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    Reactive Attachment Disorder    

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Reactive Attachment Disorder

TREATMENT PATH STAGE I: | IDENTIFYING REACTIVE ATTACHMENT DISORDER | TREATMENT PATH STAGE II: REFERRALING | TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING | TREATMENT PATH STAGE IV: TREATING RAD | TREATMENT PATH STAGE V: MONITORING AND REVIEWING | RESOURCES FOR CLIENTS

This Clinical Information Guide is one in a series of guides designed to assist caseworkers and supervisors in identifying and managing clients who need mental health services. These guides use the treatment pathways model,1 which outlines five stages to assist you in obtaining the best possible mental health services for your clients. Each guide is designed to highlight the primary casework task that needs to be accomplished at each stage, and to address common questions that you might have as you complete each task.

What are the five stages of the Treatment Pathways Model?

In the identification stage, you gather information concerning the identified problems, consult with your supervisor and the behavioral health consultant, and decide whether or not your client needs to be referred to a mental health specialist. In the referral stage, you follow established procedure by completing required documentation and selecting the appropriate mental health specialist. In the assessment and diagnosis stage, you assist the specialist by furnishing relevant information concerning your client. In the treatment stage, you work collaboratively with the clinician to identify treatment goals and secure the most effective treatment available for your client. In the monitoring and reviewing stage, you ensure that reasonable treatment goals are achieved.

TREATMENT PATH STAGE I:

IDENTIFYING REACTIVE ATTACHMENT DISORDER

Primary Casework Task: To gather information to decide whether or not your client exhibits the symptoms of Reactive Attachment Disorder of Infancy and Early Childhood (RAD) that would lead you to consult with your supervisor and the behavioral health consultant to determine if a referral for an evaluation or clinical intervention is needed.

What is RAD?

Reactive Attachment Disorder is a psychiatric disorder that begins before age 5 in which a child who has experienced extremely poor care or abuse exhibits very disturbed and inappropriate social relatedness for his or her age. For example, the child may exhibit contradictory or disorganized responses to caregivers such as alternately approaching, avoiding, or resisting the caregiver's efforts to comfort or care for the child. Or, the child may not adequately distinguish between his or her primary caregiver and strangers, exhibiting excessive familiarity with people the child has never met.

How Common is RAD?

There is very little information regarding the frequency of occurrence of RAD because it is a relatively new psychiatric diagnosis. Initial research suggests that RAD is a fairly uncommon disorder. Although many young children, especially those in the child welfare system, have been abused or neglected, a very small percentage of these children exhibit the seriously impaired social relatedness that is required to obtain a RAD diagnosis.

What Causes RAD?

By definition, a child must have experienced abuse, neglect, or suffered extremely poor care to be diagnosed with RAD. This includes a child whose basic physical or emotional needs for comfort, affection, or stimulation have been disregarded, as well as a child who has experienced repeated changes of primary caregivers which have prevented the child from forming stable attachments. The risk for RAD increases for children whose parents are isolated, depressed, lack social support, or who were themselves extremely deprived or abused as children. Children who as infants were "difficult," lethargic, chronically ill, or who were separated from their caregivers during the first weeks of life may be at risk for developing RAD.

TREATMENT PATH STAGE II: REFERRAL

Primary Casework Task: To complete the required referral process, including gathering supporting documentation, and to select the appropriate mental health specialist to assess, diagnose, and treat your client.

What kinds of mental health specialists can evaluate my client?

Psychologists (Ph.D., Psy.D.) , physicians (M.D., including psychiatrists), licensed clinical social workers (L.C.S.W.), and psychiatric nurses (R.N.) have the training and background to conduct an initial evaluation for RAD.

These mental health specialists can be found at community mental health agencies, the psychiatry department of hospitals or clinics, employee assistance programs, health maintenance organizations, university or medical school-affiliated programs, state hospital outpatient clinics, family service or social service agencies, or private clinics. Appendix B of this Clinical Information Guide lists specialty clinics or providers in your geographic area that diagnose and treat RAD.

TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING RAD

Primary Casework Task: To assist the mental health specialist by furnishing relevant information concerning your client's mental health.

The first step to getting appropriate diagnosis and treatment for RAD is a thorough diagnostic evaluation by a mental health specialist. The clinician will gather a complete history of symptoms, including when they started, how long they have lasted, how severe they are, whether the child had them before and, if so, whether the symptoms were treated, and what treatment was given. Further, a history will include questions about whether other family members have had a psychiatric illness and, if treated, whether or not this treatment was effective.

