Reactive attachment disorder

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Reactive attachment disorder
Specialty Psychiatry, pediatrics

Reactive attachment disorder (RAD) is described in clinical literature as a severe disorder that can affect children, although these issues do occasionally persist into adulthood. [1] [2] [3] RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited form". In the DSM-5, the "disinhibited form" is considered a separate diagnosis named "disinhibited attachment disorder".

Contents

RAD arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent changes of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts. It is differentiated from pervasive developmental disorder or developmental delay and from possibly comorbid conditions such as intellectual disability, all of which can affect attachment behavior. The criteria for a diagnosis of a reactive attachment disorder are very different from the criteria used in assessment or categorization of attachment styles such as insecure or disorganized attachment.

Children with RAD are presumed to have grossly disturbed internal working models of relationships that may lead to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years. [4] [5] However, the opening of orphanages in Eastern Europe following the end of the Cold War in the early 1990s provided opportunities for research on infants and toddlers brought up in very deprived conditions. Such research broadened the understanding of the prevalence, causes, mechanism and assessment of disorders of attachment and led to efforts from the late 1990s onwards to develop treatment and prevention programs and better methods of assessment. Mainstream theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined beyond current classifications. [6]

Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. [7] Most such strategies are in the process of being evaluated. Mainstream practitioners and theorists have presented significant criticism of the diagnosis and treatment of alleged reactive attachment disorder or the theoretically baseless "attachment disorder" within the controversial form of psychotherapy commonly known as attachment therapy. Attachment therapy has a scientifically unsupported theoretical base and uses diagnostic criteria or symptom lists markedly different from criteria under ICD-10 or DSM-IV-TR, or to attachment behaviors. A range of treatment approaches are used in attachment therapy, some of which are physically and psychologically coercive, and considered to be antithetical to attachment theory. [8]

Signs and symptoms

Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the disorder. The initial presentation varies according to the child's developmental and chronological age, although it always involves a disturbance in social interaction. Infants up to about 18–24 months may present with non-organic failure to thrive and display abnormal responsiveness to stimuli. Laboratory investigations will be unremarkable barring possible findings consistent with malnutrition or dehydration, while serum growth hormone levels will be normal or elevated. [9]

The core feature is severely inappropriate social relating by affected children. This can manifest itself in two ways:

  1. Indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers (older children and adolescents may also aim attempts at peers). This may often appear as denial of comfort from anyone as well.
  2. Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed. [10]

While RAD occurs in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect. However, the instances of that ability are rare. [11]

The name of the disorder emphasizes problems with attachment but the criteria include symptoms such as failure to thrive, a lack of developmentally appropriate social responsiveness, apathy, and onset before 8 months. [12]

Assessment tools

There is as yet no universally accepted diagnostic protocol for reactive attachment disorder. Often a range of measures is used in research and diagnosis. Recognized assessment methods of attachment styles, difficulties or disorders include the Strange Situation Procedure (devised by developmental psychologist Mary Ainsworth), [13] [14] [15] the separation and reunion procedure and the Preschool Assessment of Attachment, [16] the Observational Record of the Caregiving Environment, [17] the Attachment Q-sort [18] and a variety of narrative techniques using stem stories, puppets or pictures. For older children, actual interviews such as the Child Attachment Interview and the Autobiographical Emotional Events Dialogue can be used. Caregivers may also be assessed using procedures such as the Working Model of the Child Interview. [19]

More recent research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah (1999). [20] The DAI is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely "having a discriminated, preferred adult", "seeking comfort when distressed", "responding to comfort when offered", "social and emotional reciprocity", "emotional regulation", "checking back after venturing away from the care giver", "reticence with unfamiliar adults", "willingness to go off with relative strangers", "self-endangering behavior", "excessive clinging", "vigilance/hypercompliance" and "role reversal". This method is designed to pick up not only RAD but also the proposed new alternative categories of disorders of attachment.

Causes

Although increasing numbers of childhood mental health problems are being attributed to genetic defects, [21] reactive attachment disorder is by definition based on a problematic history of care and social relationships. Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. [22] It has been suggested that types of temperament, or constitutional response to the environment, may make some individuals susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years. [23] In the absence of available and responsive caregivers it appears that most children are particularly vulnerable to developing attachment disorders. [24]

While similar abnormal parenting may produce the two distinct forms of the disorder, inhibited and disinhibited, studies show that abuse and neglect were far more prominent and severe in the cases of RAD, disinhibited type. The issue of temperament and its influence on the development of attachment disorders has yet to be resolved. RAD has never been reported in the absence of serious environmental adversity yet outcomes for children raised in the same environment are the same. [25]

In discussing the neurobiological basis for attachment and trauma symptoms in a seven-year twin study, it has been suggested that the roots of various forms of psychopathology, including RAD, borderline personality disorder (BPD), and post-traumatic stress disorder (PTSD), can be found in disturbances in affect regulation. The subsequent development of higher-order self-regulation is jeopardized and the formation of internal models is affected. Consequently, the "templates" in the mind that drive organized behavior in relationships may be impacted. The potential for "re-regulation" (modulation of emotional responses to within the normal range) in the presence of "corrective" experiences (normative caregiving) seems possible. [26]

Diagnosis

RAD is one of the least researched and most poorly understood disorders in the DSM. There is little systematic epidemiologic information on RAD, its course is not well established and it appears difficult to diagnose accurately. [10] There is a lack of clarity about the presentation of attachment disorders over the age of five years and difficulty in distinguishing between aspects of attachment disorders, disorganized attachment or the consequences of maltreatment. [5]

