Attachment disorder

Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about age 6 months but before about age 3 years, frequent change of caregivers or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts. A problematic history of social relationships occurring after about age 3 may be distressing to a child, but does not result in attachment disorder.

The term attachment disorder is most often used to describe emotional and behavioral problems of young children, but is sometimes applied to school-age children or even to adults. The specific difficulties implied depend on the age of the individual being assessed. Thus, no general list of symptoms of attachment disorder can legitimately be presented.

There are two main areas of theory and practice relating to the current definition and diagnosis of attachment disorder. The first is found in academic journals and books and pays close attention to attachment theory. It is described in ICD-10 and DSM-IV-TR as Reactive attachment disorder of various types. The second area is controversial and is found in clinical practice, on websites and in books and publications, has little or no evidence base and makes controversial claims relating to a basis in attachment theory.The use of these controversial diagnoses of attachment disorder is linked to the use of controversial attachment therapies to treat them. (Chaffin et al, 2006, p78)

Some authors have suggested that attachment, as an aspect of emotional development, is better assessed along a spectrum than considered to fall into two non-overlapping categories. This spectrum would have at one end the characteristics called secure attachment; midway along the range of disturbance would be insecure or other undesirable attachment styles; at the other extreme would be non-attachment, O'Connor & Zeannah (2003). Diagnostic criteria have not yet been agreed.(Chaffin et al, 2006)

The present article will consider ways of looking at attachment- related problems ranging from mild to serious.

Problems of attachment style

The majority of 12-month-old children can tolerate brief separations from familiar caregivers and are quickly comforted when the caregivers return. These children also use familiar people as a "secure base" and return to them periodically when exploring a new situation. Such children are said to have a secure attachment style, and characteristically continue to develop well both cognitively and emotionally.

Smaller numbers of children show less positive development at age 12 months. Their less desirable attachment styles may be predictors of poor later social development. Although these children's behavior at 12 months is not a serious problem, they appear to be on developmental trajectories that will end in poor social skills and relationships. Because attachment styles may serve as predictors of later development, it may be appropriate to think of certain attachment styles as part of the range of attachment disorders.

Insecure attachment styles in toddlers involve unusual reunions after separation from a familiar person. The children may snub the returning caregiver, or may go to the person but then resist being picked up. These children are more likely to have later social problems with peers and teachers, but some of them spontaneously develop better ways of interacting with other people.

A small group of toddlers show a distressing way of reuniting after a separation. Called a disorganized/disoriented style, this reunion pattern can involve looking dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors that seem to imply fearfulness of the person who is being sought. Disorganized attachment has been considered a major risk factor for child psychopathology, as it appears to interfere with regulation or tolerance of negative emotions and may thus foster aggressive behavior .

ICD-10 and DSM-IV-TR definitions

ICD-10 describes Reactive Attachment Disorder of Childhood, known as RAD, and Disinhibited Disorder of Childhood, less well known as DAD. DSM-IV-TR also describes Reactive Attachment Disorder of Infancy or Early Childhood. They divide this into two subtypes, Inhibited Type and Disinhibited Type, both known as RAD. The two classifications are similar and both include;

• markedly disturbed and developmentally inappropriate social relatedness in most contexts.
• The disturbance is not accounted for solely by developmental delay and does not meet the criteria for Pervasive Developmental Disorder.
• Onset before 5 years of age.
• Requires a history of significant neglect.
• Implicit lack of identifiable, preferred attachment figure.

ICD-10 includes in its diagnosis types of abuse in addition to neglect.

Whilst RAD is likely to occur in relation to neglectful and/or abusive childcare, there should be no automatic diagnosis on this basis as children can form stable attachments and social relationships despite marked abuse and neglect.

Boris and Zeanah's typology

Many leading attachment theorists, such as Zeannah and Leiberman, have recognized the limitations of the DSM-IV-TR and ICD-10 criteria and proposed broader diagnostic criteria. There is as yet no official consensus on these criteria. The APSAC Taskforce recognised in it's recommendations that "attachment problems extending beyond RAD, are a real and appropriate concern for professionals working with children", and set out recommendations for assessment. (Chaffin et al, 2006)

Boris and Zeanah (1999) have offered an approach to attachment disorders that is of particular value because it considers cases where children have had no opportunity to form an attachment, those where there is a distorted relationship,and those where an existing attachment has been abruptly disrupted.

Boris and Zeanah use the term "disorder of attachment" to indicate a situation in which a young child has no preferred adult caregiver. Such children may be indiscriminately sociable and approach all adults, whether familiar or not; alternatively, they may be emotionally withdrawn and fail to seek comfort from anyone. This type of attachment problem is parallel to Reactive Attachment Disorder as defined in DSM.

Boris and Zeanah also describe a condition they term "secure base distortion". In this situation, the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, may cling to the adult, may be excessively compliant, or may show role reversals in which they care for or punish the adult.

