- Describe healthy attachment and identify the four types of attachment styles
- Differentiate between reactive attachment disorder and disinhibited social engagement disorder
In general public dialogue, 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 caregiving experiences. Some use the term as a blanket term to apply to all complications stemming from underdeveloped attachments in early childhood, but the DSM-5 specifically identifies two attachment disorders—reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED)—that indicate the absence of either or both the main aspects of proximity seeking to an identified attachment figure. This absence 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 after the age of six months.
The words attachment style or pattern refer to the various types of attachment arising from early care experiences, known as either secure, insecure-avoidant, resistant, or disorganized. Some of these styles are more problematic than others, and, although they are not disorders in the clinical sense, are sometimes discussed under the term attachment disorder. For example, disorganized attachment styles are sometimes called attachment disorders because disorganized attachment is seen as the beginning of a developmental trajectory that will take the individual ever further from the normal range, culminating in actual disorders of thought, behavior, or mood. Early intervention for disorganized attachment, or other problematic styles, is directed toward changing the trajectory of development to provide a better outcome later in the person’s life.
Building on the work of Harry Harlow and his work with monkeys displaying a preference for “cloth mothers” made of soft materials rather than just a “wire mother,” John Bowlby developed the concept of attachment theory. He defined attachment as the affectional bond or tie that an infant forms with the mother (Bowlby, 1969). He believed that an infant must form this bond with a primary caregiver in order to have normal social and emotional development. In addition, Bowlby proposed that this attachment bond is powerful and continues throughout life. He used the concept of a secure base to define a healthy attachment between parent and child (1988). A secure base is a parental presence that gives children a sense of safety as they explore their surroundings. Bowlby said that two things are needed for a healthy attachment: the caregiver must be responsive to the child’s physical, social, and emotional needs and the caregiver and child must engage in mutually enjoyable interactions (Bowlby, 1969). For a brief video explanation of attachment theory, watch this video.
While Bowlby thought attachment was an all-or-nothing process, Mary Ainsworth’s (1970) research showed otherwise. Ainsworth wanted to know if children differ in the ways they bond, and if so, how. To find the answers, she used the Strange Situation procedure to study attachment between mothers and their infants (1970). In the Strange Situation, the mother (or primary caregiver) and the infant (age 12–18 months) are placed in a room together. There are toys in the room, and the caregiver and child spend some time alone in the room. After the child has had time to explore their surroundings, a stranger enters the room. The mother then leaves her baby with the stranger. After a few minutes, she returns to comfort her child.
Based on how the infants responded to the separation and reunion, Ainsworth identified three types of parent-child attachments: secure, avoidant, and resistant (Ainsworth & Bell, 1970). A fourth style, known as disorganized attachment, was later described (Main & Solomon, 1990).
The most common type of attachment—also considered the healthiest—is called secure attachment. In this type of attachment, the toddler prefers their parent over a stranger. The attachment figure is used as a secure base to explore the environment and is sought out in times of stress. Securely attached children were distressed when their caregivers left the room in the Strange Situation experiment, but when their caregivers returned, the securely attached children were happy to see them. Securely attached children have caregivers who are sensitive and responsive to their needs.
With avoidant attachment (or insecure-avoidant), the child is unresponsive to the parent, does not use the parent as a secure base, and does not care if the parent leaves. The toddler reacts to the parent the same way they react to a stranger. When the parent does return, the child is slow to show a positive reaction. Ainsworth theorized that these children were most likely to have a caregiver who was insensitive and inattentive to their needs (Ainsworth, Blehar, Waters, & Wall, 1978).
In cases of resistant attachment (or insecure-resistant/ambivalent), children tend to show clingy behavior, but then they reject the attachment figure’s attempts to interact with them (Ainsworth & Bell, 1970). These children do not explore the toys in the room, appearing too fearful. During separation in the Strange Situation, they become extremely disturbed and angry with the parent. When the parent returns, the children are difficult to comfort. Resistant attachment is thought to be the result of the caregivers’ inconsistent level of response to their child.
