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Clinical Atlas Prestige · Evidence-first

Psych VivasChild and adolescent psychiatry — attachment disorders

Psych Vivas · Child and adolescent psychiatry — attachment disorders

Attachment disorders in children — structured clinical viva

Fellowship viva on RAD/DSED: nosology, assessment, AACAP caregiving-first care, APSAC rejection of coercive attachment therapies, BEIP/ERA prognosis framing.

clinical
On this page & tools

Target exams

FRANZCPMRCPsychABPNMD-DNB

Target exams

FRANZCPMRCPsychABPNMD-DNB
Prompt
You are the CAMHS registrar. A 4-year-old looked-after child with prior severe neglect is described by carers as either shut down when hurt or, with other adults, alarmingly overfamiliar. A private therapist has offered a paid 'attachment holding programme.' Discuss diagnosis (RAD vs DSED vs style), differential including ASD, multiagency plan, and why coercive therapies are refused.

Interpretation

Reveal interpretation

This is a looked-after preschooler with severe early insufficient care and mixed social presentation requiring careful mapping to RAD (inhibited) versus DSED (disinhibited) — not a casual "attachment issues" label and not insecure style alone.[1][3]

Assessment priorities. Confirm extremes of insufficient care; multi-setting observation with familiar carer and stranger; full criteria; ASD/ADHD/language/cognition screen; safeguarding status and placement stability; stranger-related absconding risk.[1]

Management. AACAP-aligned: stable sensitive caregiving, reduce placement moves, carer coaching (ABC/sensitivity models), psychoeducation that residual DSED can persist without meaning current carers are failing, treat comorbidity, multiagency review.[1][4][6]

Hard refusal. Coercive holding/"attachment holding programmes" are contraindicated — APSAC task force: unproven and potentially dangerous. Offer written rationale and evidence-based alternatives.[2]

Prognosis talk. ERA/BEIP framing: environment matters; inhibited features often improve; disinhibited social engagement may be stickier; earlier quality care better — hope with realistic timelines.[4][5]

Key points

Two disorders

RAD withdrawn vs DSED overfamiliar — both need extremes of insufficient care.

Care is treatment

Stable sensitive primary caregiving first; coach carers; no attachment drug.

APSAC red line

Refuse coercive holding and rebirthing therapies explicitly.
[1] [2] [4]

References

  1. [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. [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. [3]Gleason MM, Fox NA, Drury S, et al. Validity of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types J Am Acad Child Adolesc Psychiatry, 2011.PMID 21334562
  4. [4]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
  5. [5]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
  6. [6]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