Attachment disorder
Attachment disorders are disorders of mood, behavior, and social relationships arising from unavailability of normal socializing care and attention from primary caregiving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers between three months and three years of age, frequent change or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts resulting in a lack of basic trust. A problematic history of social relationships occurring after about age three may be distressing to a child, but does not result in attachment disorder.
''Attachment'' and ''attachment disorder''
is primarily an evolutionary and ethological theory. In relation to infants, it primarily consists of proximity seeking to an attachment figure in the face of threat, for the purpose of survival. Although an attachment is a "tie", it is not synonymous with love and affection, despite their often going together; a healthy attachment is considered an important foundation of all subsequent relationships. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain consistent caregivers for some time. Parental responses lead to the development of patterns of attachment which in turn lead to "internal working models" that guide one's feelings, thoughts, and expectations in later relationships.A fundamental aspect of attachment is called basic trust. Basic trust is a broader concept than attachment in that it extends beyond the infant-caregiver relationship to "the wider social network of trustable and caring others" and "links confidence about the past with faith about the future". "Erikson argues that the sense of trust in oneself and others is the foundation of human development" and with a balance of mistrust produces hope.
In the clinical sense, a disorder is a condition requiring treatment as opposed to risk factors for subsequent disorders. There is a lack of consensus about the precise meaning of the term "attachment disorder", but there is general agreement that such disorders arise only after early adverse caregiving experiences. Reactive attachment disorder indicates the absence of either or both the main aspects of proximity seeking to an identified attachment figure. This can occur in institutions, with repeated changes of caregiver, or from extremely neglectful primary caregivers who show persistent disregard for a child's basic attachment needs after the age of 6 months. Current official classifications of RAD under DSM-IV-TR and ICD-10 are largely based on this understanding of the nature of attachment.
The words attachment style or pattern refer to the various types of attachment arising from early care experiences, called secure, anxious-ambivalent, anxious-avoidant,, and disorganized. Some of these styles are more problematic than others, and, although they are not disorders in the clinical sense, are sometimes discussed under the term 'attachment disorder'.
Discussion of the disorganized attachment style sometimes includes it under the rubric of attachment disorders because disorganized attachment is seen as the beginning of a developmental trajectory that takes a person ever further from the normal range, culminating in actual disorders of thought, behavior, or mood. Early intervention for disorganized attachment, or other problematic styles, is directed toward changing the trajectory of development to provide a better outcome later in life.
Zeanah and colleagues proposed an alternative set of criteria of three categories of attachment disorder, namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". These classifications consider a disorder a variation that requires treatment rather than an individual difference within the normal range.
Boris and Zeanah's typology
Many leading attachment theorists, such as Zeanah and Leiberman, have recognized the limitations of the DSM-IV-TR and ICD-10 criteria and proposed broader diagnostic criteria. There is as yet no official consensus on these criteria. The APSAC Taskforce recognised in its recommendations that "attachment problems extending beyond RAD, are a real and appropriate concern for professionals working with children", and set out recommendations for assessment.Boris and Zeanah, have offered an approach to attachment disorders that considers cases where children have had no opportunity to form an attachment, those where there is a distorted relationship, and those where an existing attachment has been abruptly disrupted. This would significantly extend the definition beyond the ICD-10 and DSM-IV-TR definitions because those definitions are limited to situations where the child has no attachment or no attachment to a specified attachment figure.
Boris and Zeanah use the term "disorder of attachment" to indicate a situation in which a young child has no preferred adult caregiver. Such children may be indiscriminately sociable and approach all adults, whether familiar or not; alternatively, they may be emotionally withdrawn and fail to seek comfort from anyone. This type of attachment problem is parallel to reactive attachment disorder as defined in DSM and ICD in its inhibited and disinhibited forms as described above.
Boris and Zeanah also describe a condition they term "secure base distortion". In this situation, the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, may cling to the adult, may be excessively compliant, or may show role reversals in which they care for or punish the adult.
The third type of disorder discussed by Boris and Zeanah is termed "disrupted attachment". This type of problem, which is not covered under other approaches to disordered attachment, results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed. The young child's reaction to such a loss is parallel to the grief reaction of an older person, with progressive changes from protest to despair, sadness, and withdrawal from communication or play, and finally detachment from the original relationship and recovery of social and play activities.
Most recently, Daniel Schechter and Erica Willheim have shown a relationship between maternal violence-related posttraumatic stress disorder and secure base distortion which is characterized by child recklessness, separation anxiety, hypervigilance, and role-reversal.
