The neurobiological effects of childhood maltreatment on brain structure, function, and attachment

Childhood maltreatment is a risk factor for psychopathologies, and influences brain development at specific periods, particularly during early childhood and adolescence. This narrative review addresses phenotypic alterations in sensory systems associated with specific types of childhood maltreatment exposure, periods of vulnerability to the neurobiological effects of maltreatment, and the relationships between childhood maltreatment and brain structure, function, connectivity, and network architecture; psychopathology; and resilience. It also addresses neurobiological alterations associated with maternal communication and attachment disturbances, and uses laboratory-based measures during infancy and case-control studies to elucidate neurobiological alterations in reactive attachment disorders in children with maltreatment histories. Moreover, we review studies on the acute effects of oxytocin on reactive attachment disorder and maltreatment and methylation of oxytocin regulatory genes. Epigenetic changes may play a critical role in initiating or producing the atypical structural and functional brain alterations associated with childhood maltreatment. However, these changes could be reversed through psychological and pharmacological interventions, and by anticipating or preventing the emergence of brain alterations and subsequent psychopathological risks.

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.

Attachment disorder symptoms in foster children: development and associations with attachment security

BACKGROUND

Children in foster care constitute a risk population for developing symptoms of attachment disorders. However, little is known about the longitudinal course of attachment disorders and their association with attachment security in foster children.

METHOD

This longitudinal study assessed attachment disorder symptoms in a sample of foster children (n = 55) aged 12 to 82 months. Foster parents with a newly placed foster child were assessed at three points during the first year of placement. At all assessment points, the Disturbance of Attachment Interview (DAI; Smyke and Zeanah in Disturbances of attachment interview, Tulane University, New Orleans, 1999) and the Attachment Q-sort (AQS; Waters and Deane in Monogr Soc Res Child Dev 50:41-65, 1985 German version as reported (Schölmerich and Leyendecker in Deutsche Übersetzung des attachment behavior Q-Set, revision 3.2. Unpublished manual, Ruhr University Bochum, Bochum, 1999) were used to investigate the interplay between disorder symptoms and attachment security.

RESULTS

The results revealed that the symptoms of attachment disorders decreased. The decrease was more pronounced for the inhibited than for the disinhibited symptoms with marked changes in the first 6 months of placement. There was a noticeable gender difference in the development with boys showing a more pronounced decrease in inhibited attachment disorder symptoms and a stronger increase of attachment security. After 12 months, no significant gender effects were found. Regarding the association between symptoms of attachment disorders and attachment security, a significant negative correlation between the inhibited attachment disorder symptoms and attachment security was found 12 months after placement.

CONCLUSIONS

Attachment disorder symptoms decreased in the stable foster care environment. Thus, foster care seems to be an effective placement option regarding children's attachment development.

Short version of the Inventory of Parental Representations, a self-report for attachment assessment among adolescents

BACKGROUND

 The Inventory of Parental Representations (IPR), a self-administered questionnaire, was developed primarily to identify styles of attachment in adolescence. However, it did not present stable psychometric properties in the various American studies carried out. The aim of this study was to adapt the IPR in French and to provide a shorter version with improved psychometric properties and sound content.

METHODS

The cross-cultural adaptation and content validity were carried out based on qualitative analysis by an Expert Committee and 10 non-clinical adolescents. For the quantitative analyses a cohort of 535 adolescent volunteers was enrolled, corresponding to 1070 responses, and divided into two groups: development and validation. The study of the metric properties of the adapted version of the IPR was realized in the development group, a sample of 275 responses. In case of mediocre results in the Confirmatory Factor Analysis, the development of a new and reduced IPR structure was planned using a mixed method including Classical Test Theory and Rasch Modelling in the development group. Subsequently, the study of the psychometric properties of the short, adapted version was confirmed in an independent sample of 795 responses (validation group).

