Attachment Disorders

Attachment disorders have been described in the psychological and psychiatric literature for approximately 50 years.[1, 2, 3, 4, 5] These disorders are the psychological result of negative experiences with caregivers, usually since infancy, that disrupt the exclusive and unique relationship between children and their primary caregiver(s). Oppositional and defiant behaviors may be the result of disruptions in attachment.

Many children experience the loss of primary caregivers, either because they are physically separated from them or because the caregiver is incapable of providing adequate care. Removal from primary caregivers can cause serious problems by breaking primary attachments, even if alternate caregivers are competent.

Attachment refers to a set of behaviors and inferred emotions that can be observed in infants. Humans need attachments with others for their psychological and emotional development, as well as for their survival. Early manifestations of attachment include the unique and exclusive relationship between infants and their parents. Parents and infants establish a continuous relationship that has specific features, and the quality of this relationship colors the child’s relationships for the rest of his or her life.

Both caregivers and infants have biologic preprogrammed instinctive equipment that serves to foster their relationship. Most people have a strong attraction to and desire to care for babies. In addition, a baby’s crying and clinging reinforce his or her efforts to obtain care and attention. Parents also have instinctive behaviors, such as soothing a crying infant, caressing the infant, making sounds that appeal to the infant, and mirroring the infant (ie, playfully imitating the baby’s facial expressions), all of which trigger tenderness and a caregiving instinct.

Attachment develops in infants through repeatedly being looked after and appropriately responded to by caregivers and thereby being convinced that someone is available to soothe, console, and comfort them. Infants may become attached to others who have a consistent presence in their lives; however, it is their relationship with the primary caregiver(s) that plays the most critical role in determining the basis for future attachments. Primary attachment figure(s) cannot suddenly be replaced, because that relationship is unique and stable.

The nature and quality of early attachments provide the basis on which children develop an internal working model of relationships that serves as a template for future relationships. These working models of relationships can be positive (eg, people can be trusted, confided in, or helpful in distress) or negative (ie, no one can be trusted, no one cares, and no one is available to offer help or support).

Babies internalize their parents (and other attachment figures) as a secure base. This allows them to feel safe internally and to explore the world around them with confidence. It also allows them to experience positive interpersonal exchanges with other children. Infants can then return to the caregiver to refuel emotionally before proceeding with further exploration.

Diagnostic criteria (DSM-5)

In the American Psychiatric Association’sDiagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), reactive attachment disorder (RAD) was a single diagnosis with 2 subtypes, emotionally withdrawn/inhibited and indiscriminately social/disinhibited. In the fifth edition of the manual (DSM-5), however, these subtypes are defined as distinct disorders—namely, RAD and disinhibited social engagement disorder (DSED), respectively.[6]

DSM-5 requires social neglect (defined as an absence of adequate caregiving during childhood) for a diagnosis of either RAD or DSED. Their common etiology notwithstanding, the 2 disorders are expressed in distinct ways. RAD is expressed as an internalizing disorder with depressive symptoms and withdrawn behavior, whereas DSED is expressed through disinhibition and externalizing behavior.

In RAD, the child does not initiate and respond to social interactions in a developmentally appropriate manner. RAD is a disorder of nonattachment and is related to loss of the primary attachment figure and lack of opportunity to establish a new attachment with a primary caregiver. A nonattachment disorder may also develop if the baby never had the opportunity to develop at least 1 attachment with a reliable caregiver who was continuously present in the baby’s life.[7, 8, 9]

The specific DSM-5 diagnostic criteria for RAD are as follows:

• A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following: (1) the child rarely or minimally seeks comfort when distressed and (2) the child rarely or minimally responds to comfort when distressed

• A persistent social and emotional disturbance characterized by at least 2 of the following: (1) minimal social and emotional responsiveness to others, (2) limited positive affect, and (3) episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers

• The child has experienced a pattern of extremes of insufficient care as evidenced by at least 1 of the following: (1) social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults; (2) repeated changes of primary caregivers that limit opportunities to form stable attachments (eg, frequent changes in foster care); and (3) rearing in unusual settings that severely limit opportunities to form selective attachments (eg, institutions with high child-to-caregiver ratios)

• The care described in the third criterion is presumed to be responsible for the disturbed behavior described in the first criterion (eg, the disturbed behavior began after the inadequate care)

• The criteria for autism spectrum disorder are not met

• The disturbance is evident before age 5 years

• The child has a developmental age of at least 9 months

In DSED, the child participates in diffuse attachments and exhibits indiscriminate sociability and excessive familiarity with strangers. The child has repeatedly lost attachment figures or has had multiple caregivers and has never had the chance to develop a continuous and consistent attachment to at least 1 caregiver. Disruption of successive attachment relationships causes the infant to renounce attachments altogether.