According to the American Academy of Child and Adolescent Psychiatry (AACAP), children who exhibit signs of reactive attachment disorder need a comprehensive psychiatric assessment and individualized treatment plan. The signs or symptoms of RAD may also be found in other psychiatric disorders and AACAP advises against giving a child this label or diagnosis without a comprehensive evaluation. [27] Their practice parameter states that the assessment of reactive attachment disorder requires evidence directly obtained from serial observations of the child interacting with his or her primary caregivers and history (as available) of the child's patterns of attachment behavior with these caregivers. It also requires observations of the child's behavior with unfamiliar adults and a comprehensive history of the child's early caregiving environment including, for example, pediatricians, teachers, or caseworkers. [4] In the US, initial evaluations may be conducted by psychologists, psychiatrists, Licensed Marriage and Family Therapists, Licensed Professional Counselors, specialist Licensed Clinical Social Workers or psychiatric nurses. [28]

In the UK, the British Association for Adoption and Fostering (BAAF) advise that only a psychiatrist can diagnose an attachment disorder and that any assessment must include a comprehensive evaluation of the child's individual and family history. [29]

According to the AACAP Practice Parameter (2005) the question of whether attachment disorders can reliably be diagnosed in older children and adults has not been resolved. Attachment behaviors used for the diagnosis of RAD change markedly with development and defining analogous behaviors in older children is difficult. There are no substantially validated measures of attachment in middle childhood or early adolescence. [4] Assessments of RAD past school age may not be possible at all as by this time children have developed along individual lines to such an extent that early attachment experiences are only one factor among many that determine emotion and behavior. [30]

Criteria

ICD-10 describes reactive attachment disorder of childhood, known as RAD, and disinhibited attachment disorder, less well known as DAD. DSM-IV-TR also describes reactive attachment disorder of infancy or early childhood divided into two subtypes, inhibited type and disinhibited type, both known as RAD. The two classifications are similar and both include:

ICD-10 states in relation to the inhibited form only that the syndrome probably occurs as a direct result of severe parental neglect, abuse, or serious mishandling. DSM states in relation to both forms there must be a history of "pathogenic care" defined as persistent disregard of the child's basic emotional or physical needs or repeated changes in primary caregiver that prevents the formation of a discriminatory or selective attachment that is presumed to account for the disorder. For this reason, part of the diagnosis is the child's history of care rather than observation of symptoms.

In DSM-IV-TR the inhibited form is described as persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and contradictory responses (e.g., the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting or may exhibit "frozen watchfulness", hypervigilance while keeping an impassive and still demeanour). [32] Such infants do not seek or accept comfort at times of threat, alarm or distress, thus failing to maintain "proximity", an essential element of attachment behavior. The disinhibited form shows diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures). [32] There is therefore a lack of "specificity" of attachment figure, the second basic element of attachment behavior.

The ICD-10 descriptions are comparable save that ICD-10 includes in its description several elements not included in DSM-IV-TR as follows:

The first of these is somewhat controversial, being a commission rather than omission and because abuse in and of itself does not lead to attachment disorder.

The inhibited form has a greater tendency to ameliorate with an appropriate caregiver, while the disinhibited form is more enduring. [33] ICD-10 states the disinhibited form "tends to persist despite marked changes in environmental circumstances". Disinhibited and inhibited are not opposites in terms of attachment disorder and can coexist in the same child. [34] The question of whether there are two subtypes has been raised. The World Health Organization acknowledges that there is uncertainty regarding the diagnostic criteria and the appropriate subdivision. [35] One reviewer has commented on the difficulty of clarifying the core characteristics of and differences between atypical attachment styles and ways of categorizing more severe disorders of attachment. [36]

As of 2010, the American Psychiatric Association has proposed to redefine RAD into two distinct disorders in the DSM-V. [37] Corresponding with the inhibited type, one disorder will be reclassified as Reactive Attachment Disorder of Infancy and Early Childhood. [31]

In regards to pathogenic care, or the type of care in which these behaviors are present, a new criterion for Disinhibited Social Engagement Disorder now includes chronically harsh punishment or other types of severely inept caregiving. Relating to pathogenic care for both proposed disorders, a new criterion is rearing in atypical environments such as institutions with high child/caregiver ratios that cut down on opportunities to form attachments with a caregiver. [37]

Differential diagnosis

The diagnostic complexities of RAD mean that careful diagnostic evaluation by a trained mental health expert with particular expertise in differential diagnosis is considered essential. [38] [39] [40] Several other disorders, such as conduct disorders, oppositional defiant disorder, anxiety disorders, post traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with RAD, leading to over and under diagnosis. RAD can also be confused with neuropsychiatric disorders such as autism, pervasive developmental disorder, childhood schizophrenia and some genetic syndromes. Infants with this disorder can be distinguished from those with organic illness by their rapid physical improvement after hospitalization. [9] Autistic children are likely to be of normal size and weight and often exhibit a degree of intellectual disability. They are unlikely to improve upon being removed from the home. [9] [38] [39] [40]

Alternative diagnosis

In the absence of a standardized diagnosis system, many popular, informal classification systems or checklists, outside the DSM and ICD, were created out of clinical and parental experience within the field known as attachment therapy. These lists are unvalidated and critics state they are inaccurate, too broadly defined or applied by unqualified persons. Many are found on the websites of attachment therapists. Common elements of these lists such as lying, lack of remorse or conscience and cruelty do not form part of the diagnostic criteria under either DSM-IV-TR or ICD-10. [41] Many children are being diagnosed with RAD because of behavioral problems that are outside the criteria. [38] There is an emphasis within attachment therapy on aggressive behavior as a symptom of what they describe as attachment disorder whereas mainstream theorists view these behaviors as comorbid, externalizing behaviors requiring appropriate assessment and treatment rather than attachment disorders. However, knowledge of attachment relationships can contribute to the cause, maintenance and treatment of externalizing disorders. [42]

The Randolph Attachment Disorder Questionnaire or RADQ is one of the better known of these checklists and is used by attachment therapists and others. [43] The checklist includes 93 discrete behaviours, many of which either overlap with other disorders, like conduct disorder and oppositional defiant disorder, or are not related to attachment difficulties. Critics assert that it is unvalidated [44] and lacks specificity. [45]