A child is diagnosed with RAD when the child displays symptoms that meet criteria of the American Psychiatric Association's Diagnostic and Statistical Manual Fourth Edition (DSM-IV). The child must exhibit very disturbed social relatedness that begins before 5-years-old and is as evidenced by one of the following:

    (1) contradictory or disorganized responses to caregivers such as alternately approaching, avoiding, or resisting the caregiver's efforts to comfort or care for the child.

    (2) inability to distinguish appropriate from non-appropriate attachments (for example,

    clinging to strangers)

The child must also have experienced extremely poor care, including one of the following:

    · persistent disregard for emotional needs for comfort, stimulation, or affection

    · persistent disregard for basic physical needs

    · repeated changes of primary caregivers that prevented formation of a stable attachment

The child should not be diagnosed with RAD if the symptoms can be accounted for by a developmental disability such as Mental Retardation, or by Pervasive Developmental Disorder (formerly called "Autism").

TREATMENT PATH STAGE IV: TREATING RAD

Primary Task: To secure the most effective treatment available for your client's RAD and to work collaboratively with the treating clinician to identify treatment goals and objectives.

What Treatments are Effective for RAD?

No scientifically established treatments exist for RAD. Currently, recommended clinical practice involves psychotherapy that includes the child and caregiver. This treatment focuses on teaching the caregiver how to eliminate neglect and poor parenting. In addition, the caregiver learns:

1. about the disorder

2. about activities that promote normal child development

3. how to play with the child

4. how to manage the child's aggressive and problematic behaviors

5. how to communicate effectively with the child

Holding Therapy or Rage Reduction Therapy are not currently accepted clinical practice. These treatments are not approved by DCFS for treatment of RAD.

How do I collaborate with the mental health specialist and my client to design treatment goals?

Developing treatment goals is a critical step in the treatment process. Clear, objective treatment goals enable the client, family, and service provider to address the client's mental health needs.

There are two broad kinds of treatment goals: Administrative and clinical. Administrative goals involve the completion or non-completion of services. Examples of administrative goals include the number of psychotherapy sessions that a client attends. Clinical treatment goals address two domains related to a client's overall functioning: symptom or behavior change, and changes in daily functioning ability

a) Symptom change -- A change in the symptoms or behaviors associated with RAD, such as increased eye contact or improved ability to seek out appropriate caretakers when distressed.

b) Functional change -- A change in the areas of functioning that are typically affected by RAD, such as improved ability to get along with other young children or siblings, or fewer episodes of approaching strangers in the community.

You will need to collaborate with the child's caregiver and the mental health specialist to create treatment goals that address the child's symptoms and the areas of functioning that are critical to the child fulfilling his or her service plan. You will need to work with the mental health specialist to determine the manner and frequency with which treatment goals will be measured.

TREATMENT PATH STAGE V: MONITORING AND REVIEWING

Primary Task: To ensure that you receive timely and appropriate documentation from the mental health specialist that reviews progress towards treatment objectives.

How do I know if treatment is working?

The child's ability to relate to his or her primary caregiver will improve. For example, the child may seek out physical affection when needed in an appropriate manner, or the child may not longer seek care-giving from strangers.

Treatment Outcomes

What role do I play in monitoring my client's treatment goals?

Usually the mental health specialist will gauge the success of intervention services by observing changes in the child's behavior and functioning. Because of your extensive knowledge of the child's behavior, the specialist may ask you about the child's functional change in different areas. For example, the specialist may ask you about the child's ability to engage with the caregiver or biological parent during visits.

If your client is not improving, you will want to talk with the mental health specialist or physician concerning factors in the child's life that could be complicating recovery. Perhaps after treatment began, additional life stress or change occurred in the child's life, such as a disrupted placement or a medical problem.

What kind of documentation should I expect from the mental health specialist?

You should expect quarterly treatment summaries that highlight your client's progress toward all administrative and clinical treatment goals. If you review a treatment summary and find that it differs significantly from your observations of the child, you will want to contact the mental health specialist to discuss your concerns. You will also want to contact the specialist if you believe that new goals should be added to your client's treatment plan.

RESOURCES FOR CLIENTS

Where can my client obtain information about RAD?

Because it is a relatively new and rare psychiatric disorder, there is very little reliable information regarding the diagnosis and treatment of RAD. You can obtain general information about parenting and psychiatric illness from the following agencies:

National Institute of Mental Health

Office of Communications and Public Liaison

Information Resources and Inquiries Branch

6001 Executive Boulevard, Rm. 8184, MSC 9663

Bethesda, MD 20892-9663

(301) 443-4513

nimhinfo@nih.gov.

