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(→‎''Attachment'' and ''attachment disorder'': replacing section on 'official' attachment disorder)
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Zeanah and colleagues proposed an alternative set of criteria (see below) of three categories of attachment disorder, namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". These classifications retain the basis that a disorder is such as to require treatment.<ref name="Prior & Glaser"/>
 
Zeanah and colleagues proposed an alternative set of criteria (see below) of three categories of attachment disorder, namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". These classifications retain the basis that a disorder is such as to require treatment.<ref name="Prior & Glaser"/>
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==Official ICD-10 and DSM-IV-TR classifications==
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{{main|Reactive attachment disorder}}
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[[ICD-10]] describes [[Reactive attachment disorder|Reactive Attachment Disorder of Childhood]], known as [[RAD]], and Disinhibited Disorder of Childhood, less well known as DAD. [[DSM-IV-TR]] also describes [[Reactive attachment disorder|Reactive Attachment Disorder of Infancy or Early Childhood]]. They divide this into two subtypes, Inhibited Type and Disinhibited Type, both known as [[RAD]]. The two classifications are similar and both include;
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*markedly disturbed and developmentally inappropriate social relatedness in most contexts.
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*The disturbance is not accounted for solely by developmental delay and does not meet the criteria for Pervasive Developmental Disorder.
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*Onset before 5 years of age.
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*Requires a history of significant neglect.
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*Implicit lack of identifiable, preferred attachment figure.
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ICD-10 includes in its diagnosis psychological and physical abuse and injury in addition to neglect. This somewhat controversial, being a ''commission'' rather than ''ommission'' and because abuse of itself does not lead to attachment disorder.
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  +
The inhibited form is described as "a failure to initiate or respond...to most social interactions, as manifest by excessively inhibited responses" and such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain 'proximity', an essential element of attachment behavior. The disinhibited form shows "indiscriminate sociability...excessive familiarity with relative strangers" (DSM-IV-TR) and therefore a lack of 'specificity', the second basic element of attachment behavior. The ICD-10 descriptions are comparable. 'Disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in the same child. The inhibited form has a greater tendancy to ameliorate with an appropriate caregiver whilst the disinhibited form is more enduring.
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Whilst [[RAD]] is likely to occur in relation to neglectful and abusive childcare, there should be no automatic diagnosis on this basis alone as children can form stable attachments and social relationships despite marked abuse and neglect. Abuse can occur alongside the required factors but on its own does not explain attachment disorder. It is associated with developed, albeit disorganised attachment. Within official classifications, attachment disorganization is a risk factor but not in itself an attachment disorder. Further although attachment disorders tend to occur in the context of some institutions, repeated changes of primary caregiver or extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, not all children raised in these conditions develop an attachment disorder.<ref name="Prior & Glaser"/>
   
 
==Diagnosis==
 
==Diagnosis==

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Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about age 6 months but before about age 3 years, frequent change of caregivers or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts. A problematic history of social relationships occurring after about age 3 may be distressing to a child, but does not result in attachment disorder.

The term attachment disorder is most often used to describe emotional and behavioral problems of young children, but is sometimes applied to school-age children or even to adults. The specific difficulties implied depend on the age of the individual being assessed. Thus, no general list of symptoms of attachment disorder can legitimately be presented. The term is not found as such in any standard diagnostic manual such as the DSM-IV-TR, ICD-10, or the Diagnostic Classification: 0-3 [1].

