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All About Attachment Disorder: An Overview

Attachment disorders are the psychological result of negative experiences with caretakers, usually since infancy, that disrupt the exclusive and unique relationship between kids and their primary caretaker(s). Oppositional and defiant behaviors may be the result of disruptions in attachment.

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

Attachment disorders have been described in the psychological and psychiatric literature for approximately 50 years. The condition Rene Spitz called anaclitic depression is now considered an attachment disorder. Spitz observed young kids in an orphanage who were fed and kept clean and were initially in good physical condition but who received no consistent affection from a sole caretaker. The long-standing absence of emotional warmth took an enormous toll on the kids, primarily on their emotional development but also on their physical growth and development condition. Spitz concluded that providing only for a baby's physical needs is not sufficient for normal development.

A short while later, John Bowlby, a psychoanalyst interested in the parallels between human babies and animal babies, incorporated Harlow's research on rhesus monkeys into his study of the youngster's tie to its mother. He concluded that separations during the first few months of life negatively impact a baby's psychic organization and that separation from a parental figure causes separation anxiety.

In a film entitled A-Two-Year-Old Goes to Hospital, Bowlby shows that a baby goes through several phases in reaction to separation. The baby goes from protest to crying to a sad state and, finally, to a more desolate state of resignation regarding the loss.

Bowlby, the father of attachment theory, produced a report for the World Health Organization (WHO) highlighting the importance of parental sensitivity in adequate child development. Parental sensitivity refers to the ability of a mom or dad to read internal states and emotions in his or her baby and to respond to them in a positive and supportive manner.

Attachment refers to a set of behaviors and inferred emotions that can be observed in babies. 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 a baby and its moms & dads. Moms & dads and babies establish a continuous relationship that has specific features. The quality of this relationship colors the individual's relationships for the rest of his or her life.

Both caretaker and baby have biological preprogrammed instinctive equipment to foster their relationship. Most individuals have a strong attraction and desire to care for babies. In addition, a baby's crying and clinging (signaling behaviors) reinforce the baby's efforts to obtain care and attention. Moms & dads also has instinctive behaviors, such as soothing the crying baby, caressing it, making sounds that are appealing to the baby, and mirroring the baby (i.e., playfully imitating the baby's facial expressions), all of which trigger tenderness and a maternal instinct.

Attachment develops through repeatedly being looked after and appropriately responded to by the caretaker. This convinces the baby and young child that an individual is available to soothe, console, and comfort. Babies may develop attachments to other individuals who are consistent in their lives; however, the relationship with the primary caretaker(s) plays the most critical role in determining the youngster's basis for future attachments. The attachment figure(s) cannot suddenly be replaced by any other caretaker because that relationship is unique and stable.

Based on the nature and quality of early attachments, kids develop an internal working model of relationships that serves as a template for future relationships. These working models of relationships can be positive (i.e., individuals can be trusted, confided in, helpful in distress) or negative (i.e., no one can be trusted, individuals are not caring, one is all alone in the world). Babies internalize their moms & dads (and other attachment figures) as a secure base. This allows babies to feel internally safe and to confidently explore the world around them. It also allows them to experience positive interpersonal exchanges with other kids. The baby can come back to the caretaker to refuel emotionally before proceeding with further explorations.

Reactive attachment disorder—

Reactive attachment disorder (RAD), as defined by the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), requires etiologic factors, such as gross deprivation of care or successive multiple caretakers, for diagnosis.
  • In dis-inhibited RAD, the youngster participates in diffuse attachments, indiscriminate sociability, and excessive familiarity with strangers. The youngster has repeatedly lost attachment figures or has had multiple caretakers and has never had the chance to develop a continuous and consistent attachment to at least one caretaker. Disruption of one attachment relationship after another causes the baby to renounce attachments. The usual anxiety and concern with strangers is not present, and the baby or youngster superficially accepts anyone as a caretaker (as though individuals were interchangeable) and acts as if the relationship had been intimate and life-long.
  • In inhibited RAD, the youngster does not initiate and respond to social interactions in a developmentally appropriate manner. It is a disorder of nonattachment and is related to the loss of the primary attachment figure and the lack of opportunity for the baby to establish a new attachment with a primary caretaker. Also, a nonattachment disorder may develop because the baby never had the opportunity to develop at least one attachment with a reliable caretaker who was continuously present in the baby's life.