Treatment

Assessing the child's safety is an essential first step that determines whether future intervention can take place in the family unit or whether the child should be removed to a safe situation. Interventions may include psychosocial support services for the family unit (including financial or domestic aid, housing and social work support), psychotherapeutic interventions (including treating parents for mental illness, family therapy, individual therapy), education (including training in basic parenting skills and child development), and monitoring of the child's safety within the family environment [9]

In 2005 the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W. Boris and C.H. Zeanah) based on its published parameters for the diagnosis and treatment of RAD. [4] Recommendations in the guidelines include the following:

  1. "The most important intervention for young children diagnosed with reactive attachment disorder and who lack an attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an emotionally available attachment figure."
  2. "Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child, assessing the caregiver's attitudes toward and perceptions about the child is important for treatment selection."
  3. "Children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. After ensuring that the child is in a safe and stable placement, effective attachment treatment must focus on creating positive interactions with caregivers."
  4. "Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive (additional) treatments."

Mainstream prevention programs and treatment approaches for attachment difficulties or disorders for infants and younger children are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. [4] [46] [47] These approaches are mostly in the process of being evaluated. The programs invariably include a detailed assessment of the attachment status or caregiving responses of the adult caregiver as attachment is a two-way process involving attachment behavior and caregiver response. Some of these treatment or prevention programs are specifically aimed at foster carers rather than parents, as the attachment behaviors of infants or children with attachment difficulties often do not elicit appropriate caregiver responses. [48] Approaches include "Watch, wait and wonder," [49] manipulation of sensitive responsiveness, [50] [51] modified "Interaction Guidance", [52] "Clinician-Assisted Videofeedback Exposure Sessions (CAVES)", [53] "Preschool Parent Psychotherapy", [54] "Circle of Security", [55] [56] "Attachment and Biobehavioral Catch-up" (ABC), [57] the New Orleans Intervention, [58] [59] [60] and parent–child psychotherapy. [61] Other treatment methods include Developmental, Individual-difference, and Relationship-based therapy (DIR, also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders. [62]

The relevance of these approaches to intervention with fostered and adopted children with RAD or older children with significant histories of maltreatment is unclear. [63]

Attachment therapy

The terms attachment disorder, attachment problems, and attachment therapy, although increasingly used, have no clear, specific, or consensus definitions. However, the terms and therapies often are applied to children who are maltreated, particularly those in the foster care, kinship care, or adoption systems, and related populations such as children adopted internationally from orphanages. [64]

Outside the mainstream programs is a form of treatment generally known as attachment therapy, a subset of techniques (and accompanying novel diagnosis) for supposed attachment disorders including RAD. These "attachment disorders" use diagnostic criteria or symptom lists different from criteria under ICD-10 or DSM-IV-TR, or to attachment behaviors. Those with "attachment disorder" are said to lack empathy and remorse.

Treatments of this pseudoscientific disorder are called "Attachment therapy". In general, these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers. The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasize obedience and parental control. [65] There is considerable criticism of this form of treatment and diagnosis as it is largely unvalidated and has developed outside the scientific mainstream. [66] There is little or no evidence base and techniques vary from non-coercive therapeutic work to more extreme forms of physical, confrontational and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model. These forms of the therapy may well involve physical restraint, the deliberate provocation of rage and anger in the child by physical and verbal means including deep tissue massage, aversive tickling, enforced eye contact and verbal confrontation, and being pushed to revisit earlier trauma. [67] [68] Critics maintain that these therapies are not within the attachment paradigm, are potentially abusive, [69] and are antithetical to attachment theory. [8] The APSAC Taskforce Report of 2006 notes that many of these therapies concentrate on changing the child rather than the caregiver. [70] Children may be described as "RADs", "Radkids" or "Radishes" and dire predictions may be made as to their supposedly violent futures if they are not treated with attachment therapy. [65] The Mayo Clinic, a well known U.S. non-profit medical practice and medical research group, cautions against consulting with mental health providers who promote these types of methods and offer evidence to support their techniques; to date, this evidence base is not published within reputable medical or mental health journals. [71]

Prognosis

The AACAP guidelines state that children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. [4] However, the course of RAD is not well studied and there have been few efforts to examine symptom patterns over time. The few existing longitudinal studies (dealing with developmental change with age over a period of time) involve only children from poorly run Eastern European institutions. [4]

Findings from the studies of children from Eastern European orphanages indicate that persistence of the inhibited pattern of RAD is rare in children adopted out of institutions into normative care-giving environments. However, there is a close association between duration of deprivation and severity of attachment disorder behaviors. [72] The quality of attachments that these children form with subsequent care-givers may be compromised, but they probably no longer meet criteria for inhibited RAD. [73] The same group of studies suggests that a minority of adopted, institutionalized children exhibit persistent indiscriminate sociability even after more normative caregiving environments are provided. [26] Indiscriminate sociability may persist for years, even among children who subsequently exhibit preferred attachment to their new caregivers. Some exhibit hyperactivity and attention problems as well as difficulties in peer relationships. [74] In the only longitudinal study that has followed children with indiscriminate behavior into adolescence, these children were significantly more likely to exhibit poor peer relationships. [75]

Studies of children who were reared in institutions have suggested that they are inattentive and overactive, no matter what quality of care they received. In one investigation, some institution-reared boys were reported to be inattentive, overactive, and markedly unselective in their social relationships, while girls, foster-reared children, and some institution-reared children were not. It is not yet clear whether these behaviors should be considered as part of disordered attachment. [76]

There is one case study on maltreated twins published in 1999 with a follow-up in 2006. This study assessed the twins between the ages of 19 and 36 months, during which time they had multiple moves and placements. [77] The paper explores the similarities, differences and comorbidity of RAD, disorganized attachment and post traumatic stress disorder. The girl showed signs of the inhibited form of RAD while the boy showed signs of the indiscriminate form. It was noted that the diagnosis of RAD ameliorated with better care but symptoms of post traumatic stress disorder and signs of disorganized attachment came and went as the infants progressed through multiple placement changes. At age three, some lasting relationship disturbance was evident.

