Title: An act relating to screening and treating children with attachment disorders.

Brief Description: Establishing a program to screen and treat children with attachment disorders.

Sponsors: Senate Committee on Ways & Means (originally sponsored by Senators Zarelli, Prentice, Rasmussen and Roach).

Brief History:

Early Learning & Children's Services: 2/21/08, 2/28/08 [DPA].

HOUSE COMMITTEE ON EARLY LEARNING & CHILDREN'S SERVICES

Majority Report: Do pass as amended. Signed by 7 members: Representatives Kagi, Chair; Roberts, Vice Chair; Haler, Ranking Minority Member; Walsh, Assistant Ranking Minority Member; Goodman, Hinkle and Pettigrew.

Staff: Sydney Forrester (786-7120).

Background:

Reactive Attachment Disorder
The Diagnostic and Statistical Manual of Mental Disorders (DSM), published by the American Psychiatric Association, defines reactive attachment disorder (RAD) by the following criteria: disturbed and developmentally inappropriate social relationships beginning before age 5; failure to respond to or initiate social interactions, or being inappropriately friendly and familiar with strangers; and a result of failure of early care to meet the baby's or child's emotional needs for comfort and affection, failure of early care to attend to the child's physical needs, or repeated changes in the primary caregiver.

A 2006 report from a task force convened by the American Professional Society on the Abuse of Children (APSAC) indicates that attachment therapy is a young and diverse field and the benefits and risks for many attachment-related treatments remain scientifically undetermined. The task force cautioned that because the DSM has recognized only RAD, and not other attachment or relationship disorders, a child described as having RAD may actually fail to meet formal diagnostic criteria for the disorder, and consequently the label should be viewed cautiously. The task force concluded its report with a set of 22 detailed recommendations regarding RAD assessment, diagnosis, treatment, and interventions.

Screening and Treatment of Children in Foster Care
The Department of Social and Health Services (DSHS) Children's Administration (CA) does not routinely screen children for RAD specifically, although the routine child health and education screening tool (CHET) may identify the need for further mental health assessment of a child. Typical interventions and therapies provided to many maltreated children are consistent with accepted and noncontroversial attachment interventions, including promoting and supporting caregiver qualities such as environmental stability, consistency and safety, parental sensitivity, and overall responsiveness to children's physical and emotional needs.

The Children's Mental Health Evidence-based Practice Institute
In 2007 the Legislature established the Children's Mental Health Evidence-based Practice Institute (Institute) at the University of Washington in HB 1088. The Institute is charged with improving the implementation of evidence-based and research-based practices by providing sustained and effective training and consultation to licensed children's mental health providers and child-serving agencies who are implementing evidence-based or research-based practices for treatment of children's emotional or behavioral disorders, or who are interested in adapting these practices to better serve ethnically or culturally diverse children. The Institute also serves as a statewide resource to the DSHS and other entities on child and adolescent evidence-based, research-based, promising, or consensus-based practices for children's mental health treatment, maintaining a working knowledge through ongoing review of academic and professional literature, and knowledge of other evidence-based practice implementation efforts in Washington and other states.

Summary of Amended Bill:

The CA, in collaboration with the Institute, shall implement a pilot program in Clark County to identify and respond to the needs of young children in foster care who are at risk of developing attachment-related conditions or problems. Treatments must be provided by licensed mental health professionals; interventions must be appropriate to children's developmental needs; and practices implemented must be consistent with the APSAC recommendations on RAD diagnosis and treatment.

The CA and the Institute must consider how the CHET might be used to identify children in need of further assessment for attachment problems. The Institute, in consultation with the CA, shall evaluate the pilot program and make recommendations regarding effectiveness of the pilot; whether expansion of the program is likely to improve outcomes; and other issues pertinent to the pilot program. To the extent funding is available, the Institute also must pursue evaluation of promising practices to determine if a sufficient evidence-base exists for those practices to be replicated statewide in responding to needs of children in foster care.

Amended Bill Compared to Second Substitute Bill:

The amendment strikes all of the underlying bill and directs implementation and evaluation of the pilot program be accomplished in collaboration with the Institute, through the use of promising and evidence-based practices and according to professional standards for children's mental health treatment.

The underlying bill directed the pilot be implemented in Clark County through a contract with a provider currently serving the CA's children and families, and called for the provider to train CA staff on use of the interventions. All children age 9 years and under entering foster care in Clark County were required to be screened for RAD, following development of a screening tool required by September 2008. The Joint Legislative Audit and Review Committee was to conduct the evaluation of the program and report back to the Legislature.

Appropriation: None.

Fiscal Note: Available.

Effective Date of Amended Bill: The bill takes effect 90 days after adjournment of session in which bill is passed.

Staff Summary of Public Testimony:

(In support) Regardless of whether children are eventually adopted from foster care into loving homes, there are still some children who clearly have RAD. Early and direct intervention is needed to prevent these children from becoming predatory later in life. There is no resource to treat RAD in Washington. There are models that work to treat RAD and there are options available. It does not make sense to wait until everyone agrees on how to treat these kids. The model available in Clark County also addresses children with developmental delay.

(With concerns) Reactive attachment disorder is very complex and often misunderstood. There is a significant amount of controversy around the validity of diagnosis as well as some of the treatments used. Any provider selected should be a licensed mental health professional and be an expert in the field of children's mental health. There is concern that September 2008 is too soon to develop a screening tool and we would suggest examining existing tools to see if any can be validated to screen for RAD. It is not clear how a RAD screening tool would fit the CHET.

Assigning the RAD label to children can present some risks for children. The DSHS has not seen any research to dictate exactly how RAD should be addressed effectively. There is a good body of evidence generally regarding attachment problems with very young children and some of the more promising practices are being implemented with children in foster care.

(Opposed) None.

Persons Testifying: (In support) Senator Zarelli, prime sponsor.

(With concerns) Barb Putnam and Dana Phelps, Department of Social & Health Services - Children's Administration.

Persons Signed In To Testify But Not Testifying: None.