice Parameter is a revision of a previous Parameter addressing reactive attachment disorder that was published in 2005. It reviews the current status of reactive attachment disorder (RAD) and disinhibited social engagement disorder (DESD) with regard to assessment and treatment. Attachment is a central component of social and emotional development in early childhood, and disordered attachment is defined by specific patterns of abnormal social behavior in the context of "insufficient care" or social neglect. Assessment requires direct observation of the child in the context of his or her relationships with primary caregivers. Treatment requires establishing an attachment relationship for the child when none exists and ameliorating disturbed social relatedness with non-caregivers when evident.

Emotional competence and behavior problems: Differences across Preschool Assessment of Attachment classifications.

This study examined attachment in association with preschoolers' emotional functioning among 54 predominantly low-income families living in Appalachia. Attachment was assessed at age 4 years using the Strange Situation (Ainsworth, Blehar, Waters, & Wall, 1978) and classified with the PAA (Crittenden, 2004). Emotional competence was measured via an interview about children's memories for six emotions, rated in terms of both emotion understanding and regulation. Parent-, teacher-, and self-reports of children's internalizing and externalizing symptoms were also completed. Questionnaires and interviews assessed socioeconomic risk and parental symptoms and negative childhood experiences. Children's PAA strategies were significantly associated with risks, emotion regulation and understanding, and symptoms. Children using highly coercive strategies showed the greatest difficulties. Emotion regulation and understanding also were associated with parent- and teacher-report of symptoms. These findings suggest that intervention efforts with at-risk youngsters should target not only attachment security, but also emotional competence skills.

Integration through relatedness in the conversational model: a case study.

OBJECTIVE: The aim of this paper is to demonstrate the principles of the conversational model in two therapies with a patient, at 16 years of age and again 20 years later. METHOD: Described is the first therapy of L, which commenced in hospital and continued twice weekly after discharge. L was an acutely disturbed 16-year-old female admitted for 4 months to the psychiatry ward, a dynamically oriented milieu of a University teaching hospital where I was training. This is followed by a brief description of L's second therapy. Supervision was through audiotape of sessions. RESULTS: At the conclusion of the first therapy, L was functioning well. Five years later, she married and had a child. She was referred to me again after she attempted suicide following an acute stressful event which resulted in hospitalization. She is more aware and reflective at present but continues to be vulnerable. CONCLUSIONS: Attention to certain aspects of the psychotherapeutic relationship is important as demonstrated in the conversational model.

Clinical assessment of attachment patterns and personality disorder in adolescents and adults.

The relevance of attachment theory and research for practice has become increasingly clear. The authors describe a series of studies with 3 aims: (a) to validate measures of attachment for use by clinicians with adolescents and adults, (b) to examine the relation between attachment and personality pathology, and (c) to ascertain whether factor analysis can recover dimensions of attachment reflecting both interpersonal and narrative style. In 3 studies, experienced clinicians provided psychometric data using 1 of 4 attachment questionnaires (2 adolescent and 2 adult samples). Attachment dimensions predicted both personality pathology and developmental experiences in predictable ways. Factor analysis identified 4 dimensions that replicated across adolescent and adult samples on the basis of a combination of interpersonal and narrative indicators: secure, dismissing, preoccupied, and incoherent/disorganized.

Attachment, psychotherapy, and assessment: a commentary.

This article, a commentary, discusses questions and issues generated by 7 articles on the relationship between attachment theory and research, and psychotherapy and clinical assessment. The issues include the following: attachment-based therapeutic interventions for adults and child-caregiver dyads, change in attachment status as an outcome goal of therapeutic intervention, attachment pattern as a moderator of treatment outcome and therapeutic approach, clinical use of attachment measures, narrative/discourse and self-report measures of attachment patterns, and application of attachment theory to new areas. In the discussion of each of these issues, suggestions are made for future research.

Falling forever: the price of chronic shock.

Manifestations of chronic shock and annihilation anxiety-including autistic defenses, chaotic relationships, disorganized attachment, split-off affective states, and vulnerability to disintegration--exist side by side with apparent ego strength and high functioning, even in nonabused patients. Chronic shock stemming from uncontained distress and failed dependency during childhood can persist throughout the lifespan, creating ripples of dysfunction that mask as character distortion and contribute to therapeutic impasse. Patients rely on omnipotent defenses to provide a sense of "having skin" in the face of the fear of breakdown, striving to avoid vulnerability, and trying to insulate themselves from shock experience. Although the relinquishment of autistic defenses and subsequent integration of disowned affect states are overwhelming and painful, patients can emerge from this process with significant shifts in intrapsychic, interpersonal, and existential/spiritual functioning. Clinical material from one psychodynamic psychotherapy group tracks the group process and growth trajectories of seven group members struggling with chronic shock. The ability to recognize subtle dissociative states is a valuable tool in the repertoire of the group psychotherapist.

Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood.

This parameter reviews the current status of reactive attachment disorder with regard to assessment and treatment. Attachment is a central component of social and emotional development in early childhood, and disordered attachment is defined by specific patterns of abnormal social behavior in the context of "pathogenic care." Clinically relevant subtypes include an emotionally withdrawn/inhibited pattern and a socially indiscriminate/disinhibited pattern. Assessment requires direct observation of the child in the context of his/her relationships with primary caregivers. Treatment requires establishing an attachment relationship for the child when none exists and ameliorating disturbed attachment relationships with caregivers when they are evident. Coercive treatments with children with attachment disorders are potentially dangerous and not recommended.

Predicting level of mental health care among children served in a delivery system in a rural state.

The purpose of this study was to establish benchmark data to assist in identifying factors associated with mental health service needs and level of care for children living in a rural state. Clinical and psycho-social needs and strengths were assessed using retrospective chart review for all children and adolescents (n=150) with symptoms or a diagnosis of reactive attachment disorder who presented to a comprehensive treatment facility between January 1997 and December 1999. Logistic regression was used to predict factors associated with inpatient admission (n=15) vs. community-based care (n=135). Significant individual contributors to the prediction of inpatient care were more limited clinical/psycho-social strengths, history of inpatient use and history of sexual abuse. Although 80 percent of children admitted to inpatient care had a history of hospitalization, two-thirds had no history of receiving community-based services and presented to current treatment with a two-year or longer history of symptoms. Approximately two-thirds of children admitted to inpatient care had a history of sexual abuse; however, one-third of these children had no history of mental health service use and presented to current treatment with a two-year or longer history of symptoms. Findings raise concerns about current efforts in public health education, community awareness and health prevention and early intervention programs for children with mental/behavioral health challenges and children and families at risk for abuse and/or neglect living in rural areas.