RESULTS

Out of 62 items translated, 13 needed adaptations. The analysis of their metric properties produced mediocre results. Content and psychometric property analyses generated two Short version of the IPR in the development group: a paternal scale for Fathers (Short IPRF) with 15 items and a maternal scale for Mothers (Short IPRM) with 16 items. The sound content and good psychometric properties were confirmed in the validation group (Short IPRF: Comparative Fit Index = 0.987, Tucker-Lewis Index = 0.982, Root Mean Square Error of Approximation = 0.027; Short IPRM: Comparative Fit Index = 0.953, Trucker-Lewis Index = 0.927, Root Mean Square Error of Approximation = 0.068). Using Rasch modelling, the attachment was correctly measured overall especially for insecure attachment.

CONCLUSIONS

A step-by-step process involving led to the generation of two questionnaires: a paternal scale, the Short IPRF, and a maternal scale with the Short IPRM providing opportunities to use this self-questionnaire to assess attachment among adolescents. Further work will provide a solid rating for this new tool.

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.

Self-esteem in adolescents with reactive attachment disorder or disinhibited social engagement disorder

BACKGROUND

Low self-esteem predicts negative outcomes and mediates the association between childhood adversity and mental health problems in adolescence. Reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) are presumably caused by early insufficient care, but their association with self-esteem is unknown.

OBJECTIVE

Investigate global and domain-specific self-esteem in adolescents with RAD or DSED.

PARTICIPANTS AND SETTING

All adolescents living in Norwegian residential youth care (RYC) (N = 306; age 12-20) were compared with a sample from the general Norwegian adolescent population (N = 10,480; age 12-20).

METHODS

Self-esteem for scholastic competence (SC), social acceptance (SA), athletic competence (AC), physical appearance (PA), romantic appeal (RA), close friendship (CF), and self-worth (SW) was investigated using the revised version of the Self-Perception Profile for Adolescents.

RESULTS

Compared to the general population, adolescents with RAD diagnosis had lower SC (mean difference, MD = -0.30, p = .020) and higher CF (MD = 0.25, p = .021), whereas adolescents with DSED diagnosis had lower SC (MD = -0.42, p = .005), SA (MD = -0.40, p = .015), AC (MD = -0.22, p = .038), PA (MD = -0.33, p = .048), and SW (MD = -0.37, p = .013). Compared to adolescents in RYC without RAD/DSED diagnoses, adolescents with DSED diagnoses had lower SA (MD = -0.42, p = .012) and SW (MD = -0.32, p = .037). More RAD symptoms were associated with lower SA (B = -0.051, p = .013), AC (B = -0.048, p = .028), RA (B = -0.053, p = .007), and CF (B = -0.052, p = .005). More DSED symptoms were associated with lower SC (B = -0.125, p = .038).

CONCLUSION

Both global and domain-specific self-esteem in adolescents with RAD or DSED should be assessed; developmental support and treatment plans should be adjusted accordingly.

Validity of reactive attachment disorder and disinhibited social engagement disorder in adolescence

Although reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) are acknowledged as valid disorders in young children, controversy remains regarding their validity in adolescence. An unresolved question is whether symptoms of RAD and DSED are better conceptualized as other psychiatric disorders at this age. All adolescents (N = 381; 67% consent; 12-20 years old) living in residential youth care in Norway were interviewed to determine the symptoms and diagnosis of RAD/DSED and other common psychiatric disorders using the Child and Adolescent Psychiatric Assessment (CAPA). The construct validity of RAD and DSED, including structural and discriminant validity, was investigated using confirmatory factor analysis and latent profile analysis. Two-factor models distinguishing between symptoms of RAD and DSED and differentiating these symptoms from the symptoms of other psychiatric disorders revealed better fit than one-factor models. Symptoms of RAD and DSED defined two distinct latent groups in a profile analysis. The prevalence of RAD was 9% (95% CI 6-11%), and the prevalence of DSED was 8% (95% CI 5-11%). RAD and DSED are two distinct latent factors not accounted for by other common psychiatric disorders in adolescence. RAD and DSED are not uncommon among adolescents in residential youth care and therefore warrant easy access to qualified health care and prevention in high-risk groups.