In the follow-up case study when the twins were aged three and eight years, the lack of longitudinal research on maltreated as opposed to institutionalized children was again highlighted. The girl's symptoms of disorganized attachment had developed into controlling behaviors—a well-documented outcome. The boy still exhibited self-endangering behaviors, not within RAD criteria but possibly within "secure base distortion", (where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment). At age eight the children were assessed with a variety of measures including those designed to access representational systems, or the child's "internal working models". The twins' symptoms were indicative of different trajectories. The girl showed externalizing symptoms (particularly deceit), contradictory reports of current functioning, chaotic personal narratives, struggles with friendships, and emotional disengagement with her caregiver, resulting in a clinical picture described as "quite concerning". The boy still evidenced self-endangering behaviors as well as avoidance in relationships and emotional expression, separation anxiety and impulsivity and attention difficulties. It was apparent that life stressors had impacted each child differently. The narrative measures used were considered helpful in tracking how early attachment disruption is associated with later expectations about relationships. [26]

One paper using questionnaires found that children aged three to six, diagnosed with RAD, scored lower on empathy but higher on self-monitoring (regulating your behavior to "look good"). These differences were especially pronounced based on ratings by parents, and suggested that children with RAD may systematically report their personality traits in overly positive ways. Their scores also indicated considerably more behavioral problems than scores of the control children. [78]

Epidemiology

Epidemiological data are limited, but reactive attachment disorder appears to be very uncommon. [1] The prevalence of RAD is unclear but it is probably quite rare, other than in populations of children being reared in the most extreme, deprived settings such as some orphanages. [24] There is little systematically gathered epidemiologic information on RAD. [38] A cohort study of 211 Copenhagen children to the age of 18 months found a prevalence of 0.9%. [79]

Attachment disorders tend to occur in a definable set of contexts such as within some types of institutions, in the presence of repeated changes of primary caregiver or of extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, but not all children raised in these conditions develop an attachment disorder. [80] Studies undertaken on children from Eastern European orphanages from the mid-1990s showed significantly higher levels of both forms of RAD and of insecure patterns of attachment in the institutionalized children, regardless of how long they had been there. [81] [82] [83] It would appear that children in institutions like these are unable to form selective attachments to their caregivers. The difference between the institutionalized children and the control group had lessened in the follow-up study three years later, although the institutionalized children continued to show significantly higher levels of indiscriminate friendliness. [81] [84] However, even among children raised in the most deprived institutional conditions the majority did not show symptoms of this disorder. [72]

A 2002 study of children in residential nurseries in Bucharest, in which the DAI was used, challenged the current DSM and ICD conceptualizations of disordered attachment and showed that inhibited and disinhibited disorders could coexist in the same child. [82]

There are two studies on the incidence of RAD relating to high risk and maltreated children in the U.S. Both used ICD, DSM and the DAI. The first, in 2004, reported that children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups, however this was mainly the proposed new classification of disrupted attachment disorder rather than the DSM or ICD classified RAD or DAD. [85] The second study, also in 2004, attempted to ascertain the prevalence of RAD and whether it could be reliably identified in maltreated rather than neglected toddlers. Of the 94 maltreated toddlers in foster care, 35% were identified as having ICD RAD and 22% as having ICD DAD, and 38% fulfilled the DSM criteria for RAD. [34] This study found that RAD could be reliably identified and also that the inhibited and disinhibited forms were not independent. However, there are some methodological concerns with this study. A number of the children identified as fulfilling the criteria for RAD did in fact have a preferred attachment figure. [86]

It has been suggested by some within the field of attachment therapy that RAD may be quite prevalent because severe child maltreatment, which is known to increase risk for RAD, is prevalent and because children who are severely abused may exhibit behaviors similar to RAD behaviors. [40] The APSAC Taskforce consider this inference to be flawed and questionable. [40] Severely abused children may exhibit similar behaviors to RAD behaviors but there are several far more common and demonstrably treatable diagnoses which may better account for these difficulties. [87] Further, many children experience severe maltreatment and do not develop clinical disorders. [87] Resilience is a common and normal human characteristic. [88] RAD does not underlie all or even most of the behavioral and emotional problems seen in foster children, adoptive children, or children who are maltreated and rates of child abuse and/or neglect or problem behaviors are not a benchmark for estimates of RAD. [40]

There are few data on comorbid conditions, but there are some conditions that arise in the same circumstances in which RAD arises, such as institutionalization or maltreatment. These are principally developmental delays and language disorders associated with neglect. [4] Conduct disorders, oppositional defiant disorder, anxiety disorders, post-traumatic stress disorder and social phobia share many symptoms and are often comorbid with or confused with RAD. [40] [77] Attachment disorder behaviors amongst institutionalized children are correlated with attentional and conduct problems and cognitive levels but nonetheless appear to index a distinct set of symptoms and behaviors. [72]

History

Reactive attachment disorder first made its appearance in standard nosologies of psychological disorders in DSM-III, 1980, following an accumulation of evidence on institutionalized children. The criteria included a requirement of onset before the age of 8 months and was equated with failure to thrive. Both these features were dropped in DSM-III-R, 1987. Instead, onset was changed to being within the first 5 years of life and the disorder itself was divided into two subcategories, inhibited and disinhibited. These changes resulted from further research on maltreated and institutionalized children and remain in the current version, DSM-IV, 1994, and its 2000 text revision, DSM-IV-TR, as well as in ICD-10, 1992. Both nosologies focus on young children who are not merely at increased risk for subsequent disorders but are already exhibiting clinical disturbance. [89]