Problems of attachment style
The majority of 1-year-old children can tolerate brief separations from familiar caregivers and are quickly comforted when the caregivers return. These children also use familiar people as a "secure base" and return to them periodically when exploring a new situation. Such children are said to have a secure attachment style, and characteristically continue to develop well both cognitively and emotionally.Smaller numbers of children show less positive development at age 12 months. Their less desirable attachment styles may be predictors of poor later social development. Although these children's behavior at 12 months is not a serious problem, they appear to be on developmental trajectories that will end in poor social skills and relationships. Because attachment styles may serve as predictors of later development, it may be appropriate to think of certain attachment styles as part of the range of attachment disorders.
Insecure attachment styles in toddlers involve unusual reunions after separation from a familiar person. The children may snub the returning caregiver, or may go to the person but then resist being picked up. They may reunite with the caregiver, but then persistently cling to the caregiver, and fail to return to their previous play. These children are more likely to have later social problems with peers and teachers, but some of them spontaneously develop better ways of interacting with other people.
A small group of toddlers show a distressing way of reuniting after a separation. Called a disorganized/disoriented style, this reunion pattern can involve looking dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors that seem to imply fearfulness of the person who is being sought. Disorganized attachment has been considered a major risk factor for child psychopathology, as it appears to interfere with regulation or tolerance of negative emotions and may thus foster aggressive behavior. Disorganized patterns of attachment have the strongest links to concurrent and subsequent psychopathology, and considerable research has demonstrated both within-the-child and environmental correlates of disorganized attachment.
Possible mechanisms
One study has reported a connection between a specific genetic marker and disorganized attachment associated with problems of parenting. Another author has compared atypical social behavior in genetic conditions such as Williams syndrome with behaviors symptomatic of RAD.Typical attachment development begins with unlearned infant reactions to social signals from caregivers. The ability to send and receive social communications through facial expressions, gestures and voice develops with social experience by seven to nine months. This makes it possible for an infant to interpret messages of calm or alarm from face or voice. At about eight months, infants typically begin to respond with fear to unfamiliar or startling situations, and to look to the faces of familiar caregivers for information that either justifies or soothes their fear. This developmental combination of social skills and the emergence of fear reactions results in attachment behavior such as proximity-seeking, if a familiar, sensitive, responsive, and cooperative adult is available. Further developments in attachment, such as negotiation of separation in the toddler and preschool period, depend on factors such as the caregiver's interaction style and ability to understand the child's emotional communications.
With insensitive or unresponsive caregivers, or frequent changes, an infant may have few experiences that encourage proximity seeking to a familiar person. An infant who experiences fear but who cannot find comforting information in an adult's face and voice may develop atypical ways of coping with fearfulness such as the maintenance of distance from adults, or the seeking of proximity to all adults. These symptoms accord with the DSM criteria for reactive attachment disorder. Either of these behavior patterns may create a developmental trajectory leading ever farther from typical attachment processes such as the development of an internal working model of social relationships that facilitates both the giving and the receiving of care from others.
Atypical development of fearfulness, with a constitutional tendency either to excessive or inadequate fear reactions, might be necessary before an infant is vulnerable to the effects of poor attachment experiences.
Alternatively, the two variations of RAD may develop from the same inability to develop "stranger-wariness" due to inadequate care. Appropriate fear responses may only be able to develop after an infant has first begun to form a selective attachment. An infant who is not in a position to do this cannot afford not to show interest in any person as they may be potential attachment figures. Faced with a swift succession of carers the child may have no opportunity to form a selective attachment until the possible biologically determined sensitive period for developing stranger-wariness has passed. It is thought this process may lead to the disinhibited form.
In the inhibited form infants behave as if their attachment system has been "switched off". However the innate capacity for attachment behavior cannot be lost. This may explain why children diagnosed with the inhibited form of RAD from institutions almost invariably go on to show formation of attachment behavior to good carers. However children with the inhibited form as a consequence of neglect and frequent changes of caregiver continue to show the inhibited form for far longer when placed in families.
Additionally, the development of Theory of Mind plays a role in emotional development. Theory of Mind is the ability to know that the experience of knowledge and intention lies behind human actions such as facial expressions. Although it is reported that very young infants have different responses to humans than to non-human objects, Theory of Mind develops relatively gradually and possibly results from predictable interactions with adults. However, some ability of this kind must be in place before mutual communication through gaze or other gesture can occur, as it does by seven to nine months. Some neurodevelopmental disorders, such as autism, have been attributed to the absence of the mental functions that underlie Theory of Mind. It is possible that the congenital absence of this ability, or the lack of experiences with caregivers who communicate in a predictable fashion, could underlie the development of reactive attachment disorder.