Infants and children with DSED do not manifest the usual anxiety and concern with strangers, and they superficially accept anyone as a caregiver (as though people were interchangeable) and act as if the relationship had been intimate and lifelong. The social impulsivity of this disorder is different from the global impulsivity of attention-deficit/hyperactivity disorder (ADHD).

The specific DSM-5 diagnostic criteria for DSED are as follows:

• A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least 2 of the following: (1) reduced or absent reticence in approaching and interacting with unfamiliar adults; (2) overly familiar verbal or physical behavior (inconsistent with culturally sanctioned and age-appropriate social boundaries); (3) diminished or absent checking-back with adult caregivers after venturing away, even in unfamiliar settings; and (4) willingness to go off with an unfamiliar adult with minimal or no hesitation

• The behaviors described in the first criterion are not limited to impulsivity (as in in ADHD) but also include socially disinhibited behavior

• The child has experienced a pattern of extremes of insufficient care, as evidenced by at least 1 of the following: (1) social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults; (2) repeated changes of primary caregivers that limit opportunities to form stable attachments (eg, frequent changes in foster care); and (3) rearing in unusual settings that severely limit opportunities to form selective attachments (eg, institutions with high child-to-caregiver ratios)

• The care described in the third criterion is presumed to be responsible for the disturbed behavior described in the first criterion (eg, the disturbed behavior began after the inadequate care)

• The child has a developmental age of at least 9 months.

With both RAD and DSED, if the disorder has been present for longer than 12 months, it is specified as persistent; if the child exhibits all the symptoms of RAD or DSED, with each symptom manifesting at relatively high levels, the disorder is further specified as severe.

Reactive attachment disorder

If caregivers are not reliably or consistently present or if they respond in an unpredictable and uncertain way, infants cannot establish a pattern of confident expectation. One result is insecure attachment, or a less-than-optimal internal sense of confidence and trust in others, beginning with caregivers. The child then uses psychological defenses (eg, avoidance or ambivalence) to avoid disappointments with the caregiver. This process is thought to contribute to a negative working model of relationships that leads to lifelong insecurity.

Disinhibited social engagement disorder

Young children exposed to multiple caregivers simultaneously or sequentially do not easily experience the sense of security associated with unique and exclusive longstanding relationships. They have no opportunity to learn to trust 1 person, because all of their past relationships have been interrupted, disrupted, or consistently unreliable.

Children with DSED resort to psychological defense mechanisms (eg, relying only on themselves and not expecting to be soothed, cared for, or consoled by adults) to survive. Instead of relying on one person, they inhibit any sense of fear or loneliness and develop a pseudocomfort with whoever is available. These children are thought to suppress the conscious experience of fear only as a result of a psychological defense. They are afraid of trusting anyone and being further disappointed. This pattern can continue into adult life and adversely affect adult relationships.

Attachment disorders independent of DSM-5

In reversed attachment, the child becomes the source of comfort to the parent, who is insecure and vulnerable. The usual relationship is inverted, and it is the infant who, though unable to reassure the parent completely, provides the security in the relationship.

In angry attachment, a strong relationship exists between parent and infant that is unique and exclusive; however, the relationship is marked by angry features and exchanges. The dyad members are angry with each other but not with other people around them.

Mary Ainsworth developed an attachment classification based on the behavior of infants (typically aged 10-13 months) in the presence of a stranger during and after a short separation from their primary caregivers.[10] This classification distinguishes between secure and insecure attachments as follows:

• Behavioral patterns associated with secure attachments include some distress at separation, preference for a parent over a stranger, and a search for comfort from the parent upon reunion

• Behavioral patterns associated with insecure attachments, such as avoidant and ambivalent styles, include lack of distress upon separation and avoidance of, or anger toward, the mother upon reunion

Approximately 65% of American middle-class children are thought to have secure attachments with primary caregivers, whereas 35% exhibit an insecure attachment style. Not all children who show an insecure attachment to primary caregivers are diagnosed with a disorder; in some cases, they did not receive pathologic care, and in others, their insecure attachment was not severe.

The lack of a secure attachment style affects the child throughout life. It must be kept in mind, however, that an insecure attachment should not be equated with a disorder. The Ainsworth attachment classification yields only a suggestion of a child’s internal state; it is not a diagnostic tool for attachment disorders.

Multiple situations can lead to attachment disorders.

