A guide for health professionals working with
immigrant and refugee children and youth

Attachment disorders

Key points

  • Attachment disorders are uncommon in the general population but common in populations where early life experience has been extremely pathogenic.
  • The DSM-V recognizes 2 distinct forms of attachment disorder: reactive attachment disorder and disinhibited social engagement disorder. The first involves the inability to attach to a preferred caregiver, and the second involves indiscriminate sociability and disinhibited attachment behaviours.
  • The common causal factor for both disorders is early “pathogenic care”, meaning a child’s opportunities for selective attachment have been seriously constricted.
  • Both disorders are long-lasting, although enhanced caregiving can mitigate reactive attachment disorder.
  • Safe and responsive caregiving, while treating comorbid conditions, is recommended.
  • Several unvalidated commercial treatments for attachment disorders exist that are potentially harmful and should be avoided.

Background

Attachment disorders are rare in Canada, likely under 1% in the general population but in children who have experienced gross maltreatment or substandard institutionalization in early life, the prevalence is higher, and possibly as high as 40%.1,2 There are no estimates of attachment disorders in refugee populations, although one might expect that the extreme demands of pre-flight, flight and resettlement can elevate risk for attachment disorders.  Classic attachment theory holds that a child’s species-specific need for physical closeness with an attachment figure (or figures) is amplified by stressful conditions. John Bowlby, who introduced the concept that attachment is essential for healthy physical and psychological development in humans,3 believed  that the first 9 months of life were the critical period for attachment development. Other authorities believe this critical period may be as long as the first 3 years of a child’s life. Children who have an attachment figure (or figures) in early life can more easily explore their environment and retreat to safety if exploration or their environment seems threatening. Exploratory behaviours help to build a child’s sense of efficacy and control in the social environment.

Issues around who is an attachment figure in a child’s life are important. Most attachment studies are based on observing mother-infant pairs, but monotropic bonding (that is, one caregiver/one infant) is rare in everyday life. In most of the world, dominant patterns of caregiving involve multiple family members, extended family and the community. Some research suggests that monotropic relationships give rise to strong psychological attachments and a search for autonomy (independence) in later life. “Allotropic” child-rearing, where more than one attachment figure is involved, may give rise to a more generalized conception of whom to trust, leading to a tendency to interdependence rather than independence in later life.4 Different attachment styles may reflect dominant cultural values, such as collectivism versus individualism.5

As a caution against theoretical “imperialism”, it must be remembered that every culture has evolved its own set of practices for loving and protecting the young. Similarly, each version of attachment can contribute effectively to individual well-being, to community functioning and cultural survival – or it would not have survived the test of time. However, cultural competence is not the same as accepting or justifying any parenting practice in the name of cultural sensitivity. Cruelty, enmeshment and disengagement are pathological regardless of cultural context.6

Studies of infant-mother interactions in conditions where the child is exposed to a laboratory stressor, such as in the “strange situation procedure”, have suggested 4 different categories of attachment behaviour:7,8

  • Securely attached. Here, caregivers are a secure base for exploration of the environment and children actively seek contact upon reunion.
  • Insecure-avoidant. Here, children explore their environment independently but avoid the caregiver upon reunion.
  • Insecure-ambivalent. Here, children have difficulty separating from their caregiver in order to explore but resist contact after reunion.
  • Disorganized. Any strategy for dealing with distress involving the caregiver collapses. Children show a range of behaviours that cannot or do not reduce stress if the caregiver is involved.

Remember:

  • Infants are genetically predisposed to attach.
  • The ways this relationship is expressed depends strongly on a child’s environment, and especially on parental sensitivity and responsiveness:
    • Consistently sensitive, responsive parents are more likely to have securely attached infants.
    • Consistently insensitive parents are more likely to have infants with avoidant attachment.
    • Inconsistently sensitive parents are more likely to have children with ambivalent resistant attachments.
    • Frightened or frightening parents are more likely to have children with disorganized attachments.
  • Insecure attachment relationships are a risk factor for later pathology but are not pathological in and of themselves.

Each of these patterns of attachment has been observed across cultures but their prominence within particular cultures can vary widely.5 The category names are useful descriptors but they also carry value judgments (e.g., securely attached sounds healthier than insecurely attached). However, too little research has addressed how a child’s context, including cultural and socioeconomic factors, affects these patterns and implications for future development. Disorganized attachment, characterized by behaviours such as freezing or crouching on the floor if exposed to a perceived threat, along with signs of confusion, apprehension or depression in the presence of an attachment figure, is considered to be an early predictor of future psychopathology.9

It is important to note that while insecure patterns of attachment suggest risk factors, particularly in the context of a high-risk environment, they are not pathological in and of themselves. This is a point of confusion in the refugee literature, with authors frequently confounding insecure and disorganized attachment with attachment disorders per se.10,11

Attachment disorders are different again. They follow on the absence or breakdown of normal attachment relationships, particularly if this happens in the first 3 years of life. Specific disorders are described below.

