Psych CASC / OSCE · Child and adolescent psychiatry — attachment disorders
Explain RAD/DSED and refuse coercive therapy — CASC communication station
MRCPsych/FRANZCP-style communication station: explain DSED vs RAD, insufficient-care aetiology without blaming adoptive parents, AACAP caregiving plan, and explicit refusal of coercive attachment therapies.
On this page & tools
Target exams
Station brief
Format. Communication station, approximately 7–10 minutes active time after reading. You are the CAMHS psychiatry registrar. [1]
Candidate instructions. Engage non-blaming parents; explain working diagnosis of disinhibited social engagement features after early institutional deprivation (clarify RAD vs DSED in plain language); explain that residual stranger approach does not mean they are failing; outline caregiving-first and carer-coaching plan; refuse coercive holding therapy with a clear safety rationale; address medication expectations honestly; check understanding and agree next steps. [1][2]
Candidate scenario
Your formulation supports DSED-spectrum presentation after documented extremes of insufficient care, improving warmth at home with good adoptive care, ongoing stranger-boundary risk, and no indication for medication targeting attachment. Parents are exhausted, ashamed, and under social-media pressure to buy holding therapy. [1][3]
Marking domains
- Empathy and de-shaming of adoptive parents
- Accurate plain-language RAD vs DSED and insufficient-care aetiology
- Clear stranger-safety plan without catastrophising
- Explicit, professional refusal of coercive attachment therapies
- Caregiving-first and carer-coaching plan (ABC/sensitivity concepts)
- Honest limited role of medication and shared decision-making [1][2][4]
Reveal assessor key
Open. Name time; acknowledge effort and fear; ask priorities (blame, holding therapy, tablets, safety).[1]
Explain. Early severe lack of consistent caregiving can disrupt how children use relationships. Two patterns exist: withdrawn (RAD) and overfamiliar with strangers (DSED). Your child's stranger pattern fits the second more than "ordinary shyness" or simple naughtiness. This came from early deprivation, not from your current loving care failing.[1][3]
Safety. Agree practical supervision plans for outings and strangers; this is risk management, not punishment.[1]
Treatment. Best evidence supports stable sensitive caregiving and skilled carer coaching (including attachment-informed programmes such as ABC-style approaches) — not forced holding. Tablets do not create attachment; medication only if a separate condition (for example ADHD) is diagnosed later.[1][4][5]
Refuse harmful therapy. Holding/rebirthing programmes are not recommended by professional task forces, can be dangerous, and we will not refer to them. Offer written information and follow-up.[2]
Close. Summarise plan, invite questions, crisis contacts if absconding risk escalates, review date. [1]
References
- [1]Zeanah CH, Chesher T, Boris NW Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder J Am Acad Child Adolesc Psychiatry, 2016.PMID 27806867
- [2]Chaffin M, Hanson R, Saunders BE, et al. Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems Child Maltreat, 2006.PMID 16382093
- [3]O'Connor TG, Rutter M Attachment disorder behavior following early severe deprivation: extension and longitudinal follow-up J Am Acad Child Adolesc Psychiatry, 2000.PMID 10846304
- [4]Yarger HA, Lind T, Raby KL, et al. Intervening With Attachment and Biobehavioral Catch-Up to Reduce Behavior Problems Among Children Adopted Internationally: Evidence From a Randomized Controlled Trial Child Maltreat, 2022.PMID 33882710
- [5]Fox NA, Nelson CA 3rd, Zeanah CH The Effects of Psychosocial Deprivation on Attachment: Lessons from the Bucharest Early Intervention Project Psychodyn Psychiatry, 2017.PMID 29244624