White matter changes in children and adolescents with reactive attachment disorder: A diffusion tensor imaging study

Childhood maltreatment is associated with altered brain structure and function and is a major risk factor for psychopathology, including reactive attachment disorder (RAD). However, whether changes to white matter microstructural integrity are associated with RAD is unclear. We used diffusion tensor imaging (DTI) to assess group differences in fractional anisotropy (FA) in patients with RAD (n = 25; mean age = 13.2) to typically developing (TD) controls (n = 33; mean age = 13.0). To further interpret differences in FA, additional parameters such as mean diffusivity (MD), axial diffusivity (AD) and radial diffusivity (RD) were assessed. We found that FA values in the body of corpus callosum (CC) and in the projection and thalamic pathways, including the posterior limb of the internal capsule and corona radiata (anterior, posterior, and superior), were significantly higher in the RAD than in the TD group. Additionally, RAD group showed significantly lower RD values in the body of the CC and abovementioned pathways than TD group. Our findings indicate that RAD is associated with altered structure of the CC and projection and thalamic pathways, which may play a role in emotion regulation. The aberrant development of these tracts in RAD may reflect stress-related psychophysiological responses.

Attachment disorders diagnosed by community practitioners: a replication and extension

BACKGROUND

While considered a rare diagnosis, reactive attachment disorder (RAD) is simultaneously the subject of considerable debate. A recent report suggested that RAD is overdiagnosed in community settings and that conduct problems may be used to make a diagnosis of RAD (Woolgar & Baldock, Child and Adolescent Mental Health, 20, 2015, 34-40). This study seeks to replicate and extend these findings.

METHOD

Clinical assessment data from 100 consecutive admissions of maltreated foster and adopted children (ages 3-17) to a specialty treatment clinic in the United States were reviewed. Measures included semi-structured interviews of RAD and disinhibited social engagement disorder (DSED) symptoms and caregiver-report questionnaires of emotional problems, conduct problems, and the quality of the parent-child relationship.

RESULTS

Of the 100 cases reviewed, 39 presented with a diagnostic history of RAD, DSED, or 'attachment disorder'. Of these cases, three were diagnosed in-clinic with DSED; no cases met diagnostic criteria for RAD according to DSM-5 criteria. However, analyses found that those diagnosed with RAD by community-based clinicians were significantly more likely to display conduct problems and to be adopted (as opposed to in foster care).

CONCLUSIONS

These findings confirm those of Woolgar and Baldock (Child and Adolescent Mental Health, 20, 2015, 34-40). It appears that the diagnostic criteria of RAD are commonly being inaccurately applied in general community-based practice. Clarification of diagnostic criteria for RAD in recent revisions of diagnostic taxonomies, the accumulation of empirical data on RAD, and improved instrumentation are either poorly disseminated or inadequately implemented in community-based practice settings.

Signs of attachment disorders and social functioning among early adolescents with a history of institutional care

BACKGROUND

Institutional rearing is associated with increased risk for reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED). Disorders of attachment involve disturbances in children's primary caregiving relationships, and are likely to disturb multiple domains of social functioning.

OBJECTIVE

To examine associations between signs of RAD and DSED and social functioning in early adolescence.

PARTICIPANTS AND SETTING

Our participants were 110 children with a history of institutional rearing and 50 community comparison adolescents from the Bucharest Early Intervention Project, based in Bucharest, Romania. Participants were assessed at age 12 years (M age in years = 12.80, SD = 0.71).

METHOD

Signs of RAD and DSED were obtained through caregiver report. Reports of social functioning were provided by caregivers and teachers. General and specific domains of social functioning were identified using bi-factor modeling. A general social functioning factor and four specific factors were revealed: peer conflict, caregiver views as victim, teacher views as victim, and social competence.

RESULTS

Signs of RAD predicted poorer general social functioning (β=-0.36, p < .01, 95% confidence interval [CI] [-.33, -.09]) and poorer social competence (β=-0.38, p < .01, 95% CI[-0.05, -.01]) above and beyond time spent in institutional care and placement disruptions. Signs of DSED (β=-0.38, p < .001, 95% CI[-0.49, -.16]) along with placement disruptions (β=-0.22, p < .05, 95% CI[-.29, -.01]) predicted poorer general social functioning above and beyond time spent in institutional care. Signs of DSED predicted higher scores on caregiver views as victim (β = 0.29, p < .05, 95% CI[0.02, 0.14]) and lower scores on social competence (β=-0.29, p < .01, 95% CI[-.06, -.01]) above and beyond time spent in institutional care and placement disruptions.

