ADHD and Attachment

1

• ADHD and Attachment
• Victoria Thompson
• April 6th, 2009

2
Overview

• Attachment
• Literature
• 2 Empirical Studies
• Developmental Model
• Reactive Attachment Disorder

3
Attachment

• Close emotional bond between two people that is
  enduring across space and time
• Proximity-seeking behavior by a dependent
  organism when he or she feels discomfort
• Internal Working Models
• Mental representations of the self, attachment
  figures, and relationships in general.
• Include expectations regarding behaviors and
  emotions
• Source Ladnier Massanari, 2000

4
Attachment Styles

• Secure
• Caregiver as a secure base
• Insecure
• 3 Types
• Ambivalent
• Child contacts caregiver for support while
  simultaneously rejecting her attempts to soothe
  him
• Avoidant
• Child rejects or avoids caregiver
• Disorganized/Disoriented
• Child lacks a consistent strategy for organizing
  his comfort seeking behaviors
• Source Ladnier Massanari, 2000

5
Converging Body of Literature

• Executive Functioning (EF)
• Early healthy attachment experiences necessary
  for the development of EF
• Insecurely attached children show EF deficits
• Children with ADHD typically show EF deficits
• Hypothalamic-Pituitary-Adrenal (HPA) Axis
• Insecure attachments associated with atypical
  reactivity of this system to stressors
• Secure attachment associated with typical
  reactivity
• Some children with ADHD show atypical reactivity
• Source Crittendon Kulbotten, 2007

6
Literature cont.

• Orbitofrontal Cortex
• Crucial to emotional regulation, decision-making
  and processing of rewards
• Anxious attachment inhibits development of the
  orbitofrontal cortex
• Anxious attachment may result in chronic
• Emotion lability
• Impulsivity
• Unpredictable and intense behavior
• Orbitofrontal cortex has been found to be
  functionally disturbed in people with ADHD
• Source Crittendon Kulbotten, 2007

7
Literature cont.

• Dopamine Receptor D4 (DRD4) Gene
• Link between infant attachment and DRD4 gene
• Same gene found to be linked to ADHD
• Disorganized attached children carry 7 repeat
  allele of the DRD4 gene
• Securely attached children do not carry this
  allele
• Not carrying this allele may act as a resilience
  factor in the optimal development of attachment
• Children with ADHD who have 7 repeat allele tend
  to be more impulsive then children with ADHD who
  do not have this allele
• Early attachment might mediate or moderate the
  DRD4-related genetic risk for ADHD
• Source Crittenden Kulbotten, 2007

8
Literature cont.

• Children that are insecurely attached and
  children with ADHD show EF deficits
• Insecure attachment and ADHD is associated with
  atypical reactivity of the HPA axis to stressors
• Children that have an anxious attachment style
  and children with ADHD show abnormalities of the
  orbitofrontal cortex
• Both insecure attachment and ADHD have been
  linked to the DRD4 gene
• These findings suggest a possible interaction
  between genetic vulnerability and early
  attachment experience, which is expressed in the
  form of symptoms that define ADHD
• Source Crittenden Kulbotten, 2007

9
Self-Regulation

• Attachment theory the early parent-child
  relationship serves as the foundation for the
  emergence of self-regulation skills
• Research has consistently shown that insecurely
  attached children are more vulnerable to deficits
  in self-regulation then securely attached
  children
• Insecure attachment is associated with deficits
  in self-regulation, as is ADHD
• Source Clark, Ungerer, Chahoud, Johnson,
  Stiefel, 2002

10
Social Functioning

• Insecurely attached children have trouble
  developing and maintaining healthy relationships
• Children with ADHD show difficulties in social
  functioning as well
• Source Clarke et al., 2002

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Secure Infant Attachment Histories

• Increased attention span
• High levels of positive affect
• High levels of persistence in problem-solving
  situations
• Flexibility
• Impulse control
• Task orientation
• Delay of gratification
• Children with ADHD experience difficulties in the
  above areas
• Source Clarke et al., 2002

12
Family Functioning

• Insecure attachment relationships are associated
  with parental involvement characterized by
• Minimal involvement
• Negativity
• Lack of responsivity to infant signals
• Intrusiveness
• In lab settings, mothers of children with ADHD
  show similar behavior (Danforth, Barkley,
  Stokes, 1991 for review).
• Source Clarke et al., 2002