Young children with RAD, who typically have been exposed to multiple caregivers simultaneously or sequentially, do not easily experience the sense of security associated with unique and exclusive long-standing relationships. They have had no opportunity to learn to trust a primary caregiver, because their past relationships were interrupted, disrupted, or consistently unreliable. The following factors are relevant:

• Gross neglect

• Gross insensitivity in the caregiver

• Abandonment by caregiver at the peak of attachment needs (end of first year of life)

• Repeated abandonment by caregiver

DSED is the most common type of attachment disturbance in clinical settings. Many children with DSED have been placed in multiple foster homes or have lived with different relatives. Their parents are unable to create a sense of permanency in their lives; many of the parents experience legal problems, engage in illegal drug use, abuse alcohol, or have personality disturbances, which make them unable to provide stability for the child. The following factors are relevant:

• Multiple caregivers, either sequentially or concurrently

• Multiple disruptions in attachment relationships

• Several changes in foster home placement

Risk factors

Risk factors for attachment disorders are the same as those associated with poor parenting, maltreatment, and neglect. A number of psychosocial factors place some children at particular risk—for example, caregivers who abuse drugs, who have multiple unmanageable stressors, or who have been maltreated or have experienced multiple attachment disruptions themselves. Genetic factors are also significant.[11]

United States statistics

No epidemiologic studies of frequency or prevalence of attachment disorders in children exist; however, statistical data regarding adoptions and foster care placement are available. On the basis of such data, it may be possible to estimate approximately how many children have attachment disorders. According to DSM-5, the prevalence of RAD in high-risk populations (ie, children severely neglected and placed in foster care or institutions) is less than 10%, and the prevalence of DSED in these populations is about 20%.[6]

International statistics

International data are sparse. Many children (eg, certain children from Romania and China) have lived in orphanages for most or all of their lives and have had little opportunity for attachment, or else have lived in bleak conditions with multiple caregivers and are emotionally and cognitively deprived. In such environments, it can be difficult to determine exactly what causes a child to have difficulties in relating and communication, in development of trust, and in linguistic and cognitive development.

Age-, sex-, and race-related demographics

The onset of attachment disorders comes before the age of 5 years. Typically, the disorder has its roots in infancy. The more serious effects of disruptions in attachment relationships tend to persist and manifest themselves in the preschool and school years. In more muted forms (eg, mistrust and difficulties in establishing supportive, sensitive, and intimate relationships), they last into adolescence and adulthood.

No information in the scientific literature suggests that attachment disorders have a sexual predilection. No evidence suggests a greater prevalence of attachment disorders in a particular racial or ethnic group, except in specific countries with unusual child care practices.

Without treatment and new attachments, the child’s chances of achieving normal emotional development, building trusting relationships, and experiencing and tolerating intimacy and closeness with other human beings is very poor.

Children with attachment disorders are difficult to parent, to teach, and to befriend. As a result, these children are likely to have additional problematic experiences that will complicate attempts to heal. The basic problems that led to the attachment disorder in the first place (eg, abuse and abandonment by parents because of substance abuse, emotional problems, and stress) tend to give rise to other problems for the child, including poor medical care and injuries.

A frequent concern of potential adoptive parents or caregivers is deciding when the child is unable to develop a new attachment or to warm up to new caregivers after multiple past disruptions. After the first few months of life, concerns arise as to whether forming an attachment to a new person as well as the old one is possible.

During the school years, establishing a close and intimate bond with a new caregiver or family seems possible. Of course, the new attachment is a complex phenomenon determined by multiple factors, such as the child’s temperament, previous experiences with caregivers, the nature of the new parents, and how sensitively the new caregivers deal with the problem.

Rene Spitz noted that children in orphanages were prone to physical illness and had decreased appetites. They exhibited some stereotyped movements, self-stimulation, and an empty look in the eyes. They lacked normal responses of interest when people came close. They cried vaguely or softly many times a day and seemed unhappy. Many of these children seemed depressed and unresponsive to initiatives for interaction, as if resigned to affective deprivation. They children also had a much higher mortality than noninstitutionalized peers.

For reactive attachment disorder (RAD), there must be a history of gross neglect, lack of contingent responses, and little or no attention, interaction, and affection. For disinhibited social engagement disorder (DSED), there must be a history of multiple caregivers, sequential changes in caregiver, disrupted relationships, and placement with different people for long periods. The child does not develop preferential attachments and secure base behavior toward 1 person but instead develops an undifferentiated closeness with anyone who approaches.