Attachment disorders independent of DSM-IV –
  • In angry attachment, a strong relationship exists between mom or dad and baby 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 individuals around them.
  • In reversed attachment, the youngster becomes the source of comfort to the mom or dad, who is insecure and vulnerable; the relationship is inverted and the baby, although unable to reassure the parent completely, provides the security.

Mary Ainsworth developed an attachment classification based on the behavior of babies (typically aged 10-13 mo) in the presence of a stranger during and after a short separation from their primary caretakers.
  • Approximately 65% of American middle-class kids are thought to have secure attachments with primary caretakers, whereas 35% exhibit an insecure attachment style. Not all kids who show an insecure attachment to primary caretakers are diagnosed with RAD, either because they did not receive pathological care or because their insecure attachment is not severe. The lack of a secure attachment style affects the youngster throughout life; however, an insecure attachment should not be confused with a disorder. The Ainsworth attachment study is only a suggestion of an internal state of the youngster. It is not a diagnostic tool for attachment disorders.
  • Behavioral patterns associated with insecure attachments, such as avoidant and ambivalent styles, include lack of distress upon separation and avoidance of, or anger toward, mother upon reunion.
  • Behavioral patterns associated with secure attachments include some distress at separation, preference for a mom or dad over a stranger, and a search for comfort from the mom or dad upon reunion.

Pathophysiology—

Inhibited RAD:

If caretakers are not reliably or consistently present or if they respond in an unpredictable and uncertain way, babies are not able to 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 caretakers. The kid then uses psychological defenses (e.g., avoidance or ambivalence) to avoid disappointments with the caretaker. This is thought to contribute to a negative working model of relationships that leads to insecurity for the rest of the youngster's life.

Dis-inhibited RAD:

Young kids exposed to multiple caretakers simultaneously or sequentially do not easily experience the sense of security associated with unique and exclusive long-standing relationships. No opportunity exists to trust one individual because past relationships were interrupted, disrupted, or consistently unreliable. Kids with dis-inhibited attachment resort to psychological defense mechanisms (e.g., relying only on themselves and not expecting to be soothed, cared for, or consoled by adults) to survive. Instead of relying on one individual, any sense of fear or loneliness is inhibited and the kids develop a pseudo-comfort with whoever is available. The youngster is thought to suppress the conscious experience of fear only as a result of a psychological defense. The youngster is afraid of trusting anyone and being further disappointed. This pattern can continue into adult life and adversely affect adult relationships.

Frequency—

United States:

No epidemiologic studies of frequency or prevalence of attachment disorders in kids exist; however, statistical data regarding adoptions and foster care placement are available. One might estimate, based on the number of foster care placements and disruptions in relationships, approximately how many kids can have attachment disorders.

International:

Many kids, examples being certain kids from Romania and China, have lived in orphanages and have had little opportunity for attachment or they have lived in bleak conditions with multiple caretakers and are emotionally and cognitively deprived. In the midst of such deprivation and so many disruptions in relationships, determining exactly what causes a youngster to have difficulties in relating and communicating, in development of trust, and in linguistic and cognitive development can be difficult.

Race:

No evidence suggests greater prevalence of attachment disorders in a particular racial or ethnic group unless as noted above in specific countries with unusual youngster care practices.

Sex:

No information in the scientific literature suggests a sex predilection exists.

Age:

Onset of attachment disorders is in kids younger than 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 (e.g., mistrust and difficulties in establishing supportive, sensitive, and intimate relationships), they last into adolescence and adulthood.

Clinical—

History:

Rene Spitz noted that the kids in the orphanage were prone to physical illness and had decreased appetites. They exhibited some stereotyped movements, self-stimulation, and an empty look in their eyes. They lacked normal responses of interest when individuals came close. They cried vaguely or softly many times a day and seemed unhappy. Many of these kids seemed depressed and unresponsive to initiatives for interaction, as if they were resigned to their situation of affective deprivation. These kids also had a much higher mortality rate than non-institutionalized pediatric populations.

A history of gross neglect, lack of contingent responses, and little or no attention, interaction, and affection are required to establish a diagnosis of inhibited RAD. For a diagnosis of dis-inhibited RAD, a history of multiple caretakers, sequential changes in caretaker, disruptions in relationships, and placement with different individuals for considerable periods must exist. The youngster does not develop preferential attachments and secure base behavior toward a specific individual but instead develops an undifferentiated closeness with anyone who approaches the youngster.

