AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Attachment 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 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 children 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 caregiver. The long-standing absence of emotional warmth took an enormous toll on the children, 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 infants and animal babies, incorporated Harlow's research on rhesus monkeys into his study of the child'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 an infant goes through several phases in reaction to separation. The infant 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 parent 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 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 an infant and its parents. Parents and infants establish a continuous relationship that has specific features. The quality of this relationship colors the person's relationships for the rest of his or her life.

Both caregiver and baby have biological preprogrammed instinctive equipment to foster their relationship. Most people 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. Parents also has instinctive behaviors, such as soothing the crying infant, caressing it, making sounds that are appealing to the infant, and mirroring the infant (ie, 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 caregiver. This convinces the baby and young child that a person is available to soothe, console, and comfort. Infants may develop attachments to other people who are consistent in their lives; however, the relationship with the primary caregiver(s) plays the most critical role in determining the child's basis for future attachments. The attachment figure(s) cannot suddenly be replaced by any other caregiver because that relationship is unique and stable.

Based on the nature and quality of early attachments, children develop an internal working model of relationships that serves as a template for future relationships. These working models of relationships can be positive (ie, people can be trusted, confided in, helpful in distress) or negative (ie, no one can be trusted, people are not caring, one is all alone in the world). Babies internalize their parents (and other attachment figures) as a secure base. This allows infants to feel internally safe and to confidently explore the world around them. It also allows them to experience positive interpersonal exchanges with other children. The infant can come back to the caregiver 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 caregivers, for diagnosis.

• In inhibited RAD, the child 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 infant to establish a new attachment with a primary caregiver. Also, a nonattachment disorder may develop because the baby never had the opportunity to develop at least one attachment with a reliable caregiver who was continuously present in the baby's life.
• In disinhibited RAD, the child participates in diffuse attachments, 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 one caregiver. Disruption of one attachment relationship after another causes the infant to renounce attachments. The usual anxiety and concern with strangers is not present, and the infant or child superficially accepts anyone as a caregiver (as though people were interchangeable) and acts as if the relationship had been intimate and life-long.

Attachment disorders independent of DSM-IV

• In reversed attachment, the child becomes the source of comfort to the parent, who is insecure and vulnerable; the relationship is inverted and the infant, although unable to reassure the parent completely, provides the security.
• 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 mo) in the presence of a stranger during and after a short separation from their primary caregivers.

• 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, 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 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 child 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 child. It is not a diagnostic tool for attachment disorders.

Pathophysiology

Inhibited RAD

If caregivers 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 caregivers. The child then uses psychological defenses (eg, avoidance or ambivalence) to avoid disappointments with the caregiver. This is thought to contribute to a negative working model of relationships that leads to insecurity for the rest of the child's life.

Disinhibited RAD

Young children exposed to multiple caregivers 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 person because past relationships were interrupted, disrupted, or consistently unreliable. Children with disinhibited attachment 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, any sense of fear or loneliness is inhibited and the children develop a pseudocomfort with whoever is available. The child is thought to suppress the conscious experience of fear only as a result of a psychological defense. The child 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 children 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 children can have attachment disorders.

International

Many children, examples being certain children from Romania and China, have lived in orphanages and have had little opportunity for attachment or they have lived in bleak conditions with multiple caregivers and are emotionally and cognitively deprived. In the midst of such deprivation and so many disruptions in relationships, determining exactly what causes a child 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 child care practices.

Sex

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

Age

Onset of attachment disorders is in children 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 (eg, mistrust and difficulties in establishing supportive, sensitive, and intimate relationships), they last into adolescence and adulthood.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

Rene Spitz noted that the children 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 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 they were resigned to their situation of affective deprivation. These children also had a much higher mortality rate than noninstitutionalized 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 disinhibited RAD, a history of multiple caregivers, sequential changes in caregiver, disruptions in relationships, and placement with different people for considerable periods must exist. The child does not develop preferential attachments and secure base behavior toward a specific person but instead develops an undifferentiated closeness with anyone who approaches the child.

• Inhibited RAD
• • Failure to thrive
  • Poor hygienic condition
  • Underdevelopment of motor coordination and a pattern of muscular hypertonicity because of diminished holding
  • May appear bewildered, unfocused, and understimulated
  • Blank expression, with eyes lacking the luster and joy that is usually observed
  • No evidence of the usual responses to interpersonal exchanges
    • Appearance of not knowing body language
    • Does not pursue, initiate, or follow up on cues for an exchange or interaction.
    • No exploration of another person's face or facial expression
    • Does not approach or withdraw from another person
    • May avoid eye contact and protest or fuss if a person 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)
• Disinhibited RAD
• • Instead of caution, excessive familiarity or psychological promiscuousness with unknown persons
  • Can give hugs to anyone who approaches them and go with that person if asked
  • 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:

• Signs of physical maltreatment, such as old fractures or bruises
• Effects of undernutrition and rashes because of not changing 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 because left in bed much of the time in cases of nonattachment
• If severe, growth retardation

Causes

Multiple situations can lead to attachment disorders.