Definition, distinction, and description

The DSM-IV defined reactive attachment disorder (RAD) as a single disturbance with 2 subtypes. The DSM-V (like the ICD-10) recognizes RAD as 2 separate disorders: reactive attachment disorder of infancy and early childhood and disinhibited social engagement disorder (DSED). Both are trauma- and stress-related disturbances linked to conditions of extreme social neglect or “pathogenic care”12, which limit a child’s opportunities to form selective attachments to a preferred caregiver (or caregivers).

When a child is not able to form even one selective or preferred attachment in early life, RAD is indicated. The child with RAD is not insecurely attached; rather, there is no preferred attachment figure to offer safety or affection.13,14 Children with RAD do not seek or respond to comforting when distressed. They may resist comforting when it is offered and show little social or emotional reciprocity. These features are not isolated or transient but form a durable, cross-contextual pattern.1  RAD is similar to internalizing disorders in that children often show signs of withdrawal, inhibition and disturbed emotion regulation, such as low mood and high anxiety.14,15

Case 1: Reactive attachment disorder of infancy and early childhood 

Cawaale, aged 4 years, 2 months, has been referred by his paediatrician, based on concerns expressed by his mother. She has said: “I have no relationship with Cawaale”, who also appears to be sad and withdrawn most of the time.  When physically hurt, Cawaale shows little reaction other than to isolate himself in another room or a corner. He rebuffs his mother’s attempts to comfort him, turning his back or moving out of arm’s reach. When he enters his JK classroom in the morning, Cawaale always seems anxious and sometimes cries, but refuses to be comforted by either his mother or the teachers. His JK teacher reports that the boy is “hard to reach”. Cawaale rarely responds to peer overtures and approaches adults only for help with functional needs, for example putting on his coat or opening his lunch.

Cawaale was born in Mogadishu.  He was transient almost from birth, moving on an almost weekly basis as his father attempted to elude a hostile warlord politician. Cawaale’s mother acknowledges that her son received little care beyond the physical basics during this time. On several occasions he was left with others (political sympathisers) for periods of days or weeks. She knows little about the care he received during these periods.

When Cawaale was 9 months old, his father disappeared. His mother still does not know what happened to him. She fled to a refugee camp in Kenya, where they lived in a one-room tarpaulin-covered shelter with a dirt floor. His mother had to leave Cawaale alone much of the time while she taught English to supplement their finances. When Cawaale was 3 years old, Canada accepted mother and son as government-assisted refugees.  They came to Canada several months later.  After some initial difficulties, Cawaale’s mother found housing and a minimum-pay position in the hospitality industry. She works 12-hour days, 6 days a week. Cawaale spends time before and after school in a local, family-run daycare.  Cawaale’s mother is unhappy with the quality of care he receives there. In particular, she complains that Cawaale receives little one-on-one attention from the caregivers.  However, her financial situation limits her care options.

Learning points:

  • There is a need for the health care provider to clarify parental roles in a child’s RAD.
    • Was neglect due to environmental/circumstantial demands that precluded adequate caregiving?
    • Was neglect due to the impact of environmental/circumstantial contingencies on a parent’s mental state (e.g., post traumatic stress disorder, depression), which precluded adequate caregiving?
    • Was neglect due to lack of parenting capacity independent of emigration?
    • Are any of these issues ongoing or have they been resolved?
  • Parents may feel hurt by child’s lack of attachment.
    • Supportive counselling or an intervention targeting parent-child interaction may be indicated.
  • Parents may need intervention aimed at resolving trauma-related emotional difficulties, including PTSD and depression.
  • An interview and an educational intervention with out-of-home care providers to change the child’s behaviour may be indicated.
  • Child-focussed intervention should compass associated emotional symptoms.
  • Social support for the family should be implemented to the fullest extent possible.
  • Ensure that the family receives all government assistance and benefits to which they are entitled.

