Attachment Disorders

Definitions: 

Attachment Disorder:  An attachment disorder is a condition in which individuals have difficulty forming healthy, loving, lasting, and intimate relationships with others.

DSMIV Categories of Attachment Disorders:

Separation Anxiety Disorder: Excessive anxiety concerning separation from the home or from those to whom the person is attached.  Because of the excessive need to be near attachment figures, this disorder interferes with the formation of healthy relationships. 
Reactive Attachment Disorder: Markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age 5 and is associated with grossly pathological care.
Inhibited Type: The disturbance in social relatedness is exhibited in the failure to initiate and/or respond to social interactions in a developmentally appropriate way.
Disinhibited Type: The disturbance in social relatedness is exhibited in indiscriminate sociability or lack of selectivity in the choice of attachment figures.



Etiology:

Attachment disorders begin before birth, just as attachment begins before birth. According to Daniel Siegel (2001), “the mind develops at the interface between human relationships and the unfolding structure and function of the brain.” Therefore, the quality of relationships, from conception on, play a crucial role in the development of the individual mind. Another complicating factor is that the earlier in life a disruption occurs, the more difficult it is to get to this underlying cause of dysfunction. Most of the literature on attachment and attachment disorders deals with what happens after birth. Also, these very early experiences may manifest with symptoms of other psychological disorders. With these complications in mind, we will focus here on the DSMIV categories of attachment disorders, whose etiologies we can more clearly identify with post-birth experiences. In the case of Separation Anxiety Disorder, early separations and/or excess anxiety on the part of the primary caregiver nurtures this excess anxiety in the child. So, this behavior makes sense from the point of view of the child. It is an exaggeration of the survival instinct that informs the child that separation from the caregiver is dangerous and life-threatening. The DSMIV clearly identifies grossly pathological care as the primary contributing factor to Reactive Attachment Disorder. We see this extreme version of attachment disorder in children who have severely neglected and/or physically and emotionally abused in early infancy. 

Developmental Issues:

Separation anxiety is likely to be overcome or buried as the child matures. Most parents expect some clingy behavior in the second 6 months of a child’s life, as they have matured to the point of recognizing caregivers and develop fear of strangers. However, if this very anxious behavior continues past age two, some intervention may be indicated. The anxious behavior may resurface during transition stages, such as beginning a new school, without cause for undue concern. However, if the anxiety seems to increase with each transition or is excessive, intervention may be indicated, along with the diagnosis of Separation Anxiety Disorder.         By definition, Reactive Attachment Disorder begins before the age of 5 years, although it may not come to the attention of a mental-health provider until a few years later. The child’s behavior may seem paradoxical. What they need most is connection with a primary caregiver, but their behavior seems designed to prevent exactly that. Early intervention simplifies treatment. When a child comes to you at the age of 8, after several years in foster care, with multiple caregivers, and you see the tremendous need in her eyes that is so at odds with her behavior, it may be difficult to see that, under all of that anger and resistance, there is an infant still crying out to be loved and accepted. Interventions do need to respect the child’s chronological age, while still addressing that underlying need. We can do that with primarily non-verbal interventions. Even those interventions that have an overlay of verbal interaction need to provide that primary emotional connection in order to begin the healing of these very early wounds. It is uncommon for a child in middle years to allow this inner-infant’s needs to be seen, much less met. So our interventions need, on the surface, to be appropriate for the child’s chronological age, while non-verbal interactions accompanying the intervention address the underlying need.


Common Assessment Tools:

Unfortunately, there are few, if any, assessment tools specifically designed to identify attachment disorders in children, so we have to rely on the intake interview to identify risk factors.  Identifying the attachment category for the child, however, can be very helpful. See the discussion below for details on this research tool. 


Discussion:

       As implied in the name, Attachment Disorder, we are dealing with attachment problems in this diagnosis. Therefore, it is important to review attachment theory to shed light on what can go wrong in this process.  The theory was introduced by John Bowlby (Bowlby, 1969) in the 1960s.  Subsequent research by Mary Ainsworth (1978) and others (Main & Cassidy, 1988; Main & Solomon, 1986) have brought it to its current state of acceptance and expansion into study of the lifelong impacts of early attachment patterns. Some of the latest research focuses on the physiological components of attachment, specifically how secure attachment contributes to healthy development of the brain and nervous system (Seigel, 1999; Seigel & Hartzell, 2003).

