rad, attachment disorders, complex trauma, etc. what difference does the name make and who cares...

RAD, Attachment Disorders, Complex Trauma, etc.

What difference does the name make and who cares anyway?

Todd Nichols

ATTACh 2007 Conference

© 2007, Family Attachment Center Inc., www.familyattachment.com

Overview Attachment, Attachment Disorders, and Reactive

Attachment Disorder

Alternative classifications Complex Posttraumatic Disorder Disorders of Nonattachment

DSM Process


Attachment Terminology Inconsistent Names still evolving

Academics Clinicians Parents

Effect of confusion Create terms to fill in Lots of inconsistent and inappropriate use


Literature Search Results

Words in Article TitleReactive Attachment Attachment Disorder Disorder(s)

1900-1980 0 01981-1990 1 21990-2000 10 212001-2007 51 59

Databases searched:CINAHL Plus with Full Text, PsycARTICLES, PsycINFO, SocINDEX with Full Text


Literature Search Results

Words in Article TitleReactive Attachment Attachment Posttraumatic Disorder Disorder(s) Stress Disorder

1900-1980 0 0 11981-1990 1 2 4061990-2000 10 21 1,7782001-2007 51 59 2,311

Databases searched:CINAHL Plus with Full Text, PsycARTICLES, PsycINFO, SocINDEX with Full Text


Lack of clarity

Some names DO have clear definitions Important to know definitions that are established and

accepted, particularly when communicating with various groups


Attachment John Bowlby, Mary Ainsworth Attachment theory articulated between 1940s

and 1970s Influenced by Freud and psychoanalysis

Shift in emphasis from internal fantasy life and psychic processes (psychoanalytic) to real events--nurture, sensitivity, and care


Disciplines that Influenced Attachment Theory

Psychoanalytic Evolutionary Ethology


Post-Attachment Fields That Continue Support

Developmental psychology Trauma Stress Neuroscience


Attachment Classifications Ainsworth-Strange Situation Classifications based on response to stressful situations.

Reunion episode especially important Ainsworth classifications

Secure Insecure

Avoidant Ambivalent

Mary Main and Judith Solomon classification Insecure Disorganized


Important points about classifications Attachment classifications are not clinical

diagnoses 30% of “normal” population has an insecure attachment Potential exception is Disorganized Attachment

Classifications may differ depending on dyad Example

Child-mother insecure/ambivalent Child-father secure

So, attachment classification is relationship specific


Practical Implication 1

It is technically incorrect to say a child is “insecurely attached.”



It is technically incorrect to say a child is “insecurely attached.”

The correct phrasing would be to say the child has an insecure attachment with his (or her) mother, for example.


Attachment classifications Insecure-Ambivalent

Insecure-Avoidant

Disorganized


Strange Situation Descriptions Avoidant Ambivalent Disorganized Up to separation

Fails to cry on separation.

Wary or distressed even prior to separation, with little exploration.

Post separation

Actively avoids and ignores parent on reunion.

Fails to settle and take comfort in parent upon reunion, usually continues to focus on parent and cry. Fails to return to exploration after reunion.

Throughout Little or no proximity or contact-seeking, no distress, no anger. Response to parent unemotional. Focus on toys or environment.

Preoccupied with parent throughout procedure; angry or passive.

Displays disorganized and/or disoriented behaviors in parent’s presence, suggesting temporary collapse of behavioral strategy. May freeze with a trance-like expression, hands in air. May rise at parent’s entrance, then fall prone and huddles on floor, or may cling while crying hard and leaning away with gaze averted.

Source: Hesse, E. (1999). The adult attachment interview: Historical and current perspectives. In J. Cassidy and P. R. Shaver (Eds.), Handbook of Attachment: Theory, Research and Clinical Applications (pp. 395-433). New York: Guilford Press.


Reactive Attachment Disorder Clear, but evolving, definition

First appeared in DSM III 1980 Differentiate from nonorganic Failure to Thrive

Required condition of failure to thrive Required inappropriate social relatedness in most contexts Required onset prior to 8 months

inconsistent with developmental literature, which says kids form selective attachments between 6 and 12 months


Reactive Attachment Disorder Major revision in DSM-III-R in 1987

Dropped failure to thrive requirement Age of onset modified to first 5 years Inhibited and disinhibited types added Pathogenic care requirement

