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Treatment of almost all medical conditions has been affected by the COVID-19 pandemic. NICE has issued rapid update guidelines in relation to many of these. This guidance is changing frequently. Please visit https://www.nice.org.uk/covid-19 to see if there is temporary guidance issued by NICE in relation to the management of this condition, which may vary from the information given below.
Attachment disorder describes patterns of behaviour which are the result of a lack of development of normal bonds with a primary caregiver in early childhood. Normal attachment results in a security which forms the base allowing a child to explore his/her environment, develop relationships, learn to deal with emotions and manage stressful situations. Attachment difficulties arise mainly in children who have not had a normal connection with a parent figure due to neglect, abuse, institutionalisation or disruption of care.
The International Classification of Diseases 10th edition (ICD-10) classifies attachment disorder as one of the disorders of social functioning with onset in childhood and adolescence. It recognises two subtypes, which arise in the first five years of life, and in the context of a history of abnormal care:
- Reactive attachment disorder (RAD): RAD is a consistent pattern of inhibited, emotionally withdrawn behaviour towards adult caregivers. When distressed, the child rarely or minimally seeks comfort, and rarely or minimally responds to comfort. There is minimal social and emotional responsiveness to others, and limited positive affect; there are 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. For example, social neglect or deprivation with persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults. A history of repeated changes of primary caregivers may be noted, resulting in limited opportunities to form stable attachments, or rearing in unusual settings that severely limit opportunities to form selective attachments - for example, within institutions.
- Disinhibited attachment disorder, also known as disinhibited social engagement disorder (DSED): attention-seeking and indiscriminately friendly behaviour. Attachment is described as diffuse rather than selectively focused and there are poorly modulated peer interactions. There is no sensitivity towards social boundaries.
There is some controversy regarding this classification within the literature, and the Diagnostic and Statistical Manual of Mental Disorders version 5 (DSM-5) categorises the two as different disorders rather than two subtypes of attachment disorder. In DSM-5, reactive attachment disorder is the sole attachment disorder, whilst disinhibited social engagement disorder is classed as a different condition.
There are also four patterns of attachment described, which do not form part of the diagnosis of attachment disorder, but may be associated with "attachment difficulties":
- Secure: children are able to be comforted by their primary caregiver and use that person as a safe base from which to explore their environment.
- Insecure avoidant: attachment behaviour is downplayed by these children and they do not give signals regarding need for comfort.
- Insecure resistant (ambivalent): there is "up-regulation" of attachment behaviour, with excessive amounts of distress and/or anger at separation from their caregiver and difficulty in calming the child after reunion.
- Disorganised: behaviour patterns are disorganised. The caregiver may be the source of the stress as well as the supposedly safe base. Behavioural patterns may be contradictory and unpredictable.
Attachment disorders arise almost exclusively where there has been pathogenic care. Therefore, causes include:
- Child maltreatment, such as neglect or abuse.
- Multiple care placements.
- Separation from primary caregiver (due to illness, death, war, etc).
- Drug and alcohol abuse by parents.
- Conditions causing children to seek asylum.
Evidence suggests that genetic factors do not play a role and attachment disorders arise primarily as a result of the care environment to which the child is exposed.
Attachment disorder is rare in the general population but higher in children and young people in the care system, or on the edge of care. In 2014, there were approximately 69,000 looked‑after children and young people in England alone. A Danish study estimated prevalence to be 0.9% in infants aged 18 months. Rates of attachment disorder in deprived populations are also known to be higher, with one UK-based study finding prevalence of reactive attachment disorder to be 1.4% in children aged 6-8 years in a deprived area.
Clear specific attachment bonds normally become present between 6 and 9 months of age. In normal infants, this is demonstrated by the baby preferring one individual to give comfort and expressing distress when separated from that individual. There is also normally a wariness of strangers which begins at this stage. Normal parent-child interactions from birth are needed for this attachment to develop. From the age of 6-9 months it is possible to pick up signs of attachment disorder.
In the healthcare setting, signs of possible attachment disorder include:
- Noticeable neglectful behaviour by the primary caregiver, such as not comforting the baby or child in distress, or not responding to needs such as hunger or a dirty nappy.
- Inappropriate interaction noticed between the baby or child and the primary caregiver; hostile, insensitive, neglectful or unresponsive.
- Lack of smiling or responsiveness in the baby or child. Does not seek attention or comfort, or resorts to extreme measures to gain attention. Rejection of demonstrations of comfort. Avoidance of touch or gestures of affection.
- Lack of distress in situations which would be expected to cause distress.
- Indiscriminate, excessive friendliness towards healthcare workers.
- Inconsolable crying.
- Emotional and behavioural difficulties: anxiety, depression, social withdrawal, somatisation, aggression, challenging behaviours.
The National Institute for Health and Care Excellence (NICE) advises use of the following assessment tools in the diagnosis of attachment disorder, depending on the age of the child:
- Strange Situation Procedure for children aged 1-2 years. Behaviour is assessed towards the attachment figure during and following a brief separation.
- Modified versions of the Strange Situation Procedure for children aged 2-4 years (either the Cassidy Marvin Preschool Attachment Coding System or the Preschool Assessment of Attachment). Behaviour following more prolonged separation is observed. The situation must provide a degree of stress for the child in order to demonstrate a reaction.
- Attachment Q‑sort for children aged 1-4 years. Children are observed in a number of set environments.
