Trauma-Focused Cognitive Behavioural Therapy Concerning Childhood Trauma and Reactive Attachment

The beginning of life is the most important phase. By age three, a child’s brain will be 90% developed (Winston & Chicot, 2016). The child's brain is complicated and vulnerable (Winston & Chicot, 2016). Several interactions and communications between a child and caregiver occur in the first part of life, which creates pathways in the brain that assist with memories and relationships. If appropriate attached relationships do not exist, normal human experiences may be difficult to achieve. Disruption in a relationship can involve neglect and inconsistencies (Winston & Chicot, 2016). Having disruption in the relationship alters growth and development within a child’s physical and psychological needs (Vega et al., 2019). These types of disruptions can result in a lack of bond between caregiver and child and therefore result in a future of behavioural problems, such as withdrawal, aggression, impulsiveness, and other socially inappropriate behaviour (Vega et al., 2019).

In the DSM-5, RAD is classified as a trauma and stressor-related disorder that begins in early childhood. It is primarily caused by social neglect and maltreatment (Winston & Chicot, 2016). Symptoms of RAD can include failure to seek comfort, lack of eye contact, dissociation, hypervigilance and unpredictable responses (Moran et al., 2017). Children affected by this disorder have issues forming emotional attachments and also have a decreased ability to produce positive emotions (Winston & Chicot, 2016). In regards to behaviour in children with RAD, their moods can be unstable and their bodies often live in a fight, flight, or freeze response. They also require to be in full control of their environments and decision-making (Winston & Chicot, 2016). Fortunately, RAD can be responsive with the proper care and the symptoms of RAD can reduce (Gleason et al., 2011).

Trauma-Focused Cognitive Behavioural Therapy

TF-CBT is a therapeutic approach mainly for children and adolescents and their nonoffending caregivers (De Arellano et al., 2014). This approach uses cognitive behavioural principles and exposure techniques to address symptoms of trauma exposures, relationships between new caregivers, and behavioural challenges that are in RAD. De Arellano et al (2014) explain the phases that are addressed in TF-CBT as psychoeducation, coping skills, gradual exposure, cognitive processing of trauma-related thoughts and beliefs, caregiver involvement, behavioural modelling, and body safety skills (De Arellano et al., 2014). This type of therapeutic approach tailors each treatment for individuals and provides a process for the child and caregiver to learn and have healthy attachments (De Arellano et al., 2014). For the caregivers, TF-CBT is helpful because it allows them to learn and develop strategies to reduce stress; create a safe space; assist with social skills; control feelings and thoughts; and lastly, assist in creating structured opportunities for the RAD client (De Arellano et al., 2014). When these are taught to the caregiver, the client will be able to process the trauma healthily, as well as learn to cope and regulate aggravations that can lead to traumatic reactions (De Arellano et al., 2014). The results of the De Arellano et al. (2014) study was that there is a moderate rate of evidence that TF-CBT has an impact on behavioural problems with traumatized youth in the trauma and stressor-related disorder category. This could be due to the bias and exclusion of vulnerable populations in this study. To compare, in the study by Minnis et al. (2013), they assessed vulnerable populations and their result concluded the prevalence of RAD was 1.40%, which was higher than the researchers had believed.

Co-occurring Diagnoses

Children with RAD often continue having difficulties throughout childhood, even if they have nurturing adopted families. This is because they often have co-occurring diagnoses, some undiagnosed (Minnis et al., 2013). In Minnis et al. (2013) the results from the study showed that the children who were diagnosed with RAD were also living with co-occurring undiagnosed psychological disorders. This study shows that children often go undiagnosed with several conditions until later on in life when it is often seen as too late. Children with RAD are likely to continue into their adulthood with a range of difficulties and high-risk behaviours.