The broad theoretical framework for current versions of RAD is attachment theory, based on work conducted from the 1940s to the 1980s by John Bowlby, Mary Ainsworth and René Spitz. Attachment theory is a framework that employs psychological, ethological and evolutionary concepts to explain social behaviors typical of young children. Attachment theory focuses on the tendency of infants or children to seek proximity to a particular attachment figure (familiar caregiver), in situations of alarm or distress, behavior which appears to have survival value. [90] This is known as a discriminatory or selective attachment. Subsequently, the child begins to use the caregiver as a base of security from which to explore the environment, returning periodically to the familiar person. Attachment is not the same as love and/or affection although they are often associated. Attachment and attachment behaviors tend to develop between the ages of six months and three years. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time. [91] Caregiver responses lead to the development of patterns of attachment, that in turn lead to internal working models which will guide the individual's feelings, thoughts, and expectations in later relationships. [92] [93] For a diagnosis of reactive attachment disorder, the child's history and atypical social behavior must suggest the absence of formation of a discriminatory or selective attachment.

The pathological absence of a discriminatory or selective attachment needs to be differentiated from the existence of attachments with either typical or somewhat atypical behavior patterns, known as styles or patterns. There are four attachment styles ascertained and used within developmental attachment research. These are known as secure, anxious-ambivalent, anxious-avoidant, (all organized) [13] and disorganized. [14] [15] The latter three are characterised as insecure. These are assessed using the Strange Situation Procedure, designed to assess the quality of attachments rather than whether an attachment exists at all. [4]

A securely attached toddler will explore freely while the caregiver is present, engage with strangers, be visibly upset when the caregiver departs, and happy to see the caregiver return. The anxious-ambivalent toddler is anxious of exploration, extremely distressed when the caregiver departs but ambivalent when the caregiver returns. The anxious-avoidant toddler will not explore much, avoid or ignore the parent—showing little emotion when the parent departs or returns—and treat strangers much the same as caregivers with little emotional range shown. The disorganized/disoriented toddler shows a lack of a coherent style or pattern for coping. Evidence suggests this occurs when the caregiving figure is also an object of fear, thus putting the child in an irresolvable situation regarding approach and avoidance. On reunion with the caregiver, these children can look dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors implying fear of the person who is being sought. It is thought to represent a breakdown of an inchoate attachment strategy and it appears to affect the capacity to regulate emotions. [94]

Although there are a wide range of attachment difficulties within the styles which may result in emotional disturbance and increase the risk of later psychopathologies, particularly the disorganized style, none of the styles constitute a disorder in themselves and none equate to criteria for RAD as such. [95] A disorder in the clinical sense is a condition requiring treatment, as opposed to risk factors for subsequent disorders. [4] Reactive attachment disorder denotes a lack of typical attachment behaviors rather than an attachment style, however problematic that style may be, in that there is an unusual lack of discrimination between familiar and unfamiliar people in both forms of the disorder. Such discrimination does exist as a feature of the social behavior of children with atypical attachment styles. Both DSM-IV and ICD-10 depict the disorder in terms of socially aberrant behavior in general rather than focusing more specifically on attachment behaviors as such. DSM-IV emphasizes a failure to initiate or respond to social interactions across a range of relationships and ICD-10 similarly focuses on contradictory or ambivalent social responses that extend across social situations. [89] The relationship between patterns of attachment in the Strange Situation and RAD is not yet clear. [96]

There is a lack of consensus about the precise meaning of the term "attachment disorder". [97] The term is frequently used both as an alternative to reactive attachment disorder and in discussions about different proposed classifications for disorders of attachment beyond the limitations of the ICD and DSM classifications. [89] It is also used within the field of attachment therapy, as is the term reactive attachment disorder, to describe a range of problematic behaviors not within the ICD or DSM criteria or not related directly to attachment styles or difficulties at all. [98]

Research

Research from the late 1990s indicated there were disorders of attachment not captured by DSM or ICD and showed that RAD could be diagnosed reliably without evidence of pathogenic care, thus illustrating some of the conceptual difficulties with the rigid structure of the current definition of RAD. [99] Research published in 2004 showed that the disinhibited form can endure alongside structured attachment behavior (of any style) towards the child's permanent caregivers. [34]

Some authors have proposed a broader continuum of definitions of attachment disorders ranging from RAD through various attachment difficulties to the more problematic attachment styles. There is as yet no consensus, on this issue but a new set of practice parameters containing three categories of attachment disorder has been proposed by C.H. Zeanah and N. Boris. The first of these is disorder of attachment, in which a young child has no preferred adult caregiver. The proposed category of disordered attachment is parallel to RAD in its inhibited and disinhibited forms, as defined in DSM and ICD. The second category is secure base distortion, where the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, cling to the adult, be excessively compliant, or show role reversals in which they care for or punish the adult. The third type is disrupted attachment. Disrupted attachment is not covered under ICD-10 and DSM criteria, and results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed. [100] This form of categorisation may demonstrate more clinical accuracy overall than the current DSM-IV-TR classification, but further research is required. [6] [101] The practice parameters would also provide the framework for a diagnostic protocol. Most recently, Daniel Schechter and Erica Willheim have shown a relationship between some maternal violence-related posttraumatic stress disorder and secure base distortion (see above) which is characterized by child recklessness, separation anxiety, hypervigilance, and role-reversal. [102]

Some research indicates there may be a significant overlap between behaviors of the inhibited form of RAD or DAD and aspects of disorganized attachment where there is an identified attachment figure. [94]

An ongoing question is whether RAD should be thought of as a disorder of the child's personality or a distortion of the relationship between the child and a specific other person. It has been noted that as attachment disorders are by their very nature relational disorders, they do not fit comfortably into nosologies that characterize the disorder as centered on the person. [103] Work by C.H. Zeanah [34] indicates that atypical attachment-related behaviors may occur with one caregiver but not with another. This is similar to the situation reported for attachment styles, in which a particular parent's frightened expression has been considered as possibly responsible for disorganized/disoriented reunion behavior during the Strange Situation Procedure. [104]

