Attachment disorder

Overview
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 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 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 )

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 be non-attachment. (O'Connor & Zeanah, 2003 ) Diagnostic criteria have not yet been agreed. (Chaffin et al, 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 an evolutionary 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. Although an attachment is a "tie" it is not synonymous with love and affection. There are two main aspects to attachment behaviour. The first is maintaining proximity to another and the second is the specificity of the other (Bowlby 1969, p181). A disurbance of attachment indicates the absence of either or both. 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. Current official classifications under DSM-IV-TR and ICD-10 are largely based on this understanding of the nature of attachment.

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.

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 farther from the normal range, culminating in actual disorders of thought, behavior, or mood. 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 retain the basis that a disorder is such as to require treatment.

Official ICD-10 and DSM-IV-TR classifications
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; ICD-10 includes in its diagnosis psychological and physical abuse and injury in addition to neglect. This somewhat controversial, being a commission rather than ommission and because abuse of itself does not lead to attachment disorder.
 * 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.

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.

Whilst RAD is likely to occur in relation to 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. It is associated with developed, albeit disorganised attachment. 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.

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 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 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. 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.

Diagnosis
Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation procedure (Mary Ainsworth), the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA", Crittenden 1992), the Observational Record of the Caregiving Environment ("ORCE") and the Attachment Q-sort ("AQ-sort" ) More recent research also uses the Disturbances of Attachment Interview or "DAI" developed by 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. Most research will use a combination of measures.

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 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 )

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 are not related to attachment, or not related to any clinical disorder at all.

The APSAC Taskforce Report (2006) describes 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 effective prevention programs and treatment approaches for attachment disorder based on Attachment theory. All approaches concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver. 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 Parent-Child psychotherapy (Leiberman et al 2000). Other known treatment methods include 'Circle of Security' (Marvin et al, 2002) and 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.

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 caregivers. Critics maintain that the link between this kind of therapy and attachment theory is at best tenuous. Many of these therapies concentrate on changing the child rather than the caregiver. (Chaffin et al 2006 )

Additional Reading

 * Holmes, J (2001). The Search for the Secure Base. Philadelphia: Brunner-Routledge.
 * Cassidy, J; Shaver, P (eds.) (1999). Handbook of Attachment: Theory, Research, and Clinical Applications. New York: Guilford Press.
 * Zeanah, CH (ed.) (1993). Handbook of Infant Mental Health. New York: Guilford Press.
 * Bowlby, J (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. London: Routledge; New York: Basic Books. ISBN 0-415-00640-6.