rad, attachment disorders, complex trauma, etc. what difference does the name make and who cares...
TRANSCRIPT
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
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Attachment Terminology Inconsistent Names still evolving
Academics Clinicians Parents
Effect of confusion Create terms to fill in Lots of inconsistent and inappropriate use
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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
© 2007, Family Attachment Center Inc., www.familyattachment.com
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
© 2007, Family Attachment Center Inc., www.familyattachment.com
Lack of clarity
Some names DO have clear definitions Important to know definitions that are established and
accepted, particularly when communicating with various groups
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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
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Disciplines that Influenced Attachment Theory
Psychoanalytic Evolutionary Ethology
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Post-Attachment Fields That Continue Support
Developmental psychology Trauma Stress Neuroscience
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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
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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
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Practical Implication 1
It is technically incorrect to say a child is “insecurely attached.”
© 2007, Family Attachment Center Inc., www.familyattachment.com
Practical Implication 1
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.
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Attachment classifications Insecure-Ambivalent
Insecure-Avoidant
Disorganized
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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.
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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
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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
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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
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Practical Implication 2
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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
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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.
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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.
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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.
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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
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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
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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
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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
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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.
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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
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