Autism
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Psychoeducational Treatment of Children with Autism and Reactive Attachment
Disorder
Nahit Motavalli Mukaddes, F. Nimet Kaynak, Gülsevim Kinali, Hümeyra Besikci and Halim Issever
Autism 2004 8: 101
DOI: 10.1177/1362361304040642
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Psychoeducational treatment
of children with autism and
reactive attachment disorder
N A H I T M O TAVA L L I M U K A D D E S
autism © 2004
SAGE Publications
and The National
Autistic Society
Vol 8(1) 101–109; 040642
1362-3613(200403)8:1
University
of Istanbul, Istanbul, Turkey
F. N I M E T K AY N A K
Istanbul University, Istanbul, Turkey
GÜLSEVIM KINALI
Istanbul University, Istanbul, Turkey
HÜMEYRA BEȘIKCI
HALIM ISSEVER
Istanbul University, Istanbul, Turkey
Istanbul University, Istanbul, Turkey
The aim of the study was to evaluate and compare the
efficacy of short-term psychoeducational treatment in children with
autism and reactive attachment disorder (RAD). Ten boys with autism
aged 24–66 months and 11 children with RAD (nine boys and two
girls) aged 30–70 months were included in the study. The Ankara
Developmental Screening Inventory was used to monitor progress
following a 14-session psychoeducational programme. This focused on
establishing a reciprocal-dyadic interaction between children and their
caregivers and it also provided an educational programme for
emotional, social, and language development. Although both groups
showed significant changes on all scales of the ADSI, the children with
RAD showed greater improvement than the autism group in their total
development score, on the language-cognitive subscale, and in
social/self-care abilities.
A B S T R AC T
K E Y WO R D S
autism;
psychoeducation;
reactive
attachment
disorder;
Turkey
ADDRESS
Correspondence should be addressed to: P R O F E S S O R D R N A H I T
M O T A V A L L I M U K A D D E S , Istanbul Tip Fakultesi PTT si PK: 53, Çapa, Istanbul,
Turkey 34272. e-mail:[email protected]
Introduction
Impairments in reciprocal social interaction in children are seen in their
most extreme form in autistic spectrum disorders. However, there are other
clinical conditions involving social impairments that may seem ‘autisticlike’ but do not meet criteria for autistic disorder (Scheering, 2001).
Reactive attachment disorder (RAD) is one of these conditions. The
presence of inappropriate social interaction (DSM-IV: American Psychiatric
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DOI: 10.1177/1362361304040642
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Association, 1994), delays in language development and deficits in communication skills (Bowlby, 1969; Cicchetti, 1989; Gaensbauer and Sands,
1979; Mukaddes et al., 2000; Provence and Lipton, 1962; Richter and
Volkmar, 1994; Spitz, 1945) and self-stimulating behaviours in children
with RAD (Mukaddes et al., 2000; Richter and Volkmar, 1994) cause difficulties in differentiating this condition from autistic disorders. DSM-IV
notes the necessity of the existence of pathogenic care for diagnosis of RAD.
Richter and Volkmar (1994) in their RAD case series also argue that
‘response to treatment’ is an important factor in distinguishing between the
two clinical entities of RAD and autism.
Psychoeducational treatment, social skills programming, behavioural
modifications and parent support programmes are some treatment
approaches that can be applied to cases with social, communicative and
behavioural problems (from autistic disorders to RAD). Treatments based
on behavioural strategies are amongst the best evaluated for children with
autism and it appears that such treatments are most effective if they involve
parents and are implemented early in the child’s development (Lovaas,
1987; Schreibman, 2000). Ozonoff and Cathcart (1998) evaluated the
effectiveness of a TEACCH-based home programme intervention for young
children with autism. In this project they taught parents how to work with
their preschool autistic children at home, focusing on cognitive, academic
and pre-vocational skills essential to later school success. Children in the
home programme treatment group improved significantly more than
those in the non-treatment control group on the Psychoeducational
Profile–Revised (PER–R) subtests of imitation, fine motor and conceptual
skills. The authors suggested that home programme intervention was effective in enhancing development in young children with autism.