There are currently two main areas of theory and practice relating to the definition and diagnosis of attachment disorder, and considerable discussion about a broader definition altogether. The first main area is based on scientific inquiry, is found in academic journals and books and pays close attention to attachment theory. It is described in ICD-10 and DSM-IV-TR as Reactive attachment disorder. The second area is controversial and is found in clinical practice, on websites and in books and publications, has little or no evidence base and makes controversial claims relating to a basis in attachment theory.[2]The use of these controversial diagnoses of attachment disorder is linked to the use of controversial attachment therapies to treat them. (Chaffin et al, 2006, p78[3])

Thirdly, some authors have suggested that attachment, as an aspect of emotional development, is better assessed along a spectrum than considered to fall into two non-overlapping categories. This spectrum would have at one end the characteristics called secure attachment; midway along the range of disturbance would be insecure or other undesirable attachment styles; at the other extreme would be non-attachment. (O'Connor & Zeanah, 2003[4]) Diagnostic criteria have not yet been agreed. (Chaffin et al, 2006[3])

Finally, the term is also sometimes used to cover difficulties arising in relation to various attachment styles which are not psychiatric diagnoses or mental disorders.

Attachment and attachment disorder

Main article: Attachment theory

Attachment theory is an evolutionary 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. There are two main aspects to attachment behavior. The first is maintaining proximity to another and the second is the specificity of the other (Bowlby 1969, p181). A disturbance of attachment indicates the absence of either or both. This can occur either in institutions, or with repeated changes of caregiver, or from extremely neglectful primary caregivers who show persistent disregard for the child's basic attachment needs. Current official classifications under DSM-IV-TR and ICD-10 are largely based on this understanding of the nature of attachment.

In the clinical sense, a disorder is a condition requiring treatment as opposed to risk factors for subsequent disorders.(AACAP 2005, p1208[5]) There is a lack of consensus about the precise meaning of the term 'attachment disorder' although there is general agreement that such disorders only arise following early adverse care-giving experiences.

The words 'attachment style' refer to the various types of attachment arising from early care experiences, called 'secure', 'anxious-ambivalent', 'anxious-avoidant', (all organized), and 'disorganized'. Some of these styles are more problematical than others, and although they are not disorders in the clinical sense, are sometimes discussed under the term 'attachment disorder'.

Discussion of 'disorganized attachment' style sometimes includes this style under the rubric of attachment disorders because disorganized attachment is seen as the beginning of a developmental trajectory that will take the individual ever farther 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 the person's life.

Zeanah and colleagues proposed an alternative set of criteria (see below) of three categories of attachment disorder, namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". These classifications retain the basis that a disorder is such as to require treatment.[2]

Official ICD-10 and DSM-IV-TR classifications

Main article: Reactive attachment disorder

ICD-10 describes Reactive Attachment Disorder of Childhood, known as RAD, and Disinhibited Disorder of Childhood, less well known as DAD. DSM-IV-TR also describes Reactive Attachment Disorder of Infancy or Early Childhood. They divide this into two subtypes, Inhibited Type and Disinhibited Type, both known as RAD. The two classifications are similar and both include;

  • markedly disturbed and developmentally inappropriate social relatedness in most contexts.
  • The disturbance is not accounted for solely by developmental delay and does not meet the criteria for Pervasive Developmental Disorder.
  • Onset before 5 years of age.
  • Requires a history of significant neglect.
  • Implicit lack of identifiable, preferred attachment figure.

ICD-10 includes in its diagnosis psychological and physical abuse and injury in addition to neglect. This somewhat controversial, being a commission rather than ommission and because abuse of itself does not lead to attachment disorder.

The inhibited form is described as "a failure to initiate or respond...to most social interactions, as manifest by excessively inhibited responses" and such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain 'proximity', an essential element of attachment behavior. The disinhibited form shows "indiscriminate sociability...excessive familiarity with relative strangers" (DSM-IV-TR) and therefore a lack of 'specificity', the second basic element of attachment behavior. The ICD-10 descriptions are comparable. 'Disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in the same child. The inhibited form has a greater tendancy to ameliorate with an appropriate caregiver whilst the disinhibited form is more enduring.

