Empirically-guided assessment of complex trauma for children in foster care: A focus on appropriate diagnosis of attachment concerns.

Abstract

Complex trauma is defined as repeated or prolonged exposure to traumatic events perpetrated within the caregiving relationship during early childhood. Diagnostic decision making is challenging for this vulnerable population, given the widespread impact of these experiences across domains of developmental, social, emotional, and behavioral functioning. One domain, attachment, receives considerable attention for youth within the child welfare system, leading to frequent diagnosis of attachment disorders (i.e., reactive attachment disorder and disinhibited social engagement disorder). This is concerning, given the rarity, level of misunderstanding, associated stigma, and lack of psychometrically sound measures to assess attachment disorders. This article provides an overview of complex trauma and its effects, with a focus on attachment concerns. It subsequently describes one statewide assessment program for youth in the child welfare system with a history of experiencing complex trauma, elaborating on strengths and areas of future growth. A case study demonstrates the program's adherence to established guidelines and the resulting diagnoses and recommendations.

Validity of reactive attachment disorder and disinhibited social engagement disorder in adolescence

“…A previous study, also part of the current mental health project on adolescents in Norwegian RYC, revealed that 78.1% of girls and 60.4% of boys self-reported exposure to maltreatment, and the authors concluded that virtually all had likely experienced some form of neglect [ 33 ]. Moreover, adolescents in the current mental health project have reported high levels of parental chronic illness, mental illness or drug use [ 29 ], indicating increased risk of pathogenic care prior to out-of-home placement [ 10 ]. Furthermore, serious neglect was reported for 86% of school-aged foster children in Norway [ 34 ], a group regarded as exposed to less risk than adolescents in RYC.…”

“…Although there is growing evidence that RAD and DSED symptoms may persist into adolescence and early adulthood [5][6][7][8][9], controversy remains regarding their diagnostic classification. Whereas some denominate RAD and DSED as valid diagnostic constructs in adolescence, others question whether symptoms of RAD and DSED may then be better conceptualized as more common psychiatric disorders [2,10]. Hitherto, RAD and DSED have been evidenced as distinct from other psychopathology until middle childhood [11][12][13][14][15][16], but their discriminant validity in adolescence remains unstudied.…”

Reactive attachment disorder and disinhibited social engagement disorder in adolescence: co-occurring psychopathology and psychosocial problems

“…Childhood maltreatment and neglect are associated with a wide range of psychiatric disorders and psychosocial problems [1][2][3] and may, in severe cases, cause reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) [4]. Distinguishing between various health effects of childhood adversity may be clinically challenging, and there is a particular risk and tendency to misdiagnose RAD and DSED [5,6], either by the under-identification of common psychiatric disorders and neurodevelopmental problems and the over-identification of attachment problems [5,[7][8][9] or vice versa [10,11]. Misdiagnosis may result in missed treatment and developmental support, prolonging individual suffering, functional impairment, and societal costs.…”

How do youth in foster care view the impact of traumatic experiences?

“…Complex traumas experienced by children are often perpetrated by their primary attachment figures and can hence severely impact this relationship and attachment representations (John et al, 2019). Through interactions with attachment figures, children develop internal working models of themselves and their environment, and learn to interact with others and understand their own value and worth.…”

“…Moreover, they may not have learned how to properly regulate their emotions in times of distress (Cook et al, 2005;Van Der Kolk, 2005). Due to the importance of attachment in relation to (complex) trauma (John et al, 2019), children in foster care are particularly interesting. They are removed from both their attachment figures and the traumatic environment, while simultaneously placed with new parental figures.…”