Unlike children with RAD, some children with DSED are able to form a preferred attachment and this attachment may even be secure,14,16 although this is unusual. More typically, children with DSED show less differentiation among adults.13 They may appear to be attention-seeking and interpersonally superficial.1 Regardless of attachment status, however, the primary feature of DSED is indiscriminate sociability and uninhibited attachment behaviours, such as a lack of wariness with  strangers, inappropriate approach and readiness to leave with a stranger. Social boundaries diminish with these children, making them more likely to “explore” the “personal space” of unfamiliar adults and to seek physical contact with them.14,15 DSED is also associated with high activity levels and impulsivity, and can resemble attention-deficit hyperactivity disorder (ADHD).

Case 2: Disinhibited social engagement disorder

Arom, aged 6 years, 3 months, was referred for assessment by her Grade 1 teacher, who expressed concerns about Arom’s noncompliance with classroom rules and routines and her frequent bouts of crying.  When teacher intervened, Arom has responded by screaming and kicking. According to this same teacher, Arom seems friendly but has not made a good friend with another child. She prefers to interact with the teacher and her assistant, but neither feels that she has a close relationship with them.  Arom’s language skills are described as “delayed”.

Arom attended a first interview with both her parents. They reported that Arom is an only child, and that she was adopted from a Thai orphanage when she was 2 years, 6 months old. The parents know little of Arom’s experience in the orphanage. They emigrated to Canada from West Bengal as young children themselves. Both work as lawyers and the family is financially secure. They have extended families in Canada, on whom they have relied heavily for child care. Arom rotated among 3 nearby homes on alternate days of the week. Her mother feels hurt that she does not “have a special place in Arom’s heart – Arom loves whoever she is with”.

At one point in the interview, Arom attempts to cuddle with her mother on the couch but her mother moves away, explaining to the interviewer: “She wants something”. Arom shows no reaction but immediately climbs into her father’s lap. He treats her affectionately, smiling and hugging his daughter, but he also shrugs apologetically at the interviewer, saying, “I don’t know what else to do”. After a few minutes, Arom leaves her father to climb into the interviewer’s lap. Later, when the interviewer rises to leave the room, Arom attempts to follow. Arom is easily distracted by her father’s offer of a ball. Later, when that same ball rolls under a table, within sight but just beyond reach, Arom tries tenaciously to retrieve it, but finally moves on to other toys without asking for adult assistance.

Arom is alternately cooperative and uncooperative during the interview, often failing to follow instructions issued by her mother or the interviewer. She is more compliant with her father’s directives. Both parents concur that Arom is defiant and that it is “often easier to just let her have her way.” Although Arom smiles freely, especially toward her father, she speaks little. Formal testing showed mild but significant delays in receptive and expressive language.

Learning points:

  • This child’s parents may be hurt and baffled by her lack of preferential attachment, to the point of helplessness.
  • There may be a danger that the adoption will fail:
    • Education and supportive counselling may be indicated.
    • A parenting intervention may be indicated.
    • Social support for the family should be implemented to the fullest extent possible.
  • Issues of stranger safety must be emphasized with the parents and the child.
  • Insofar as possible, stable, predictable child arrangements should be implemented.
  • Intervention for ADHD-like symptoms, including impulsivity and noncompliance, may be indicated.

No data are available yet to substantiate the DSM-V definitions of RAD and DSED. The information offered here is based on the study of RAD subtypes described in the DSM-IV. The diagnostic clarifications recommended for the DSM-V14 promise further insights into both disorders in future.

What’s the same? What’s the difference?

  • Both reactive attachment disorder of infancy and early childhood and disinhibited social engagement disorder are trauma- and stress-related disturbances linked to social neglect so extreme as to impair a child’s opportunities to form attachments to a preferred caregiver (or caregivers). Specific elements of “pathogenic care” and how they affect onset and differentiation of disorder are not well understood.
  • Reactive attachment disorder happens when no figure is found to attach to in early life.
  • Disinhibited social engagement disorder involves indiscriminate sociability and disinhibited attachment behaviours.

Causes and mitigating factors

The essential elements of pathogenic care and their association with the onset and differentiation of disorder are not well understood.14 However, we know that pathogenic care is a necessary but insufficient condition for attachment disorder. Not all children who experience such conditions develop RAD or DSED; indeed, most do not. We also know that the behavioural, interpersonal and psychological manifestations of RAD and DSED are highly distinct. What we know at least suggests that there are often factors, intrinsic to each child and to many early environments, which can and usually do moderate outcome.

Environmental considerations and what differentiates low quality care from pathogenic care are always difficult to ascertain or study in very young children.14 However, known risk factors include: length of time in institutional care, adoption (in institution-reared children), parental maltreatment, having a mother who has been hospitalized for psychiatric reasons, or extremely disrupted mother/child communication (in home-reared children). 13,14,17 And while such risk factors influence the course of each disorder, they do not seem to influence whether a given child develops RAD or DSED.