  Mary Ainsworth originally identified three attachment patterns in toddlers with the “Strange Situation.” In this research model, the following 8 steps are followed.
1.Parent and infant are introduced to the experimental room.
2.Parent and infant are alone. Parent does not participate while infant explores.
3.Stranger enters, converses with parent, then approaches infant. Parent leaves inconspicuously.
4.First separation episode: Stranger's behavior is geared to that of infant.
5.First reunion episode: Parent greets and comforts infant, then leaves again.
6.Second separation episode: Infant is alone.
7.Continuation of second separation episode: Stranger enters and gears behavior to that of infant.
8.Second reunion episode: Parent enters, greets infant, and picks up infant; stranger leaves inconspicuously.

  The infant's behavior upon the parent's return provided the basis for classifying the infant into one of three categories; secure, insecure-avoidant, and insecure-anxious/ambivalent attachment. A fourth category was later added, labeled insecure-disorganized/disoriented attachment (Main & Solomon, 1988). The fourth category was discovered when it was observed that many children with an established background of abuse and/or neglect were difficult to classify (Carlson, et al, 1989), as they seemed to show a combination of approach, avoidance, and resistance

Secure infants seek proximity or contact, or greet the parent from a distance with a smile or wave.

Avoidant infants avoid the parent and may avoid eye contact with the parent.

Anxious/ambivalent infants may passively or actively show hostility toward the parent or may exhibit extreme clinginess.

Disorganized/disoriented infants may show a combination of any of the above and/or vacillate between approach and avoidance.

Avoidant infants may develop later symptoms of Oppositional Defiant Disorder, while Separation Anxiety Disorder might be developed in Anxious/ambivalent infants. The Disorganized/disoriented category, in the extreme, would be seen in Reactive Attachment Disorder.

  To put a personal face on the disorders, the following vignettes are provided. 

  This first vignette provides an example of a child who may be suffering from Separation Anxiety Disorder:

  Bethany is a shy, 6-year-old, who has become increasingly fearful of any separation from her mother. This has reached the point of refusal to go to school. Since her mother had been a full-time caregiver and Bethany hadn’t attended a pre-school program, the symptoms didn’t become obvious until she entered kindergarten. The patience of her kindergarten teacher and the fact that Bethany was already acquainted with most of the children from her previous play-groups, kept the symptoms within bounds for another year. Bethany does not allow her mother out-of-sight now, and sits on her lap during the intake interview. Mother reports that she has always been a clingy child, but seemed to be on-target in all other aspects of her development. There have been no prolonged separations since Mother was hospitalized for a period of four weeks, beginning when Bethany was just one-month of age. Mother was formerly a pre-school teacher and enjoyed encouraging Bethany’s development through reading and craft activities. She also arranged twice weekly play-groups so that Bethany was exposed to other children and had plenty of opportunities for peer interaction. Bethany tolerated brief separations when her parents went out for an evening with only mild upset, although the degree of upset seemed to increase as she got older. The parents apparently decreased the frequency of these evenings as Bethany’s discomfort increased. 

  The following vignette provides an example of a child who may be suffering primarily from Reactive Attachment Disorder of the inhibited type:

  Stan is 3-years-of-age and is being brought to therapy by his foster mom in accord with the recommendation of his social worker. Stan is small for his age, but has shown excess aggressive behavior with his foster-siblings, who are older. He resists being comforted by his foster mom and tends to hit at her when she attempts to hug him or pick him up. His language development is below the expected level and he employs language minimally in his contact with others. He seems to be constantly “on guard.” Stan was placed in foster care following an investigation of physical and verbal abuse at the hands of his mother and her live-in boyfriend, reported by neighbors. This is Stan’s second experience of being removed from his mother’s care. His first took place at age 10- months and lasted until his mother completed the terms of her reunification plan 6 months later.

  The following vignette provides an example of Reactive Attachment Disorder of the disinhibited type:

  Rachel is an adorable 18-month-old child, who readily smiles and wants to be held by any adult she meets. At first meeting, one wonders why this child’s parents are seeking therapy for her. The intake interview reveals that Rachel came to their home one year before, at the age of 6-months.  They were delighted with this very loving child, who seemed only to want to please. She had been given up for adoption by her fourteen-year-old mother, who was a foster child herself. She had initially wanted to keep her baby, but was unable to live up to the expectations of the social workers in charge of their case. A foster-adopt home for the infant, Rachel, was then sought and she came to live with the Smiths. As Rachel became mobile, they began to have concerns about her readiness to go to any stranger she happened to meet. Mrs. Smith also noticed that her warmth and friendliness seemed driven and somewhat empty of genuine feeling.

