Attachment disorders and relational trauma — formative SAQs

SAQ 1 — Naming the disorder and choosing relationship-based care (10 marks)

A 4-year-old placed in foster care six weeks ago, after chronic neglect, will not seek comfort from his carer when hurt, pushes her away when she offers it, yet wanders off happily with strangers in the clinic. The carer asks whether an SSRI would help him "settle and attach." ^{[1] [2]}

Questions

1. Using the behavioural pattern and the caregiving history, classify this child's presentation. Which disorder best fits, and which coexisting disorder must you actively consider? (3 marks) ^[2]
2. Outline the first-line management plan, naming an evidence-based intervention and its active ingredient. (4 marks) ^{[7] [13]}
3. Address the carer's request for an SSRI, and state two treatments or approaches that must not be used. (3 marks) ^[13]

Model answer

Classification (3). The emotionally withdrawn and inhibited pattern — minimal comfort-seeking and minimal response to comfort, with persistent social and emotional disturbance, after chronic neglect — meets reactive attachment disorder; the indiscriminate wandering-off with strangers means disinhibited social engagement disorder must also be actively considered, since the two disorders can coexist and are not a spectrum. The shared gateway is grossly pathogenic care, which the history provides. ^{[1] [2]}

First-line management (4). Safety and a stable, committed placement come first; the active ingredient of recovery is a reliable, responsive carer. The evidence-based relationship interventions are delivered to the carer-child dyad — Attachment and Biobehavioral Catch-up (ABC), which Dozier showed normalises cortisol and improves attachment behaviours in foster infants, and Child-Parent Psychotherapy for trauma-exposed young children. The plan supports the carer as the intervention, not the child alone. ^{[7] [9] [13]}

SSRI and contraindicated approaches (3). An SSRI has no first-line role for the attachment disorder itself and should not be started to "treat" it; medication is reserved for diagnosed comorbid depression or anxiety on its own merits. Coercive "holding therapy" and any unregulated attachment techniques are harmful and must not be used, and the diagnosis must not be made on a single observation or by blaming the current carer. ^[13]