Rachel Pritchett

Neurodevelopmental problems in maltreated children referred with indiscriminate friendliness

We aimed to explore the extent of neurodevelopmental difficulties in severely maltreated adopted children. We recruited 34 adopted children, referred with symptoms of indiscriminate friendliness and a history of severe maltreatment in their early childhood and 32 typically developing comparison children without such a history, living in biological families. All 66 children, aged 5-12 years, underwent a detailed neuropsychiatric assessment. The overwhelming majority of the adopted/indiscriminately friendly group had a range of psychiatric diagnoses, including Attention Deficit Hyperactivity Disorder (ADHD), Post-Traumatic Stress Disorder (PTSD) and Reactive Attachment Disorder (RAD) and one third exhibited the disorganised pattern of attachment. The mean IQ was 15 points lower than the comparison group and the majority of the adopted group had suspected language disorder and/or delay. Our findings show that school-aged adopted children with a history of severe maltreatment can have very complex and sometimes disabling neuropsychiatric problems.

Prevalence of reactive attachment disorder in a deprived population

BACKGROUND Reactive attachment disorder (RAD) is associated with early childhood maltreatment and has unknown population prevalence beyond infancy. AIMS To estimate RAD prevalence in a deprived population of children. METHOD All 1646 children aged 6-8 years old in a deprived sector of an urban UK centre were screened for RAD symptoms. Parents of high and low scorers were interviewed using semi-structured interviews probing for psychopathology and individuals likely to have RAD were offered face-to-face assessment. RESULTS Questionnaire data were available from 92.8% of teachers and 65.8% of parents. Assessments were conducted with 50% of those invited and missing data were imputed--based on the baseline data--for the rest. We calculated that there would be 23 children with definite RAD diagnoses, suggesting that the prevalence of RAD in this population was 1.40% (95% CI 0.94-2.10). CONCLUSIONS In this deprived general population, RAD was not rare.

Quick, simple measures of family relationships for use in clinical practice and research. A systematic review

BACKGROUND Family functioning has been implicated in the onset of child and adult psychopathology. Various measures exist for assessing constructs in the areas of parent-child relationships, parental practices and discipline, parental beliefs, marital quality, global family functioning and situation-specific measures. OBJECTIVES To identify systematically all questionnaire measures of family functioning appropriate for use in primary care and research. METHODS A systematic literature review was conducted, following PRISMA guidelines and searching 14 bibliographic databases using pre-determined filters, to identify family functioning measures suitable for use in families with children from 0 to 3 years old. RESULTS One hundred and seven measures of family functioning were reported and tabulated and the most commonly used measures were identified. CONCLUSIONS There are numerous measures available demonstrating characteristics, which make them suitable for continued use. Future research is needed to examine the more holistic measurement of family functioning using integration of multi-informant data.

Reactive Attachment Disorder in the General Population: A Hidden ESSENCE Disorder

Reactive attachment disorder (RAD) is a severe disorder of social functioning. Previous research has shown that children with RAD may have poor cognitive and language abilities; however, findings mainly come from biased, institutionalised samples. This paper describes the characteristics of all children who were given a suspected or likely diagnosis of reactive attachment disorder in an epidemiological study of approximately 1,600 children investigating the prevalence of RAD in the general population. We found that children with RAD are more likely to have multiple comorbidities with other disorders, lower IQs than population norms, more disorganised attachment, more problem behaviours, and poorer social skills than would be found in the general population and therefore have a complex presentation than can be described as ESSENCE. We discuss the clinical and educational implications.

A Feasibility Randomised Controlled Trial of the New Orleans Intervention for Infant Mental Health: A Study Protocol

Child maltreatment is associated with life-long social, physical, and mental health problems. Intervening early to provide maltreated children with safe, nurturing care can improve outcomes. The need for prompt decisions about permanent placement (i.e., regarding adoption or return home) is internationally recognised. However, a recent Glasgow audit showed that many maltreated children “revolve” between birth families and foster carers. This paper describes the protocol of the first exploratory randomised controlled trial of a mental health intervention aimed at improving placement permanency decisions for maltreated children. This trial compares an infants mental health intervention with the new enhanced service as usual for maltreated children entering care in Glasgow. As both are new services, the trial is being conducted from a position of equipoise. The outcome assessment covers various fields of a childs neurodevelopment to identify problems in any ESSENCE domain. The feasibility, reliability, and developmental appropriateness of all outcome measures are examined. Additionally, the potential for linkage with routinely collected data on health and social care and, in the future, education is explored. The results will inform a definitive randomised controlled trial that could potentially lead to long lasting benefits for the Scottish population and which may be applicable to other areas of the world. This trial is registered with ClinicalTrials.gov (NC01485510).