Effects

RAD. Little information is available regarding RAD symptom stability. One study suggests that RAD symptoms stabilize between 22 and 54 months of age, and last longer in children who have been institutionalized for longer periods of time.16,18 Fortunately, RAD is extremely responsive to fostering and enhanced caregiving,13,14 ,16 although some children continue to show compromised attachments as they age.1

DSED. Indiscriminate behaviours associated with this disorder tend to persist into adolescence.13,14 Overfriendliness and attention-seeking  have been observed in formerly institutionalized children between 4 and 8 years of age. Overly-friendly behaviour is particularly tenacious. By age 16, as indiscriminate behaviour with adults becomes less pronounced, this behaviour persists with peers.14 Unsurprisingly, studies have shown that DSED symptoms are particularly stable in children who remain institutionalized for a long time.16 Children with DSED appear to be less responsive to enhanced caregiving than children with RAD.13,14

Co-morbid psychiatric disorders

Attachment disorders often exist alongside other disorders associated with early deprivation. For RAD, these may include depression, problems in social relatedness, PTSD and cognitive and language delays. For DESD, co-morbid disorders may include problems in social relatedness, externalizing disorders (particularly ADHD), PTSD and cognitive and language delays. In children with either attachment disorder, such co-morbid disorders can improve with enhanced care.

Diagnosis and treatment

Attachment disorders are difficult to diagnose. Practice guidelines1 call for repeated observations of the child interacting with primary caregivers as well as a history of the child’s interactions with these caregivers. Observation of the child with unfamiliar adults is also required, as is a detailed history of the child’s early caregiving environment, based on multiple sources.  Also, there are no specific, validated tools for screening or assessing attachment disorders. A positive diagnosis can only be made based on interviews, history and behavioural observation.

Be aware of the following basic criteria if you are considering reactive attachment disorder of infancy and early childhood in a newcomer patient: 14

  • Extremely disturbed and developmentally inappropriate attachment behaviours, usually appearing between the developmental age of 9 months (when the child is capable of forming selective attachments) and 5 years of age, when the child turns selectively to an attachment figure rarely or not at all.
  • Persistent social and emotional disturbance, with at least 2 of following behaviours: lack of responsiveness to others, restricted ability to experience and/or display positive emotions such as delight or wonder, unexplained irritability, sadness or fearfulness when interacting with nonthreatening adults.
  • An absence of criteria for autistic spectrum disorder.
  • A history of pathogenic care.

Look for the following if disinhibited social engagement disorder is being considered:

  • A pattern of approaching and interacting with unfamiliar adults, with at least 2 of the following behaviours: reduced reticence, overfamiliarity, reduced adult caregiver referencing, and unhesitating willingness to leave with an unfamiliar adult.
  • These behaviours are not characterized by impulsivity, as in the case of ADHD.
  • A history of pathogenic care.
  • A developmental age of at least 9 months.

Warning!

Many proposed “treatments” to enhance attachment can cause harm and should be strenuously avoided. Dangerous interventions include:

  • Physical restraint or coercion (e.g., ‘therapeutic’’ or “compression” holding)
  • “Reworking” of trauma (e.g., “rebirthing therapy”)
  • Promoting regression for “reattachment”.

Such methods have no empirical support and have been associated with serious harm, including death.1

Although the diagnosis of an attachment disorder is based primarily on the child’s behaviour, it is also necessary to assess caregiving attitudes, perceptions and behaviours. Clinicians may need to integrate information from multiple sources across multiple contexts. When taking cultural factors into account, consider the newcomer family’s macroculture (e.g., China) and, as much as possible, any regional variations (e.g., Is the family from rural mainland China or Hong Kong?). 

Culture provides an important context for assessing children’s behaviour.  For example, open parenting patterns, common in parts of Africa and India, encourage the use of non-kinship terms such as “auntie” or even “mother” for non-nuclear family or even non-family members. Some West African cultures rely heavily on age-graded peer socialization: to an outsider, it may seem that people use terms such as “brother” and “sister” indiscriminately, whereas this relational and linguistic pattern may be the result of culturally sanctioned rearing patterns.

Stranger anxiety is probably universal. It usually emerges around the age of 8 months and can help to protect a developing, exploring child from harm. However, culture affects the ways that this predisposition is acted out. In parts of Brazil and Africa, for example, welcoming the stranger is a strong cultural norm. There is evidence that, in children, this cultural practice can lead to either a more welcoming or more indifferent attitude toward strangers than is typical in children of Euroamerican families.