  Although these vignettes might give the impression that an early separation from one’s primary caregiver very early in life is essential to the diagnoses, other disruptions in care might also lead to an attachment rupture. For example, an illness of the child or caregiver might disrupt bonding and attachment. Disturbances in attachment can take on mild to severe forms. The milder forms, while they might not meet the DSM-IV criteria, are still of concern, and symptoms can be mitigated by early intervention. The forms of attachment disorder mirror the attachment patterns previously delineated.

Ambivalent sub-type:  Angry, oppositional, and potentially violent.
Anxious sub-type: Clingy, anxious, shows separation anxieties.
Avoidant sub-type:  Very compliant, agreeable, and superficially      engaging.
Disorganized sub-type:  Bizarre symptoms, thinking can be distorted
     and chaotic.

  Much current research (Cassidy & Shaver, 1999; Siegel & Hartzell, 2003) focuses on the lifelong patterns of attachment that seem to result from our very early experience. This research reinforces the nature of attachment as a very basic building block for human beings on many levels of functioning. Nurturing secure attachment is the antidote to attachment disorders of any type.

  Effective interventions help the child and parent experience the “ABC’s of attachment: attunement, balance, and coherence.” (Seigel & Hartzell, 2003). The sharing and coordination of internal states through eye contact, facial expression, tone of voice, gestures, bodily posture, timing, and intensity of response facilitate attunement. Balance refers to an internal state of balance involving regulation of physiological processes.  Coherence is the result of well-integrated, organized, and adaptive brain functioning. One key element is the ability of the parent to enter the child’s world in order to facilitate attunement, balance, and coherence in the “between” space of the dyad. The primary, overriding goal is to create the feelings of safety, security, and connection needed to develop secure attachment at any age.

           

References:      
Ainsworth, M., Blehar, M, Waters, E., & Wall, S. (1978). Patterns of
   attachment: A Psychological study of the strange situation. Hillsdale,
   NJ: Erlbaum.
Bowlby, J. (1969).  Attachment , Vol. 1 of Attachment and loss.
   London: Hogarth Press.
Carlson, V., Cicchetti, D., Barnett, D., & Braunwald, K. (1989).              
   Disorganized/disoriented attachment relationships in maltreated
   infants. Developmental Psychology, 25, 525-531.
Cassidy, J.; & Shaver, P. (Eds.) (1999). Handbook of attachment theory
   and research. New York:Guilford Press.
Main, M., & Cassidy, J. (1988). Categories of response to reunion with
   the parent at age six: Predictable from infant attachment
   classifications and stable over a one-month period. Developmental
   Psychology, 24, 415-426.
Main, M.; & Solomon, J. (1986). Discovery of an insecure
   disorganized/disoriented attachment pattern: Procedures, findings
   and implications for classification of behaviour.
Siegel, D. (1999). The developing mind. New York: Guilford Press.
Siegel, D. (2001). Toward an interpersonal neurobiology of the developing     mind:  Attachment relationships, “Mindsight,”and neural integration.
  Infant Mental Health Journal. 22(1-2) 67-94
Siegel, D. & Hartzell, M. (2003). Parenting from the inside out.  New
   York: Tarcher.
Yogman, M.& Brazelton, T. Affective development in infancy.  p. 95-124     Norwood, NJ:Ablex.



Online Resources:
Association for Treatment and Training in the Attachment of Children (ATTACh). http://www.attach.org
Attachment Disorder Support Group.  http://www.syix.com/adsg
Focus Adolescent Services (Attachment and attachment disorder page.  Especially helpful for clinicians is the pdf. document titled “Characteristics of Attention Deficit Disorder, Bipolar 1 Disorder and Reactive Attachment Disorder).   http://www.focusas.com
RadKid.Org.  http://radkid.org

Many other sites can be found by searching on http://www.google.com with the search term “attachment disorders.”  However, the four listed above have been consistently helpful and reliable.