Attachment disorders and relational trauma — OSCE

OSCE communication-and-counselling station assessing a four-year-old placed in foster care six weeks ago after chronic neglect, who will not seek comfort from his carer yet wanders off with strangers — testing the two-disorder structure, caregiving-history assessment, the no-first-line-medication and no-holding-therapy counselling, and a safeguarding conversion when ongoing contact-visit harm is disclosed.

osce communication and counselling3 min readVerification in progress

Prompt

Marcus is a four-year-old boy placed with his foster carer, Aroha, six weeks ago after chronic neglect in his birth home, with two earlier short-term placements. Aroha reports that Marcus never comes to her when he is hurt, pushes her away when she tries to comfort him, and seems 'checked out', yet in the waiting room he walked off holding the hand of a stranger and hugs unfamiliar adults freely. She is exhausted and tearful, and asks whether the GP can 'start something to help him attach', because a friend recommended a therapist who uses 'holding therapy to force the bond'. During the assessment Aroha confides that Marcus returns from weekly contact visits with his birth father with new bruises and is frightened for days afterwards.

Candidate information (2 minutes reading, 12 minutes station)

You are the general paediatric registrar in an outpatient clinic. Marcus, aged four, is brought by his foster carer Aroha six weeks after placement following chronic neglect. Read the presentation, then conduct the assessment and counselling. The examiner will role-play Aroha. [1] [13]

Paediatrics Fellowship Pro

You have read the opening of this case. The complete unit — every section and its primary-source references — is part of the Paediatrics Fellowship fellowship atlas.

References7Show ledger

[1]Zeanah CH, Scheeringa M, Boris NW, Heller SS, Smyke AT, Trapani J Reactive attachment disorder in maltreated toddlers. Child Abuse Negl, 2004.PMID 15350771
[2]Gleason MM, Fox NA, Drury S, Smyke A, Egger HL, Nelson CA 3rd, 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of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types.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
[3]Gleason MM, Fox NA, Drury SS, Smyke AT, Nelson CA 3rd, Zeanah CH Indiscriminate behaviors in previously institutionalized young children. Pediatrics, 2014.PMID 24488743
[4]Smyke AT, Zeanah CH, Gleason MM, Drury SS, Fox NA, Nelson CA, et al A randomized controlled trial comparing foster care and institutional care for children with signs of reactive attachment disorder. Am J Psychiatry, 2012.PMID 22764361
[7]Dozier M, Peloso E, Lewis E, Laurenceau JP, Levine S Effects of an attachment-based intervention on the cortisol production of infants and toddlers in foster care. Dev Psychopathol, 2008.PMID 18606034
[9]Lieberman AF, Ghosh Ippen C, Van Horn P Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial. J Am Acad Child Adolesc Psychiatry, 2006.PMID 16865033
[13]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