CONCLUSIONS

Attachment disorder signs in early adolescence are problematic for social functioning, although the manifestation of these social difficulties differs based on whether RAD or DSED signs are present.

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.

A prospective longitudinal study of Reactive Attachment Disorder following early institutional care: considering variable- and person-centered approaches

Although the study of reactive attachment disorder (RAD) in early childhood has received considerable attention, there is emerging interest in RAD that presents in school age children and adolescents. We examined the course of RAD signs from early childhood to early adolescence using both variable-centered (linear mixed modeling) and person-centered (growth mixture modeling) approaches. One-hundred twenty-four children with a history of institutional care from the Bucharest Early Intervention Project, a randomized controlled trial of foster care as an alternative to institutional care, as well as 69 community comparison children were included in the study. While foster care was associated with steep reductions in RAD signs across development, person-centered approaches indicated that later age of placement into families and greater percent time in institutional care were each associated with prolonged elevated RAD signs. Findings suggest the course of RAD is variable but substantially influenced by early experiences.

Reactive Attachment Disorder and attachment theory from infancy to adolescence: review, integration, and expansion

In reviewing the preceding articles, I emphasize the predominance of relational theories in the study of development as a way of demonstrating the evolutionary and relational extremity of reactive attachment disorder (RAD). The lack (or distortion?) of mutuality, RAD's defining feature, has implications for all aspects of development, not least of which is self-regulation. I review each article in this special issue, emphasizing important features, integrating across studies, expanding their links to attachment theory, and recommending future directions. Finally, I conduct two meta-analyses of the samples in this special issue, one meta-analysis addressing convergent validity of RAD assessment instrumentation developed by authors represented here and the other addressing the links between RAD and internalizing and externalizing behaviors. This special issue exploits the disaggregation of reactive attachment and disinhibited social engagement disorders to move the field forward in remarkable ways, both methodologically and substantively.

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.

Incidence and Comorbidity of Reactive Attachment Disorder: Based on National Health Insurance Claims Data, 2010-2012 in Korea

OBJECTIVE

We aimed to investigate the current diagnostic incidence, and medical and psychiatric comorbidities of reactive attachment disorder (RAD) using the National Health Insurance Review and Assessment (HIRA) claims data.

METHODS

To examine the diagnostic incidence, we selected patients who were under 10-year-old and who had at least one medical claim containing a 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) code for RAD (F94.1 and F94.2) and who had not been diagnosed in the previous 360 days, from 2010 to 2012. In this study, we used the term 'reactive attachment disorder' representing for both RAD per se and Disinhibited social engagement disorder. Comorbid disorders were categorized according to ICD-10.

RESULTS

Among 14,029,571, the total population under 10-year-old during 2010-2012, incident cases of RAD were 736. The mean diagnostic incidence of RAD was 5.25 per 100,000 annually. Language disorders (F80-84) were the most common psychiatric comorbidities in both boys and girls in age groups 0-3 years and 4-6 years, and attention deficit hyperactivity disorder was the most common in both sex aged 7-9 years. In non-psychiatric comorbidities, diseases of the respiratory system (J00-99) were the commonest in both sex in all age groups, and diseases of the digestive system (K00-99) were the next.

CONCLUSION

RAD was very rare in practice and would be disguised as other psychiatric disorders. Children with RAD might have more medical comorbidities than typically developed children.

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.

Beyond Reactive Attachment Disorder: How Might Attachment Research Inform Child Psychiatry Practice?

This article provides an updated review of attachment research with a focus on how comprehensive clinical assessment and intervention informs the care of young children. Child psychiatrists can serve as an important part of care coordination teams working with young children who have histories of early maltreatment and/or disruption in caregiving whether or not the children they are seeing meet criteria for an attachment disorder. Child psychiatrists should be familiar with both comprehensive assessment and the recent attachment-based interventions and appreciate how pharmacotherapy can be a useful adjunctive intervention when intensive therapy alone is ineffective.