13
Family Function cont.

• Families of children with ADHD experience
  difficulties in a number of areas that are
  considered risk factors for insecure attachment
• Poor psychological functioning
• Increased levels of depression and other
  psychiatric diagnoses in parents
• High rates of marital distress and separation
• Social isolation
• Source Clark et al., 2002

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Early Parent-Child Relations and ADHD

• Maternal intrusiveness assessed when infants were
  6 months old more powerfully predicted
  distractibility in early childhood and
  hyperactivity in middle childhood, than did
  biological or temperament factors (Carlson,
  Jacobvitz, Sroufe, 1995)
• Clinical case reviews suggest that children with
  ADHD have early parent-child relationships that
  are similar to those with insecure attachments

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Early Parent-Child Relations and ADHD cont.

• Haddad and Garralda (1992) described severely
  disrupted early attachment relationships in
  children presenting to clinics with ADHD, which
  were not accompanied by biological indicators
• Stiefel (1997) linked the emergence of symptoms
  in a clinical cohort of ADHD to a lack of
  sustained parental attention during the first
  years of the childs life

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Converging Body of Literature

• Suggests
• Attachment not peripheral to an understanding of
  ADHD
• Appears to be an association between attachment
  and ADHD
• Attachment theory offers a new perspective on
  ADHD, which might help us to better treat those
  with the disorder
• Source Clarke et al., 2002

17
Clarke, Ungerer, Chahoud, Johnson, Stiefel, 2002

• Participants
• 19 boys, 5 10 yrs old with ADHD
• 19 boys, 5 10 yrs old without ADHD
• Compared on 3 representational measures
• 2 Internal Working Models
• 1 Self

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Clarke et al., 2002

• Separation Anxiety Test
• Pictures of parent-child separation experiences
• Questions about characters feelings and actions
• How does the boy feel?
• What is the boy going to do?
• How does it all end?
• Scoring
• Vulnerability and need in severe separations
• Self-confidence about handling mild separations
• Degree of avoidance in discussing the separation
• Containment of negative emotions
• Childs general emotional experience of the
  parent-child relationship

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Clarke et al., 2002

• Family Drawings
• Draw a picture of family, identify all persons in
  the drawing and state relationship to each person
• Scored based on the presence or absence of 24
  specific drawing signs
• To assess the context and patterning of the
  drawing signs, 8 global rating scales were used
• Family Pride/Happiness
• Vulnerability
• Emotional Distance/Isolation
• Tension/Anger
• Role Reversal
• Bizarreness/Dissociation
• Global Pathology

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Self-Interview

• 20 Questions assessing self-concept
• Can you tell me something you like about
  yourself?
• Can you tell me 5 words that describe you?
• Scoring
• Richness of Descriptions
• Openness/Flexibility
• Coherency

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Results

• Overall, ADHD group obtained poorer scores on all
  three measures, indicating predominantly insecure
  attachments
• Separation Anxiety Test
• Less likely to express an appropriate level of
  concern, fear, or feelings of sadness about
  difficult separations
• Expressed extreme feelings and behaviors
• Less likely to express confidence and feelings of
  well being in the context of easier separations

22
Results cont.

• Coping strategies involving retribution,
  hostility, or hatred
• Situations spiraled into disasters beyond their
  and others control
• Predominantly negative descriptions of the
  parent-child relationship
• Family Drawings
• Differed markedly from control group
• Suggested lower levels of family pride and higher
  levels of vulnerability, tension, anger, role
  reversal in the mother-child relationship,
  bizarreness, dissociation, and overall pathology

23
Results cont.

• Relationship anxiety tended to predominate
• Themes of anger, confusion, and low self-esteem
• These themes were expressed in a variety of ways
• Distorted and/or frightening figures
• Unusual symbols
• Little color or detail
• Overall reckless quality

24
Results cont.

• Self-Interview
• In the ADHD group, their self-descriptions were
  less richly developed and coherent relative to
  controls, conveying a less developed sense of
  self
• Less open and flexible in their self-concept
• Often presented a negative self-concept
• Often appeared emotionally disconnected

25
Overall

• Results suggest that the nature of attachment
  insecurity in this ADHD group is one of
  heightened emotional expression characterized by
  strong, out of control affects
• Didnt display the open, flexible emotional
  expression that is considered to reflect a secure
  internal working model
• Responses suggest insecure attachment style
• In this context, the impulsivity, negative
  attention-seeking, recklessness, hyperactivity,
  and frequent oppositionality seen in ADHD
  children can be viewed as a strategy to gain
  attention from a less than optimally available
  caregiver

