Normally babies develop a close attachment bond with their main caregiver (usually their parents) within the first months of life. If they are in a situation where they do not receive normal love and care, they cannot develop this close bond. This may result in a condition called attachment disorder. It usually happens to babies and children who have been neglected or abused, or who are in care or separated from their parents for some reason.
The effect of not having this bond is problems with behaviour and in dealing with emotions and new situations. This can cause effects which carry on right through childhood and into their adult life. However, if attachment disorder is picked up early, it can often be put right. This may be by helping the parents or carers respond better to the needs of the child. Sometimes the child may need to be removed from a damaging home environment and placed with other carers.
What is child attachment disorder?
Child attachment disorder is a broad term for a series of difficulties that can develop in children who were neglected or abused in early childhood.
"Attachment" is a well-established concept in childhood development. Babies and infants form a relationship with adults that care for them, who are sensitive and responsive to their needs, and who remain a stable presence in their life. These interactions are very important for children to set their expectations and understanding of social relationships in future.
When children don't form an attachment relationship with a trusted adult in infancy, they can go on to develop a series of emotional, behavioural, and social problems, called child attachment disorder. This might happen if their caregiver is neglectful, abusive, or absent.
Who does child attachment disorder affect?
Child attachment disorder (CAD) always develops before the age of 5 years and usually much earlier. It always occurs in children who have not had normal care as a baby. Examples of children at risk of attachment disorder include:
- Children who have been neglected or abused.
- Children in care institutions.
- Children who have been placed with a series of different carers.
- Children who have been separated from their parents, through illness, death, war, etc.
- Children whose parents abuse drugs or alcohol.
- Children whose parents have serious mental health problems.
What are the signs of child attachment disorder?
It may be possible to recognise signs that a baby is developing attachment disorder, from the lack of connection between the baby and his/her mother or caregiver (attachment style). For example:
- The baby cries inconsolably.
- The mother or caregiver doesn't seem to react to the baby when the child is distressed.
- The mother or carer doesn't respond to the baby's needs - for example, hunger or needing a nappy change.
- The mother or carer doesn't seem to smile at the baby or have any eye contact.
Later, once attachment disorder has developed, signs might include:
- The baby or child doesn't turn to his/her mother or main caregiver when upset.
- The baby or child avoids physical touch or being comforted.
- The baby or child does not smile or respond when interacting with an adult.
- The child does not show any affection towards his/her parent or caregiver.
- The baby or child does not seem to be upset in situations where you might expect them to be upset.
- The child does not play with toys or engage in interactive games with others.
- The child has difficult, aggressive behaviour towards other children or adults.
- The child is very withdrawn and does not interact with other children or adults.
- The child is anxious, fearful, or depressed.
- The child is unable to control his/her temper or anger.
- The child is not getting on very well at school.
- By the time the child is a teenager, they may be more likely to be in trouble with the police. They may have anxiety, depression or phobias.
- The child is inappropriately friendly to children or adults they don't know.
- The child may hug people they don't know, or in inappropriate situations (a doctor or teacher for example).
- The child has no wariness of strangers. The child may go off with somebody they don't know without checking with their parent(s) or caregiver.
Types of child attachment disorder
Normally a baby develops a close attachment bond to his or her mother by the age of 6 to 9 months. This happens because the mother has provided food or milk when the baby is hungry, cuddles when the baby is upset, and nappy changes when needed, etc.
The baby has come to learn that this person will be there to respond to any needs. This gives the baby or young child the confidence and stability to explore the environment around them and to deal with new situations. You can see this happening around the age of 6 to 9 months, when babies become upset when parted from their mother and become wary of strangers.
For babies and young children who have never had this one person who looks after their needs properly, there is no secure attachment. There is no safe base from which to form relationships, explore new situations and deal with stresses. The end result of this is a set of difficulties with behaviour and emotion, which can affect the development of the child. This is known as attachment disorder.
There are two types of attachment disorder:
- Reactive attachment disorder (RAD).
- Disinhibited attachment disorder.
Reactive attachment disorder (RAD)
Children with reactive attachment disorder show a consistent pattern of inhibited, emotionally withdrawn behaviour towards adult caregivers. The child rarely or minimally seeks comfort when distressed, and rarely or minimally responds to comfort when distressed.
There is minimal social and emotional responsiveness to others, limited positive affect, and episodes of unexplained irritability, sadness, or fearfulness that are evident even during non-threatening interaction with adult caregivers.
The child has typically experienced a pattern of extremes of insufficient care, such as social neglect or deprivation with persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
There may be a history of repeated changes of primary caregivers that limit opportunities to form stable attachments, or rearing in unusual settings that severely limit opportunities to form selective attachments - eg, within institutions.
Disinhibited attachment disorder
This is also called disinhibited social engagement disorder (DSED). Children with this type of attachment disorder are excessively and inappropriately friendly towards people they don't know.
How is child attachment disorder treated?
Attachment disorder is caused by the child not having a loving responsive carer, so the main treatment is to make sure they feel loved by their parent or main caregiver and know the relationship is secure.
How this is done will depend on the situation. In some cases, parents may need help in learning how to respond to the needs of their children (parenting skills training). Specialist advice should be available through the local children's social services.
In other situations, a child may be removed from an uncaring environment and provided with a caring foster parent or adoptive parent. Once a child is in a caring environment where they feel safe and cared for, most signs of RAD improve very quickly. Those children with DSED may continue to have the symptoms even after they are well cared for.
There is no medication for CAD; it is treated in practical ways, by changing the situation. Sometimes talking (psychological) therapy is used for the difficult behaviours that children with attachment disorder develop. Strategies which may be used, depending on the age and situation of the child include:
- Finding the child a stable, permanent and caring placement.
- Video feedback training programmes for parents or caregivers.
- Other training programmes or support for parents or caregivers (including sensitivity and behavioural therapy).
- Family therapy (parent-child psychotherapy).
- Play therapy in groups.
- Training and support for foster carers, guardians and adoptive parents.
- Cognitive behavioural therapy (CBT). This is a type of talking therapy which may be used to give young people who have been maltreated help in coming to terms with the problems they have had.
If you have concerns about a child who may have attachment disorder, or a child who is not being cared for properly, call social services. In the UK you can also call the National Society for the Prevention of Cruelty to Children (NSPCC) Child Protection helpline (freephone 0808 800 5000).
How can child attachment disorder be prevented?
Attachment disorder is entirely preventable. If babies have access to stable, loving care they will not go on to develop attachment disorder. It is important that health, social care and education professionals are aware of the risks for attachment disorder and the signs of it.
Children placed in care should have long-term stable placements, rather than a series of different carers. If possible they should be with family. Foster carers, guardians and adoptive parents should have special training and support to help prevent attachment disorder, and to manage the situation if it has already occurred.
Other sources of information
Depending on the situation of the child and the caregiver, there are a number of support groups which offer information and advice. The local children's social services team would normally be involved and provide help and advice.
Further reading and references
Kliewer-Neumann JD, Zimmermann J, Bovenschen I, et al; Assessment of attachment disorder symptoms in foster children: comparing diagnostic assessment tools. Child Adolesc Psychiatry Ment Health. 2018 Aug 1712:43. doi: 10.1186/s13034-018-0250-3. eCollection 2018.
NSPCC; Neglect: Signs, indicators and effects
Winokur M, Holtan A, Batchelder KE; Kinship care for the safety, permanency, and well-being of children removed from the home for maltreatment. Cochrane Database Syst Rev. 2014 Jan 311:CD006546. doi: 10.1002/14651858.CD006546.pub3.