Whilst RAD is likely to occur in relation to neglectful and abusive childcare, there should be no automatic diagnosis on this basis alone as children can form stable attachments and social relationships despite marked abuse and neglect. Abuse can occur alongside the required factors but on its own does not explain attachment disorder. It is associated with developed, albeit disorganised attachment. Within official classifications, attachment disorganization is a risk factor but not in itself an attachment disorder. Further although attachment disorders tend to occur in the context of some institutions, repeated changes of primary caregiver or extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, not all children raised in these conditions develop an attachment disorder.[2]

Diagnosis

Recognized assessment methods of attachment styles, difficulties or disorders include the Strange Situation procedure (Mary Ainsworth), the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA", Crittenden 1992), the Observational Record of the Caregiving Environment ("ORCE") and the Attachment Q-sort ("AQ-sort" [6][7]) More recent research also uses the Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah, (1999). This is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely having a discriminated, preferred adult, seeking comfort when distressed, responding to comfort when offered, social and emotional reciprocity, emotional regulation, checking back after venturing away from the care giver, reticence with unfamiliar adults, willingness to go off with relative strangers, self endangering behavior, excessive clinging, vigilance/hypercompliance and role reversal. [8] Most research will use a combination of measures.Attachment is fundamental to healthy development, normal personality, and the capacity to form healthy and authentic emotional relationships[9]. How can one determine whether a child has attachment issues that require attention? What is normal behavior, and what are the signs of attachment issues? When adopting an infant, will attachment problems develop? These and other related questions are often at the forefront of adoptive parents’ minds.

Attachment is the base of emotional health, social relationships, and one's world view[10]. The ability to trust and form reciprocal relationships affects the emotional health, security, and safety of the child, as well as the child's development and future inter-personal relationships. The ability to regulate emotions, have a conscience, and experience empathy all require secure attachment. Healthy brain development is built on a secure attachment relationship.

Children who are adopted after the age of six months are at risk for attachment problems. Normal attachment develops during the child's first two to three years of life. Problems with the mother-child relationship during that time, orphanage experience, or breaks in the consistent caregiver-child relationship interfere with the normal development of a healthy and secure attachment. There are wide ranges of attachment difficulties that result in varying degrees of emotional disturbance in the child. One thing is certain; if an infant's needs are not met consistently, in a loving, nurturing way, attachment will not occur normally and this underlying problem will manifest itself in a variety of symptoms.

When the attachment-cycle is undermined and the child’s needs are not met, and normal socializing shame is not resolved, mistrust begins to define the perspective of the child and attachment problems result[11]. The cycle can become undermined or broken for many reasons[12]

  • Multiple disruptions in care giving
  • Post-partum depression causing an emotionally unavailable mother
  • Hospitalization of the child causing separation from the parent and/or unrelieved pain. For example, stays in a NICU or repeated hospitalizations during infancy.
  • Parents who have experienced their own relational trauma, leading to neglect, abuse (physical/sexual/verbal), or inappropriate parental responses not leading to a secure/predictable relationship
  • Genetic factors
  • Pervasive developmental disorders
  • Caregivers whose own needs are not met, leading to overload and lack of awareness of the infants needs

The child may develop basic mistrust (Erikson), impeding effective attachment behavior. The developmental stages following these first three years continue to be distorted and/or retarded, and common symptoms emerge. It is very important to realize that when one is trying to parent a child with attachment difficulties one must focus on the cause of the behaviors and not on the symptoms or surface behaviors. Furthermore, the following behaviors can be indicators of a variety of problems. A child exhibiting several of these behaviors should receive a comprehensive evaluation by a licensed mental health professional to determine the cause of these symptoms. Many of these symptoms can be seen in children who have experienced complex trauma [13], attachment difficulties and other issues [14] [15] .