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Discussion

• Findings contrary to the results of Chahoud
  (2000), in which the same exact participants were
  used as in Clarke et al. (2002)
• Chahoud rated segments of child-directed play,
  mother-directed play, a teaching task, and
  clean-up activity on variables such as
  gratification, involvement, and sensitivity
• Results showed no differences between the ADHD
  group and controls
• 16 of the 19 children in the ADHD group were
  being treated with stimulant medications and 15
  had received some level of psychological
  intervention

27
Discussion

• Claim that the effects of these medical and
  behavioral interventions may have been to mask
  underlying relational problems, at least in terms
  of their manifestation in a lab-based interaction
• Traditional treatment approaches may temporarily
  or even permanently improve the behavioral
  manifestations of ADHD, but they do not attempt
  to impact on the childs internal working model
  or the parents view of the child
• So, parent-child relationship problems will still
  be evident

28
Discussion

• Discrepancy between their findings and those of
  of Chahoud (2000) challenge the claim that
  research showing reversal of problematic
  parent-child interactional patterns following
  treatment with stimulant medications indicates
  that the difficult interactions seen in
  unmedicated kids are mainly due to child factors

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Implications for Treatment

• If we can identify secure and insecure children
  with ADHD, we can tailor their treatment more to
  their needs
• If there is a secure relationship, parent
  training may be appropriate, as parents may be
  able to focus on the current interaction and
  apply behavior management skills objectively and
  consistently
• However, if the relationship is insecure,
  relationship issues may need to be addressed
  first before parents can be expected to focus on
  applying behavior management skills and making
  enduring changes

30
Limitations

• ADHD group all referrals
• No inclusion of non-ADHD psychiatric control
  group and/or a non-clinic sample with ADHD
• Small sample size prevented examination of the
  impact of comorbidity on attachment insecurity in
  children with ADHD or a comparison of findings
  for the different subtypes
• All boys
• Inclusion of children of hospital employees in
  control group

31
Unanswered Questions

• Not clear whether quality of caregiving
  contributes directly to the development of
  ADHD-related problems or if the childs behaviors
  lead to disturbances in interactions
• Role of child characteristics should not be
  overlooked
• Likely a transactional model in which attachment
  processes are conceptualized as a function of
  complex and ongoing interactions among parent,
  child, and environmental/experiential factors

32
Unanswered Questions cont.

• Longitudinal research is needed to disentangle
  the effects of these different factors on the
  development of attachment security and ADHD
• Provide info regarding risk and protective
  factors and suggest strategies for early
  interventions

33
Pinto, Turton, Hughes, White, Gillberg, 2006

• Is there an association between
  disorganized/disoriented attachment and later
  ADHD?
• Participants
• Cohort of 104 children
• 1 yrs old Attachment style assessed by using the
  Strange Situation
• 6 8 yrs old ADHD assessed

34
Pinto et al., 2006

• Assessment of ADHD
• ADHD Rating Scale-IV
• Mothers and teachers independently
• Observer-rated assessment of ADHD (developed by
  Pinto et al.)
• 30 min doll-play story completion task
• Child was required to listen to the story and
  then complete a series of story stems presented

35
Pinto et al., 2006

• 3 broad areas, each with different measures
• Hyperactivity fidgeting, getting up from chair
  and talkativeness
• Inattention lack of persistent active listening,
  distractibility, and needing prompting to
  continue with the story
• Impulsivity child interrupting the assessor to
  take over the narrative before story stem
  completion and interrupting with something
  unrelated before the question is finished
• Measures were rated on a 4-point Likert-type
  scale (0never, 1occasionally, 2 some of the
  time, and 3constantly)

36
Pinto et al., 2006

• Put the mother-rated, teacher-rated, and
  observer-rated assessments together to arrive at
  a categorical diagnoses for ADHD
• Probable case child was given a score of 20 or
  more on the parent-rated and teacher-rated
  assessment plus a score of 2 or more for the
  observed ratings
• Possible case the above criteria were not met
  but the child was given a score of 18 or more on
  either the parent- or teacher-rated assessment
  and a score of 10 or more on the same scale rated
  by the other (parent or teacher), plus a score of
  2 or more for the observed rating

