CAHMS - Attachment and Behavioural Disorders Flashcards
what is Reactive attachment disorder?
Markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before the age of five and is associated with grossly pathological care.
what 3 types of care by the parent are associated with the development of reactive attachment disorder?
A persistent disregard for the child’s emotional needs for comfort, stimulation, and affection
Persistent disregard for the child’s physical needs
Repeated changes of primary caregivers
what are the features of RAD?
Individuals have difficulty forming lasting, loving and intimate relationships
Medically, it can include: malnutrition, growth delay, evidence of physical abuse, vitamin deficiencies, or infectious diseases.
who does RAD occur in?
1% of all children
20% of children in care
higher prevalence in children orphaned at a young age
what causes an increased risk of RAD in children?
neglect
being orphaned
etc
can RAD improve?
yes
onset as early as 2 months old - can hence improve/remission if supportive environment afterwards
what are the 2 types of RAD?
inhibited
disinhibited
what is inhibited RAD?
children fail to initiate and respond to social interactions in a developmentally appropriate way
interactions with the child often met with avoidance and resisting to comforting, often hypervigilant or highly ambivalent
e.g - child doesn’t seek comfort from parent/caregiver during time of threat etc
what is disinhibited RAD?
child has inability to display appropriate selective attachments
also known as disinhibited social engagement disorder (DSED)
more enduring over time
e.g - child displays excessive familiarity with strangers, indiscriminate sociability or lack of selectivity in their choices of attachment figure
why is attachment important?
forms healthy personality including:
- development of consciousness
- ability to become self-reliant
- ability to think logically
- ability to cope with frustration and stress
- ability to handle fear or a threat to self
- development of relationships
what might children with attachment disorders struggle with?
lack empathy poor self esteem poor problem solving difficulties with emotional regulation highly impulsive
give 8 potential causes of attachment disorder
frequent changes in parent/caregiver
extended separation from parent/caregiver
frequent moves and/or placements in foster care or institutions
Traumatic experiences
Young or inexperienced mother with poor parenting skills
Neglect
Abuse
Potentially, neurodevelopmental difficulties (in particular ASD) can contribute
healthy versus alien self?
healthy = parent relates to child and their feelings, understands what they feel, child responds and mirrors this, knows that they are worth someone caring for them and their feelings alien = where child develops attachment disorder, parent cant reciprocate what the child is feeling, cant feel/understand what they are feeling so the child cant respond, is confused and cant bond/form attachment
what is the conclusion of the healthy vs alien self theory?
continuous neglect/not empathising with child or experiencing their feelings can cause attachment disorder
give 8 alarming symptoms in very young children
Persistent and medically unexplained severe Colic
Poor eye contact, difficulty tracking
No reciprocal smile response
Delayed gross motor skill development (sitting, crawling, etc.)
Difficulty being comforted (extreme crying, constant whining)
Resists affection and cuddling from caregiver/parent
Appear stiff, display tactile defensiveness
Poor sucking response when eating
give 11 common symptoms of attachment disorder in older children and young people
Lack of self-control / impulsive
Speech and language delays
Lack of conscience / shows no remorse
Lack an understanding of social boundaries, often in others personal space
Indiscriminately affectionate with strangers or inhibition or hesitancy in social interactions
Avoids/overseeks physical contact
Hyperactive
Aggressive. Destructive towards self, property and others
Food issues: hordes, gorges, refuses to eat, hides food
Often on guard, anxious, wary
Prefers to play alone
when does the majority of damage/neglect to a child happen?
pre-verbal (before the child can use language)
describe the underlying reason behind the anger in adolescence
can be shame based
often results from past experiences of humiliating abuses of power where they are made to feel worthless, useless and unworthy of respect
these experiences can leave a seething undercurrent of rage as a result of a distorted sense of self
is there a familial link to attachment disorder?
yes
children with attachment disorder often grow up to have children of their own with attachment disorder
can be because they don’t know how to parent
can also have a genetic aspect - cortisol
how can childhood experience alter the brain?
interact with genetics to change the structure of the brain resulting in behavioural change
- can alter number of neurons
- increase/decrease number of dendritic branches and number of synapses
- can determine how emotional centres of the brain communicate with the cortex and its higher functioning
what 4 differential diagnoses may attachment disorder be mistaken for?
conduct disorder
depression
ASD
ADHD
how does each disorder differ with attachment disorder?