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.

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.

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.

Attachment disorders versus more common problems in looked after and adopted children: comparing community and expert assessments

BACKGROUND

Attachment disorders in adopted and fostered children may be overdiagnosed and could obscure more common disorders.

METHODS

A case note review of 100 referrals to a specialist adoption and fostering service compared community referrals with the specialist assessments of attachment disorders.

RESULTS

Attachment disorders were identified four times more often in community referrals versus the specialist service, but this only partly explained the significant under-identification of more common disorders in the community, especially for neurodevelopmental factors and conduct disorder by up to 10-fold.

CONCLUSIONS

The relevant practice parameters are discussed and implications for service models for adopted and fostered children reviewed.

Disinhibited reactive attachment disorder symptoms impair social judgements from faces

Typically developing adults and children can rapidly reach consensus regarding the trustworthiness of unfamiliar faces. Maltreated children can have problems with trusting others, yet those with the disinhibited form of reactive attachment disorder (dRAD) can be indiscriminately friendly. Whether children with dRAD symptoms appraise and conform to typical judgements about trustworthiness of faces is still unknown. We recorded eye movements of 10 maltreated dRAD children and 10 age and gender matched typically developing control children while they made social judgements from faces. Children were presented with a series of pairs of faces previously judged by adults to have high or low attractiveness or trustworthiness ratings. Typically developing children reached a consensus regarding which faces were the most trustworthy and attractive. There was less agreement among the children with dRAD symptoms. Judgments from the typically developing children showed a strong correlation between the attractiveness and trustworthiness tasks. This was not the case for the dRAD group, who showed less agreement and no significant correlation between trustworthiness and attractiveness judgments. Finally, both groups of children sampled the eye region to perform social judgments. Our data offer a unique insight in children with dRAD symptoms, providing novel and important knowledge for their rehabilitation.

Cortisol secretion in children with symptoms of reactive attachment disorder

Maltreated children with reactive attachment disorder (RAD) have severe problems with social relationships and affect regulation. An association between early maltreatment and changes in the daily rhythm of cortisol secretion has already been reported for maltreated toddlers. We sought to find out whether such changes were apparent in school-age children with symptoms of RAD, who had experienced early maltreatment but were currently adopted in well-functioning families. We recruited 66 children: 34 adopted children, aged 5-12 years, with an early history of maltreatment and with social difficulties such as indiscriminate friendliness; and 32 age- and sex-matched comparison children with no history of maltreatment or social difficulties. Daily rhythms of cortisol production were determined from saliva samples collected over 2 days. The adopted group had significantly lower absolute levels of cortisol compared to the control group, but a typical profile of cortisol secretion. There was no association between cortisol secretion and symptom scores for psychopathology.

Residential Childcare Workers' Knowledge of Reactive Attachment Disorder

BACKGROUND

  Reactive Attachment Disorder (RAD) is associated with a history of 'pathogenic care' therefore residential childcare workers are likely to come into contact with children with this disorder. An 'appropriately supportive environment' may be a mitigating factor in terms of the disorder's severity and duration (Corbin, 2007); therefore it is important that behaviours suggestive of RAD are recognised early and that these children are given the attention they require in the care setting. We aimed to gain an understanding of residential childcare workers' knowledge of RAD to determine if their understanding of RAD was sufficient to recognise RAD-like behaviour.

METHOD

  A mixed methods study (qualitative focus groups and whole population survey) was undertaken with residential childcare workers.

RESULTS

  Liaison with Child and Adolescent Mental Health Services was seen by residential workers as being useful and workers thought their knowledge of mental health problems had improved in recent years. However, less than half of respondents (49.1%) identified RAD from a case history given in the questionnaire.

CONCLUSIONS

  Child and Adolescent Mental Health Services staff and residential workers may need more specialised training on RAD to be able to recognise behaviours suggestive of the disorder and refer appropriately, ensuring the child's needs are met as early as possible.