37
Results

• 26 of infants were classified as disorganized
• 7.8 of children met probable ADHD case
  criteria
• 10.7 of children met possible ADHD case
  criteria
• 23.1 of mothers vs. 24.3 of teachers rated the
  child above cut-off score of 20
• Mother and teacher-rated ADHD scores were highly
  correlated

38
Results cont.

• No association between infant disorganized
  attachment and later childhood ADHD caseness
• Rate of probable ADHD caseness in the children
  was similar to that of the general population
  rate for ADHD
• Mean disorganized scores were 4.06 (SD1.43) in
  the probable case group, 3.68 (SD1.87) in the
  possible case group, and 3.58 (SD. 1.72) in the
  noncase group
• Significant correlation between disorganized
  scores and teacher rated ADHD symptoms (more
  strongly associated with inattention than
  hyperactivity)

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Discussion

• What are the attributes of disorganized infants
  that teachers (but not mothers) observe several
  years later as ADHD symptoms?
• Likely that both mothers and teachers would find
  hyperactivity hard to manage but that mothers may
  be less sensitive to inattention and perhaps are
  not troubled or become habituated to this aspect
  of ADHD
• Lent credence by the trend in their results for
  disorganized attachment to be more strongly
  associated with teacher-rated inattention than
  with hyperactivity

40
Limitations

• Small sample size
• Half of the cohort had experienced a major trauma
  (stillbirth), whereas the other half had not
• In depth clinical psychiatric examination
  specifically for ADHD and comorbid conditions was
  not included
• Therefore, the conclusions can only be tentative
•  

41
Clinical Implications

• Attachment issues should be addressed in children
  presenting with disruptive behavior disorder, at
  least in those presenting with symptoms of ADHD
  that do not amount to full-blown clinical ADHD
  caseness

42
Ladniers Massanaris (2000) Model

• Based on theory and clinical experience
• Noticed that many of their ADHD patients shared
  deficits in
• ability to regulate emotions and behavior
• ability to form healthy relationships with others
• Consistent with the classic symptoms of an
  attachment-disordered child

43
Ladnier Massanari, 2000

• Also noted that research has shown that a failure
  to form a secure attachment early in life, can
  result in cognitive, emotional, and behavioral
  changes
• Hyperactivity
• Impulsivity
• Impaired social functioning

44
Ladnier Massanari, 2000

• Sought to answer two questions
• 1. Is there a causal connection between
  attachment failure and ADHD?
• 2. Would it be possible to create a developmental
  model, based on attachment theory, that would
  provide a valid and credible explanation for the
  origin of ADHD and suggest a treatment plan that
  could offer a child more than temporary relief
  from symptoms?

45
Ladnier Massanari, 2000

• Underlying belief that attachment trauma in early
  childhood results in developmental deficits
  which, in the absence of remedial parenting, are
  likely to be manifested as the symptoms of ADHD
• The model can be most simply stated as the
  following
• Bonding breaks gt Attachment deficits gt Symptoms
  of ADHD
• Bonding break is an event or combination of
  events that causes physiological trauma and
  developmental arrest and interferes with a
  childs opportunity to form a secure attachment
  with a caregiver

46
Ladnier Massanari, 2000

• Begins with 3 major assumptions
• 1. A child diagnosed with ADHD has experienced a
  bonding break(s) before the age of 2
• 2. The bonding break(s) have interfered with the
  process of healthy attachment between child and
  caregiver and created developmental deficits in
  the child
• 3. The family system the child grew up in was not
  healthy enough to overcome those deficits

47
Ladnier Massanari, 2000

• Basic idea
• The failure to attach to an adult caregiver as a
  result of a bonding break(s) results in
  psychological and physiological trauma
• This trauma interferes with an infants
  neurological and hormonal maturation
• This interference results in developmental delays
  (attachment deficits)
• These delays are reflected in emotional and
  behavioral problems that are manifested in the
  symptoms of ADHD

48
Bonding Breaks

• 4 Types
• Prenatal Influences
• Inattentive Caregivers
• Situational Traumas
• Faulty Parenting
• Most experience a combination of bonding breaks,
  sequentially or simultaneously

49
Prenatal Influences

• In typical development, a healthy newborn arrives
  in the world programmed to attach to a suitable
  caregiver
• However, some newborns arrive in a state of
  distress and extreme hyperarousal. For example,
  premature babies babies that were exposed
  prenatally to chronic and acute levels of stress
  hormones or chemical compounds or toxins
• These newborns are not programmed to seek out a
  caregiver because their state of emotional alarm
  prevents them from responding to attaching cues
  in their caregiver

