The relevance of development of coherent speech of preschool children

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Children need sensitive and responsive caregivers to develop secure attachments. RAD arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child’s communicative efforts. Children with RAD are presumed to have grossly disturbed internal working models of relationships that may lead to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years. Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. Most such strategies are in the process of being evaluated.

Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the disorder. The initial presentation varies according to the child’s developmental and chronological age, although it always involves a disturbance in social interaction. The core feature is severely inappropriate social relating by affected children. Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed. Actions that otherwise would be classified as psychopathy, such as mutilating animals, harming siblings or other family, or harming themselves intentionally. While RAD occurs in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect. However, the instances of that ability are rare.

The name of the disorder emphasizes problems with attachment but the criteria includes symptoms such as failure to thrive, a lack of developmentally appropriate social responsiveness, apathy, and onset before 8 months. There is as yet no universally accepted diagnostic protocol for reactive attachment disorder. Often a range of measures is used in research and diagnosis. Although increasing numbers of childhood mental health problems are being attributed to genetic defects, reactive attachment disorder is by definition based on a problematic history of care and social relationships.

Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. While similar abnormal parenting may produce the two distinct forms of the disorder, inhibited and disinhibited, studies show that the abuse and neglect was far more prominent and severe in the cases of RAD, disinhibited type. The issue of temperament and its influence on the development of attachment disorders has yet to be resolved. RAD has never been reported in the absence of serious environmental adversity yet outcomes for children raised in the same environment are the same.