Child attachment disorder

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.

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.

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.

Or:

• 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.

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.

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.

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.

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.