In RAD intervention is complicated by the fact that there are frequently
comorbid mental health, medical and developmental conditions that also
need to be assessed and treated (Hanson and Spratt, 2000). Although a
variety of treatments including dyadic psychotherapy (Keren et al., 1998)
and psychoeducational treatment (Mukaddes et al., 2000) have been
utilized, there is a little evaluative assessment of therapeutic approaches for
this condition.
In the present study we aimed to provide a standardized psychoeducational intervention package derived from the TEACCH-based home programme (Schopler, 1987; Schopler et al., 1984; 1995) to children with
autism and children with RAD and to compare their responses to the same
programme.
AU T I S M
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M U K A D D E S E T A L . : P S Y C H O E D U C AT I O N A L T R E AT M E N T
Method
Assessments
Participants were referred to our Pervasive Developmental Disorder Clinic
because of their problems in social-affective and communicative areas.
At the time of referral, all patients and their mothers and fathers were
evaluated uisng a semi-structured interview format. This interview includes
75 items and was designed (by the first author) to assess the psychiatric
symptoms of cases with pervasive developmental disorders (PDD) and to
differentiate cases with RAD from PDD groups. The first part of this interview retrospectively reviewed family history, pregnancy, emotional, social,
motor and language development and behaviour in the children. It also
assessed the quality of care given to the children from birth to the referral
time and collected information on pathological care, abuse, neglect and
other environmental factors. The second part of the interview evaluated
present psychiatric symptoms including deficits in communication, imitative abilities, and behavioural problems. Two 45 minute interviews took
place. The mother–child relationship was observed during a third assessment of 20 minutes duration. Interviews were conducted by the first and
second authors. After all interviews and investigations were completed,
children who had experienced significant pathological care and neglect
were considered for a diagnosis of RAD. Diagnoses of both groups were
made using DSM-IV criteria. Since criteria for the presence of pathogenic
care are limited, two clinicians independently assessed the following issues
in the interviews and determined the presence or absence of pathogenic
care:
•
•
•
•
•
the quality of interaction between the mother or primary caregiver
and/or the father or secondary caregiver and the child
level of responsiveness of the caregiver to the child’s need
level and quality of emotional stimulation during interaction between
the caregiver and the child
level of physical and emotional support provided to the child by the
caregiver
quality of play activities, and the composition of a typical day in respect
of the relationships between the caregiver and the child in different age
groups.
The Ankara Developmental Screening Inventory (ADSI) (Savasir et al.,
1998) was used to obtain parents’ reports about children’s development at
baseline and at the end of intervention. The ADSI is a 154-item scale widely
used in Turkey for the assessment and evaluation of social, cognitive and
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communicative levels of children between 0 and 6 years old. Each item has
three choices (yes, no, don’t know).
The ADSI includes four subscales. The total development score reflects
the general development level of the child and it is obtained from the total
of the four subscales.
AU T I S M
•
•
•
•
The language-cognitive subscale (65 items) contains items related to
the child’s understanding and use of language, simple problem solving
abilities and notions of numbers and time.
The fine motor subscale (26 items) contains items related to visualmotor skills ranging from simple eye–hand coordination to complex
fine motor behaviours.
The gross motor subscale (24 items) contains items related to
movement, strength, balance and coordination.
The social interaction skills and self-care abilities subscale (39 items)
contains items related to eating, drinking, dressing, self-care, toilet
training, independence, social interaction and initiative taking.
The inter-rater reliability of the instrument for all age groups is high
(Cronbach = 0.99 for 0–12 months; 0.98 for 13–44 months; 0.88 for
45–72 months) (see Savasir et al., 1998).
Only those cases for whom both clinicians rated the presence of pathogenic care were diagnosed as having RAD.
