Friday, 14 January 2005 - 10:00 AM

This presentation is part of: Early Intervention in Children

“Success Stories:” Identifying “What Works” in Treating Reactive Attachment Disorder

James Drisko, PhD, Smith College School for Social Work.

Purpose: This study examined responses from adoptive parents, treating clinicians and child welfare workers to determine what intervention components lead to marked progress in children with Reactive Attachment Disorder [RAD]. Work with these children bridges mental health practice, child welfare, and schools: key areas of social work practice that need a stronger evidence base. O’Connor and Zeanah (2003) report that “there is no empirically supported effective treatment for RAD.” There are no Cochrane (or similar) systematic reviews on RAD and very limited empirical study on this disorder beyond single case studies so further exploratory/formative work is indicated.

Methods: Ten families of children with RAD who had been judged by clinical social workers or child welfare workers to have made considerable and enduring progress were nominated for in-depth study. The children ranged from 7 to 22 at interview; with family 6 to 11 years. Initially all the children had difficulty trusting, emotional constriction, peer relationship issues and 7 had PTSD symptoms. Families consented to 2 semi-structured interviews to identify what factors led to this progress. Further, their clinicians and child welfare workers were each separately interviewed (as possible), providing triangulation and additional perspectives (Professionals N=15). Probes explored specific strategies leading to progress and identified strengths. Responses were analyzed using Glaser and Strauss’ constant comparative method; organized using ATLAS.ti software. Strong inter-coder reliability was established, peer reviews helped identify omissions and biases, member checks insured the analysis reflected participants’ views in a valid manner.

Results: Gains shown by these children included deepened familial relationships, better control of moods and behavior, improved ability to articulate feelings, better peer relationships, academic progress and decreased PTSD symptoms. Ten core categories were developed. Parents attributed these gains to several factors which center on areas of special strength evident in these families. Parents made a strong initial commitment and “bond.” Parents persisted in the face of many challenges to develop true attachments over several years. These parents all kept a positive outlook. In terms of daily life, parents were always available, physically, visually or aurally. Parents provided a highly structured living environment: “Like a residential treatment center.” Parents also employed behavioral management techniques of many kinds and were able to quickly appraise their effectiveness and appropriate use. Psychologically, parents showed remarkable ability to be intersubjectively attuned to their child – despite confusing cues and behavior. Parents maintained a balanced appraisal of their child, finding strengths while noting limitations. Parents were able to both seek out and to effectively use social supports (family and informal and formal supports). They encouraged their children to be involved in peer activities even when problems emerged and they had to serve as “coaches” and “consultants to group leaders.” Progress was notable, but did not completely overcome the effects of profound early challenges.

Implications: Even allowing for retrospective recall bias, this study extends the available knowledge base regarding interventions for RAD. Findings affirm and add to the available case study literature. Findings also outline a tentative treatment package for future prospective study.

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