- Manchester Child Attachment Story Task, McArthur Story Stem Battery and Story Stem Attachment Profile for children aged 4-7 years. Stories with stressful scenarios involving a child and their parents are started and the children complete them verbally or using toys to enact the story.
- Child Attachment Interview for children and young people aged 7-15 years. The child is asked to describe their relationship with caregivers in various situations.
- Adult Attachment Interview for young people (aged 15 years and over) and their parents or carers.
The most important part of management is to improve the child-carer relationship which has given rise to the attachment disorder, where this is possible and relevant. For children who have been in abusive situations, then moved to stable foster homes, there is evidence that the abnormal attachment behaviours resolve. It is important to find and support stable placements for looked-after children, which should be within a family wherever possible. Parenting programmes both for parents and foster carers can improve attachment security in a child. There is no evidence for individual psychological therapy for the child.
Strategies to help the associated behaviours which may ensue include the therapies used in all individuals with these behaviours, regardless of attachment issues. For example, this may include cognitive behavioural therapy (CBT), interpersonal therapy, family therapy, eye movement desensitisation and reprocessing (EMDR), or dialectical behaviour therapy. To date, there is limited research into these therapies, specifically in children with attachment disorder, and it is not known if strategies need adapting for this group of children.
There is no place for pharmacotherapy in attachment disorder.
Basic principles of care advised by NICE guidelines are:
- Equal access to consistent care regardless of living situation, ethnic group, nationality and health status.
- Stable and consistent management processes and structures.
- Stable placements which are long-term where possible, using kinship placements where in the best interest of the child or young person. This should include education and training for prospective carers, specific to the needs of those with attachment difficulties, and ongoing support and advice after placement.
- Careful explanation to the child or young person prior to a change of carers, and involving them in the process.
- Improving the likelihood of permanent placement such as adoption.
- Keeping siblings together where possible.
- Preserving the personal history of the child or young person.
- Safeguarding and monitoring during interventions.
- Supporting children in schools and other educational settings. There should be training for education providers, and support from educational psychologists and health and social care provider organisations.
Specific interventions approved by NICE include:
- For children of preschool age:
- A video feedback programme for parents, foster carers, guardians or adoptive parents.
- Parental sensitivity and behavioural therapy. (Also for parents, foster carers, guardians, adoptive parents.)
- Home visiting programmes.
- Parent-child psychotherapy for those who have been or at risk of maltreatment.
- For children and young people of school age:
- Parental sensitivity and behavioural therapy.
- Intensive training and support for foster carers, guardians and adoptive parents.
- Group therapeutic play sessions (children of primary school age).
- Group-based educational sessions for caregivers and children/young people (late primary school or early secondary school stage).
- Trauma-focused CBT for those who have been maltreated.
Children with attachment disorder may experience developmental delay. There may be reduction in academic achievement at school, due to a number of factors including withdrawal, disruptive behaviour and difficulties in relationships with both peers and authority figures.
People with reactional attachment disorder have a higher prevalence of anxiety and phobias. Those with disinhibited attachment disorder/disinhibited social engagement disorder may be at higher risk of anxiety, depression, aggressive behaviour and being taken advantage of due to their disinhibition. Both groups may have emotional and behavioural disturbances. There may be an increased risk of contact with the youth justice system, although this is probably due to a number of factors rather than attachment issues alone.
RAD generally settles quite quickly when appropriate stable attachment figures are provided. Unless that happens, it tends to persist. Disinhibited attachment disorder can persist, even when the care situation has stabilised. However, studies have mostly focused on children who were initially in institutionalised care and it is not known how these results relate to others in different situations.
NICE guidelines of 2015 focus on early recognition of the potential for attachment disorder, and prevention or early management by improving the care environment. Also prominent is the need for all those who may be involved with children at risk of attachment disorder to be able to recognise the signs or potential and step in to intervene. This includes health and social care workers, those working in schools and education institutions (including nurseries and preschools), as well as foster carers, potential adoptive parents and those working in care institutions. Attachment disorder can be prevented by providing children with a safe, caring, stable primary caregiver and environment.
Further reading and references
Beyond the adoption order: challenges, interventions and adoption disruption; Research report April 2014, Dept for Education, GOV.UK.
The ICD-10 Classification of Mental and Behavioural Disorders; World Health Organization
Highlights of Changes from DSM-IV-TR to DSM-5; American Psychiatric Association, 2013
Skovgaard AM; Mental health problems and psychopathology in infancy and early childhood. An epidemiological study. Dan Med Bull. 2010 Oct57(10):B4193.
Minnis H, Macmillan S, Pritchett R, et al; Prevalence of reactive attachment disorder in a deprived population. Br J Psychiatry. 2013 May202(5):342-6. doi: 10.1192/bjp.bp.112.114074. Epub 2013 Apr 11.
Joseph MA, O'Connor TG, Briskman JA, et al; The formation of secure new attachments by children who were maltreated: an observational study of adolescents in foster care. Dev Psychopathol. 2014 Feb26(1):67-80. doi: 10.1017/S0954579413000540. Epub 2013 Oct 29.
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.
Zeanah CH, Gleason MM; Annual research review: Attachment disorders in early childhood--clinical presentation, causes, correlates, and treatment. J Child Psychol Psychiatry. 2015 Mar56(3):207-22. doi: 10.1111/jcpp.12347. Epub 2014 Oct 31.