The draft of the proposed DSM-V suggests dividing RAD into two disorders, Reactive Attachment Disorder for the current inhibited form of RAD, and Disinhibited Social Engagement Disorder for what is currently the disinhibited form of RAD, with some alterations in the proposed DSM definition. [105]

See also

Notes

  1. 1 2 DSM-IV-TR (2000) American Psychiatric Association p. 129.
  2. ↑ Schechter DS, Willheim E (July 2009). "Disturbances of attachment and parental psychopathology in early childhood". Child and Adolescent Psychiatric Clinics of North America. 18 (3): 665–86. doi:10.1016/j.chc.2009.03.001. PMC   2690512 . PMID   19486844.
  3. ↑ Marinus van IJzendoorn MH; Femmie Juffer (May 2005). "Behavior Problems and Mental Health Referrals of International Adoptees". The Journal of the American Medical Association. 293 (20): 2501–2515. doi:10.1001/jama.293.20.2501. PMID   15914751. S2CID   25576414.
  4. 1 2 3 4 5 6 7 8 9 10 Boris, Neil W.; Zeanah, Charles H.; Work Group on Quality Issues (November 2005). "Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood". Journal of the American Academy of Child and Adolescent Psychiatry. 44 (11): 1206–19. doi: 10.1097/01.chi.0000177056.41655.ce . PMID   16239871.
  5. 1 2 Prior & Glaser (2006), p. 228.
  6. 1 2 O'Connor TG, Zeanah CH (2003). "Attachment disorders: assessment strategies and treatment approaches". Attach Hum Dev. 5 (3): 223–44. doi:10.1080/14616730310001593974. PMID   12944216. S2CID   21547653.
  7. ↑ Prior & Glaser (2006), p. 231.
  8. 1 2 O'Connor TG, Nilsen WJ (2005). "Models versus Metaphors in Translating Attachment Theory to the Clinic and Community". In Berlin LJ, Ziv Y, Amaya-Jackson L and Greenberg MT (eds.). Enhancing Early Attachments: Theory, Research, Intervention, and Policy. pp. 313–26. The Guilford Press. Duke series in Child Development and Public Policy. ISBN   1-59385-470-6.
  9. 1 2 3 4 Sadock, BJ; Sadock VA (2004). Kaplan & Sadock's Concise Textbook of Clinical Psychiatry . Philadelphia: Lippincott Williams and Wilkins. pp.  570–72. ISBN   978-0-7817-5033-2.
  10. 1 2 Chaffin et al. (2006), p. 80. The APSAC Taskforce Report
  11. ↑ Rutter M (2002). "Nature, nurture, and development: from evangelism through science toward policy and practice". Child Dev. 73 (1): 1–21. doi:10.1111/1467-8624.00388. PMID   14717240.
  12. ↑ RICHTERS, MARGOT MOSER; VOLKMAR, FRED R. (1 March 1994). "Reactive Attachment Disorder of Infancy or Early Childhood". Journal of the American Academy of Child & Adolescent Psychiatry. 33 (3): 328–332. CiteSeerX   10.1.1.527.9988 . doi:10.1097/00004583-199403000-00005. PMID   7513324. S2CID   13058511.
  13. 1 2 Ainsworth MD, Blehar M, Waters E, Wall S (1979). Patterns of Attachment: A Psychological Study of the Strange Situation. Lawrence Erlbaum Associates. ISBN   0-89859-461-8
  14. 1 2 Main M, Solomon J (1986). "Discovery of an insecure disorganized/disoriented attachment pattern: procedures, findings and implications for the classification of behavior". In Brazelton TB and Yogman M (Eds.) Affective development in infancy, pp. 95–124. Norwood, NJ: Ablex ISBN   0-89391-345-6
  15. 1 2 Main M, Solomon J (1990). "Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation". In Greenberg M, Cicchetti D and Cummings E (Eds.) Attachment in the preschool years: Theory, research and intervention, pp. 121–60. Chicago: University of Chicago Press. ISBN   0-226-30630-5.
  16. ↑ Crittenden PM (1992). "Quality of attachment in the preschool years". Development and Psychopathology. 4 (2): 209–41. doi:10.1017/S0954579400000110. S2CID   143894461.
  17. ↑ National Institute of Child Health and Human Development, D (1996). "Characteristics of infant child care: Factors contributing to positive caregiving". Early Childhood Research Quarterly. 11 (3): 269–306(38). doi:10.1016/S0885-2006(96)90009-5.
  18. ↑ Waters E, Deane K (1985). "Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behavior in infancy and early childhood". In Bretherton I and Waters E (Eds.) Growing pains of attachment theory and research: Monographs of the Society for Research in Child Development 50, Serial No. 209 (1–2), pp. 41–65.
  19. ↑ Zeanah CH, Benoit D (1995). "Clinical applications of a parent perception interview in infant mental health". Child and Adolescent Psychiatric Clinics of North America. 43 (3): 539–554. doi:10.1016/S1056-4993(18)30418-8.
  20. ↑ Smyke A, Zeanah CH (1999). "Disturbances of Attachment Interview". Available on the Journal of the American Academy of Child and Adolescent Psychiatry website at www.jaacap.com via Article plus. Retrieved on 3 March 2008.
  21. ↑ Mercer (2006), pp. 104–05.
  22. ↑ Prior & Glaser (2006), p. 218.
  23. ↑ Marshall PJ, Fox NA (2005). "Relationship between behavioral reactivity at 4 months and attachment classification at 14 months in a selected sample". Infant Behavior and Development. 28 (4): 492–502. doi:10.1016/j.infbeh.2005.06.002.
  24. 1 2 Prior & Glaser (2006), p. 219.
  25. ↑ Zeanah CH, Fox NA (2004). "Temperament and attachment disorders". J Clin Child Adolesc Psychol. 33 (1): 32–41. doi:10.1207/S15374424JCCP3301_4. PMID   15028539. S2CID   9416146.
  26. 1 2 3 Heller SS, Boris NW, Fuselier SH, Page T, Koren-Karie N, Miron D (2006). "Reactive attachment disorder in maltreated twins follow-up: from 18 months to 8 years". Attach Hum Dev. 8 (1): 63–86. doi:10.1080/14616730600585177. PMID   16581624. S2CID   34947321.
  27. ↑ Reactive Attachment Disorder. Archived 3 February 2008 at the Wayback Machine American Academy of Child & Adolescent Psychiatry, Facts for Families, No. 85; Updated December 2002. Retrieved on 13 February 2008.
  28. ↑ For examples see Reactive Attachment Disorder Archived 28 December 2007 at the Wayback Machine , DCFS, State of Illinois and DBHS Practice Protocol: Disturbances and Disorders of Attachment (PDF), Arizona Department of Health Services, 2 October 2006. Retrieved on 23 February 2008.