Risk factors for vulnerable youth in urban townships in South Africa: The potential contribution of reactive attachment disorder

Reactive attachment disorder (RAD) is a psychiatric disorder developing in early or middle childhood as a consequence of significant failures in the caregiving environment. RAD results in children failing to relate socially, either by exhibiting markedly inhibited behaviour or by indiscriminate social behaviour and is associated with significant socio-behavioural problems in the longer term. This study examined RAD in South Africa, a setting with high environmental risks. We recruited a sub-sample of 40 10-year-old children from a cohort enrolled during pregnancy for whom early attachment status was known. Children were purposefully selected to represent the four attachment categories using the data available on the strange situation procedure (SSP) at 18 months. The Manchester Child Attachment Story Task (MCAST) assessed current attachment and RAD was diagnosed using a standardised assessment package. A high proportion of the children (5/40% or 12.5%) fulfilled diagnostic criteria for RAD; all were boys and were displaying the disinhibited type. SSP classification at 18 months was not significantly associated with RAD symptoms at age of 10 years, while current MCAST classifications were. This suggests that children in this sample are at much higher risk of RAD than in high-income populations, and despite a fairly typical attachment distribution in this population at 18 months, RAD was evidenced in later childhood and associated with current attachment disorganisation. The strengths of this research include its longitudinal nature and use of diagnostic assessments. Given increasing evidence that RAD is relatively stable over time and introduces longer term socio-behavioural risks; the high rate of RAD in this sample (12.5%) highlights potential developmental threats to children in low- and middle-income countries (LMICs). Our results should be interpreted with caution given sample size and risk of selection bias. Further research is needed to confirm these findings.

Challenges of Assessing Maltreated Children Coming into Foster Care

Children who have experienced early adversity have been known to be at risk of developing cognitive, attachment, and mental health problems; therefore, it is crucial that children entering foster care can be properly assessed as early as possible. There are known difficulties in assessing children in foster care, for example, in finding a reliable informant. An ongoing randomised controlled trial in Glasgow, Scotland, recruiting infants entering foster care, provides a unique opportunity to explore some of the issues which need to be considered when assessing these children. The assessment data of 70 infants entering care is described while exploring the reliability of foster carers as informants and the importance of infant engagement with tasks. This group of infants was shown to be having more problems than children from the general population. While correlations were found between a carers level of concern about a child and the severity of a childs problem, there were still a number of children displaying worrying problem scores whom foster carers did not report concern. The childs engagement in the cognitive task showed associations with the childs attainment on the task. Findings emphasise the importance of a holistic assessment for these children and all should be considered as potential cases with Maltreatment-Associated Psychiatric Problems (MAPP).

Can behaviour during immunisation be used to identify attachment patterns? A feasibility study

BACKGROUND Infant attachment is a strong predictor of mental health, and current measures involve placing children into a stressful situation in order to observe how the child uses their primary caregiver to assuage their distress. OBJECTIVES This study aimed to explore observational correlates of attachment patterns during immunisation. PARTICIPANTS AND SETTING 18 parent-child pairs were included in the study. They were all recruited through a single general medical practice. METHODS Infant immunisation videos were observed and coded for parenting behaviours as well as pain promoting and pain reducing strategies. Results were compared between different attachment groups, as measured with the Manchester Child Attachment Story Task. RESULTS Parents of securely attached children scored higher on positive Mellow Parenting Observational System behaviours, but not at a statistically significant level. Parents of securely attached children were also significantly more likely to engage in pain reducing behaviours (p<0.01) than parents of insecurely attached children. CONCLUSIONS Robust composite measures for attachment informative behaviours in the immunisation situation should be developed and tested in a fully powered study.

Mental health of infants in foster care

It is now well established that children in foster care are at increased risks of experiencing mental health problems, for example, Ford et al 1 described findings from 1453 looked after and accommodated children in a sample of over 10 000 children aged 5–15 years and found that 46.4% of the accommodated children received a diagnosis compared with 8.5% of the general population. Our team2 conducted a systematic review examining the way child characteristics affected child outcomes from care and found that, of the studies which found an effect of age on outcome, three-quarters found more positive outcomes, in terms of finding a permanent placement, for children who entered care at …

Invisible children: attempting to engage the most vulnerable families

Cullen et al [1][1] describe childhood antecedents of schizophrenia: such prospective studies are rare. Retrospective research suggests that as the number of adverse childhood experiences increases, so does the risk for health problems, including alcohol misuse, ischaemic heart disease, suicide