ADHD/DAMP, attachment and reactive attachment disorder (RAD)

Penny Turton

Helen Minnis

Chris Gillberg

ADHD/DAMP, attachment and reactive attachment disorder (RAD)

Are attachment problems important in understanding ADHD?

Is RAD recognisable as a syndrome?

Does RAD and ADHD overlap?

Infant Disorganised Attachment and ADHD

A Prospective Study of Children Next-Born after Stillbirth

St George’s University of London

Grant holder:

Patricia Hughes

Team:

Penelope Turton, Carmen Pinto, Christopher Gillberg, Sarah White, Julia Ward, Samantha Riches, Patricia Hughes

Background

Neuroanatomical/ biochemical/ genetic factors can’t explain whole variance in presentation of ADHD

Environmental factors (e.g.maternal depression and social disadvantage) may be implicated in aetiology of ADHD

Some clinical reports suggest history of insecure attachment might also be implicated in ADHD

Disorganised attachment (D) is established marker of psychological vulnerability

Both attachment related factors and neurobiological factors reported as predisposing to disorganisation

D is associated with problematic stress management/ elevated risk of problem externalising behaviours at 6 years

Children with ADHD are usually disorganized, inattentive and impulsive from a very young age

Could infant D behaviors be an

indication of incipient ADHD?

AIMS: to investigate any association

between infant disorganised attachment behaviour and later ADHD

to identify factors explaining ADHD outcomes after controlling for mediating variables

Method

Subjects: Cohort of 104 children who had significant levels of disorganised attachment in infancy

Assessments: Mother / teacher rated ADHD symptoms* plus observer-rated hyperactivity, together with range of relevant maternal variables

*ADHD Rating Scale-IV (DuPaul, Power, Anastopoulos &

Reid, 1998).

Results 27 (26%) infants were classified as D 8 children (7.8%) met ‘probable’ ADHD

case criteria 11 children (10.7%) met ‘possible’

ADHD case criteria 24 (23.1%) of mothers vs. 25 (24.3%)

of teachers rated the child above cut-off score of 20

Mother and teacher-rated ADHD scores were highly correlated

Did infant D predict ADHD? No clear-cut association of infant

disorganized attachment and later childhood ADHD caseness.

There was a significant correlation between infant D and teacher rated teacher rated ADHDADHD symptoms (more inattention than hyperactivity)

What are the attributes of D infants that teachers (but not mothers) observe several years later as ADHD symptoms?

Interpretation D behaviours (freezing, stilling, sudden

interruptions of intended actions) present as inattention?

Teachers more sensitive to inattention, while mothers become habituated?

Mothers have lower tolerance threshold for hyperactivity? (mother-rated hyperactivity was associated with lower SCID GAF score)

Maternal psychology/behaviour play a role in mild “ADHD-like” child problems?

Comorbidity in Reactive Attachment Disorder

RAD diagnostic study funded by Chief Scientist Office of Scottish Executive

Grantholders: Eric Taylor, Tom O’Connor, Anthony Pelosi, David Young, James Barnes

Research Team: Julie Arthur, Michael Follan, Amanda Burston, Brenda Connolly

Expert Panel: Jonathan Green, Danya Glaser (with Eric Taylor and Tom O’Connor)

TEDS collaborators: Robert Plomin, Angelica Ronald

DSM-IV Diagnostic Criteria for Reactive Attachment Disorder

Inhibited type

excessively inhibited, hypervigilant or highly ambivalent and contradictory responses

Disinhibited type

indiscriminate sociability with marked inability to exhibit appropriate selective attachments

Comorbidity in RAD

Comorbidity in RAD

The RPQ is an 18-item questionnaire for RAD symptoms.

Analysis of RPQ items from 13,472 8 year olds:

•Inhibited and Disinhibited factors separate from each other in factor analysis but not in cluster analysis

•In factor analysis, RAD factors are distinct from conduct problems, hyperactivity and emotional problems

Comorbidity in RAD

40 “RAD”

children

aged 5-8

Assessment for RAD, ADHD,

ODD, CD, ASD

Diagnostic research in RAD

40 GP control

children

aged 5-8

Components of RAD assessment

•Structured parental interview for RAD based on existing measures in CAPA/PAPA format

•CAPA/PAPA modules for CD/ODD and ADHD and the 3-DI autism module.

•Teacher questionnaire based on RPQ

•Observational measure of child behaviour with parent and strangers

•Diagnosis checked by panel of experts reviewing positive interview items and video material

Comorbidity in RAD

Comorbidity in RAD

Of the first 53 children, (28 controls including 2 with other clinical diagnoses and 25 RAD cases):

•52% (13) RAD cases met criteria for ODD

•12% (3) RAD cases met criteria for Conduct Disorder

•12% (3) RAD cases met criteria for ASD

•2 children met criteria for ODD and ASD but not RAD

Comorbidity in RAD

•68% (17) RAD cases met criteria for ADHD

•No children met criteria for ADHD but not RAD

•Of the apparently comorbid RAD/ADHD cases, less than half (47%) were rated as abnormal (7%) or borderline (40%) for hyperactivity on the teacher SDQ

Comorbidity in RAD

Future research planned:

•Use our RAD assessment package with children who have a clinical diagnosis of ADHD

•Qualitative research to understand any differences in the nature of disinhibition in ADHD and RAD

Conclusions

Disorganised attachment in infancy does not predict clinical ADHD

Disorganised attachment in infancy predicts ADHD-like (mild) behaviours in early school age

There is a very high rate of comorbid ADHD in RAD

Future research (and clinical practice?) in ADHD and RAD needs to take both “conditions” into account