  29. ↑ Attachment Disorders, their Assessment and Intervention/Treatment Archived 2 October 2008 at the Wayback Machine (PDF). British Association for Adoption and Fostering, Position Statement 4, 2006. Retrieved on 23 February 2008
  30. ↑ Mercer (2006), p. 116.
  31. 1 2 3 Diagnostic and Statistical Manual of Mental Disorders: Text Revision . American Psychiatric Association. 2000. pp.  943. ISBN   978-0-89042-025-6.
  32. 1 2 American Psychiatric Association (2000). "Diagnostic criteria for 313.89 Reactive attachment disorder of infancy or early childhood". Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision (DSM-IV-TR) ed.). United States: AMERICAN PSYCHIATRIC PRESS INC (DC). ISBN   978-0-89042-025-6.
  33. ↑ Prior & Glaser (2006), pp. 220–21.
  34. 1 2 3 4 Zeanah CH, Scheeringa M, Boris N, Heller S, Smyke A, Trapani J (August 2004). "Reactive Attachment Disorder in Maltreated Toddlers". Child Abuse & Neglect. 28 (8): 877–88. doi:10.1016/j.chiabu.2004.01.010. PMID   15350771.
  35. ↑ World Health Organisation (1992) International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). Geneva: World health Organization.
  36. ↑ Zilberstein K (2006). "Clarifying core characteristics of attachment disorders". American Journal of Orthopsychiatry . 76 (1): 55–64. doi:10.1037/0002-9432.76.1.55. PMID   16569127. S2CID   25416390.
  37. 1 2 Proposed Revision Reactive Attachment Disorder, American Psychiatric Association (2012). Retrieved from http://www.dsm5.org/ProposedRevisions/Pages/proposedrevision.aspx?rid=120
  38. 1 2 3 4 Hanson RF, Spratt EG (2000). "Reactive Attachment Disorder: what we know about the disorder and implications for treatment". Child Maltreat. 5 (2): 137–45. doi:10.1177/1077559500005002005. PMID   11232086. S2CID   21497329.
  39. 1 2 Wilson SL (2001). "Attachment disorders: review and current status". J Psychol. 135 (1): 37–51. doi:10.1080/00223980109603678. PMID   11235838. S2CID   7226465.
  40. 1 2 3 4 5 6 Chaffin et al. (2006), p. 81. The APSAC Taskforce Report
  41. ↑ Chaffin et al. (2006), pp. 82–83. The APSAC Taskforce Report
  42. ↑ Guttmann-Steinmetz S, Crowell JA (2006). "Attachment and externalizing disorders: a developmental psychopathology perspective". J Am Acad Child Adolesc Psychiatry. 45 (4): 440–51. doi:10.1097/01.chi.0000196422.42599.63. PMID   16601649.
  43. ↑ Randolph, Elizabeth Marie. (1996). Randolph Attachment Disorder Questionnaire. Institute for Attachment, Evergreen CO.
  44. ↑ Mercer J (2005). "Coercive restraint therapies: a dangerous alternative mental health intervention". MedGenMed. 7 (3): 6. PMC   1681667 . PMID   16369232.
  45. ↑ Cappelletty G, Brown M, Shumate S (2005). "Correlates of the Randolph Attachment Disorder Questionnaire (RADQ) in a Sample of Children in Foster Placement". Child and Adolescent Social Work Journal. 22 (1): 71–84. doi:10.1007/s10560-005-2556-2. S2CID   143743052. The findings showed that children in foster care have reported symptoms within the range typical of children not involved in foster care. The conclusion is that the RADQ has limited usefulness due to its lack of specificity with implications for treatment of children in foster care
  46. ↑ Prior & Glaser (2006), p. 231.
  47. ↑ Bakermans-Kranenburg M, van IJzendoorn M, Juffer F (2003). "Less Is More: Meta-Analyses of Sensitivity and Attachment Interventions in Early Childhood" (PDF). Psychological Bulletin. 129 (2): 195–215. doi:10.1037/0033-2909.129.2.195. PMID   12696839. S2CID   7504386 . Retrieved 2 February 2008.
  48. ↑ Stovall KC, Dozier M (2000). "The development of attachment in new relationships: single subject analyses for 10 foster infants". Dev. Psychopathol. 12 (2): 133–56. doi:10.1017/S0954579400002029. PMID   10847621. S2CID   746807.
  49. ↑ Cohen N, Muir E, Lojkasek M, Muir R, Parker C, Barwick M, Brown M (1999). "Watch, wait and wonder: testing the effectiveness of a new approach to mother-infant psychotherapy". Infant Mental Health Journal. 20 (4): 429–51. doi:10.1002/(SICI)1097-0355(199924)20:4<429::AID-IMHJ5>3.0.CO;2-Q.
  50. ↑ van den Boom D (1994). "The influence of temperament and mothering on attachment and exploration: an experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants". Child Development. 65 (5): 1457–77. doi:10.2307/1131277. JSTOR   1131277. PMID   7982362.
  51. ↑ van den Boom D (1995). "Do first-year intervention effects endure? Follow-up during toddlerhood of a sample of Dutch irritable infants". Child Dev. 66 (6): 1798–816. doi:10.2307/1131911. JSTOR   1131911. PMID   8556900.
  52. ↑ Benoit D, Madigan S, Lecce S, Shea B, Goldberg S (2002). "Atypical maternal behaviour toward feeding disordered infants before and after intervention". Infant Mental Health Journal. 22 (6): 611–26. doi:10.1002/imhj.1022.
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  54. ↑ Toth, S; Maughan A; Manly J; Spagnola M; Cicchetti D (2002). "The relative efficacy of two in altering maltreated preschool children's representational models: implications for attachment theory". Development and Psychopathology. 14 (4): 877–908. doi:10.1017/S095457940200411X. PMID   12549708. S2CID   30792141.
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Mental disorders diagnosed in childhood can be neurodevelopmental, emotional, or behavioral disorders. These disorders negatively impact the mental and social wellbeing of a child, and children with these disorders require support from their families and schools. Childhood mental disorders often persist into adulthood. These disorders are usually first diagnosed in infancy, childhood, or adolescence, as laid out in the DSM-5 and in the ICD-11.