American Academy of Child and Adolescent Psychiatry

3615 Wisconsin Avenue, N.W.

Washington, DC 20016

(202) 966-7300

www.aacap.org

American Psychiatric Association

1400 K Street, N.W.

Washington, DC 20005

(202) 682-6000

www.psych.org

American Psychological Association

750 First Street, N.E.

Washington, DC 20002

(202) 336-5500

www.apa.org

APPENDIX A

Treatment Path Stage Clinical Information Casework & Administrative

Tasks

I. Identification of problem

1. A child who has experienced extremely poor care or abuse before the age of 5 exhibits very disturbed and inappropriate social relatedness for his or her age. For example, the child may exhibit contradictory or disorganized responses to caregivers such as alternately approaching, avoiding, or resisting the caregiver's efforts to comfort or care for the child. Or, the child may not adequately distinguish between his or her primary caregiver and strangers, exhibiting excessive familiarity with people the child has never met.

Casework Tasks:

a) Obtain information from client and caregivers.

b) Observe client

c) Review clinical records

d) Consult with supervisor & behavioral health team

Administrative Task:

· Document in case record

II. Referral

Licensed mental health specialists that evaluate for RAD are:

a) Physicians (M.D., including psychiatrists)

b) psychologists (Ph.D., Psy.D.)

c) Licensed clinical social workers (LCSW)

d) Psychiatric Nurses (RN)

Administrative Tasks:

a) Complete referral to licensed mental health specialist.

b) Include relevant clinical and case records with your referral.

c) Document in case record.

III A. Assessment

Assessment by mental health specialist must include:

a) Interview and observation of child and caregiver

b) Review of case and clinical records

Administrative Task: Insure mental health specialist has all relevant casework and clinical records.

III B. Diagnosis

Child exhibits very disturbed social relatedness that begins before 5-years-old. The child has experienced extremely poor care, such as a disregard for physical, social, or emotional needs, or repeated changes of caregivers. The child's disturbed social relatedness may be exhibited as:

1. excessive shyness, wariness, or ambivalent and contradictory responses to caregivers (for example, approaching, then avoiding them)

2. inability to distinguish appropriate from non-appropriate attachments (for example, clinging to strangers)

The child's problems can not be accounted for by a developmental delay such as Mental Retardation, or by Pervasive Developmental Disorder (formerly known as "Autism").

Administrative Task: Insure mental health specialist has all relevant casework and clinical records.

IV. Treatment

No scientifically established treatments exist for this disorder.

Currently, recommended clinical practice involves psychotherapy that includes the child and caregiver. This treatment focuses on teaching the caregiver how to eliminate neglect and poor parenting. In addition, the parent learns:

1. about the disorder

2. about activities that promote normal child development

3. how to play with the child

4. how to manage the child's aggressive and problematic behaviors

5. how to communicate effectively with the child

Holding Therapy and Rage Reduction Therapy have no formal research support and are not DCFS-approved treatments.

Casework Task: Work collaboratively with mental health specialist to establish clear, measurable administrative and clinical treatment goals that assess your client's attendance and his or her change in:

a) RAD Symptoms

b) functioning in areas relevant to the case plan. These areas might include home, school, work, and relations with family and friends.

V. Monitoring & Review of

Treatment

The mental health specialist collects data from the child and caregiver by interview, observation, and by reports from significant others, including the caseworker.

Casework Tasks:

a) Work with mental health specialist, child, and caregiver to evaluate progress toward treatment goals.

b) If necessary, work with specialist to revise treatment goals or to consider other kinds of treatment.

Administrative Tasks:

a) Obtain copies of quarterly, written treatment summaries from mental health specialist. Summaries should document client's progress toward clinical and

administrative treatment goals.

b) Document in case record.

APPENDIX B

LOCAL CLINICAL RESOURCES

1 The treatment pathway for RAD is summarized in Appendix A.

TREATMENT PATH STAGE I: | IDENTIFYING REACTIVE ATTACHMENT DISORDER | TREATMENT PATH STAGE II: REFERRALING | TREATMENT PATH STAGE III: ASSESSING AND DIAGNOSING | TREATMENT PATH STAGE IV: TREATING RAD | TREATMENT PATH STAGE V: MONITORING AND REVIEWING | RESOURCES FOR CLIENTS

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