Participants
Ten boys with autism aged 24–66 months (mean 43.20 ± 15.17) and 11
children (nine boys, two girls) with RAD aged 30–70 months (mean 48.36
± 13.99) were included in the study. Children were diagnosed as having
RAD on the basis that they had been exposed to emotional neglect and
because of the lack of parenting skills of their caregivers. According to
parental reports of the quality of care provided to their children in the first
2 years of life, children were exposed to social isolation for much of the
time and received only minimal verbal-affective stimulation. Ten of 11
children were exposed to TV for between 5 and 11 hours per day in the
first year of life and did not receive enough verbal-affective stimulus from
their parents. Nine out of the 11 mothers reported their inability to understand and respond to their child’s needs. However, well-known risk factors
associated with RAD/neglect, such as single-parent household, family
disorganization, economic difficulties, parental mental retardation, social
isolation, frequent changes in caregiving or repeated long-term hospitalizations were not found in this sample. Possible prenatal, perinatal and postnatal risk factors that seemed to be related to pathogenic care were:
unplanned pregnancy (n = 8), disappointment of parents about the sex of
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M U K A D D E S E T A L . : P S Y C H O E D U C AT I O N A L T R E AT M E N T
their children (n = 5), psychiatric symptoms in mother during pregnancy
(n = 6), postpartum depressive symptoms (n = 6), child’s physical
problems after birth (n = 1), and prematurity (n = 1).
Treatment
All children and their mothers were enrolled in a standardized psychoeducational treatment programme conducted by experienced child educators. Each weekly treatment session lasted 45 minutes and focused on
developing a reciprocal interaction between children and their parents,
enhancing communicative language, modifying stereotypic behaviours and
increasing self-care skills. The intervention focused primarily on parent
training and was based on the principles and framework of the TEACCH
programme principles (Schopler et al., 1995).
In the first stage of the programme (sessions 1 and 2), parents were
informed about the nature of their children’s problems. Parents were also
encouraged to verbalize their emotional states, and the most common
issues raised concerned feelings of guilt. Strategies about coping with guilt
were introduced, and parents were educated about how a stable and stimulating relationship could be started. They were also advised about play
activities that were appropriate for children’s social-emotional development.
The second stage (10 to 12 sessions) consisted of child-directed play
activities. Parents were given the opportunity to play and interact with their
child, and to observe the interaction provided by the educator in the
sessions. Parents were then able to practise these techniques at home. They
were also given the opportunity to discuss feelings about the home and
clinic sessions with the educator. Some clinic sessions involved the parent
and educator working together on dyadic play activities and others involved
only child and therapist. Parents were taught techniques to improve their
children’s self-care skills and how to cope with aggression and other behavioural difficulties. Social and language training programmes were also
introduced.
The final evaluative phase of the study was conducted after 3 months
of intervention. This focused on the child’s social-emotional contact and
communication skills in the parent–child relationship, interactions during
play and the presence of psychiatric symptoms. Parents’ reports about
possible improvements were also evaluated. Decisions about sending the
child to a day care facility, requirements for additional language development interventions and further remedial interventions were assessed.
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AU T I S M
Results
All of the participants in both groups completed the treatment programme
and both groups showed significant improvement in all subscales of the
ADSI from baseline to post-intervention. On the ADSI the children with
autism showed statistically significant improvements in total development
score (z = 2.81, p = 0.005), language-cognitive subscale (z = 2.81, p =
0.005), social and self-care subscale (z = 3.06, p = 0.002), fine motor
subscale (z = 3.05, p = 0.002) and gross motor subscale (z = 2.66, p =
0.008) (see Table 1).
The children with RAD also showed significant improvements in total
development score (z = 3.06, p = 0.002), language-cognitive subscale (z =
2.84, p = 0.004), social and self-care subscale (z = 2.80, p = 0.005), fine
motor subscale (z = 3.06, p = 0.002) and gross motor subscale (z = 2.80,
p = 0.005).
