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, resulting in problematic social expectations and behaviors. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about six months but before about three 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 three 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 and a child's attachment-related behaviors may be very different with one familiar adult than with another, suggesting that the disorder is within the relationship and interactions of the two people rather than an aspect of one or the other personality. [Zeanah, 2005] No list of symptoms can legitimately be presented but generally the term attachment disorder refers to the absence or distortion of age-appropriate social behaviors with adults. For example, in a toddler, attachment-disordered behavior could include a failure to stay near familiar adults in a strange environment or to be comforted by contact with a familiar person, whereas in a six-year-old attachment-disordered behavior might involve excessive friendliness and inappropriate approaches to strangers.

There are currently two main areas of theory and practice relating to the definition and diagnosis of attachment disorder, and considerable discussion about a broader definition altogether. The first main area is based on scientific enquiry, is found in academic journals and books and pays close attention to attachment theory. It is described in ICD-10 as reactive attachment disorder, or "RAD" for the inhibited form, and disinhibited attachment disorder, or "DAD" for the disinhibited form. In DSM-IV-TR both comparable inhibited and disinhibited types are called reactive attachment disorder or "RAD". 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. [ Prior & Glaser p 183] 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]

Thirdly, 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 benon-attachment. [O'Connor & Zeanah, (2003)] Agreement has not yet been reached with respect to diagnostic criteria. [ Chaffin et al p. (2006)]

Finally, the term is also sometimes used to cover difficulties arising in relation to various attachment styles which may not be disorders in the clinical sense.

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

"Attachment" and "attachment disorder"

Attachment theory is primarily an evolutionary and ethological theory. In relation to infants, it primarily consists of "proximity seeking" to an "attachment figure" in the face of threat, for the purpose of survival. [Bowlby (1970) p 181] Although an attachment is a "tie" it is not synonymous with love and affection although they often go together and a healthy attachment is considered to be an important foundation of all subsequent relationships. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time. Parental responses lead to the development of patterns of attachment which in turn lead to 'internal working models' which will guide the individual's feelings, thoughts and expectations in later relationships. [Bretherton & Munholland (1999) p 89]

In the clinical sense, a disorder is a condition requiring treatment as opposed to risk factors for subsequent disorders. [AACAP 2005, p1208] There is a lack of consensus about the precise meaning of the term 'attachment disorder' although there is general agreement that such disorders only arise following early adverse caregiving experiences. Reactive attachment disorder indicates the absence of either or both the main aspects of "proximity seeking" to an identified "attachment figure". This can occur either in institutions, or with repeated changes of caregiver, or from extremely neglectful primary caregivers who show persistent disregard for the child's basic attachment needs after the age of 6 months. Current official classifications of RAD under DSM-IV-TR and ICD-10 are largely based on this understanding of the nature of attachment.

The words "attachment style" refer to the various types of attachment arising from early care experiences, called "secure", "anxious-ambivalent", "anxious-avoidant", (all organized), and "disorganized". Some of these styles are more problematical than others, and, although they are not disorders in the clinical sense, are sometimes discussed under the term 'attachment disorder'.

Discussion of 'disorganized attachment' style sometimes includes this style under the rubric of attachment disorders because disorganized attachment is seen as the beginning of a developmental trajectory that will take the individual ever further from the normal range, culminating in actual disorders of thought, behavior, or mood. [Levy K.N. et al (2005)] Early intervention for disorganized attachment, or other problematic styles, is directed toward changing the trajectory of development to provide a better outcome later in the person's life.

Zeanah and colleagues proposed an alternative set of criteria (see below) of three categories of attachment disorder, namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". These classifications consider that a disorder is a variation that requires treatment rather than an individual difference within the normal range. [Prior & Glaser (2006) p 223]

Classification

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, and
*implicit lack of identifiable, preferred attachment figure.ICD-10 includes in its diagnosis psychological and physical abuse and injury in addition to neglect. This is somewhat controversial, being a "commission" rather than "omission" and because abuse of itself does not lead to attachment disorder.

The inhibited form is described as "a failure to initiate or respond...to most social interactions, as manifest by excessively inhibited responses" and such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain 'proximity', an essential element of attachment behavior. The disinhibited form shows "indiscriminate sociability...excessive familiarity with relative strangers" (DSM-IV-TR) and therefore a lack of 'specificity', the second basic element of attachment behavior. The ICD-10 descriptions are comparable. 'Disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in the same child. The inhibited form has a greater tendency to ameliorate with an appropriate caregiver whilst the disinhibited form is more enduring. [Prior & Glaser 2006, p. 220-221.]

Whilst RAD is likely to occur following neglectful and abusive childcare, there should be no automatic diagnosis on this basis alone as children can form stable attachments and social relationships despite marked abuse and neglect. Abuse can occur alongside the required factors but on its own does not explain attachment disorder. Experiences of abuse are associated with the development of disorganised attachment, in which the child prefers a familiar caregiver, but responds to that person in an unpredictable and somewhat bizarre way. Within official classifications, attachment disorganization is a risk factor but not in itself an attachment disorder. Further although attachment disorders tend to occur in the context of some institutions, repeated changes of primary caregiver or extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, not all children raised in these conditions develop an attachment disorder. [Prior & Glaser (2006) p218-219]

Boris and Zeanah's typology

Many leading attachment theorists, such as Zeanah 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 its 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 (2006) p 86]

Boris and Zeanah (1999), [Boris & Zeannah (1999)] have offered an approach to attachment disorders that 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. This would significantly extend the definition beyond the ICD-10 and DSM-IV-TR definitions because those definitions are limited to situations where the child has no attachment or no attachment to a "specified" attachment figure.

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 and ICD in its inhibited and disinhibited forms as described above.