• Inhibited RAD: Young children who are exposed to multiple caregivers 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 person because past relationships were interrupted, disrupted, or consistently unreliable.
• • 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
• Disinhibited RAD: Promiscuous or disinhibited attachment disorders have a phenomenology opposite that of inhibited attachment disorders. This is the most common type of attachment disturbance in clinical settings. Many children with this condition 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.
• • Multiple caregivers sequentially or concurrently
  • Multiple disruptions in attachment relationships
  • Several changes in foster home placement
• Risk factors: Risk factors are the same as those associated with poor parenting, maltreatment, and neglect. A number of psychosocial factors place some children at particular risk, such as caregivers who abuse drugs, have multiple unmanageable stressors, or have been maltreated or have experienced multiple attachment disruptions themselves.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Growth retardation
Language disorder, receptive

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

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

Imaging Studies

• No imaging studies are used to diagnose this condition.

Histologic Findings

No histologic findings are related to attachment disorders.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

An appropriate treatment program for a child with multiple challenges requires the participation of several specialists. Most of the treatment is provided by primary caregivers, such as parents or substitute parents, in their everyday interactions with the child. Hopefully, 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.

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

Several therapeutic ingredients seem important in treating inhibited RAD and disinhibited RAD. When caregivers provide the ingredients described below, the child may experience healthy dependency, rely on someone, and trust a new person. That is to say, the child 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 caregiver must have time and be ready, without judging, to listen to the child. Limits must be set for the child, but these should be set in the context of empathy and compassion. Only when the verbal children 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 caregiver.
• Stability refers to the permanence of the attachment figure. The child needs time to develop trust in a new primary caregiver. After disruption(s), these children need to learn to recognize their needs and to learn that these needs can be met repeatedly by the same person.
  • The child might fear that the caregiver will disappear, die, or go away, thus leading to another disruption.
  • Some children take a long time (more than a year) 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 and is crucial in care taking. Inform substitute caregivers that, although the child may or may not be mature cognitively, the child's emotional development is frequently delayed in areas such as emotional expression, attachment, and age-appropriate independence. Hopefully, during the course of treatment, the child will gradually begin to develop feelings of dependency toward the primary caregiver because the child learns to expect the caregiver will be physically and emotionally available at times of crisis. During this process, caution parents 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 typically is 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. Recommend that the parents, in a sensitive way, allow the child to express and experience that dependency. Encourage parents to think of the child 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. These children 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 caregiver 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 child (eg, if the caregiver comes or goes) may suddenly be 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. Encourage caregivers to see these behaviors as positive signs that a new attachment and a deeper level of trust have formed because the child 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.

• Endocrinologist or nutritionist for short stature and malnourishment
• Pediatric gastroenterologist to rule out gastroenterological problems

Diet

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 (see Physical).

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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 child; however, these treatments are not addressed specifically to the attachment disorder.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• No specific indication exists for treatment of attachment disorders with inpatient hospitalization; however, occasionally, some children and, particularly, adolescents may require a period of inpatient hospitalization to address issues such as mistrust or lack of emotional involvement with others. For instance, with the adolescent who has had multiple placements, foster homes, or group homes, a period of inpatient treatment may be beneficial in helping the child face fears of becoming close to any person. Also, therapy during hospitalization may help the child work on overcoming the fear of acknowledging dependency needs and the fear of acknowledging desires for attention and affection.
• 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 children may be a suitable alternative to prevent further foster care placement failures.

Further Outpatient Care

• Child therapy and relational therapy (eg, parent-child, parent-infant) may be useful for many children and caregivers. 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 very important to avoid 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 the child's mind. New caregivers may need considerable emotional support to deal with challenging and difficult behaviors in their children.

In/Out Patient Meds

• No pharmacologic treatments specifically indicated for attachment disorders exist; however, children 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 caregiving and often result in the loss of the primary caregivers, possibly causing posttraumatic stress symptoms. They include the following:
• • Exposure to drugs in utero
  • Neglect of the needs of the baby because of parental substance abuse
  • Multiple stressors, such as economic hardship, family conflict or violence (eg, physical abuse of the baby), and crowding in the house
• Because of the attachment disorder, children who have experienced multiple losses tend to engage in defiant behavior, are noncooperative with adults, experience pervasive anger and resentment, and develop an exploitative attitude toward other people.
• Persistence of the nonattachment or the superficial exploitation of people, with fear of closeness and intimacy, is a major complication. When children become parents, they may transmit difficulties in attachment (ie, the parents may be insensitive emotionally and may be unavailable) to their own children.
• When the child 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.
• The child 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 hyperarousal associated with posttraumatic stress. Additionally, the child 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 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 of experiencing academic problems. 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.

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

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• Reserve diagnosis of attachment disorders for cases clearly related to nonattachment (eg, gross neglect, separation, loss of the caregiver) or disinhibited superficial attachments (eg, multiple caregivers).
• • In some facilities, clinicians have become very interested in attachment disturbances. As a result, they may view practically any behavioral disturbance in a child 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 (eg, neglect or multiple caregivers in rapid succession).
  • Many children experience disruptions in their relationships with caregivers, and many children become aggressive, hypervigilant, or defiant. However, these children 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.
  • Many infants seem to be oblivious to their caregivers; they do not exhibit fear and are very disinhibited. 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 caregivers guides the diagnosis.
  • Finally, in children who are nonrelational 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 caregivers and by the development of imaginative play and communicational intent (which are absent or grossly impaired in the child with a developmental disorder).

Special Concerns

• 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, the concern exists of whether or not 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.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

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Article Last Updated: Aug 2, 2006