  • Superficially engaging and charming behavior, phoniness
  • Avoidance of eye contact
  • Indiscriminate affection with strangers
  • Lack of affection in a reciprocal manner
  • Destructiveness to self, others, and material things
  • Cruelty to animals
  • Crazy lying (lying in the face of the obvious)
  • Poor impulse control
  • Learning lags
  • Lack of cause/effect thinking
  • Lack of conscience
  • Abnormal eating patterns
  • Poor peer relationships
  • Preoccupation with fire and/or gore
  • Persistent nonsense questions and chatter indicating a need to control
  • Inappropriate clinginess and demandingness
  • Inappropriate sexuality

It is important to get a thorough evaluation as one symptom can have many causes. There are a variety of evidence-based methods to assess a child's pattern and style of attachment such as the Strange situation developed by Mary Ainsworth and a variety of narrative methods. Among adults, the Adult Attachment Interview is a frequently used research method.

Causes of attachment disorders

The cause is some break in the early attachment relationship that results in difficulties trusting others [16]. The child experiences a fear of close authentic emotional relationships because early maltreatment or other difficulties has "taught" the child that adults are not trust worthy and that the child is unloved and unlovable. Fundamentally, the cause is a developmental delay. The child may be chronologically six, ten, or fifteen, but developmentally these children may be younger. It is often useful to consider, "at what age would this behavior be normal?" Frequently one may find that the child’s behavior would be normal if the child were of a younger age.

Chronic Maltreatment (abuse or neglect) or other disruptions to the normal attachment relationship cause [17]:

  • Fear of intimacy
  • Overwhelming feelings of shame (not guilt... shame causes a person to want to hide and not be seen. So, for example, some children’s chronic lying can be seen as a manifestation of this pervasive sense of shame. A lie is then another way to hide.)
  • Chronic feelings of being unloved
  • Chronic feelings of being unlovable
  • A distorted view of self, other, and relationships based on past maltreatment
  • Lack of trust
  • Feeling that nothing the child does can make a difference; hence, low motivation and poor academic performance
  • A core sense of being Bad
  • Difficulty asking for help
  • Difficulty relying on others in a cooperative and collaborative manner

Older adopted children (see Adoption article for additional details.) need time to make adjustments to their new surroundings. They need to become familiar with their caregivers, friends, relatives, neighbors, teachers, and others with whom they will have repeated contact. They need to learn the ins and outs of new household routines and adapt to living in a new physical environment. Some children have cultural or language hurdles to overcome. Until most of these tasks have been accomplished, they may not be able to relax enough to allow the work of attachment to begin. In the meantime, behavioral problems related to insecurity and lack of attachment, as well as to other events in the child's past, may start to surface. Some start to get labels, like "manipulative," "superficial," or "sneaky." On the inside, this child is filled with anxiety, fear, grief, loss, and often a profound sense of being bad, defective, and unlovable. The child has not developed the self-esteem that comes with feeling like a valued, contributing member of a family. The child cares little about pleasing others since his relationships with them are quite superficial.

Children who have experienced physical or sexual abuse, physical or psychological neglect, or orphanage life will begin to show difficulties as young as six-months of age [18]. For example, the signs of difficulties for an infant include the following:

  • Weak crying response or rageful and/or constant whining; inability to be comforted
  • Tactile defensiveness
  • Poor clinging and extreme resistance to cuddling: seems stiff as a board
  • Poor sucking response
  • Poor eye contact, lack of tracking
  • No reciprocal smile response
  • Indifference to others
  • Failure to respond with recognition to parents
  • Delayed physical motor skill development milestones (creeping, crawling, sitting, etc.)
  • Flaccidity

Treatment

There is a variety of effective prevention programs and treatment approaches for attachment disorder based on Attachment theory. All approaches concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver. Approaches with a sound evidential and theoretical base include the following:

  1. 'Circle of Security' (Marvin et al, 2002)
  2. Dyadic Developmental Psychotherapy [19] Cite error: Closing </ref> missing for <ref> tag
  3. 'Watch, wait and wonder' (Cohen et al, 1999),
  4. manipulation of sensitive responsiveness, (van den Boom 1994 and 1995),
  5. modified 'Interaction Guidance' (Benoit et al, 2001),
  6. 'Preschool Parent Psychotherapy' (Toth et al, 2002)
  7. Parent-Child psychotherapy (Leiberman et al 2000).
  8. Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders.