However, compared with the autism group, children with RAD showed
significantly more improvement in the total development score (p = 0.05),
Table 1 Changes over the course of treatment for children with autism (group
I) and children with RAD (group II)
Treatment Median
Median
groups
(baseline) (the end)
Total
Group I
development
score
Group II
16.50
22.50
18.56
34.00
Group I
15.50
20.00
Group II
16.50
29.50
Social/selfGroup I
care abilities
subscale
Group II
16.50
26.75
21.00
35.50
Group I
18.50
26.75
Group II
20.50
34.00
Group I
49.00
51.00
Group II
50.00
57.00
Language –
cognitive
subscale
Fine motor
subscale
Gross motor
subscale
a Wilcoxon
Significance Differences between the two groups
(within the —————————————––
Median Mean rank Significanceb
group)a
z = 2.81
p = 0.005
z = 3.06
p = 0.002
z = 2.81
p = 0.005
z = 2.84
p = 0.004
z = 3.06
p = 0.002
z = 2.80
p = 0.005
z = 3.05
p = 0.002
z = 3.06
p = 0.002
z = 2.66
p = 0.008
z = 2.80
p = 0.005
6
13.75
4
9.50
6
14.50
6
9.14
14.63
p = 0.05
8.36
15.33
p = 0.01
9.00
14.75
p = 0.04
9.68
13.75
14.13
7.50
12.41
6
11.63
signed ranks test.
U-test.
b Mann–Witney
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p = 0.11
p = 0.78
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the language-cognitive subscale (p = 0.01) and the social and self-care
subscale (p = 0.04) of the ADSI (Table 1). There was no interaction between
the mean differences, group and sex (p < 0.05).
Discussion
The common characteristics of children with autism and RAD are delay in
language development, impairments or restriction in social and emotional
responsiveness, deficits in self-care skills and the presence of bizzare behavioural patterns. However, the two conditions have completely different aetiologies. In this study we aimed to compare the treatment responses of these
two groups of children in the areas of social-emotional development,
language and behavioural difficulties following a standardized treatment
procedure.
The positive response to treatment indicates that the TEACCH approach
is effective for both groups. Previous studies have demonstrated the effectiveness of TEACCH-based home intervention (Ozonoff and Cathcart,
1998) and supportive programmes for parents of children with autism. The
response to treatment in our autistic group is similar to that reported by
Ozonoff and Cathcart (1998) in terms of improvements in imitation, fine
motor and conceptual skills. TEACCH-based programmes have also been
found to be effective in the few existing studies of children with RAD
(Mukaddes et al., 2000).
The paucity of treatment studies for RAD is a result of diagnostic difficulties. Until this diagnosis was included in DSM-III in 1980, severe maltreatment and deprivation were thought to be the most prominent causative
factors and studies mostly focused on institutionalized children. However,
despite the fact that all of the children in our study were living with their
biological parents, they were not receiving adequate stimulation for their
cognitive and emotional development, because of deficits in parenting
skills. Nevertheless, the treatment programme resulted in rapid improvements and parents in both groups shows high levels of motivation in using
what they had learned.
The finding that children with RAD showed greater improvements in
language-cognitive skills, social development and self-care skills than the
autistic group replicates the results of Richter and Volkmar (1994) who
reported that children with RAD showed better response to treatment than
children with autism. These authors have emphasized the importance of
‘the treatment response’ in differential diagnosis of these two groups of
children. Mukaddes et al. (2000) also found improvements in children with
RAD following modification of environmental factors, and it was their rapid
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response to treatment that was the key element in distinguishing them from
children with PDD.
In conclusion, although this study has a number of methodological
limitations, such as small sample size and a relatively short follow-up
period, it is important in terms of being the first study to evaluate the
responses of children with RAD and autism in a standardized treatment programme. However, there is a need for further research in this area with
larger samples and longer-term follow-up.
AU T I S M
References
(1994) Diagnostic and Statistical Manual of Mental
Disorders, 4th edn (DSM-IV). Washington, DC: APA.
B OW L B Y, J . (1969) Attachment and Loss. Volume I: Attachment. Harmondsworth: Penguin.
