Attachment disorders and relational trauma — formative SAQs

SAQ 1 — Naming the disorder and choosing relationship-based care (10 marks)

A 4-year-old placed in foster care six weeks ago, after chronic neglect, will not seek comfort from his carer when hurt, pushes her away when she offers it, yet wanders off happily with strangers in the clinic. The carer asks whether an SSRI would help him "settle and attach." [1] [2]

Questions

1. Using the behavioural pattern and the caregiving history, classify this child's presentation. Which disorder best fits, and which coexisting disorder must you actively consider? (3 marks) [2]
2. Outline the first-line management plan, naming an evidence-based intervention and its active ingredient. (4 marks) [7] [13]
3. Address the carer's request for an SSRI, and state two treatments or approaches that must not be used. (3 marks) [13]

Model answer

Classification (3). The emotionally withdrawn and inhibited pattern — minimal comfort-seeking and minimal response to comfort, with persistent social and emotional disturbance, after chronic neglect — meets reactive attachment disorder; the indiscriminate wandering-off with strangers means disinhibited social engagement disorder must also be actively considered, since the two disorders can coexist and are not a spectrum. The shared gateway is grossly pathogenic care, which the history provides. [1] [2]

First-line management (4). Safety and a stable, committed placement come first; the active ingredient of recovery is a reliable, responsive carer. The evidence-based relationship interventions are delivered to the carer-child dyad — Attachment and Biobehavioral Catch-up (ABC), which Dozier showed normalises cortisol and improves attachment behaviours in foster infants, and Child-Parent Psychotherapy for trauma-exposed young children. The plan supports the carer as the intervention, not the child alone. [7] [9] [13]

SSRI and contraindicated approaches (3). An SSRI has no first-line role for the attachment disorder itself and should not be started to "treat" it; medication is reserved for diagnosed comorbid depression or anxiety on its own merits. Coercive "holding therapy" and any unregulated attachment techniques are harmful and must not be used, and the diagnosis must not be made on a single observation or by blaming the current carer. [13]

SAQ 2 — Evidence, recovery and safeguarding disposition (10 marks)

A 3-year-old adopted from an institution overseas shows indiscriminate friendliness, developmental delay, and emerging dysregulation. The adoptive parents ask what the long-term outlook is and whether "a few counselling sessions" will fix it. [3] [4]

Questions

1. Cite the evidence that placement into family care after institutional deprivation changes the trajectory, and explain what mediates recovery. (3 marks) [4]
2. Set a realistic prognosis for the indiscriminate behaviours and outline the monitoring plan. (3 marks) [3] [14]
3. Describe the closed-loop disposition, naming the safeguards against an open-loop CAMHS referral. (4 marks) [13]

Model answer

Evidence and mechanism (3). The Bucharest Early Intervention Project randomised institutionally-reared children to foster care versus continued institutional care and showed that placement reduces signs of reactive attachment disorder; McGoron showed that attachment mediates the effect of caregiving on psychopathology after early deprivation. The mechanism of recovery is the relationship — a stable, attuned carer re-organises attachment and stress regulation. [4]

Prognosis and monitoring (3). Recovery is expected when care becomes reliable, but indiscriminate behaviours of DSED tend to be more persistent than the withdrawn behaviours of RAD, so the parents should not be promised a quick fix. Monitor emerging comfort-seeking and response to comfort, reduced indiscriminate behaviour, better regulation, and developmental and school gains over months rather than weeks. [3] [14]

Closed-loop disposition (4). Name the clinician who owns the plan and the follow-up date; document an interim carer strategy with return precautions (behavioural re-emergence, new disclosures, placement breakdown, abuse recurrence); coordinate child protection, school, and the general practitioner; deliver a phased relationship-based intervention via local CAMHS or early-intervention pathways; and provide interim carer coaching, safety planning, and school liaison through any waitlist rather than an open-loop referral that leaves the child exposed. [13] [14]