1. Inhibited RAD-
  • Blank expression, with eyes lacking the luster and joy that is usually observed
  • Failure to thrive
  • May appear bewildered, unfocused, and under-stimulated
  • No evidence of the usual responses to interpersonal exchanges
  • Poor hygienic condition
  • Underdevelopment of motor coordination and a pattern of muscular hyper-tonicity because of diminished holding
  • Appearance of not knowing body language
  • Does not approach or withdraw from another individual
  • Does not pursue, initiate, or follow up on cues for an exchange or interaction.
  • May avoid eye contact and protest or fuss if an individual comes too close or attempts to touch or hold them (have developed avoidant behaviors because they do not expect interaction and have learned not to interact when an adult approaches)
  • No exploration of another individual's face or facial expression

2. Dis-inhibited RAD-
  • Can give hugs to anyone who approaches them and go with that individual if asked
  • Instead of caution, excessive familiarity or psychological promiscuousness with unknown individuals
  • May approach a complete stranger for comfort, food, to be picked up, or to receive a toy

Physical—

No specific physical signs of attachment disorder exist. Nevertheless, indirect indicators may be present, such as the following:
  • A syndrome characterized by excessive appetite in kids who have been in several foster homes
  • Effects of under-nutrition and rashes because of not changing diapers frequently
  • Excessive appetite and excessive thirst in kids who experience severe stress
  • Flattened back of the head because left in bed much of the time in cases of nonattachment
  • If severe, growth retardation
  • Signs of physical maltreatment, such as old fractures or bruises

Causes—

Multiple situations can lead to attachment disorders.

1. Inhibited RAD: Young kids who are exposed to multiple caretakers simultaneously or sequentially do not easily experience the sense of security associated with unique and exclusive long-standing relationships. No opportunity exists to trust one individual because past relationships were interrupted, disrupted, or consistently unreliable.
  • Abandonment by caretaker at the peak of attachment needs (end of first year of life)
  • Gross insensitivity in the caretaker
  • Gross neglect
  • Repeated abandonment by caretaker

2. Dis-inhibited RAD: Promiscuous or dis-inhibited attachment disorders have a phenomenology opposite that of inhibited attachment disorders. This is the most common type of attachment disturbance in clinical settings. Many kids with this condition have been placed in multiple foster homes or have lived with different relatives; their moms & dads are unable to create a sense of permanency in their lives. Many of the moms & dads experience legal problems, engage in illegal drug use, abuse alcohol, or have personality disturbances, which make them unable to provide stability for the youngster.
  • Multiple caretakers sequentially or concurrently
  • Multiple disruptions in attachment relationships
  • Several changes in foster home placement

3. Risk factors: Risk factors are the same as those associated with poor parenting, maltreatment, and neglect. A number of psychosocial factors place some kids at particular risk, such as caretakers who abuse drugs, have multiple unmanageable stressors, or have been maltreated or have experienced multiple attachment disruptions themselves.

Workup—

Laboratory Studies:
  • Studies related to neglect and nutritional deprivation (e.g., anemia caused by iron deficiency, high level of lead caused by pica) exist.
  • No directly related laboratory studies exist.

Imaging Studies:
  • No imaging studies are used to diagnose this condition.

Histologic Findings:
  • No histologic findings are related to attachment disorders.

Treatment—

Medical Care:

An appropriate treatment program for a youngster with multiple challenges requires the participation of several specialists. Most of the treatment is provided by primary caretakers, such as moms & dads or substitute moms & dads, in their everyday interactions with the youngster. Hopefully, these caretakers can rely on the expertise and advice of a mental health professional who is aware of the emotional needs of kids, the phenomenology of attachment disruptions, and the need to repair and recreate the sense of security in the youngster. Referral to a mental health professional may be critical.