Once a diagnosis is made, the clinician’s most important role is to advocate for the provision of a safe and responsive caregiver. Treatment is then implemented, working with the selected caregiver(s), the caregiver-child dyad (and/or family), and if appropriate, one-on-one with the child.1 Caregivers must be involved in treatment. Children with an attachment disorder may also need adjunctive treatment for aggression and oppositional behaviour. Exercise extreme caution in selecting treatment modality. Be sure to consult the American Professional Society on the Abuse of Children guidelines for determining valid attachment treatments.19

Selected resources

References

  1. Boris NW, Zeanah CH; Work Group on Quality Issues. Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. J Am Acad Child Adolesc Psychiatry 2005;44(11):1206-19.
  2. Skovgaard AM, Houmann T, Christiansen E, et al. The prevalence of mental health problems in children 1(½) years of age – the Copenhagen Child Cohort 2000. J Child Psychol Psychiatry 2007; 48(1): 62-70.
  3. Bowlby J. Attachment and Loss: Volume 1, Attachment. London, U.K.: Pimlico, 1968.
  4. Keller H. Attachment and culture. Journal of Cross-cultural Psychology 2013;44(2):175-94.
  5. Erdman P, Ng KM, eds. Attachment: Expanding the Cultural Connections. New York, NY: Routledge/Taylor and Francis, 2010.
  6. Shi L. Contextual thinking in attachment: Implications for clinical assessment and interventions in cultural contexts. In:  Erdman P, Ng KM, eds. Attachment: Expanding the Cultural Connections. New York, NY: Routledge/Taylor and Francis, 2010.
  7. Ainsworth MD, Blehar MC, Waters E, Wall S. Patterns of Attachment: A Psychological Study of the Strange Situation. Hillside, NJ: Erlbaum, 1978.
  8. Main M, Solomon J. Discovery of a new, insecure-disorganized/disoriented attachment pattern. In Brazelton TB, Yogman M (eds.) Affective Development in Infancy. Norwood, NJ: Ablex, 1986.
  9. Hennighausen K, Lyons-Ruth K. Disorganization of behavioral and attentional strategies toward primary attachment figures: From biologic to dialogic processes. In: Carter S, Ahnert L, eds. Attachment and bonding: A new synthesis. Dahlem Workshop Report 92, Cambridge, MIT Press, 2005.
  10. Batista-Pinto Wiese E. Culture and migration: Psychological trauma in children and adolescents. Traumatology 2010;16(4):142-52.
  11. Stauffer S. Trauma and disorganized attachment in refugee children: Integrating theories and exploring treatment options. Refugee Survey Quarterly 2009;27(4):150-63.
  12. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4thedn., (DSM-IV-TR). Washington, DC: APA, 2000.
  13. Rutter M, Kreppner J, Sonuga-Barke E. Emanuel Miller Lecture: Attachment insecurity, disinhibited attachment, and attachment disorders: Where do research findings leave the concepts? J Child Psychol Psychiatry 2009;50(5):529-43.
  14. Zeanah CH, Gleason MM. Reactive attachment disorder: A review for DSM-V. Washington, DC:  American Psychiatric Association, 2010.
  15. Schechter DS, Wilheim E. Disturbances of attachment and parental psychopathology in early childhood. Child Adolesc Psychiatr Clin N Am 2009;18(3):665-86.
  16. Gleason MM, Fox NA, Drury S, et al. Validity of evidence-derived criteria for reactive attachment disorder: Indiscriminately social/disinhibited and emotionally withdrawn/inhibited types. J Am Acad Child Adoles Psychiatry2011;50(3):216-31.
  17. Lyons-Ruth K, Bureau J-F, Riley CD, et al. Socially indiscriminate attachment behavior in the Strange Situation: Convergent and discriminant validity in relation to caregiving risk, later behavior problems, and attachment insecurity. Dev Psychopathol 2009;21(2): 355-72.
  18. Zeanah CH, Keyes A, Settles L. Attachment relationship experiences and child psychopathology. Ann N Y Acad Sci 2003;1008:22-30.
  19. Chaffin M, Hanson R, Saunders BE, et al. Report of the APSAC Task Force on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems. Child Maltreatment 2006; 11(1):76-89.         

Editor(s)

Leslie Atkinson, PhD
Morton Beiser, MD

Last updated: November, 2016

Also available at: http://www.kidsnewtocanada.ca/mental-health/attachment-disorders
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Caring for Kids New to Canada is a resource for health professionals. The information here is not a substitute for medical advice, nor does it indicate an exclusive course of treatment or procedure to be followed. Variations, taking into account individual circumstances, may be appropriate.

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