The attachment disorder diagnosis has evoked a great deal of controversy in both scientific and clinical circles. While some academics and diagnosticians would contend that the existence of the disorder itself has not even been empirically validated, other clinical groups claim ardently that they can assess and treat the devastating, almost intractable pattern of behaviors they say are indicative of an attachment disorder. The writings of the first camp, composed primarily of academics, are found almost entirely in peer-reviewed academic journals (largely inaccessible to the broader public), while the writings of the second camp, who claim to treat attachment disorders, can be easily found on the Internet, in parenting books, and through parenting support groups. Following is an overview of the conceptual origins of attachment theory, followed by a description of the formal diagnostic criteria for the reactive attachment disorder of infancy and early childhood, a description of therapeutic approaches, and, finally, a summary of the best practices for assessment and treatment.
Attachment Theory: Conceptual And Empirical Origins
John Bowlby was the original pioneer of attachment theory. He proposed that infants are biologically predisposed to stay close to their parent figures to ensure survival. The attachment system was seen as representing a balance between exploration (for growth and development) and proximity seeking (for safety and emotion regulation). Mary Ainsworth and her colleagues identified individual differences in attachment behavior patterns in infants, first through observations, and later with a structured task called the “Strange Situation.” According to research, a secure infant will easily communicate to the caregiver a desire for closeness or contact when needed and is then able to go back to exploring the environment. Insecure infants either show little or no desire for closeness, contact, or interaction (insecure-avoidant pattern) or, conversely, display resistant or ambivalent behaviors when under stress (insecure-ambivalent pattern). Both of these insecure patterns can be seen as risk factors for later social development when they occur along with other risk factors. More recently, the disorganized/disoriented infant attachment category was identified. Disorganized infants showed inexplicable and bizarre patterns of behaviors in the presence of their caregivers when under attachment-related stress and did not appear to have an organized strategy for coping with the stress of the situation. Abused infants or infants whose caregivers struggle with unresolved trauma or loss are more likely to be disorganized with respect to attachment. Disorganized attachment in infancy and early childhood is associated with later emotional, relational, and psychological disturbances.
Reactive Attachment Disorder: Diagnostic Criteria
Reactive attachment disorder (RAD) of infancy or early childhood is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM–IV) as “markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before five years of age.” There is a disinhibited subtype, which is represented by indiscriminant sociability (the child lacks clear attachment behavior to the caregiver, is overly familiar and friendly to strangers, may have boundary disturbances). The other subtype of RAD is characterized by excessively withdrawn, disturbed, hyper vigilant, or contradictory responses in place of attachment behaviors. There is a clear presumption that experiences of “pathogenic care” (e.g., abuse, neglect, disruption) are responsible for the social relatedness difficulties. The DSM–IV offers little description of other behavioral correlates of RAD. The RAD diagnosis is arguably one of the least investigated and empirically validated diagnoses in the DSM–IV.
Features of RAD have been observed in samples of institutionalized young children, as well as in samples of abused and maltreated infants and toddlers. What is less clear is how these children look as they develop into middle childhood and adolescence and how to assess for the presence of attachment disorders in these older age ranges. At this time researchers do not have the empirical evidence needed to validate and operationalize the presence of attachment disorders in older children. Nonetheless, frontline workers who encounter children with attachment difficulties maintain clearly that these significant difficulties in attachment persist over development.
Attachment Therapy And Other Controversial Approaches
Several popular attachment treatment centers in North America have proclaimed that they have a treatment protocol to treat children with attachment disorders; their message is that their treatments will succeed where conventional treatments have failed. Much of the popular literature and many Web sites have originated from these centers. Children referred to in this literature as having an “attachment disorder” are diagnosed as having attachment disorders due to the presence of specific and severe behavioral and interpersonal problems. The difficulty is that there are no studies proving that young children diagnosed with RAD do develop these sets of behavioral disturbances. There is no doubt that a history of very difficult and traumatic early childhood experiences can lead to behavioral and emotional problems, but whether these difficulties are attributable to an attachment disorder rather than something else (e.g., posttraumatic stress disorder, neurological disruptions) remains to be seen.
Many of the treatment centers described above utilize some variant of holding therapy as part of the treatment for attachment disorders. There are several types of holding therapies, but the approach generally involves close physical contact with a therapist, and touch and eye contact are strongly encouraged. Some practices are more intrusive and coercive than others. As summarized by Thomas O’Connor and Charles Zeanah, holding therapies run counter to the central tenets of attachment therapy (which support nonintrusive responsiveness to child cues) and can be risky and even dangerous when used inappropriately and/or with a vulnerable and traumatized child. Other controversial treatments that have been proposed have included paradoxical measures and approaches aimed at promoting unconditional compliance. In the United States there have been several reported deaths of children that are thought to be related to holding therapy and its variants. According to the American Academy of Child and Adolescent Psychiatry, coercive treatments are not recommended for children with attachment disorders.
Best Practices For Assessment And Treatment
Experts agree that the best practice for assessing attachment disorders and disturbances is to create a multimodal and comprehensive assessment protocol. Included in the assessment with a younger child should be a structured observation of attachment behaviors, ideally, using a one-way mirror and a variety of tasks such as a separation-reunion and a challenging task. The observation should be set up such that the child’s behavior with a stranger can be observed in contrast with his or her behavior with the caregiver. With an older child or adolescent, social cognitions and attachment representations are largely assessed using narrative and interview methods. In addition to these direct relational assessments, questionnaire and interview methods are recommended to determine the presence of social, emotional, and behavioral concerns across different contexts and from different perspectives. A developmental history interview should include specific questions pertaining to the first 5 years of life; the presence of abuse, neglect, or other attachment related traumas; and the presence of inhibited or undifferentiated attachment behavior patterns. Zeanah and his colleagues have created and validated a structured interview for assessing these behavior patterns in the young child.
There is some research to establish best practices for treatment when the child is an infant, toddler, or very young child. Generally, dyadic therapy, where the focus of the therapy is on enhancing interactions between caregiver and child, is seen as most appropriate for the treatment of attachment disorders in infancy and early childhood. The caregiver is supported in being a secure base for the troubled child, and responding to the child’s attachment needs and signals, even when these are difficult to read and obscured by behaviors and contradictory cues. There is little empirically validated research on the treatment of attachment disorders in middle childhood and adolescence. That said, using interventions aimed at establishing a safe attachment relationship for the child when none exists, intervening in existent disturbed attachment relationships with caregivers, and providing support for stressed caregivers are generally seen as best practices for intervention with this group.
- American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.
- Boris, N., et al. & the American Academy of Child and Adolescent Psychiatry (AACAP). (2005).
- Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early Journal of the American Academy of Child and Adolescent Psychiatry, 44(11), 1206–1219.
- Haugaard, J. J., & Hazen, C. (2004). Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: Reactive attachment disorder. Child Maltreatment, 9(2), 154–160.
- O’Connor, T. G., & Zeanah, C. H. (2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment and Human Development, 5(3), 223–244.
- Zeanah, C. H., & Boris, N. W. (2000). Disturbances and disorders of attachment in early childhood. In H. Zeanah (Ed.), Handbook of infant mental health (2nd ed., pp. 353–368). New York: Guilford Press.
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