Child Attachment Disorder
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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.
What is child attachment disorder?
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.
Types of attachment disorder[1, 2]
The International Classification of Diseases 11th edition (ICD-11) classifies reactive attachment disorder and disinhibited social engagement disorder as two of the disorders specifically associated with stress, with onset in childhood.
Reactive attachment disorder (RAD)
RAD occurs in the context of grossly inadequate child care (eg, severe neglect, maltreatment, institutional deprivation) and is characterised by grossly abnormal attachment behaviours in eary childhood. Even when an adequate primary caregiver is newly available, the child does not turn to them for comfort, nurture and support. They rarely display security-seeking behaviours towards any adult and do not respond when comfort is offered. RAD can only be diagnosed in children and features of the disorder develop within the first 5 years of life. It cannot be diagnosed before the age of 1 year or in the context of Autism spectrum disorder.
Disinhibited attachment disorder
This is also known as disinhibited social engagement disorder (DSED) and was previously categorised as a subtype of attachment disorder, but is now recognised by both ICD-11 and DSM-5 as a separate disorder.
Like RAD it occurs in the context of grossly inadequate childcare. The child approaches adults indiscriminately, lacks reticence to approach, will go away with unfamiliar adults and exhibits overly familiar behaviour towards strangers. It can only be diagnosed in children and features of the disorder develop within the first 5 years of life. It cannot be diagnosed before the age of 1 year or in the context of Autism spectrum disorder.
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.
What causes attachment disorders? (Aetiology)
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.
How common is attachment disorder? (Epidemiology)
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 2019 there were 102,000 looked-after children in the UK. 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.
Symptoms of attachment disorder (presentation)
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.
- Verbal or physical violation of socially appropriate physical and verbal boundaries.
- 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.
Attachment disorder treatment and management
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 can resolve, with around half of such adolescents showing secure attachment to their foster parents.
It is important to find and support stable placements for looked-after children. It is thought that it is often preferable for this to be with the child's extended family, when circumstances permit. 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
- 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
- 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.
Children with RAD have a diminished capacity for resilience, due to the trauma encountered in early life, which causes a permanent state of stress. Even with early intervention they continue to experience difficulties in every aspect of their life from classroom learning to developing a secure sense of self. Early identification and intervention have been shown to improve outcomes and parental support and education are key.
Attachment disorder prevention
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, 2014
International Classification of Diseases 11th Revision; World Health Organization, 2019/2021
Highlights of Changes from DSM-IV-TR to DSM-5; American Psychiatric Association, 2013
Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care; NICE Guideline (November 2015)
Looked after children statistics briefing; NSPCC, March 2021
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.
Ellis EE, Yilanli M, Saadabadi A; Reactive Attachment Disorder, May 2022