Attachment disorders are, frankly, a mess. They're the fallout from a childhood where the essential scaffolding of connection was either missing or actively detrimental. Think of it as building a house without a foundation – eventually, everything crumbles. These aren't just fleeting moods or behavioral quirks; they're deeply ingrained patterns of relating to the world, born from the stark absence of consistent, nurturing care from primary caregivers in those crucial early years. This isn't about a few missed hugs; it’s about experiences like severe neglect, outright abuse, the jarring disruption of caregiving bonds between three months and three years of age, or a revolving door of caregivers. It can also stem from a caregiver’s persistent failure to respond to a child’s attempts at connection, which erodes the fundamental bedrock of trust. If a child manages to navigate these early storms and develops social relationship issues later, say after age three, that’s a different beast, not necessarily an attachment disorder.
Attachment and Attachment Disorder
To truly grasp attachment disorders, one must first grapple with the foundational principles of attachment theory. This isn't some airy-fairy concept; it's rooted in evolutionary and ethological principles. At its core, attachment in infants is a survival mechanism – a primal drive to seek proximity to a trusted figure when faced with danger. It’s not synonymous with mere affection, though the two often intertwine. A healthy attachment is the bedrock upon which all future relationships are built. Infants forge these bonds with adults who are not only sensitive and responsive to their social cues but also provide consistent care over a significant period. These early interactions shape what are known as "internal working models," blueprints that dictate how we perceive and navigate our relationships throughout life.
A critical component of this is what’s termed "basic trust." This concept extends beyond the infant-caregiver dyad, encompassing a broader sense of confidence in the wider social network. It’s the belief that the world, and the people in it, are generally reliable and caring. As Erik Erikson posited, this sense of trust forms the very foundation of human development, a delicate balance with mistrust that ultimately fosters hope.
Now, when we talk about a "disorder" in the clinical sense, we're referring to a condition that necessitates intervention, not merely a risk factor for future problems. The term "attachment disorder" itself is a bit nebulous, lacking a universally agreed-upon definition. However, there's a consensus that these disorders emerge exclusively from adverse early caregiving experiences. Reactive attachment disorder (RAD), for instance, is characterized by a marked absence of either or both the primary aspects of seeking proximity to a specific attachment figure. This often manifests in institutional settings, with frequent caregiver changes, or from profoundly neglectful primary caregivers who consistently disregard a child's fundamental attachment needs after six months of age. The current diagnostic manuals, like DSM-IV-TR and [ICD-10], largely reflect this understanding.
It's crucial to distinguish between "attachment styles" or patterns – secure, anxious-ambivalent, anxious-avoidant, and disorganized – and a clinical disorder. While some styles are clearly more problematic than others, they aren't disorders in the strict sense. However, the disorganized attachment style is often discussed under the umbrella of attachment disorders because it's seen as the nascent stage of a developmental trajectory that can lead to significant disruptions in thought, behavior, and mood. Early intervention for disorganized attachment, or other problematic styles, is aimed at course-correcting this trajectory toward a more favorable outcome.
Charles H. Zeanah and his colleagues proposed a more expansive framework, categorizing attachment disorders into three distinct types: "no discriminated attachment figure," "secure base distortions," and "disrupted attachment disorder." This perspective views these conditions as deviations requiring clinical attention, rather than mere variations within the normal range.
Boris and Zeanah's Typology
Many prominent attachment theorists, including Zeanah and Leiberman, have acknowledged the limitations of existing diagnostic criteria in the DSM-IV-TR and ICD-10. They've put forth broader diagnostic criteria, though no official consensus has been reached. The APSAC Taskforce, for instance, recognized the importance of "attachment problems extending beyond RAD" as a legitimate concern for professionals working with children and offered recommendations for assessment.
Boris and Zeanah (1999) introduced a nuanced approach to attachment disorders, encompassing situations where children have had no opportunity to form attachments, those with distorted relationships, and those where established attachments have been abruptly severed. This definition significantly broadens the scope beyond the narrower definitions in the ICD-10 and DSM-IV-TR, which are primarily concerned with the absence of an attachment or a specifically identified attachment figure.
In their typology, Boris and Zeanah use the term "disorder of attachment" to describe young children who lack a preferred adult caregiver. These children might exhibit indiscriminate sociability, approaching any adult, or conversely, become emotionally withdrawn and avoid seeking comfort from anyone. This mirrors the inhibited and disinhibited forms of reactive attachment disorder described in the DSM and ICD.