DSM IV 1994 Next DSM Revision expected 2011


Criticisms of R.A.D. Not based on attachment (child-caregiver)

relationship Maltreatment syndrome Requirement of inappropriate social relatedness

in most contexts Only appropriate for kids with NO selective

attachment


Attachment Disorders There is a large group of children with significant

clinical features related to disordered attachment relationships who are not captured by current diagnostic classifications

Attachment-exploration balance Secure base and safe haven


Alternative Classification Systems Lieberman, Zeanah, Boris, and others

Disorders of nonattachment With emotional withdrawal With indiscriminate sociability

Secure base distortions With self-endangerment With inhibition With vigilance/hypercompliance With role reversal

Disrupted attachment

Source: Zeanah, C. H. & Boris, N. W. Disturbances and disorders of attachment in early childhood. In C. H. Zeanah (Ed.), Handbook of Infant Mental Health, 2nd ed. (pp. 353-368). New York: Guilford.


Continuum of attachment levels

Source: Boris, N. W. & Zeanah, C. H. (1999). Disturbances and disorders of attachment in infancy: An overview. Infant Mental Health Journal, 20, 1-9.


Alternative Classification Systems Complex Trauma-dual problem

Children’s exposure to traumatic events Multiple traumatic events that occur within caregiving

system, which is supposed to be the source of safety and stability

Simultaneous or sequential occurrences of maltreatment--emotional abuse and neglect, sexual abuse, physical abuse, witness domestic violence--that are chronic and begin in early childhood

Initial exposure puts individual at elevated risk for subsequent exposure

Source: Cook, A., Blaustein, M.. Spinazzola, J., & van der Kolk, B. (Eds.). (2003). Complex Traumain Children and Adolescents: White Paper from the National Child Traumatic Stress NetworkComplex Trauma Task Force. National Child Traumatic Stress Network: Los Angeles.


Alternative Classification Systems Complex Trauma-dual problem (cont.)

Impact of exposure on long term outcomes Range of clinical symptomatology after such exposure

Multiple domains of impairment Attachment Biology Affect Regulation Dissociation Behavioral Control Cognition Self-Concept


DSM Focii Unite DSM and ICD classifications 6 initial focus area-White papers

Basic nomenclature issues Basic and clinical neuroscience and genetics Advances in developmental science Personality and relational disorders Mental disorders and disability Cross-cultural issues

3 additional focus areas added Gender Geriatric Infants and young children Source: dsm5.org


DSM V Timeline-Publication 20111999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

White papers

Publish Research Agenda

Conferences

Workgroups

Begin Task Force Appts.

Planning Stage

Formal Revision


DSM Task Force David J. Kupfer, M.D. chair Darrel A. Regier, M.D., M.P.H. vice chair Chairs of 20-25 work groups plus others


Task Force Members William Narrow, M.D., M.P.H., research director, DSM-V Task Force Maritza Rubio-Stipec, Sc.D., statistics and methods director William T. Carpenter Jr., M.D., chair, Psychosis Work Group Francisco Xavier Castellanos, M.D., chair, Externalizing Disorders Wilson M. Compton, M.D., M.P.E. Joel E. Dimsdale, M.D., chair, Somatoform Disorders Work Group Javier Escobar, M.D., M. Sc. Jan Fawcett, M.D., chair, Mood Disorders Work Group Steven E. Hyman, M.D., rapporteur, Spectra Study Group Dilip Jeste, M.D., chair, Dementia, Delirium, Amnestic & Other Cognitive

Disorders Work Group Helena C. Kraemer, Ph.D. Daniel T. Mamah, M.D., M.P.E. James McNulty, A.B., Sc.B.


Task Force Members Howard B. Moss, M.D. Charles O'Brien, M.D., Ph.D., chair, Substance-Related Disorders Work Group Roger Peele, M.D. Katherine A. Phillips, M.D., chair, Anxiety Disorders Work Group Daniel Pine, M.D., chair, Childhood/Adolescent Disorders Work Group Charles F. Reynolds III, M.D., Ph.D., chair, Sleep Disorders Work Group Andrew E. Skodol II, M.D., chair, Personality Disorders Work Group Susan Swedo, M.D., chair, Autism & Other PDD Work Group B. Timothy Walsh, M.D., chair, Eating Disorders Work Group Philip Wang, M.D., Dr. P.H. William Womack, M.D. Kimberly A. Yonkers, M.D., rapporteur, Gender & Cross-Cultural Study Group


Family Attachment Center18322C Minnetonka Blvd

Deephaven, MN 55391

952-475-2818

www.familyattachment.com

rad, attachment disorders, complex trauma, etc. what difference does the name make and who cares...

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