The third type of disorder discussed by Boris and Zeanah is termed "disrupted attachment." This type of problem, which is not covered under other approaches to disordered attachment, results from an abrupt separation or loss of a familar caregiver to whom attachment has developed. The young child's reaction to such a loss is parallel to the grief reaction of an older person, with progressive changes from protest (crying and searching) to despair, sadness, and withdrawal from communication or play, and finally detachment from the original relationship and recovery of social and play activities.

Alternative Diagnosis of Attachment Disorder

In the absence of officially recognized diagnostic criteria, and beyond the ambit of the discourse on a broader set of criteria discussed above, the broad term attachment disorder has been increasingly used by some clinicians to refer to a broader set of children whose behavior is affected by lack of a primary attachment figure, a seriously unhealthy attachment relationship with a primary caregiver, or a disrupted attachment relationship.(Chaffin et al, 2006)

A common feature of this diagnosis is the use of extensive lists of "symptoms" which include many behaviours that are likely to be a consequence of neglect or abuse, but not related to attachment, or not related to any disorder at all.

The APSAC Taskforce Report (2006) dscribes the issues as follows;

"Many of the controversial attachment therapies have promulgated quite broad and nonspecific lists of symptoms purported to indicate when a child has an attachment disorder. For example, Reber (1996) provided a table that lists “common symptoms of RAD.” The list includes problems or symptoms across multiple domains (social, emotional, behavioral and developmental) and ranges from DSM-IV criteria for RAD (e.g., superficial interactions with others, indiscriminate affection toward strangers, and lack of affection toward parents), to nonspecific behavior problems including destructive behaviors; developmental lags; refusal to make eye contact; cruelty to animals and siblings; lack of cause and effect thinking; preoccupation with fire, blood, and gore; poor peer relationships; stealing; lying; lack of a conscience; persistent nonsense questions or incessant chatter; poor impulse control; abnormal speech patterns; fighting for control over everything; and hoarding or gorging on food. Others have promulgated checklists that suggest that among infants, “prefers dad to mom” or “wants to hold the bottle as soon as possible” are indicative of attachment problems (Buenning, 1999). Clearly, these lists of nonspecific problems extend far beyond the diagnostic criteria for RAD and beyond attachment relationship problems in general. These types of lists are so nonspecific that high rates of false-positive diagnoses are virtually certain. Posting these types of lists on Web sites that also serve as marketing tools may lead many parents or others to conclude inaccurately that their children have attachment disorders." .(Chaffin et al, 2006)

Treatment

There is a variety of evidence-based and effective prevention programs and treatment approaches for attachment disorder based on Attachment theory. Approaches with a sound evidential and theoretical base include 'Watch, wait and wonder' (Cohen et al, 1999), manipulation of sensitive responsiveness, (van den Boom 1994 and 1995), modified 'Interaction Guidance' (Benoit et al, 2001), 'Preschool Parent Psychotherapy' (Toth et al, 2002), and 'Circle of Security' (Marvin et al, 2002) and Parent-Child psychotherapy (Leiberman et al 2000). Promising treatment methods include Developmental, Individual-difference, Relationship-based therapy DIR and Floor Time by Stanley Greenspan.

There is also a considerable variety of treatments for attachment disorders diagnosed on the controversial basis outlined above, popularly known as attachment therapy. These therapies have little or no evidence base and vary from mild therapeutic work to more extreme forms of physical and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the evergreen model. In general these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new carers. Critics maintain that the link between this kind of therapy and attachment theory is at best tenuous.

See also

• Attachment theory
• Attachment therapy
• John Bowlby
• Reactive attachment disorder
• Stanley Greenspan
• Post Traumatic Stress Disorder
• Complex Post Traumatic Stress Disorder
• emotional dysregulation

Additional Reading and References

• Handbook of Infant Mental Health, edited by Charles Zeanah, MD, Guilford Press, 1993, NY.
• Handbook of Attachment: Theory, Research, and Clinical Applications, edited by Jude Cassidy, Ph.D., & Phillip Shaver, Ph. D, Guilford Press, NY (1999).
• "Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy" Child and Adolescent Social Work Journal. 12(6), December 2005.
• O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244:Taylor and Francis
• Hughes, D. (1999) Building the Bonds of Attachment, NY: Guilford Press.
• Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 3, 263–278.
• Hughes, D. (2003). Psychological intervention for the spectrum of attachment disorders and intrafamilial trauma. Attachment & Human Development, 5, 271–279.
• Holmes, J., The Search for the Secure Base, (2001), Brunner-Routledge, Philadelphia, PA.
• Bowlby, J., A Secure Base, (1988), Basic Boosk, NY.
• Briere, J., and Scott, C., (2006) Principles of Trauma Therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage.

External links

• Adoption: Attachment & Bonding
• Support for Parents - The Attachment Disorder Site
• "Association for Treatment and Training in the Attachment of Children"
• Support for Parents - The Attachment Disorder Site
• "Attachment facilitating parenting"