50
Inattentive Caregivers

• Occurs when a healthy infant is born to
  caregivers who fail to provide the minimum amount
  of warmth needed for attachment to occur
• Do not provide behaviors such as eye contact,
  soothing words and touch, breast-feeding,
  holding, rocking and smiling
• These behaviors are needed for attachment to
  occur
• Inattentive caregivers neglect their infants
  because they are self-centered and lack empathy
  for others or because they lack sufficient info
  or motivation to provide the nurturance their
  infant needs

51
Situational Traumas

• Includes a variety of conditions and events that
  occur outside the control of the primary
  caregiver
• For example, premature babies, separation for
  caregiver due to death, or illness on the part of
  the parent or child

52
Faulty Parenting

• Prevalent in home situations where the child
  experiences trauma that is very difficult, if not
  impossible, for him or her to overcome
• These situations are typically characterized by
  the following
• 1. Absence of a healthy relationship between two
  caring adults
• 2. A pattern of exposure to yelling, criticism,
  sarcasm, and violence
• 3. Parenting that lacks respect, discipline,
  structure and consistency

53
Attachment Deficits

• Bonding breaks result in attachment deficits
• characteristics that appear to be absent or
  underdeveloped in a child, as evidenced by
  emotions and behaviors that are developmentally
  inappropriate
• These deficits might correspond to specific
  regions of neural circuitry in a childs brain
  that have not developed normally because of early
  bonding breaks
• Attachment Deficits are divided into two groups
• Deficits in Self Regulation
• Deficits in Relating Skills

54
Deficits in Self Regulation

• Impulse Control
• Self-soothing
• Initiative
• Perseverance
• Patience
• Inhibition

55
Deficits in Self-Relating Skills

• Empathy
• Trust
• Affection
• Reciprocity
• Expression
• Respect

56
Cycle of Conflict Between Caregiver and Child

• Cycle perpetuates and worsens the symptoms of
  ADHD.
• Child experiences strong negative emotion (anger,
  fear, sadness)
• Since the child lacks the capacity for
  self-soothing, impulse-control and expression, he
  or she attempts to connect with the parent
  through intrusive, demanding, attention-seeking
  behaviors
• Parent begins to feel irritation and resentment
  and is unable to express empathy, affection or
  respect for the child

57
Cycle of Conflict Between Caregiver and Child

• Parent responds by criticizing, threatening or
  hitting child
• Child reacts by tuning the parent out and
  silently planning revenge or becomes defiant and
  coercive and raises the level of his acting-out
  behaviors
• Parent feels angry and scared and either gives up
  and withdraws or raises the level of conflict in
  an effort to defeat the child.
• Both child and parent are left frustrated and
  angry and determined to get even by winning the
  next fight

58
Treatment

• Treatment of choice should be family therapy
• Children are not likely to make significant
  changes in their thoughts and behaviors without
  simultaneous changes in their family systems
• Developed a model for family therapy based on
  corrective attachment theory, family systems
  theory, and cognitive and behavioral techniques

59
Engage the Primary Caregiver as Clients and
Cotherapists

• Parents Problems
• Medication-Seeking Parent
• Exhausted, Overwhelmed Parent
• Guilty Parent
• Cotherapists
• Collect biopsychosocial info about the parents
• Childs history
• Outline basic goals and objectives of treatment
• Listen to Parents Concerns

60
Formulate a Detailed Assessment of the Childs
Problems

• Behavior
• Feeling
• Thinking
• A child who does not form a secure attachment
  with a primary caregiver does not think the same
  thoughts as a healthy child
• Distorted thoughts and delusional belief are a
  consequence of bonding breaks and attachment
  deficits
•  

61
Formulate a Detailed Assessment of the Childs
Problems

• For example, a child that doesnt learn to trust
  will develop core beliefs such as
• Adults are unreliable, unresponsive and
  untrustworthy
• Being close to others is not pleasant
• I must control others in order to be safe

62
Formulate a Detailed Assessment of the Childs
Problems

• A child that doesnt receive the modulating
  responses he needs from a primary caregiver fails
  to learn self-regulation and may hold beliefs
  such as
• I am not able to control myself
• When I want something, I should not have to wait
  for

