Factors contributing to continuity and discontinuity in child psychopathology from infancy to childhood: An explorative study.

This study examined the psychopathology and socioemotional functioning of school-aged children treated during infancy and a comparison group of children without symptoms or treatment history. Our goal was to identify the factors associated with the continuity of psychopathology from infancy to childhood. The sample comprised 54 Israeli children, 30 with treatment history as infants in an infant mental health clinic and 24 with no treatment history. A 2 × 2 study design, with treatment history (treated/non-treated) and current psychiatric diagnosis (diagnosed vs. non-diagnosed), was used and group differences in children's psychopathology (Development and Well-Being Assessment (DAWBA)), socioemotional functioning (Vineland Adaptive Behavior Scales-Second Edition (VABS-II)), maternal stress (Parenting Stress Index-Short Form (PSI/SF)) and psychopathology (Symptom Checklist-90-Revised (SCL-90-R)), family functioning (Family Assessment Device (FAD)), and mother-child relational patterns (Coding Interactive Behavior (CIB)) were assessed. We found no differences between the previously treated and non-treated groups in the rate of given Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision (DSM-IV-TR) diagnosis. However, there was an interactive effect of treatment history × current psychiatric diagnosis, with the highest level of maternal stress in mothers of children exhibiting both early and late emotional and/or behavioral symptoms. Implications of these findings for identifying children and families at risk for continued child psychopathology and the importance of early parent-child psychotherapy interventions are discussed.

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.

Thalamic Volume Is Related to Increased Anterior Thalamic Radiations in Children with Reactive Attachment Disorder.

Reactive attachment disorder (RAD) is associated with childhood maltreatment and affects approximately 1% of the general population. Recent data suggest that childhood maltreatment is associated with brain alterations in white and gray matter. However, the neural mechanisms of RAD-related brain alterations remain unknown. Herein, we evaluated the white matter pathways and gray matter volumes in 31 and 41 age-matched children with RAD and typical development (TD), respectively, by analyzing T1- and diffusion-weighted images. An increased fractional anisotropy (FA) and axial diffusivity in the anterior thalamic radiations (ATR) and an increased volume in the bilateral pallidum and right thalamus were observed in children with RAD compared with those with TD. Moreover, the volume of the thalamus was associated with increased ATR FA in children with RAD. Our study confirmed the existence of atypical neurodevelopment processes in the thalamus, pallidum, and ATR in children with RAD and highlighted an interdependent relationship between the alterations in the thalamus and ATR. These findings may help to improve our understanding of the comprehensive neural mechanisms of RAD.

Mothers' Physiological and Affective Responding to Infant Distress: Unique Antecedents of Avoidant and Resistant Attachments.

In a sample of 127 mother-infant dyads, this study examined the predictive significance of mothers' physiological and observed emotional responding within distressing and nondistressing caregiving contexts at 6 months for infant attachment assessed with Fraley and Spieker's (2003) dimensional approach and the categorical approach at 12 months. Findings revealed that a lesser degree of maternal respiratory sinus arrhythmia withdrawal and higher levels of maternal neutral (vs. positive) affect within distressing (vs. nondistressing) caregiving contexts were distinctive antecedents of avoidance versus resistance assessed dimensionally (but not categorically), independent of maternal sensitivity. Discussion focuses on the usefulness of examining mothers' physiological and affective responding, considering the caregiving context, and employing the dimensional approach to attachment in identifying unique antecedents of patterns of attachment insecurity.

Inhibited symptoms of Reactive Attachment Disorder: links with working models of significant others and the self.

To better understand Reactive Attachment Disorder (RAD), the current study tested whether emotionally and behaviorally disordered children with versus without RAD differ with regard to the quality of their interpersonal behavior during interactions with teachers and with regard to their representations of self and others. Therefore, 77 children were screened for RAD symptoms and 22 likely cases of inhibited RAD were identified. To measure quality of the interactions with teachers, we observed children's trust and positive affect in dyadic interactions with teachers. For the representations of others, we measured self-reported trust in parents and teachers. For the representations of the self, two self-esteem assessments were individually administered. Results showed that, compared to children with other emotional and behavior disorders, RAD children's behavior reflected less trust in their teachers. At the level of representations, children reported less trust in teacher care. Instead, no links were found with self-report measures focusing on representations of parents and of self. These findings will be discussed in light of the ongoing discussion about whether or not attachment disorder and insecure attachment are associated concepts.

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.

Attachment Disorder behavior in early and middle childhood: associations with children's self-concept and observed signs of negative internal working models.