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

Several therapeutic ingredients seem important in treating inhibited RAD and dis-inhibited RAD. When caretakers provide the ingredients described below, the youngster may experience healthy dependency, rely on someone, and trust a new individual. That is to say, the youngster may become attached.
  • 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 but, rather, promote guarding behavior. To correct the scars or sequelae of attachment disruption, the clinician, parent, or caretaker must have time and be ready, without judging, to listen to the youngster. Limits must be set for the youngster, but these should be set in the context of empathy and compassion. Only when the verbal kids feel emotionally secure will they begin talking about what has happened to them and, likely, to their siblings and gradually develop trust in the new caretaker.
  • Stability refers to the permanence of the attachment figure. The youngster needs time to develop trust in a new primary caretaker. After disruption(s), these kids need to learn to recognize their needs and to learn that these needs can be met repeatedly by the same individual.
  1. Separations and disruptions may reactivate a defensive isolation on the part of the youngster.
  2. Some kids take a long time (more than a year) to trust a caretaker again; others trust a caretaker after receiving just a few months of sensitive care. This may be a temperamental feature (e.g., orientation toward others versus inwardness) or a reflection of the quality of the match between the youngster and the new caretaker.
  3. The youngster might fear that the caretaker will disappear, die, or go away, thus leading to another disruption.
  • Sensitivity, or emotional availability, refers to attentiveness to the youngster's needs and is crucial in care taking. Inform substitute caretakers that, although the youngster may or may not be mature cognitively, the youngster's emotional development is frequently delayed in areas such as emotional expression, attachment, and age-appropriate independence. Hopefully, during the course of treatment, the youngster will gradually begin to develop feelings of dependency toward the primary caretaker because the youngster learns to expect the caretaker will be physically and emotionally available at times of crisis. During this process, caution moms & dads to expect and tolerate occasional regressive behaviors and to view them as signs that the youngster is psychologically working through earlier phases in development.
  1. For instance, a youngster who typically is independent and suspicious of others may suddenly express needs for dependency, report fears, want to sleep in the moms & dads' bed, and wish to be mommy's little boy or girl. Recommend that the moms & dads, in a sensitive way, allow the youngster to express and experience that dependency. Encourage moms & dads to think of the youngster as emotionally younger and as having legitimate emotional needs appropriate for his or her emotional age.
  2. Some kids are almost frozen emotionally because, with multiple placements and relationships, expressing age-appropriate emotions has not been safe. These kids might at first appear to be obedient because they do not express anger and are not prone to emotional outbursts. As time goes by, expressing emotions, such as anger, jealousy, and neediness, becomes safe. The caretaker may observe the appearance of temper outbursts, jealousy, and anger toward him or her upon separation. Things that previously did not seem to matter to the youngster (eg, if the caretaker comes or goes) may suddenly be upsetting. For example, a youngster who never seemed to mind separations may strongly protest the parent's leaving by clinging or going to the mom or dad for comfort. Encourage caretakers to see these behaviors as positive signs that a new attachment and a deeper level of trust have formed because the youngster feels safe to express these developmentally appropriate dependency needs.

Surgical Care:
  • No surgical procedures to treat this condition exist.

Consultations:

Consult specialists about particular problems that may be associated with experiences of detachment and neglect, such as excessive eating and drinking.
  • Pediatric gastroenterologist to rule out gastroenterological problems
  • Endocrinologist or nutritionist for short stature and malnourishment

Diet—

No specific diet is indicated; however, many kids who have experienced disruptions and early neglect also have feeding disorders and may require treatment. Also, some kids may have excessive appetite and thirst.

Medication—

No pharmacologic treatment specifically for attachment disorders exists. Psychopharmacologic agents may be used to address problems such as explosive anger, hyperactivity, and difficulty focusing or sleeping. These agents are used at similar doses and with the same objectives as described in other articles. Treat ancillary problems in order to promote the optimal psychosocial functioning of the youngster; however, these treatments are not addressed specifically to the attachment disorder.

Follow-up—

Further Inpatient Care:
  • Unfortunately, intermediate or longer-term hospitalization is no longer available in today's economic climate. Day hospital, partial hospital, or residential care in a placement skilled in treating very disruptive, poorly attached kids may be a suitable alternative to prevent further foster care placement failures.
  • No specific indication exists for treatment of attachment disorders with inpatient hospitalization; however, occasionally, some kids and, particularly, teenagers may require a period of inpatient hospitalization to address issues such as mistrust or lack of emotional involvement with others. For instance, with the teenager who has had multiple placements, foster homes, or group homes, a period of inpatient treatment may be beneficial in helping the youngster face fears of becoming close to any individual. Also, therapy during hospitalization may help the youngster work on overcoming the fear of acknowledging dependency needs and the fear of acknowledging desires for attention and affection.

Further Outpatient Care:
  • Child therapy and relational therapy (e.g., parent-child, parent-baby) may be useful for many kids and caretakers. Caretakers may struggle with disciplining the youngster while trying to foster the youngster's ability to relate and trust. Establishing a positively oriented and developmentally appropriate behavioral management program is very important to avoid further punishment or prolonged abandonment in excessive time outs. In the context of relational play, or narrative therapy, the youngster can develop a theme that describes what is in the youngster's mind. New caretakers may need considerable emotional support to deal with challenging and difficult behaviors in their kids.