63
Formulate a Detailed Assessment of the Childs
Problems

• A child who lacks sufficient soothing interaction
  with a caregiver does not learn self-soothing and
  may be convinced that
• Feelings are dangerous and should be avoided
• Things that are not stimulating or pleasurable
  are a waste of time

64
Secure Family Environment and Remedial Parenting

• Eliminate hitting, yelling, criticism, and
  sarcasm from family interactions
• Create empathy, affection and respect
• Communication
• Create consist rules, roles, and routines
• Establish limits and boundaries
• Cooperation

65
Promote Interaction, Attunement, and Attachment
between Caregiver and Child

• Teach specific ways to use physical contact to
  promote affection and trust between child and
  caregiver
• Teach parent how to express empathy towards child
• Teach playful interactions between child and
  caregiver

66
Access Collateral Therapies to Increase
Self-Regulation and Relating Skills

• Group Therapy
• EEG Biofeedback
• Art and Play Therapy
• Organized Sports
• Medication
• Last resort
• Will only bring about temporary change, whereas
  other therapy, such as family therapy, will bring
  about more permanent change.

67
Access Collateral Therapies to Increase
Self-Regulation and Relating Skills

• Medications cont.
• Medications that maintain a state of lethargy or
  euphoria can hinder other types of therapy
• However, there are cases where they must be used
• Medication can improve symptoms, but cannot help
  in the reparation of the attachment deficits
  caused by bonding breaks between caregiver and
  child

68
Problems with Model

• Based on strictly clinical population
• No research
• Doesnt explain people with ADHD who came from
  healthy functioning families
• Doesnt explain people who have experienced
  bonding breaks and come from unhealthy
  functioning families, but have not developed ADHD
• Doesnt explain why some people can take
  medication only with no other form of
  intervention and lead healthy and fulfilling
  lives
• Applied to any group with psychological problems

69
Stiefel, 1997

• Emphasizes the detrimental role of early stress
  on the attachment relationship and that this
  could possibly lead to ADHD
• Points out that not every child who experiences
  early stressors will develop ADHD
• Claims that it is sequential patterns of
  interactional stress between the parent and child
  that hinders attachment and possibly leads to
  ADHD, rather then multiple one point in time
  stressors

70
Stiefel, 1997 cont.

• You can have multiple early life stressor, but if
  you have some intervening variable, such as
  psychosocial buffering and support, this can
  alleviate the stress and allow a healthy
  attachment relationship to develop and thus
  possible prevent the development of ADHD
• If there are no intervening variables, and the
  stress continues, this is going to hinder the
  attachment relationship and possibly lead to ADHD
  
• Therefore, if we can identify families who
  experience high levels of stress and then
  intervene, we can possible prevent ADHD from
  developing in some children

71
Reactive Attachment Disorder (RAD)

• Attachment disorder characterized by disturbed
  and developmentally inappropriate social
  relatedness that begins before 5 years of age
• Develops from a failure to form a healthy
  attachment with a primary caregiver as a result
  of severe early experiences of pathological care,
  such as extreme abuse and/or neglect
• It is uncommon
• Source American Psychiatric Association, 1994

72
Reactive Attachment Disorder cont.

• Two types
• Inhibited
• Failure to initiate and respond to most social
  interactions in a developmentally appropriate
  way, as manifest by excessively inhibited,
  hypervigilant, or highly ambivalent and
  contradictory responses
• Disinhibited
• Indiscriminate sociability with marked inability
  to exhibit appropriate selective attachment
  (e.g., excessive familiarity with relative
  strangers or a lack of selectivity in choice of
  attachment figures)
• Source American Psychiatric Association, 1994

73
Reactive Attachment Disorder

• DSM-IV points out that the Disinhibited type must
  be distinguished from the impulsive or
  hyperactive behavior seen in ADHD
• The disinhibited behavior in RAD is associated
  with attempting to form a social attachment after
  a very brief acquaintance
• RAD is typically comorbid with other disorders,
  such as ODD and ADHD
• Source American Psychiatric Association, 1994

74
Reactive Attachment Disorder

• RAD diagnostic study that also looked at
  comorbidity
• Participants 40 RAD children, 5 - 8 yrs old
• Assessed RAD symptoms with an18-item
• Assessed ADHD with ?
• Results
• 68 of the RAD cases met criteria for ADHD
• No children met criteria for ADHD but not RAD
• Source Reactive Attachment Study, n.d.

75
Questions