Most research on attachment in childhood is based on observation. In contrast, research on reactive attachment disorder (RAD) is mainly based on caregiver reports. Moreover, little is known about self-concept or internal working models (IWMs) of self and others in children with RAD. The present study examined whether caregiver reports and the frequency of observed signs of RAD reveal differences between children at risk for developing RAD symptoms and healthy controls in middle childhood. In addition, children's self-concept, observable signs of negative IWMs, and mental health were assessed. Results revealed that the RAD risk group showed increased reported and observed signs of RAD, a more negative self-concept, and more signs of negative IWMs compared to healthy controls. Signs of RAD in middle childhood were expressed trans-relational to both caregivers and strangers. Moreover, RAD symptoms were associated with negative self-concept, observed signs of negative IWMs, and poor mental health.

Inhibited symptoms of Attachment Disorder in children from institutional and foster care samples.

The main objective of the article was to study the prevalence of symptoms of the inhibited attachment disorder depending on type and quality of the caregiving environment. Analyses were based on data of a sample of institutionalized children from Georgia (N = 16), and two samples of foster children from Georgia (N = 27) and Germany (N = 55). Inhibited attachment disorder symptoms were assessed by the Disturbances of Attachment Interview (DAI) and the Rating of Inhibited Attachment Behavior (RInAB). Further assessments included behavior problems in children, quality of caregiving behavior in foster parents/caregivers, and presence of preferred caregiver in the institution. Regarding inhibited attachment behavior, expected differences between institutional (high scores) and foster samples (low scores) found for both measures (RInAB and DAI), and convergent validity between these measures was found in the institutional sample, but not in the foster samples. There were also indications of construct validity (regarding preferred caregiver in institution and caregiver supportive presence). The findings also suggest methodological issues brought about by skewed distributions of positive and negative measures in high-risk and low-risk samples, respectively.

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.

Development and validation of an observational measure of symptoms of Reactive Attachment Disorder.

Reactive Attachment Disorder (RAD) is presumed to be a consequence of social neglect and deprivation of the kind particularly associated with institutional care. Despite its clinical relevance there is a lack of assessment tools for RAD based on the direct observation of child-caregiver interaction. Here we describe the development and validation of such a tool for use with preschool children, the Rating of Inhibited Attachment Disordered Behavior (RInAB). The RInAB is composed of 17 ratings grouped in three subscales assessing (1) Attachment, (2) Exploratory, and (3) Socioemotional behavior. Participants were 134 institutionalized preschool children (M = 54.84 months; SD = 10.83; 60% boys) and their caregivers. Adequate reliability was found for RInAB subscales and total score. Confirmatory factor analyses documented the three aforementioned RInAB subscales. Correlational analyses documented: (i) construct validity via positive and significant associations with caregiver sensitivity and quality of child-caregiver relationship; (ii) convergence validity via association evidence with some emotionally/withdrawn inhibited items of the Disturbed Attachment Interview (DAI), as well as, with Child Behavior Checklist (CBCL)'s somatic complaints and withdraw syndrome scales; and (iii) discriminant validity via nonsignificant or negative associations with DAI-indiscriminate subscale, Rating of Infant and Stranger Engagement (RISE) and CBCL-externalizing problems. Discussion highlights the contributions complementary roles of RInAB for a comprehensive assessment of child RAD-related functioning.

Reactive Attachment Disorder in maltreated young children in foster care.

Reactive attachment disorder (RAD) is one of the least researched and most poorly understood psychiatric disorders. Very little is known about the prevalence and stability of RAD symptoms over time. Until recently it has been difficult to investigate RAD due to limited tools for informing a diagnosis. Utilising a newly developed observational tool along with the Disturbances of Attachment Interview. this short-term prospective longitudinal study explored RAD symptoms in maltreated young children in Scotland (n=100, age range =12-62 months) over 12 months. Children were recruited as part of The Best Services Trial (BeST?), in which all infants who came in to the care of the local authority in Glasgow due to child protection concerns were invited to participate. Prevalence of RAD was found to be 5.0% (n=5, 95% CI [0.7-9.3]) when children were first placed in to foster care. Following at least 1 year of improved care conditions, prevalence in the 76 children remaining in the study was 2.1% (n=2, 95% CI [below 0-4.7]). RAD was associated with some mental health and cognitive difficulties. While levels of carer-reported RAD symptoms decreased significantly over time, observed symptoms did not. Findings suggest that RAD resolved in a small majority of cases but further exploration in larger samples would be invaluable.