Symptoms of RAD may include the following:

• Failure to thrive

• Poor hygienic condition

• Underdevelopment of motor coordination and a pattern of muscular hypertonicity because of diminished holding

• Bewildered, unfocused, and understimulated appearance

• Blank expression, with eyes lacking the usual luster and joy

• No evidence of the usual responses to interpersonal exchanges - Appearance of not knowing body language; failure to pursue, initiate, or follow up on cues for an exchange or interaction; no exploration of another person’s face or facial expression; no approach to or withdrawal from another person; avoidance of eye contact and protesting or fussing if a person comes too close or attempts to touch or hold them

Symptoms of DSED may include the following:

• Instead of caution, excessive familiarity or psychological promiscuousness with unknown persons

• Readiness to give hugs to anyone who approaches and to go with that person if asked

• Willingness to approach a complete stranger for comfort or food, to be picked up, or to receive a toy

No specific physical signs of attachment disorder exist. Nevertheless, indirect indicators may be present, such as the following:

• Signs of physical maltreatment, such as old fractures or bruises

• Effects of undernutrition and rashes resulting from failure to change diapers frequently

• A syndrome characterized by excessive appetite in children who have been in several foster homes

• Excessive appetite and excessive thirst in children who experience severe stress

• Flattened back of the head as a result of being left in bed much of the time

• Growth retardation (in severe cases)

Children who have experienced multiple losses and who have developed attachment problems tend to engage in defiant behavior, to be uncooperative with adults, to experience pervasive anger and resentment, and to develop an exploitative attitude toward other people.

Persistence of the nonattachment or the superficial exploitation of people, commonly accompanied by fear of closeness and intimacy, is a major complication. When children become parents, they may transmit difficulties in attachment to their own children (eg, by being emotionally insensitive or unavailable) and thus perpetuate an intergenerational cycle of problems.

Children who have experienced multiple disruptions in placements and have witnessed violence may develop conduct disorder, experience difficulties in social settings, or be prone to antisocial behavior because they lack empathy and adequate exposure to appropriate models of coping and caring behavior.

Children who have experienced disrupted attachments face academic difficulties related to maltreatment and to mistrust of adults. Academic difficulties may also be related to attention problems and hyperarousal associated with posttraumatic stress. Additionally, the child may have learning disabilities and language difficulties as a consequence of genetic loading or exposure to drugs in utero.[12, 13] These disabilities may have led to the problems the parents had in caring for their child in the first place.

Even without all of those challenges, children with multiple placements and disruptions in their living situations are at risk for academic difficulties. A specific educational program designed to address those needs is necessary. If the child is a ward of the state and the school system does not promptly and appropriately respond, state-supported legal assistance is usually available to enforce compliance with federally mandated educational assessment and management.

No laboratory studies yield results that are directly relevant to attachment disorders. Studies related to neglect and nutritional deprivation (eg, anemia caused by iron deficiency or a high level of lead caused by pica) exist. No imaging studies are used to diagnose attachment disorders. No specific histologic findings are related to attachment disorders.

An appropriate treatment program for a child with multiple challenges requires the participation of several specialists.

Most of the treatment for reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) is provided by primary caregivers (eg, parents or substitute parents) in their everyday interactions with the child. Ideally, these caregivers can rely on the expertise and advice of a mental health professional who is aware of the emotional needs of children, the phenomenology of attachment disruptions, and the need to repair and recreate the sense of security in the child. Referral to a mental health professional may be critical.

Pharmacologic treatment may be helpful for ancillary problems but not for the attachment disorders themselves. No specific diet is indicated; however, many children who have experienced disruptions and early neglect also have feeding disorders and may require treatment. Also, some children may have excessive appetite and thirst.

Play therapy with a child psychotherapist, particularly in the presence of the primary caregivers, may help the child express emotional needs, fears, and anxieties in the context of play. Caregivers may become more sensitive to the issues faced by their child (eg, anger about having been abandoned, maltreated, left alone, or locked up). Also, children may be able to express their dependency needs (eg, to be a baby, to be looked after, or to be soothed) through play.

Several therapeutic ingredients seem to be important in the treatment of RAD and DSED. When caregivers provide these ingredients, the child may experience healthy dependency, come to rely on someone, and begin trust a new person. In other words, the child may become attached. These therapeutic ingredients include the following:

• Security

• Stability

• Sensitivity

Security, or a sense of psychological safety, helps promote the development of a new attachment relationship. Constant or intense stress and anxiety do not facilitate a sense of security; rather, they promote guarding behavior.

To correct the scars or sequelae of attachment disruption, the clinician, parent, or caregiver must have time and be ready to listen to the child without judging. Limits must be set for the child, but these should be set in the context of empathy and compassion. Only when verbal children feel emotionally secure will they begin talking about what has happened to them (and, probably, to their siblings) and gradually develop trust in the new caregiver.

