CAHMS - Attachment and Behavioural Disorders

Question 1

what is Reactive attachment disorder?

Answer 1

Markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before the age of five and is associated with grossly pathological care.

Question 2

what 3 types of care by the parent are associated with the development of reactive attachment disorder?

Answer 2

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

Question 3

what are the features of RAD?

Answer 3

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.

Question 4

who does RAD occur in?

Answer 4

1% of all children
20% of children in care
higher prevalence in children orphaned at a young age

Question 5

what causes an increased risk of RAD in children?

Answer 5

neglect
being orphaned
etc

Question 6

can RAD improve?

Answer 6

yes

onset as early as 2 months old - can hence improve/remission if supportive environment afterwards

Question 7

what are the 2 types of RAD?

Answer 7

inhibited

disinhibited

Question 8

what is inhibited RAD?

Answer 8

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

Question 9

what is disinhibited RAD?

Answer 9

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

Question 10

why is attachment important?

Answer 10

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

Question 11

what might children with attachment disorders struggle with?

Answer 11

lack empathy
poor self esteem
poor problem solving
difficulties with emotional regulation
highly impulsive

Question 12

give 8 potential causes of attachment disorder

Answer 12

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

Question 13

healthy versus alien self?

Answer 13

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

Question 14

what is the conclusion of the healthy vs alien self theory?

Answer 14

continuous neglect/not empathising with child or experiencing their feelings can cause attachment disorder

Question 15

give 8 alarming symptoms in very young children

Answer 15

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

Question 16

give 11 common symptoms of attachment disorder in older children and young people

Answer 16

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

Question 17

when does the majority of damage/neglect to a child happen?

Answer 17

pre-verbal (before the child can use language)

Question 18

describe the underlying reason behind the anger in adolescence

Answer 18

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

Question 19

is there a familial link to attachment disorder?

Answer 19

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

Question 20

how can childhood experience alter the brain?

Answer 20

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

Question 21

what 4 differential diagnoses may attachment disorder be mistaken for?

Answer 21

conduct disorder
depression
ASD
ADHD

Question 22

how does each disorder differ with attachment disorder?

Answer 22

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

Question 23

what co-morbidities are common with attachment disorder?

Answer 23

emotional disorders
ADHD
behavioural disorders

Question 24

what treatments are available for attachment disorder?

Answer 24

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

Question 25

what is conduct disorder?

Answer 25

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

Question 26

what type of disorder is conduct disorder?

Answer 26

behaviour disorder

Question 27

how common are behaviour disorders?

Answer 27

second most common type of mental health disorder in children and adolescence

Question 28

how does conduct disorder present?

Answer 28

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

Question 29

how does conduct disorder affect public health/economy etc?

Answer 29

higher incidence of health, social services and criminal justice system involvement
mental health co-morbidity

Question 30

what is mild-moderate conduct disorder?

Answer 30

restricted to family disorder

Question 31

what is severe conduct disorder?

Answer 31

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

Question 32

which gender with conduct disorder is more likely to be involved with criminal justice system?

Answer 32

males

Question 33

name 6 co-morbidities with conduct disorder

Answer 33

attachment difficulties (RAD)
ADHD
reading and other learning difficulties
depression
substance misuse
deviant sexual behaviour

Question 34

what is the triad of difficulties in ADHD?

Answer 34

inattention
hyperactivity
impulsivity

Question 35

what other difficulties may co-occur with ADHD?

Answer 35

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

Question 36

what causes ADHD?

Answer 36

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

Question 37

how do conduct disorder and ADHD differ?

Answer 37

conduct disorder is more environmental in cause (not a familial link)

Question 38

what are some similarities with conduct disorder and ADHD?

Answer 38

present similarly
highly co-morbid
short-term response to stimulant medication is the same
both have higher rates of antisocial personality as adults

Question 39

what causes conduct disorder?

Answer 39

no single causes - bio, social and psycho influences

• genetic
• brain injury (trigger in genetically predisposed - intrauterine, post natal CNS trauma)
• environmental (parenting, family circumstances)

Question 40

what factors within a family can predispose to antisocial behaviour?

Answer 40

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

Question 41

how can conduct disorder be managed?

Answer 41

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

Question 42

what medications can be used for conduct disorder?

Answer 42

not first line
can help in extreme causes with impulsivity and aggressive behaviour
- risperidone (antipsychotic)
- ADHD = stimulant medication
- depression - SSRIs