C I C C H E T T I , D . (1989) ‘Developmental Psychopathology in Infancy: Illustrations
from the Study of Maltreated Youngsters’, Journal of Consulting and Clinical Psychology 57:
837–45.
G A E N S B AU E R , T. J . & S A N D S , M . (1979) ‘Distorted Affective Communication in
Abused/Neglected Infants and Their Potential Impact on Caregivers’, Journal of the
American Academy of Child and Adolescent Psychiatry 18: 236–50.
H A N S O N , R . F . & S P R AT T, E . G . (2000) ‘Reactive Attachment Disorder: What We
Know about the Disorder and Implications for Treatment’, Child Maltreatment 5:
137–45.
K E R E N , M . , S P I T Z E R , S . & T YA N O , S . (1998) ‘Dyadic Psychotherapy for Early
Relationship Disorder: A Case Study’, Israel Journal of Psychiatry and Related Science 35:
262–70.
L OVA A S , O . I . (1987) ‘Behavioral Treatment and Normal Educational and Intellectual
Functioning in Young Autistic Children’, Journal of Consultation and Clinical Psychology
55: 3–9.
M U K A D D E S , N . M . , B I L G E , S . , A LYA N A K , B . & KO R A , M . E . (2000) ‘Clinical
Chacteristics and Treatment Responses in Cases Diagnosed as Reactive Attachment
Disorder’, Child Psychiatry and Human Development 30: 273–87.
O Z O N O F F , S . & C AT H C A RT, K . (1998) ‘Effectiveness of Home Program Intervention
for Young Children with Autism’, Journal of Autism and Developmental Disorder 28: 25–32.
P ROV E N C E , S . A . & L I P T O N , R . C . (1962) Infants Reared in Institutions. New York:
International University Press.
R I C H T E R , M . M . & VO L K M A R , F . R . (1994) ‘Reactive Attachment Disorder of Infancy
or Early Childhood’, Journal of American Academy of Child and Adolescent Psychiatry 33:
328–32.
S AVA S I R , I . , S E Z G I N , N . & E RO L , N . (1998) Ankara Gelisim Envanteri El Kitabi. Türk
Psikologlar Dernegi, 2. Ankara: Basim.
S C H E E R I N G , M . S . (2001) ‘The Differential Diagnosis of Impaired Reciprocal Social
Interaction in Children: A Review of Disorders’, Child Psychiatry and Human Development
32: 71–89.
S C H O P L E R , E . (1987) ‘Specific and Nonspecific Factors in the Effectiveness of a
Treatment System’, American Psychologist 42: 376–83.
S C H O P L E R , E . , M E S I B OV, G . B . , S H I G LY, R . H . & B A S H F E N D , A . (1984) ‘Helping
Autistic Children through Their Parents: The TEACCH Model’, in E . S C H O P L E R &
G . B . M E S I B OV (eds) The Effects of Autism on the Family, pp. 65–81. New York: Plenum.
A M E R I C A N P S Y C H I AT R I C A S S O C I AT I O N
108
Downloaded from aut.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on October 3, 2011
08 Mukaddes (jr/t/k) 12/1/04 9:42 am Page 109
M U K A D D E S E T A L . : P S Y C H O E D U C AT I O N A L T R E AT M E N T
S C H O P L E R , E . , M E S I B OV, G . B . & H E A R S E Y, K . (1995) ‘Structured Teaching in the
TEACCH System’, in E . S C H O P L E R & G . B . M E S I B OV (eds) Learning and Cognition in
Autism, pp. 243–68. New York: Plenum.
Behavioral/Psychoeducational Treatments for
Autism: Research Needs and Future Directions’, Journal of Autism and Developmental
Disorder 30: 373–8.
S P I T Z , R . (1945) ‘Hospitalism: An Inquiry into the Genesis of Psychiatric Conditions
in Early Childhood’, Psychoanalytic Study of the Child 1: 53–74.
S C H R E I B M A N , L . (2000) ‘Intensive
109
Downloaded from aut.sagepub.com at UNIV OF SOUTHERN CALIFORNIA on October 3, 2011