CD
- are able to form some satisfying relationships with peers and adults
depression
- are able to form appropriate social relations with those who reach out to them
ASD
- present with historical and persuasive difficulties while children with RAD are more able to adapt based on what they get out of the relationship
ADHD
- difficulties are persistent and across different settings, more able to initiate and maintain relationships
what co-morbidities are common with attachment disorder?
emotional disorders
ADHD
behavioural disorders
what treatments are available for attachment disorder?
family therapy individual therapy play therapy - helps child learn skills for interacting with peers etc medication - for symptoms of co-morbid disorders special education interventions
what is conduct disorder?
repetitive and persistent pattern of behaviour in which the basic rights of others or major age-inappropriate norms or rules are violated
- to a lesser degree it is called Oppositional Defiant Disorder (ODD) in younger children
what type of disorder is conduct disorder?
behaviour disorder
how common are behaviour disorders?
second most common type of mental health disorder in children and adolescence
how does conduct disorder present?
3 or more of the following in the past 12 months with at least 1 present in the last 6 months:
- aggression to people or animals
- destruction of property
- deceitfulness or theft
- serious violation of rules
how does conduct disorder affect public health/economy etc?
higher incidence of health, social services and criminal justice system involvement
mental health co-morbidity
what is mild-moderate conduct disorder?
restricted to family disorder
what is severe conduct disorder?
unsocialised - predominantly violent behaviour and more likely to be involved in criminal justice
socialised - more covert antisocial acts or better ability to avoid getting involved in criminal justice system
which gender with conduct disorder is more likely to be involved with criminal justice system?
males
name 6 co-morbidities with conduct disorder
attachment difficulties (RAD) ADHD reading and other learning difficulties depression substance misuse deviant sexual behaviour
what is the triad of difficulties in ADHD?
inattention
hyperactivity
impulsivity
what other difficulties may co-occur with ADHD?
cluster of impairing symptoms relating to self regulation which are
- developmentally inappropriate
- impairing functioning
- persuasive across settings (home, school, work etc)
- longstanding from age 5
what causes ADHD?
multifactorial - genetic and environmental factors
familial clustering within and across generations
60% increased risk of ADHD if parent affected
15% increased risk of ADHD if sibling affected
how do conduct disorder and ADHD differ?
conduct disorder is more environmental in cause (not a familial link)
what are some similarities with conduct disorder and ADHD?
present similarly
highly co-morbid
short-term response to stimulant medication is the same
both have higher rates of antisocial personality as adults
what causes conduct disorder?
no single causes - bio, social and psycho influences
- genetic
- brain injury (trigger in genetically predisposed - intrauterine, post natal CNS trauma)
- environmental (parenting, family circumstances)
what factors within a family can predispose to antisocial behaviour?
lack of house rules - no set routine
lack of clarity as to how children are to behave
lack of effective contingencies - inconsistent responses to undesired behaviour between parents with failure to follow through on consequences or rewards
lack of techniques to deal with crises or resolve conflict within family
lack of supervision is strongly associated with delinquency
how can conduct disorder be managed?
parent/caregiver training (if child <11)
child focused programme (child 9-14) - social and cognitive problem solving programmes
multimodal interventions (child 11-17) - intensive support to young person and family
what medications can be used for conduct disorder?
not first line can help in extreme causes with impulsivity and aggressive behaviour - risperidone (antipsychotic) - ADHD = stimulant medication - depression - SSRIs