Inpatient & Outpatient Medications:
  • No pharmacologic treatments specifically indicated for attachment disorders exist; however, kids with this condition may exhibit complications in their behavior, such as aggression, defiance, or attention deficit. Medications may be geared toward those symptoms. The treatment of these problems is covered in the respective articles.

Complications:
  • Disruptions in attachment tend not to occur as isolated events but coexist with a number of adverse psychosocial circumstances known to cause psychologic disturbance. These circumstances impede adequate parenting and care…giving and often result in the loss of the primary caretakers, possibly causing posttraumatic stress symptoms. They include the following:
  1. Exposure to drugs in utero
  2. Multiple stressors, such as economic hardship, family conflict or violence (e.g., physical abuse of the baby), and crowding in the house
  3. Neglect of the needs of the baby because of parental substance abuse
  • Because of the attachment disorder, kids who have experienced multiple losses tend to engage in defiant behavior, are non-cooperative with adults, experience pervasive anger and resentment, and develop an exploitative attitude toward other individuals.
  • Persistence of the nonattachment or the superficial exploitation of individuals, with fear of closeness and intimacy, is a major complication. When kids become moms & dads, they may transmit difficulties in attachment (i.e., the moms & dads may be insensitive emotionally and may be unavailable) to their own kids.
  • The youngster with disruptions of attachments faces academic difficulties related to maltreatment and to mistrust of adults. Academic difficulties may also be related to attentional problems and hyper-arousal associated with posttraumatic stress. Additionally, the youngster may have learning disabilities and language difficulties if exposed to drugs in utero or because of a genetic loading. These disabilities may have led to the difficulties the moms & dads had in caring for their youngster in the first place. Even without all of those challenges, kids with multiple placements and disruptions in their living situations are at risk of experiencing academic problems. A specific educational program designed to address those needs is necessary. If the youngster 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.
  • When the youngster has experienced multiple disruptions in placements and has witnessed violence, he or she may develop conduct disorder, experience difficulties in social settings, and/or be prone to antisocial behavior because he or she lacks empathy and appropriate models of coping and caring behavior.

Prognosis:
  • Without treatment and new attachments, the chance for normal emotional development, building trusting relationships, and experiencing and tolerating intimacy and closeness with other human beings is very poor.

Miscellaneous—

Medicolegal Pitfalls:
  • Reserve diagnosis of attachment disorders for cases clearly related to nonattachment (e.g., gross neglect, separation, loss of the caretaker) or dis-inhibited superficial attachments (e.g., multiple caretakers).
  1. Many babies seem to be oblivious to their caretakers; they do not exhibit fear and are very dis-inhibited. They might not have an attachment disorder but, instead, be focused on a particular stimulus and be unaware of their surroundings. This tendency to be impulsive, focused on a stimulus, and to be somewhat oblivious to danger is not necessarily a sign of an attachment disturbance but is more a sign of attentional deficit and impulsivity. The history of disruptions in relationships with caretakers guides the diagnosis.
  2. Many kids experience disruptions in their relationships with caretakers, and many kids become aggressive, hyper-vigilant, or defiant. However, these kids do not necessarily have attachment disorders. Aggressive behavior, explosions of temper, and defiance are characteristics of several disturbances in childhood; do not assume all of these are attachment disorders.
  3. In some facilities, clinicians have become very interested in attachment disturbances. As a result, they may view practically any behavioral disturbance in a youngster as caused by disruptions in attachment and, therefore, diagnose the behavior as an attachment disorder. This may create problems for the clinician because the current definition of the disorder implies pathogenic care (e.g., neglect or multiple caretakers in rapid succession).
  4. In kids who are non-relational and unresponsive to others, rule out the presence of a pervasive developmental disorder or an autistic condition. The differential diagnosis is facilitated by the history of neglect or multiple caretakers and by the development of imaginative play and communicational intent (which are absent or grossly impaired in the youngster with a developmental disorder).

Special Concerns:
  • A frequent concern of potential adoptive moms & dads or caretakers is deciding when the youngster is unable to develop a new attachment or to warm up to new caretakers after multiple past disruptions. After the first few months of life, the concern exists of whether or not forming an attachment to a new individual as well as the old one is possible. During the school years, establishing a close and intimate bond with a new caretaker or family seems possible. Of course, the new attachment is a complex phenomenon determined by multiple factors, such as the youngster's temperament, previous experiences with caretakers, the nature of the new moms & dads, and how sensitively the new caretakers deal with the problem.


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