Background
Though noted in the clinical literature for more than 50 years, attachment disorders have been studied systematically only recently. In part because of the ubiquity of attachments in ...humans, determining when aberrant behavior is best explained as an attachment disorder as opposed to insecure attachment has led to some confusion. In this selective review, we consider the literature on reactive attachment disorder and disinhibited social engagement disorder and describe an emerging consensus about a number of issues, while also noting some areas of controversy and others where we lack clear answers. We include a brief history of the classification of the disorders, as well as measurement issues. We describe their clinical presentation, causes and vulnerability factors, and clinical correlates, including the relation of disorders to secure and insecure attachment classifications. We also review what little is known and what more we need to learn about interventions.
Methods
We conducted a literature search using PubMed, PsycINFO, and Cochrane Library databases, using search terms ‘reactive attachment disorder,’ ‘attachment disorder,’ ‘indiscriminate behavior,’ ‘indiscriminate friendliness,’ ‘indiscriminate socially disinhibited reactive attachment disorder,’ ‘disinhibited social engagement disorder,’ and ‘disinhibited social behavior.’ We also contacted investigators who have published on these topics.
Findings
A growing literature has assessed behaviors in children who have experienced various types of adverse caregiving environments reflecting signs of putative attachment disorders, though fewer studies have investigated categorically defined attachment disorders. The evidence for two separate disorders is considerable, with reactive attachment disorder indicating children who lack attachments despite the developmental capacity to form them, and disinhibited social engagement disorder indicating children who lack developmentally appropriate reticence with unfamiliar adults and who violate socially sanctioned boundaries.
Conclusions
Although many questions remain to be answered, especially regarding appropriate interventions, we know considerably more about attachment disorders than we did only a decade ago.
Read the Commentary on this article at doi: 10.1111/jcpp.12373
AbstractObjectiveTo evaluate the safety and effectiveness of a composite device design (covered stent graft and bare metal stent) for the treatment of patients with acute, complicated type B aortic ...dissection (TBAD) presenting with aortic rupture and/or branch vessel malperfusion. MethodsIn this prospective, nonrandomized, multicenter study, 73 patients (65.8% male; mean age, 60.7 years) with acute, complicated TBAD were enrolled between August 2012 and January 2015 to receive treatment with the Zenith Dissection Endovascular System (William Cook Europe, Aps, Bjaeverskov, Denmark) at institutions in the United States and Japan. The primary safety end point was the rate of freedom from major adverse events at 30 days, and the primary effectiveness end point was the rate of survival at 30 days. This article reports primary outcomes at 30 days and follow-up results through 1 year, reflecting study data as of March 2018. ResultsOf 73 patients, 20 presented with aortic rupture (27%) and 57 presented with branch vessel obstruction/compromise (78%), including 4 patients presenting with both conditions. The covered stent graft was used in all patients (median, 1; range, 1-3; 1 stent graft used in 64.4%; 47/73), and the bare metal dissection stent was used in 58 of 73 patients (79.5%). Thirty-day mortality occurred in five patients (6.8%): one procedure related, three unrelated to dissection repair, and one indeterminate. Thirty-day major adverse events included myocardial infarction (1.4%), bowel ischemia (1.4%), renal insufficiency/renal failure requiring dialysis (6.8%), stroke (6.8%), paraplegia or paraparesis (5.5%), and prolonged ventilatory support (13.7%). Nine deaths occurred from 31 to 365 days (only one death related to dissection repair); the Kaplan-Meier estimate of freedom from all-cause mortality was 80.3% ± 4.7% at 1 year. Within 365 days, 9 of 73 patients (12.3%) underwent 10 secondary interventions; no patients required conversion to open surgery. At the 12-month follow-up, complete or partial thrombosis of the false lumen was seen in 100% of patients (46/46) within the stent graft region and in 97.4% of patients (38/39) within the dissection stent region. Growth (>5 mm) of the maximum transaortic diameter was observed in 14.9% of patients (7/47) in the stent graft region and in 38.5% of patients (15/39) within the dissection stent region at 12 months. ConclusionsThirty-day and 1-year results from the STABLE II study demonstrated favorable clinical and anatomical outcomes for the treatment of rupture and malperfusion in the setting of acute, complicated TBAD. Five-year follow-up is ongoing.
This study examined the validity of criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited reactive attachment disorder (RAD).
As part of a longitudinal intervention ...trial of previously institutionalized children, caregiver interviews and direct observational measurements provided continuous and categorical data used to examine the internal consistency, criterion validity, construct validity, convergent and discriminant validity, association with functional impairment, and stability of these disorders over time.
As in other studies, the findings showed distinctions between the two types of RAD. Evidence-derived criteria for both types of RAD showed acceptable internal consistency and criterion validity. In this study, rates of indiscriminately social/disinhibited RAD at baseline and at 30, 42, and 54 months were 41/129 (31.8%), 22/122 (17.9%), 22/122 (18.0%), and 22/125 (17.6%), respectively. Signs of indiscriminately social/disinhibited RAD showed little association with caregiving quality. Nearly half of children with indiscriminately social/disinhibited RAD had organized attachment classifications. Signs of indiscriminately social/disinhibited RAD were associated with signs of activity/impulsivity and of attention-deficit/hyperactivity disorder and modestly with inhibitory control but were distinct from the diagnosis of attention-deficit/hyperactivity disorder. At baseline, 30, 42, and 54 months, 6/130 (4.6%), 4/123 (3.3%), 2/125 (1.6%), and 5/122 (4.1%) of children met criteria for emotionally withdrawn/inhibited RAD. Emotionally withdrawn/inhibited RAD was moderately associated with caregiving at the first three time points and strongly associated with attachment security. Signs of this type of RAD were associated with depressive symptoms, although two of the five children with this type of RAD at 54 months did not meet criteria for major depressive disorder. Signs of both types of RAD contributed independently to functional impairment and were stable over time.