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 familiar 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.

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. [ Mercer, J (2006) p 107 ] 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. [VanIJzendoorn & Bakermans-Kranenburg (2003)] Disorganized patterns of attachment have the strongest links to concurrent and subsequent psychopathology, and considerable research has demonstrated both within-the-child and environmental correlates of disorganized attachment. [Zeanah et al (2003)]

Diagnosis

Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation procedure (Mary Ainsworth), [Ainsworth (1978), ] [Main & Solomon (1986), pp.95-124.] [Main & Solomon (1990), pp. 121-160.] the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA"), [Crittenden (1992)] the Observational Record of the Caregiving Environment ("ORCE") [National Institute of Child Health and Human Development(1996)] and the Attachment Q-sort ("AQ-sort"). [Waters and Deane (1985)] More recent research also uses the Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah, (1999). [Smyke and Zeanah (1999)] This is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely having a discriminated, preferred adult, seeking comfort when distressed, responding to comfort when offered, social and emotional reciprocity, emotional regulation, checking back after venturing away from the care giver, reticence with unfamiliar adults, willingness to go off with relative strangers, self endangering behavior, excessive clinging, vigilance/hypercompliance and role reversal.

Alternative diagnosis

In the absence of officially recognized diagnostic criteria, and beyond the ambit of the discourse on a broader set of criteria discussed above, the term attachment disorder has been increasingly used by some clinicians to refer to a broader set of children whose behavior may be 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) p 81] Although there are no studies examining diagnostic accuracy, concern is expressed as to the potential for over-diagnosis based on broad checklists and 'snapshots'. [ Chaffin et al (2006) p 82]

A common feature of this form of diagnosis within attachment therapy is the use of extensive lists of "symptoms" which include many behaviours that are likely to be a consequence of neglect or abuse, but are not related to attachment, or not related to any clinical disorder at all. Such lists have been described as "wildly inclusive". [Prior & Glaser (2006) p186-187 ] The APSAC Taskforce (2006) gives examples of such lists ranging across multiple domains from some elements within the DSM-IV criteria to entirely non-specific behavior such as developmental lags, destructive behaviors, 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. Some checklists suggest that among infants, “prefers dad to mom” or “wants to hold the bottle as soon as possible” are indicative of attachment problems. The APSAC Taskforce expresses concern that high rates of false positive diagnoses are virtually certain and that 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 (2006) p 82 ]

Treatment

There is a variety of mainstream prevention programs and treatment approaches for attachment disorder, attachment problems and moods or behaviors considered to be potential problems within the context of attachment theory. All such approaches for infants and younger children concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver. [Prior & Glaser (2006), p. 231.] [AACAP (2005) p. 17-18.] [BakermansKranenburg "et al." (2003) A meta-analysis of early interventions.] Such approaches include 'Watch, wait and wonder,' [Cohen "et al." (1999)] manipulation of sensitive responsiveness, [van den Boom (1994)] [van den Boom (1995)] modified 'Interaction Guidance,'. [ Benoit "et al." (2001)] 'Preschool Parent Psychotherapy,'. [Toth "et al." (2002)] 'Circle of Security', [Marvin et al (2002)] [Cooper et al (2005)] Attachment and Biobehavioral Catch-up (ABC), [Dozier "et al" (2005)] the New Orleans Intervention, [Larrieu & Zeanah (1998)] [Larrieu & Zeannah (2004)] [Zeannah & Smyke (2005)] and Parent-Child psychotherapy. [Leiberman "et al." (2000), p. 432.] Other known treatment methods include Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as "Floor Time") by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders [Interdisciplinary Council on Developmental & Learning Disorders. (2007). [http://www.icdl.com/dirFloortime/overview/index.shtml Dir/floortime model] .] Some of these approaches, such as that suggested by Dozier, consider the attachment status of the adult caregiver to play an important role in the development of the emotional connection between adult and child. This includes foster parents as children with poor attachment experiences often do not elicit appropriate caregiver responses from their attachment behaviors despite 'normative' care. [Dozier "et al" (2005)]

There is also a considerable variety of treatments for alleged attachment disorders diagnosed on the controversial alternative basis outlined above, popularly known as attachment therapy. These therapies have little or no evidence base and vary from talking or play therapies 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 caregivers. Critics maintain these therapies are not based on an accepted version of attachment theory. [Prior & Glaser (2006) p 262 ] The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasise obedience and parental control. [Chaffin "et al." 2006, p. 79–80. The APSAC Taskforce Report.] These therapies concentrate on changing the child rather than the caregiver. [ Chaffin et al (2006) p 79] An estimated six children have died as a consequence of the more coercive forms of such treatments and the application of the accompanying parenting techniques. [Boris 2003] [Mercer, Sarner & Rosa 2003] [Zeanah 2003]

Possible mechanisms

One study has reported a connection between a specific genetic marker and disorganized attachment (not RAD) associated with problems of parenting.
*cite journal |author=Zeanah CH, Keyes A, Settles L |title=Attachment relationship experiences and childhood psychopathology |journal=Ann. N. Y. Acad. Sci. |volume=1008 |issue= |pages=22–30 |year=2003 |pmid=14998869|doi=10.1196/annals.1301.003|url=http://www.annalsnyas.org/cgi/pmidlookup?view=long&pmid=14998869
* Zeanah, C., H. and Smyke, A., T. "Building Attachment Relationships Following Maltreatment and Severe Deprivation" In Berlin,L.,J., Ziv, Y., Amaya-Jackson, L. and Greenberg, M., T. "Enhancing Early Attachments; Theory, research, intervention, and policy" The Guilford Press, 2005 pps 195-216 ISBN 1593854706 (pbk)