See also

References

  1. Diagnostic Classification: 0-3 Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood, Zero to Three National Center for Infants, Toddlers, and Families, Washington, DC, 2002
  2. 2.0 2.1 2.2 Prior V; Glaser D (2006). Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice, London: Jessica Kingsley Publishers.
  3. 3.0 3.1 Chaffin M, et al. (Feb 2006). Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems. Child Maltreatment 11 (1): 76-89.
  4. O'Connor TG, Zeanah CH (Sep 2003). Attachment disorders: Assessment strategies and treatment approaches. Attachment & Human Development 5 (3): 223-244.
  5. Practice Parameter for the Assessment of Children and Adolescent with Reactive Attachment Disorder of Infancy and Early Childhood. Journal of the American Academy of Child and Adolescent Psychiatry. Nov; 44:
  6. Waters, E. & Deane, K. (1985). Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behavior in infancy and early childhood. In I. Bretherton & E. Waters (Eds.), Monographs of the Society for Research in Child Development, 50, nos. 1-2. pp. 41-65.[1]
  7. Marinus H. van IJzendoorn, Carolus M. J. L. Vereijken, Marian J. Bakermans-Kranenburg, and J. Marianne Riksen-Walraven 'Assessing Attachment Security With the Attachment Q Sort: Meta-Analytic Evidence for the Validity of the Observer AQS' Child Development, July/August 2004, Volume 75, Number 4, Pages 1188 – 1213 [2]
  8. Smyke,A. and Zeanah,C. (1999)'Disturbances of Attachment Interview'. Available on the Journal of the American Academy of Child and Adolescent Psychiatry website at www.jaacap.com
  9. O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244.
  10. Zeanah, C., (Ed.) (1993) Handbook of Infant Mental Health, Guilford Press, NY
  11. Bowlby, J., (1988), A Secure Base, Basic Books, NY
  12. :[3]|Attachment Disorder website
  13. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., et. al., (2005) Complex trauma in children and adolescents. Psychiatric Annals, 35, 390-398.
  14. [4]|Attachment Disorder Website
  15. [5]|Website on attachment
  16. Bowlby, J., (1988), A Secure Base, Basic Books, NY
  17. Becker-Weidman, A., & Shell, D., (2005), Creating Capacity For Attachment, Wood 'N' Barnes, Oklahoma City, OK
  18. Brodzinsky, D., Schechter, M., & Marantz, R., (1992), Being Adopted, NY, Doubleday.
  19. Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity for Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9

Additional Reading and References

  • Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity For Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9
  • Handbook of Infant Mental Health, edited by Charles Zeanah, MD, Guilford Press, 1993, NY.
  • Handbook of Attachment: Theory, Research, and Clinical Applications, edited by Jude Cassidy, Ph.D., & Phillip Shaver, Ph.D, Guilford Press, NY (1999).
  • Building the Bonds of Attachment, 2nd. Edition by Daniel Hughes, Ph.D., Guilford Press, 2006.
  • "Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy" Child and Adolescent Social Work Journal. 12(6), December 2005.
  • Creating Capacity For Attachment, (Eds.) Arthur Becker-Weidman, Ph.D., and Deborah Shell, MA, Wood 'N' Barnes, OK: 2005.ISBN 1-885473-72-9
  • O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244:Taylor and Francis
  • Hughes, Daniel, (2006) Building the Bonds of Attachment, 2nd. Edition. NY: Guilford Press.
  • Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 3, 263–278.
  • Hughes, D. (2003). Psychological intervention for the spectrum of attachment disorders and intrafamilial trauma. Attachment & Human Development, 5, 271–279.
  • Holmes, J., The Search for the Secure Base, (2001), Brunner-Routledge, Philadelphia, PA.
  • Bowlby, J., A Secure Base, (1988), Basic Boosk, NY.
  • Briere, J., and Scott, C., (2006) Principles of Trauma Therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage.

External links

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