Evidence-derived criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited RAD define two statistically and clinically cohesive syndromes that are distinct from each other, shows stability over 2 years, have predictable associations with risk factors and attachment, can be distinguished from other psychiatric disorders, and cause functional impairment.
This quick-reference guide is designed for those who work with young children in child care and school settings. Topics cover social-emotional development, biting, napping difficulties, PTSD, gender ...development, self-stimulation behaviors, and more. In addition to behavioral issues commonly seen in small children, the editors touch on epigenetics, medications, toxic stress, ACEs (adverse childhood experiences), and how to help children who have undergone traumatic experiences.
Children exposed to early institutional rearing are at risk for developing psychopathology. The present investigation examines caregiving quality and the role of attachment security as they relate to ...symptoms of psychopathology in young children exposed to early institutionalization.
Participants were enrolled in the Bucharest Early Intervention Project (BEIP), a longitudinal intervention study of children abandoned and placed in institutions at or shortly after birth. Measures included observed caregiving when children were 30 months of age, observed attachment security at 42 months, and caregiver reports of children's psychopathology at 54 months. At 54 months, some children remained in institutions, others were in foster care, others had been adopted domestically, and still others had been returned to their biological families. Thus, the children had experienced varying amounts of institutional rearing.
After controlling for gender, quality of caregiving when children were 30 months old was associated with symptoms of multiple domains of psychopathology at 54 months of age. Ratings of security of attachment at 42 months mediated the associations between quality caregiving at 30 months and fewer symptoms of psychopathology at 54 months.
Among deprived young children, high-quality caregiving at 30 months predicted reduced psychopathology and functional impairment at 54 months. Security of attachment mediated this relationship. Interventions for young children who have experienced deprivation may benefit from explicitly targeting caregiver-child attachment relationships.
Early social deprivation can negatively affect domains of functioning. We examined psychopathology at age 12 years in a cohort of Romanian children who had been abandoned at birth and placed into ...institutional care, then assigned either to be placed in foster care or to care as usual.
We used follow-up data from the Bucharest Early Intervention Project (BEIP), a randomised controlled trial of abandoned children in all six institutions for young children in Bucharest, Romania. In the initial trial, 136 children, enrolled between ages 6-31 months, were randomly assigned to either care as usual or placement in foster care. In this study we followed up these children at age 12 years to assess psychiatric symptoms using the Diagnostic Interview Schedule for Children (4th edition; DISC-IV). We also recruited Romanian children who had never been placed in an institution from paediatric clinics and schools in Bucharest as a comparator group who had never been placed in an institution. The primary outcome measure was symptom counts assessed through DISC-IV scores for three domains of psychopathology: internalising symptoms, externalising symptoms, and attention-deficit hyperactivity disorder (ADHD). We compared mean DISC-IV scores between trial participants and comparators who had never been placed in an institution, and those assigned to care as usual or foster care. Analyses were done by modified intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00747396.
We followed up 110 children from the BEIP trial between Jan 27, 2011, and April 11, 2014, and 49 children as comparators who had never been placed in an institution. The 110 children who had ever been placed in an institution had higher symptom counts for internalising disorders (mean 0·93 SD 1·68 vs 0·45 0·84, difference 0·48 95% CI 0·14-0·82; p=0·0127), externalising disorders (2·31 2·86 vs 0·65 1·33, difference 1·66 1·06-2·25; p<0·0001), and ADHD (4·00 5·01 vs 0·71 1·85, difference 3·29 95% CI 2·39-4·18; p<0·0001) than did children who had never been placed in an institution. Compared with 55 children randomly assigned to receive care as usual, the 55 children in the foster-care group had fewer externalising symptoms (mean 2·89 SD 3·00 for care as usual vs 1·73 2·61 for foster care, difference 1·16 95% CI 0·11 to 2·22; p=0·0255), but symptom counts for internalising disorders (mean 1·00 1·59 for care as usual vs 0·85 1·78 for foster care, difference 0·15 -0·35 to 0·65; p=0·5681) and ADHD (mean 3·76 4·61 for care as usual vs 4·24 5·41 for foster care, difference -0·47 -2·15 to 1·20; p=0·5790) did not differ. In further analyses, symptom scores substantially differed by stability of foster-care placement.
Early foster care slightly reduced the risk of psychopathology in children who had been living in institutions, but long-term stability of foster-care placements is an important predictor of psychopathology in early adolescence.
National Institute of Mental Health and the John D and Catherine T MacArthur Foundation.
The field of psychopathology in young children has made substantial strides in the past 3 decades, moving from discussions of whether disorders can be reliably diagnosed to sophisticated analyses of ...specific symptoms. In this issue, Hennefield et al.
explore the presentation of suicidal ideations (SIs) in children younger than 7 years. The validity of criteria for major depression in this age group is well established, but suicidality is a newer focus of research that, like the disorder itself, requires careful study to identify developmental similarities with and differences from the presentation in older children and adults.
Prior reports have suggested that young children with psychiatric disorders talk about suicide at rates of 4% to 13% and that these early SIs predict school-age SI.
Publications about suicidality in children younger than 7 have predictably elicited discussions about the challenges in interpreting the statements and behaviors in a developmentally specific manner.
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