[Symptoms of Attachment Disorder, Behavioral Regulation and Physiological Stress in Institutionalized Children]. / Bindungsstörungssymptome, Verhaltensregulation und physiologische Belastung bei Heimkindern.

Symptoms of Attachment Disorder, Behavioral Regulation and Physiological Stress in Institutionalized Children The aim of the study was to investigate the influence of attachment status (availability of a specific caregiver) and caregiving quality on behavioral and physiological adaptation and attachment disorder in institutionalized children. In a sample of children from a Georgian children's home, attachment disorder symptoms were assessed by interview and attachment and exploration behavior as well as self-regulatory behavior were assessed by observation in the natural group setting as well in structured dyadic situations. The child circadian cortisol level was determined to assess physiological adaption. Quality of caregiving was assessed in terms of sensitivity by observation. While attachment status affected the occurrence of attachment disorder symptoms and physiological stress, patterns of regulation in terms of attachment-exploration-balance and self-regulatory behavior were predicted by caregiver sensitivity.

Attachment-Related Regulatory Processes Moderate the Impact of Adverse Childhood Experiences on Stress Reaction in Borderline Personality Disorder.

In this study, the authors explored whether attachment insecurity moderates the effects of adverse childhood experiences on stress reactivity in the context of borderline personality disorder (BPD). Participants were 113 women (39 with BPD, 15 with some BPD criteria present, 59 without any BPD symptoms) who participated in the Trier Social Stress Test. Saliva samples were collected before and after the stressor and assayed for salivary alpha-amylase (sAA) and cortisol. Adverse childhood experiences were measured using the Childhood Trauma Questionnaire, and attachment by the Experiences in Close Relationships-Revised questionnaire. Results revealed that attachment avoidance and a combination of more adverse childhood experiences and attachment insecurity resulted in higher sAA levels and differences in reactivity to the stressor. Interactions between attachment anxiety and adverse childhood experiences were related to blunted cortisol reactivity. The results suggest that the influence of adverse childhood experiences on stress regulation in BPD may be moderated by attachment-related regulatory processes.

Toward an architecture of attachment disorganization: John Bowlby's published and unpublished reflections.

This article examines the construct of disorganized attachment originally proposed by Main and Solomon, developing some new conjectures based on inspiration from a largely unknown source: John Bowlby's unpublished texts, housed at the Wellcome Trust Library Archive in London (with permission from the Bowlby family). We explore Bowlby's discussions of disorganized attachment, which he understood from the perspective of ethological theories of conflict behavior. Bowlby's reflections regarding differences among the behaviors used to code disorganized attachment will be used to explore distinctions that may underlie the structure of the current coding system. The article closes with an emphasis on the importance Bowlby placed on Popper's distinction between the context of discovery and the context of justification in developmental science.

Autism and attachment difficulties: Overlap of symptoms, implications and innovative solutions.

This article explores overlap of symptoms between autism and attachment difficulties and suggests innovative solutions based on formulation. Currently, clinicians express difficulties in differentiating between these conditions contributing to misdiagnosis. Research into the prevalence of attachment difficulties among children with autism often fails to reflect detailed knowledge of attachment theory. Consequently, studies in this area employ questionable modifications to attachment measures and methods of analysis. The findings of such studies are confusing and inconsistent. Children with autism and their parents are, however, known to be at high risk of developing insecure attachment patterns. Clinical assessments based on formulation may be helpful in these cases, as they include consideration of developmental and relational factors contributing to symptom presentation. Research suggests that where parents of children with autism establish secure relationships with their children outcomes are improved. Consequently, interventions, which improve dyadic synchrony and sensitivity of parents, are likely to benefit families living with autism and attachment difficulties.

Brain activity and infant attachment history in young men during loss and reward processing.

There is now ample evidence that the quality of early attachment experiences shapes expectations for supportive and responsive care and ultimately serves to scaffold adaptation to the salient tasks of development. Nonetheless, few studies have identified neural mechanisms that might give rise to these associations. Using a moderately large sample of low-income male participants recruited during infancy (N = 171), we studied the predictive significance of attachment insecurity and disorganization at age 18 months (as measured in the Strange Situation Procedure) for patterns of neural activation to reward and loss at age 20 years (assessed during a reward-based task as part of a functional magnetic resonance imaging scan). Results indicated that individuals with a history of insecure attachment showed hyperactivity in (a) reward- and emotion-related (e.g., basal ganglia and amygdala) structures and (b) emotion regulation and self-referential processing (cortical midline structures) in response to positive and negative outcomes (and anticipation of those outcomes). Further, the neural activation of individuals with a history of disorganized attachment suggested that they had greater emotional reactivity in anticipation of reward and employed greater cognitive control when negative outcomes were encountered. Overall, results suggest that the quality of early attachments has lasting impacts on brain function and reward processing.

Signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years: Effects of institutional care history and high-quality foster care.

Two disorders of attachment have been consistently identified in some young children following severe deprivation in early life: reactive attachment disorder and disinhibited social engagement disorder. However, less is known about whether signs of these disorders persist into adolescence. We examined signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years in 111 children who were abandoned at or shortly after birth and subsequently randomized to care as usual or to high-quality foster care, as well as in 50 comparison children who were never institutionalized. Consistent with expectations, those who experienced institutional care in early life had more signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years than children never institutionalized. In addition, using a conservative intent-to-treat approach, those children randomized to foster care had significantly fewer signs of reactive attachment disorder and disinhibited social engagement disorder than those randomized to care as usual. Analyses within the ever institutionalized group revealed no effects of the age of placement into foster care, but number of caregiving disruptions experienced and the percentage of the child's life spent in institutional care were significant predictors of signs of attachment disorders assessed in early adolescence. These findings indicate that adverse caregiving environments in early life have enduring effects on signs of attachment disorders, and provide further evidence that high-quality caregiving interventions are associated with reductions in both reactive attachment disorder and disinhibited social engagement disorder.

Infant disorganized attachment: Clarifying levels of analysis.

Lack of clarity regarding the infant disorganized attachment classification has caused confusion in the clinical, forensic, and research contexts in which it is used. This article offers distinctions to clarify the concept with the goal of increasing understanding and identifying potential misapplications. In particular, attention is drawn to the fact that there are many indices used to code "disorganized attachment," and that so far they have been validated as a set rather than individually; and it is noted that the construct validation of disorganization in naturalistic settings is partially finished. Clinicians and social workers should be cautious in their interpretations of such behavior.

[Stress-induced hyperalgesia (SIH) as a consequence of emotional deprivation and psychosocial traumatization in childhood : Implications for the treatment of chronic pain]. / Stressinduzierte Hyperalgesie (SIH) als Folge von emotionaler Deprivation und psychischer Traumatisierung in der Kindheit : Konsequenzen für die Schmerztherapie.

It is now widely recognized that in many chronic pain syndromes the intensity and severity of individually perceived pain does not correlate consistently with the degree of peripheral nervous system tissue damage or with the intensity of primary afferent or spinal nociceptive neurone activity. In particular, stress and anxiety exert modulatory influences on pain depending on the nature, duration and intensity of the stressor and developmental influences on the maturation of the stress as well as the pain system. In some chronic pain syndromes, e. g. fibromyalgia, TMD or somatoform disorders, no nociceptive or neuropathic input is detectable. We summarise the studies investigating the neural substrates and neurobiological mechanisms of stress-induced hyperalgesia (SIH) in animals and humans. The review provides new perspectives and challenges for the current and future treatment of chronic pain.

Impaired neural reward processing in children and adolescents with reactive attachment disorder: A pilot study.

Reactive attachment disorder (RAD) is characterized by markedly disturbed and developmentally inappropriate social relatedness due to parental maltreatment. RAD patients often display a high number of comorbid attention deficit/hyperactivity disorder (ADHD) symptoms, and certain RAD symptoms are difficult to discriminate from ADHD. One of the core characteristics of ADHD is a decrease in neural reward processing due to dopamine dysfunction. The aim of the present study was to determine whether the brain activity involved in reward processing in RAD patients is impaired in comparison with ADHD patients and typically developed controls. Five RAD patients, 17 typically developed (TD) controls and 17 ADHD patients aged 10-16 years performed tasks with high and low monetary reward while undergoing functional magnetic resonance imaging. ADHD patients were tested before and after 3 months treatment with osmotic release oral system-methylphenidate. Before treatment, ADHD patients showed that striatal and thalamus activities only in the tasks with low monetary reward were lower than TD controls. RAD patients showed decrease in activity of the caudate, putamen and thalamus during both the high and low monetary reward conditions in comparison with all the other groups. In RAD patients, the activity of the putamen was associated with the severity of posttraumatic stress and overt dissociation. Reward sensitivity was markedly decreased in children and adolescents with RAD, as evidenced by a diminished neural response during reward perception. This suggests that dopaminergic dysfunction exists in these patients, and may inform future dopaminergic treatment strategies for RAD.