Stability refers to the permanence of the attachment figure. It takes time for a child to develop trust in a new primary caregiver. After experiencing disruption, children need to learn to recognize their needs and to understand that these needs can be met repeatedly by the same person. It is common for these children to fear that the caregiver will disappear, die, or go away, thus giving rise to another disruption.

Some children take a long time (>1 y) to trust a caregiver again; others trust a caregiver after receiving just a few months of sensitive care. This may be a temperamental feature (eg, orientation toward others versus inwardness) or a reflection of the quality of the match between the child and the new caregiver. Separations and disruptions may reactivate a defensive isolation on the part of the child.

Sensitivity, or emotional availability, refers to attentiveness to the child’s needs. Substitute caregivers should be informed that although the child may or may not be mature cognitively, his or her emotional development is frequently delayed in areas such as emotional expression, attachment, and age-appropriate independence. This delayed development makes emotional availability on the part of the caregiver especially important.

Ideally, over the course of treatment, the child will gradually begin to develop feelings of dependency toward the primary caregiver once he or she learns to expect that the caregiver will be physically and emotionally available at times of crisis. During this process, parents should be cautioned to expect and tolerate occasional regressive behaviors and to view them as signs that the child is psychologically working through earlier phases in development.

For instance, a child who is typically independent and suspicious of others may suddenly express needs for dependency, report fears, want to sleep in the parents’ bed, and wish to be mommy’s little boy or girl. In such cases, the parents should, in a sensitive way, allow the child to express and experience that dependency. It is helpful to encourage parents to think of the child, for the time being, as emotionally younger and as having legitimate emotional needs appropriate for his or her emotional age.

Some children are almost frozen emotionally because with multiple placements and relationships, expressing age-appropriate emotions has not been safe for them. At first, these children might appear to be obedient because they do not express anger and are not prone to emotional outbursts. As time goes by, however, children may start to feel that they can safely express emotions such as anger, jealousy, and neediness, and they may begin to direct temper outbursts, jealousy, and anger toward caregivers upon separation.

In this scenario, things that previously seemed not to matter to the child (eg, whether the caregiver comes or goes) may suddenly become highly upsetting. For example, a child who never seemed to mind separations may strongly protest the parent’s leaving by clinging or going to the parent for comfort. Caregivers should see these behaviors as positive signs that a new attachment and a deeper level of trust have formed because the child now feels safe enough to be able to express his or her developmentally appropriate dependency needs.

No specific pharmacologic treatment exists for RAD or DSED. However, psychopharmacologic agents may be used to address associated problems such as explosive anger, hyperactivity, and difficulty in focusing or sleeping. These agents are used at similar doses and with the same objectives as in other psychological disorders. The ancillary problems are treated with a view to promoting the optimal psychosocial functioning of the child; it should be kept in mind that pharmacotherapy does not specifically address the attachment disorders themselves.

There is no specific indication for inpatient treatment of patients with attachment disorders. Occasionally, however, children (in particular, adolescents) may need to be hospitalized for a time so that issues such as mistrust or lack of emotional involvement with others can be addressed.

For instance, an adolescent who has been through multiple placements, foster homes, or group homes may benefit from a period of inpatient treatment, which may help him or her face fears of becoming close to any person.[15] In-hospital therapy may also help a child work on overcoming the fear of acknowledging dependency needs and the fear of acknowledging desires for attention and affection.

Unfortunately, intermediate- or long-term hospitalization for attachment disorders is no longer available in today’s economic climate. Day hospital care, partial hospital care, and residential care in a placement skilled in treating very disruptive, poorly attached children may be suitable alternatives.

Preventive efforts are essential. Providing support and safe environments to stressed families and single parents is crucial for helping children to have a good early experience and to form appropriate bonds. This is preferable to removal. It is important for child welfare services and the courts to understand that removing a child from parents does harm and is not a benign intervention.

Specialists should be consulted about particular problems that may be associated with experiences of detachment and neglect (eg, excessive eating and drinking), as follows:

• Endocrinologist or nutritionist for short stature and malnourishment

• Pediatric gastroenterologist to rule out gastroenterologic problems

Over the longer term, child therapy and relational therapy (eg, parent-child or parent-infant) may be useful for many children and caregivers. In particular, new caregivers may need considerable emotional support to deal with challenging and difficult behaviors in their children.

Caregivers may struggle with disciplining the child while trying to foster the child’s ability to relate and trust. Establishing a positively oriented and developmentally appropriate behavioral management program is important for avoiding further punishment or prolonged abandonment in excessive time-outs. In the context of relational play, or narrative therapy, the child can develop a theme that describes what is in his or her mind.