They also identify "secure base distortion," a condition where a child has a preferred caregiver but cannot utilize that person as a safe haven for exploration. Such children may engage in self-endangering behaviors, cling excessively, be overly compliant, or even assume a caregiving role for the adult.
The third category, "disrupted attachment," addresses situations not covered by other frameworks. This arises from the abrupt separation from or loss of a familiar caregiver to whom the child had formed an attachment. The child's response can resemble an adult grief reaction, progressing through stages of protest, despair, sadness, withdrawal, and eventual detachment, followed by a return to social and play activities.
More recently, Daniel Schechter and Erica Willheim have illuminated the link between maternal violence-related posttraumatic stress disorder and secure base distortion, noting its association with child recklessness, separation anxiety, hypervigilance, and role reversal.
Problems of Attachment Style
The vast majority of one-year-olds can handle brief separations from their primary caregivers and are readily soothed upon their return. They also utilize familiar individuals as a "secure base" from which to explore new environments. These children are considered to have a secure attachment style and typically continue to develop well both cognitively and emotionally.
However, a smaller subset of infants exhibits less optimal developmental patterns at 12 months. Their less desirable attachment styles can serve as predictors of poorer social development later in life. While not severe problems in themselves, these behaviors suggest developmental trajectories that may lead to difficulties in social skills and relationships. Because these styles can foreshadow future challenges, it's plausible to consider certain attachment styles as existing on a continuum with attachment disorders.
Insecure attachment styles in toddlers often become apparent during reunions after a separation. These children might ignore the returning caregiver, show ambivalence by seeking contact but then resisting it, or conversely, cling persistently and abandon their prior exploration. These children are at a higher risk for later social difficulties with peers and educators, though some do spontaneously develop more adaptive interaction patterns.
A particularly concerning group of toddlers displays a disorganized or disoriented reunion pattern. This can involve appearing dazed or frightened, freezing, backing away from the caregiver while maintaining eye contact, or approaching with averted gaze. This disorganized attachment style is considered a significant risk factor for child psychopathology, as it seems to impede the regulation and tolerance of negative emotions, potentially fostering aggressive behavior. Disorganized attachment patterns show the strongest correlation with concurrent and subsequent psychopathology, with extensive research identifying both within-child and environmental correlates.
Possible Mechanisms
Research has suggested a connection between a specific genetic marker and disorganized attachment (distinct from RAD) in the context of problematic parenting. Other researchers have drawn parallels between the atypical social behaviors seen in genetic conditions like Williams syndrome and the symptoms characteristic of RAD.
Typical attachment development begins with innate infant responses to caregiver social signals. The ability to engage in reciprocal social communication through facial expressions, gestures, and vocalizations develops through social experience, typically by seven to nine months. This allows infants to interpret cues of calm or alarm. Around eight months, infants usually begin to display fear in unfamiliar or startling situations and look to familiar caregivers for guidance. This developmental confluence of social skills and emerging fear reactions leads to attachment behaviors like proximity-seeking, provided a sensitive, responsive, and consistent adult is available. Further attachment developments, such as navigating separations during toddlerhood and preschool years, hinge on factors like the caregiver's interaction style and their capacity to understand the child's emotional communications.
When caregivers are insensitive, unresponsive, or frequently changing, infants may have limited opportunities to seek proximity to a familiar figure. An infant experiencing fear but unable to find reassurance in an adult's demeanor may develop atypical coping mechanisms, such as maintaining distance or approaching any adult indiscriminately. These behaviors align with the DSM criteria for reactive attachment disorder. Either pattern can set a child on a developmental path diverging from typical attachment processes, including the formation of an internal working model that facilitates both giving and receiving care.
An atypical development of fearfulness, perhaps due to a constitutional tendency towards either excessive or inadequate fear responses, might be a prerequisite for an infant to be vulnerable to the impact of poor attachment experiences.
Alternatively, the two variations of RAD might arise from a shared inability to develop "stranger-wariness" due to inadequate care. Appropriate fear responses may only emerge after an infant has begun to form a selective attachment. An infant unable to do so cannot afford to ignore any individual, as any might become a potential attachment figure. Faced with a rapid succession of caregivers, the child may miss the critical developmental window for forming a selective attachment, and thus for developing stranger-wariness. This process is thought to contribute to the disinhibited form.