On a similar note as Minnis et al. (2013), Moran et al. (2017) explored high-risk young offenders and the rate of RAD within the prison system. RAD is associated with neglect and abuse which results in individuals having a hard time with social interactions and relating to their peers. This study produced two findings which were that young offenders are often linked with RAD and individuals with RAD also have high co-occurring psychological disorder rates. 86% of young offenders from the ages of 12-17 had shown RAD symptoms. Whereas 52% were diagnosed with RAD. Interestingly enough, a positive correlation showed between RAD and other mental health issues. The results showed that hyperactivity among RAD individuals was at 67% versus non-RAD young offenders at 21%. For general emotional difficulties, it was found that 60% of RAD individuals had difficulty versus non-RAD young offenders at 36%. In Bruce et al. (2018), there were similar findings as the study noticed that RAD was also associated with some mental health and cognitive difficulties.

Government Care Systems

Children in government care systems are at high risk for experiencing trauma and related psychosocial problems (Murray et al., 2015). It is important to note that nearly 50% of these children have clinically significant treatment needs that could involve TF-CBT (Dorsey et al., 2014). Murray et al. (2015) evaluated the effectiveness of TF-CBT with vulnerable children in and out of government care. This study put children aged 5-18 years old in either TF-CBT or treatment as usual in a randomized control trial. TF-CBT had greater success than treatment as usual in reducing trauma and stress-related symptoms when provided by counsellors.

If symptoms are left untreated, behavioural difficulties have been linked to higher rates of placement disruption and lower rates of reintegration and adoption for children in foster care (Dorsey et al., 2014). Dorsey et al. (2014), explored youth in the care of the government and the high rates of trauma that comes with parental separation. Over half of children in care have been exposed to maltreatment, neglect, and abuse from individuals that are supposed to express care for them (Dorsey et al., 2014). Behaviour difficulties are prominent in children in care and many mental health issues go untreated. These mental health issues tend to continue into childhood and eventually repeat the cycle. TF-CBT is a good fit for children in foster care as there are high rates of RAD individuals that live in these circumstances and this type of therapy can assist with behaviour and trauma symptoms. This is similar to the findings seen in Bruce et al., (2018). The researchers examined the impact that TF-CBT in regards to foster parents as there is often a disconnection even when the parent is unoffending. To do this, they used a randomized control trial and compared TF-CBT and TF-CBT with other evidence-based engagement strategies. 47 children and adolescents took part in the study with one of their foster parents. The assessed aspects of the treatment were attendance, engagement, and clinical outcomes. These were assessed at 1 month into treatment, end of treatment, and 3 months post-treatment. The results were that the children/youth and the foster parents were more likely to continue treatment and less likely to drop out before the end. These results hold promise for the increasing of chances for evidence-based treatments and graduation from treatment.

In Bruce et al. (2018) it shows how important the results of Dorsey et al. (2014) are in regards to caregivers nurturing presence in treatment and in the child’s life. In this study, the researchers explored RAD in maltreated young children in foster care. Very little is known about the prevalence and the stability of RAD over an individual's lifetime (Dorsey et al., 2014). In this longitudinal study, they researched 100 children in Scotland from the ages of 12-62 months over 12 months. Each child was in the care of the local authority for child protection. The prevalence of RAD was found to be 5% when the children were first placed in the foster care system. Within 1 year of improved conditions in their foster placements, the presence of RAD was only 2.1% prevalent.

Summary

TF-CBT is a therapeutic approach for children and their nonoffending caregivers. It uses cognitive behavioural principles and exposure techniques to address symptoms. Although there are several other trauma-focused interventions, research shows that TF-CBT works best with traumatized children as it shows a significant improvement pre to post-therapy. Children with RAD often have difficulties throughout childhood and into adulthood, many having co-occurring diagnoses. This reflects in the research done with RAD and offenders. Caregivers play a large part in the TF-CBT process. Children depend on their caregivers for several needs, including nurturement. It is important to note that for some children, RAD is a disorder that lives with them despite a nurturing caregiving environment. It is currently unknown why RAD disappears so quickly in many children, yet stays apparent in others.