<span class="mw-page-title-main">Daniel Schechter</span> American neuroscientist

Daniel S. Schechter is an American and Swiss psychiatrist known for his clinical work and research on intergenerational transmission or "communication" of violent trauma and related psychopathology involving parents and very young children. His published work in this area following the terrorist attacks on the World Trade Center in New York of September 11, 2001 led to a co-edited book entitled "September 11: Trauma and Human Bonds" (2003) and additional original articles with clinical psychologist Susan Coates that were translated into multiple languages and remain among the first accounts of 9/11 related loss and trauma described by mental health professionals who also experienced the attacks and their aftermath Schechter observed that separation anxiety among infants and young children who had either lost or feared loss of their caregivers triggered posttraumatic stress symptoms in the surviving caregivers. These observations validated his prior work on the adverse impact of family violence on the early parent-child relationship, formative social-emotional development and related attachment disturbances involving mutual dysregulation of emotion and arousal. This body of work on trauma and attachment has been cited by prominent authors in the attachment theory, psychological trauma, developmental psychobiology and neuroscience literatures

The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood-Revised is a developmentally based diagnostic manual that provides clinical criteria for categorizing mental health and developmental disorders in infants and toddlers. It is organized into a five-part axis system. The book has been translated into several languages, and its model is utilized for the assessment of children up to five years of age.

Separation anxiety disorder (SAD) is an anxiety disorder in which an individual experiences excessive anxiety regarding separation from home and/or from people to whom the individual has a strong emotional attachment. Separation anxiety is a natural part of the developmental process. It is most common in infants and little children, typically between the ages of six to seven months to three years, although it may pathologically manifest itself in older children, adolescents and adults. Unlike SAD, normal separation anxiety indicates healthy advancements in a child's cognitive maturation and should not be considered a developing behavioral problem.

Trauma focused cognitive behavioral therapy (TF-CBT) is an evidence-based psychotherapy or counselling that aims at addressing the needs of children and adolescents with post traumatic stress disorder (PTSD) and other difficulties related to traumatic life events. This treatment was developed and proposed by Drs. Anthony Mannarino, Judith Cohen, and Esther Deblinger in 2006. The goal of TF-CBT is to provide psychoeducation to both the child and non-offending caregivers, then help them identify, cope, and re-regulate maladaptive emotions, thoughts, and behaviors. Research has shown TF-CBT to be effective in treating childhood PTSD and with children who have experienced or witnessed traumatic events, including but not limited to physical or sexual victimization, child maltreatment, domestic violence, community violence, accidents, natural disasters, and war. More recently, TF-CBT has been applied to and found effective in treating complex posttraumatic stress disorder.

Disinhibited Social Engagement Disorder (DSED), or Disinhibited Attachment Disorder, is an attachment disorder in which a child has little to no fear of unfamiliar adults and may actively approach them. It can significantly impair young children's abilities to relate with adults and peers, according to the Diagnostic and Statistical Manual of Mental Disorders. As well as put them in dangerous and potentially unsafe conditions. Common examples of this include sitting on a person's lap of which they do not know or leaving with a stranger.

Adult Attachment Disorder (AAD) develops in adults as the result of an attachment disorder, or Reactive Attachment Disorder, that goes untreated in childhood. It begins with children who were not allowed proper relationships with parents or guardians early in their youth, or were abused by an adult in their developmental stages in life. According to attachment theory, causes and symptoms of the disorder are rooted in human relationships over the course of one's lifetime, and how these relationships developed and functioned. Symptoms typically focus around neglect, dysfunction, abuse, and trust issues in all forms of their relationships. These symptoms are similar to those of other attachment disorders, but focus more on relationships later in life rather than those in earlier years. To be considered to have AAD, you must demonstrate at least 2-3 of its symptoms. These symptoms include: impulsiveness, desire for control, lack of trust, lack of responsibility, and addiction. While the DSM-5 does not recognize it as an official disorder, Adult Attachment disorder is currently being studied by several groups and treatment is being developed. Some of these studies suggest splitting AAD into two groups, avoidance and anxious/ambivalent. More recent and advanced medical practice advocates for four categorisations;

The Crowell procedure is a tool used to assess the parent-child relationship. Crowell and Feldman created the assessment tool for use in a study. The tool, which includes seven activities for the parent-child dyad to complete, is used for both preventive and clinical purposes. Crowell and Feldman's 1988 piece introducing the Crowell Method has been cited in over 500 studies. The assessment procedure has also been proven to be a reliable measure in discriminating between clinical and non-clinical dyads. The procedure is also known as the Crowell Parent-Child Interaction Procedure and the Crowell Problem Solving Procedure Rating Scale.

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