Recommendations are identified as falling into one of four categories of endorsement. These categories (MS, CG, OP, NE), which are defined at the end of the "Major Recommendations" field, indicate the degree of importance or certainty of each recommendation.
- The assessment of reactive attachment disorder (RAD) requires evidence directly obtained from serial observations of the child interacting with his or her primary caregivers and history (as available) of the child's patterns of attachment behavior with these caregivers. Observations of the child's behavior with unfamiliar adults are also necessary for diagnosis. Given the association between a diagnosis of RAD and a history of maltreatment, the clinician should also gather a comprehensive history of the child's early caregiving environment, including from collateral sources (e.g., pediatricians, teachers, or caseworkers familiar with the child) [MS].
- A relatively structured observational paradigm should be conducted so that comparable behavioral observations can be established across relationships [CG].
- After assessment, any suspicion of previously unreported or current maltreatment requires reporting to the appropriate law enforcement and protective services authorities [MS].
- Maltreated children are at high risk for developmental delays, speech and language deficits or disorders, and untreated medical conditions. Referral for developmental, speech, and medical screening may be indicated [CG].
- The most important intervention for young children diagnosed with reactive attachment disorder and who lack an attachment to a discriminated caregiver is for the clinician to advocate for providing the child with an emotionally available attachment figure [MS].
- Although the diagnosis of reactive attachment disorder is based on symptoms displayed by the child, assessing the caregiver's attitudes toward and perceptions about the child is important for treatment selection [CG].
- Children with reactive attachment disorder are presumed to have grossly disturbed internal models for relating to others. After ensuring that the child is in a safe and stable placement, effective attachment treatment must focus on creating positive interactions with caregivers [MS].
- Children who meet criteria for reactive attachment disorder and who display aggressive and oppositional behavior require adjunctive treatments [CG].
- Interventions designed to enhance attachment that involve noncontingent physical restraint or coercion (e.g., "therapeutic holding" or "compression holding"), "reworking" of trauma (e.g., "rebirthing therapy"), or promotion of regression for "reattachment" have no empirical support and have been associated with serious harm, including death [NE].
Definitions
[MS] "Minimal Standards" are recommendations that are based on substantial empirical evidence (such as well controlled, double-blind trials) or overwhelming clinical consensus. Minimal standards are expected to apply more than 95 percent of the time (i.e., in almost all cases). When the practitioner does not follow this standard in a particular case, the medical record should indicate the reason.
[CG] "Clinical Guidelines" are recommendations that are based on empirical evidence (such as open trials, case studies) and/or strong clinical consensus. Clinical guidelines apply approximately 75 percent of the time. These practices should always be considered by the clinician, but there are exceptions to their application.
[OP] "Options" are practices that are acceptable, but not required. There may be insufficient empirical evidence to support recommending these practices as minimal standards or clinical guidelines. In some cases they may be the perfect thing to do, but in other cases they should be avoided. If possible, the practice parameter will explain the pros and cons of these options.
[NE] "Not Endorsed" refers to practices that are known to be ineffective or contraindicated.