In the inhibited form, infants behave as if their attachment system has been deactivated. However, the innate capacity for attachment cannot be lost. This may explain why children diagnosed with the inhibited form of RAD in institutional settings often develop attachments to good caregivers when placed in families. Conversely, children with the inhibited form resulting from neglect and frequent caregiver changes tend to exhibit these behaviors for a longer duration even within supportive family environments.
Furthermore, the development of Theory of Mind, the capacity to understand that others have their own thoughts, intentions, and feelings, plays a role in emotional development. While very young infants show differential responses to humans versus non-human objects, Theory of Mind develops gradually and is likely influenced by predictable interactions with caregivers. Some level of this ability is necessary for mutual communication through gaze or gestures, which emerges around seven to nine months. Neurodevelopmental disorders such as autism have been linked to deficits in the mental functions underlying Theory of Mind. It is conceivable that a congenital absence of this ability, or a lack of predictable caregiver interactions, could contribute to the development of reactive attachment disorder.
Diagnosis
Recognized methods for assessing attachment styles, difficulties, or disorders include the Strange Situation procedure, developed by Mary Ainsworth, as well as separation and reunion procedures, the Preschool Assessment of Attachment ("PAA"), the Observational Record of the Caregiving Environment ("ORCE"), and the Attachment Q-sort ("AQ-sort").
More recent research also employs the Disturbances of Attachment Interview or "DAI," developed by Smyke and Zeanah (1999). This semi-structured interview is administered to caregivers and assesses twelve items: the presence of a discriminated, preferred adult; seeking comfort when distressed; responding to comfort; social and emotional reciprocity; emotional regulation; checking back with the caregiver after venturing away; reticence with unfamiliar adults; willingness to go off with relative strangers; self-endangering behavior; excessive clinging; vigilance/hypercompliance; and role reversal.
Classification
The ICD-10 outlines Reactive Attachment Disorder of Childhood (RAD) and Disinhibited Disorder of Childhood (DAD). The DSM-IV-TR also describes Reactive Attachment Disorder of Infancy or Early Childhood, dividing it into two subtypes: Inhibited Type and Disinhibited Type, both known as RAD. These classifications are broadly similar and share the following criteria:
- Markedly disturbed and developmentally inappropriate social relatedness across most contexts.
- The disturbance is not solely attributable to developmental delay and does not meet the criteria for Pervasive Developmental Disorder.
- Onset before five years of age.
- A history of significant neglect.
- An implicit lack of an identifiable, preferred attachment figure.
The ICD-10 additionally includes psychological and physical abuse and injury in its diagnostic criteria, alongside neglect. This inclusion is somewhat contentious, as abuse is an act of commission rather than omission, and abuse alone doesn't invariably lead to attachment disorder.
The inhibited form is characterized by "a failure to initiate or respond... to most social interactions, as manifest by excessively inhibited responses." Such infants do not seek or accept comfort during times of distress, thereby failing to maintain "proximity," a core element of attachment behavior. The disinhibited form presents with "indiscriminate sociability... excessive familiarity with relative strangers" (DSM-IV-TR), indicating a lack of "specificity," the other fundamental aspect of attachment behavior. The ICD-10 descriptions are comparable. Notably, "disinhibited" and "inhibited" are not mutually exclusive in attachment disorders and can coexist within the same child. The inhibited form tends to improve more readily with an appropriate caregiver, while the disinhibited form is generally more persistent.
While RAD is often associated with neglectful and abusive childcare, a diagnosis should not be made solely on this basis. Children can form stable attachments and social relationships despite significant abuse and neglect. Abuse may co-occur with the necessary etiological factors but does not, in itself, explain attachment disorder. Experiences of abuse are linked to the development of disorganized attachment, where the child prefers a familiar caregiver but interacts with them in unpredictable and sometimes bizarre ways. Within official classifications, attachment disorganization is a risk factor but not, in itself, an attachment disorder. Furthermore, although attachment disorders frequently arise in institutional settings, with repeated caregiver changes, or from extremely neglectful primary caregivers who consistently disregard a child's attachment needs, not all children exposed to these conditions develop an attachment disorder.
Treatment
A variety of mainstream prevention programs and treatment approaches exist for attachment disorder, attachment problems, and mood or behavioral issues considered problematic within the framework of attachment theory. For infants and younger children, these interventions universally focus on enhancing caregiver responsiveness and sensitivity, or, when this is not feasible, on changing the caregiver. Such approaches include 'Watch, wait and wonder,' manipulation of sensitive responsiveness, modified 'Interaction Guidance,' 'Preschool Parent Psychotherapy,' Circle of Security, Attachment and Biobehavioral Catch-up (ABC), the New Orleans Intervention, and Parent-Child Psychotherapy. Other recognized treatment methods include Developmental, Individual-difference, Relationship-based therapy (DIR), also known as Floor Time, developed by [Stanley Greenspan], although DIR is primarily aimed at treating pervasive developmental disorders. Some of these approaches, such as that proposed by Dozier, emphasize the significance of the adult caregiver's attachment status in shaping the emotional connection between adult and child, including foster parents, as children with compromised attachment histories may not elicit normative caregiving responses despite receiving adequate care.
Treatment for reactive attachment disorder in children typically involves a combination of therapy, counseling, and parenting education. The primary goals are to ensure a safe living environment, foster positive interactions with caregivers, and improve peer relationships.
Medication may be used to address co-occurring conditions like depression, anxiety, or hyperactivity, but there is no direct pharmacological cure for reactive attachment disorder. A pediatrician will likely recommend a comprehensive treatment plan, which might include family therapy, individual psychological counseling, play therapy, special education services, and parenting skills classes.
Pseudoscientific Diagnoses and Treatment
In the absence of officially recognized diagnostic criteria, and extending beyond the scope of broader diagnostic frameworks, the term "attachment disorder" has been increasingly adopted by some clinicians to encompass a wider range of children whose behavior may be influenced by factors such as the absence of a primary attachment figure, a severely unhealthy attachment relationship, or a disrupted attachment. Concerns have been raised about the potential for over-diagnosis, particularly when based on broad checklists and superficial assessments, especially given the lack of studies examining diagnostic accuracy. This form of therapy, including its diagnostic methods and accompanying parenting techniques, remains scientifically unvalidated and is not considered part of mainstream psychology. In fact, despite its name, it is often deemed incompatible with established attachment theory. It has been described as potentially abusive and a pseudoscientific intervention that has led to tragic outcomes for children.
A hallmark of this pseudoscientific approach is the use of extensive lists of "symptoms" that often include behaviors that are more likely consequences of neglect or abuse, or simply typical childhood behaviors, rather than indicators of attachment pathology or any clinical disorder. These lists have been criticized as "wildly inclusive." The APSAC Taskforce (2006) provides examples of such lists, ranging from elements within the DSM criteria to entirely non-specific behaviors like developmental lags, destructive behavior, avoidance of eye contact, cruelty to animals and siblings, lack of cause-and-effect reasoning, preoccupation with morbid themes, poor peer relationships, stealing, lying, lack of a conscience, persistent nonsensical questioning or incessant chatter, poor impulse control, abnormal speech patterns, constant fighting for control, and hoarding or gorging on food. Some checklists even suggest that for infants, "prefers dad to mom" or "wants to hold the bottle as soon as possible" are indicative of attachment problems. The APSAC Taskforce expresses grave concern that "high rates of false positive diagnoses are virtually certain" and that the dissemination of such lists, particularly on websites that also serve as marketing tools, can lead many parents to inaccurately conclude their children have attachment disorders.
Furthermore, there is a significant variety of treatments offered for alleged attachment disorders diagnosed through these questionable alternative methods, commonly referred to as attachment therapy. These therapies lack robust evidence and range from talk or play therapies to more extreme forms involving physical and coercive techniques. The most well-known among these are holding therapy, rebirthing, rage-reduction, and the Evergreen model. Generally, these therapies aim to foster attachment in adopted or fostered children to their new caregivers. Critics argue that these approaches are not grounded in any accepted version of attachment theory. The theoretical underpinnings are often a blend of regression and catharsis, coupled with parenting strategies that prioritize obedience and parental control. These therapies focus on changing the child rather than the caregiver. Tragically, an estimated six children have died as a direct consequence of the more coercive forms of these treatments and the accompanying parenting techniques.
Two of the most publicized cases involved Candace Newmaker in 2001 and the Gravelles in 2003–2005. Following the extensive media attention, some proponents of attachment therapy began to modify their practices to be less potentially harmful. This shift may have been accelerated by the publication of a critical Task Force Report on the subject in 2006 by the American Professional Society on the Abuse of Children (APSAC), although such practices unfortunately persist. In 2007, ATTACh, an organization initially founded by attachment therapists, issued a White Paper explicitly opposing coercive practices in therapy and parenting.