Finally, children with disorganized attachment behaved oddly in the Strange Situation. They freeze, run around the room in an erratic manner, or try to run away when the caregiver returns (Main & Solomon, 1990). This type of attachment is seen most often in kids who have been abused or severely neglected. Research has shown that abuse disrupts a child’s ability to regulate their emotions.
While Ainsworth’s research has found support in subsequent studies, it has also met criticism. Some researchers have pointed out that a child’s temperament may have a strong influence on attachment (Gervai, 2009; Harris, 2009), and others have noted that attachment varies from culture to culture, a factor that was not accounted for in Ainsworth’s research (Rothbaum, Weisz, Pott, Miyake, & Morelli, 2000; van Ijzendoorn & Sagi-Schwartz, 2008).
Attachment styles vary in the amount of security and closeness felt in the relationship and they can change with new experiences. The type of attachment fostered in parenting styles varies by culture as well. For example, German parents value independence and Japanese mothers are typically by their children’s sides. As a result, the rate of insecure-avoidant attachments is higher in Germany and insecure-resistant attachments are higher in Japan. These differences reflect cultural variation rather than true insecurity, however (van Ijzendoorn and Sagi, 1999). Keep in mind that methods for measuring attachment styles have been based on a model that reflects middle-class, U.S. values and interpretation. Newer methods for assessing attachment styles involve using a Q-sort technique in which a large number of behaviors are recorded on cards and the observer sorts the cards in a way that reflects the type of behavior that occurs within the situation.
Watch this video to better understand Mary Ainsworth’s research and to see examples of how she conducted the experiment.
The DSM-5, classifies reactive attachment disorder (RAD) as a stressor-related disorder caused by social neglect during childhood (meaning a lack of adequate caregiving). Reactive attachment disorder (RAD) is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way, known as the “inhibited form.” The uninhibited form, which manifests as a lack of inhibitions or externalizing behavior are consistent with disinhibited social engagement disorder (DSED). The DSM-4 listed disinhibited social engagement disorder (DSED) as a subtype of RAD, but the latest version lists it as a distinct disorder. The disorders have similar patterns of insufficient care during early development, but those diagnosed with disinhibited social engagement disorder (DSED) appear more outgoing, as compared to the internalizing, withdrawn behavior, and depressive symptoms present in RAD.
Key Takeaways: RAD and DSED
|Table 1. Comparing Reactive Attachment Disorder and Disinhibited Social Engagement Disorder|
|Reactive Attachment Disorder||Disinhibited Social Engagement Disorder|
|A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
B. A persistent social and emotional disturbance characterized by at least two of the following:
|A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:
B. The behaviors in Criterion A are not limited to impulsivity (as in attention-deficit/hyperactivity disorder) but include socially disinhibited behavior.
Understanding Attachment Disorders
RAD and DSED arise from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent changes of caregivers, or a lack of caregiver responsiveness to a child’s communicative efforts. Not all, or even a majority of such experiences, result in the disorder. The diagnosis is differentiated from pervasive developmental disorder or developmental delay and from possible comorbid conditions such as intellectual development disorder (intellectual disability), all of which can affect attachment behavior. The criteria for a diagnosis of a reactive attachment disorder are very different from the criteria used in the assessment or categorization of attachment styles such as insecure or disorganized attachment.
Signs and Symptoms
Children with RAD are presumed to have grossly disturbed internal working models of relationships that may lead to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years. However, the opening of orphanages in Eastern Europe following the end of the Cold War in the early 1990s provided opportunities for research on infants and toddlers brought up in very deprived conditions. Such research broadened the understanding of the prevalence, causes, mechanism, and assessment of disorders of attachment and led to efforts from the late 1990s onwards to develop treatment and prevention programs and better methods of assessment. Mainstream theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined beyond current classifications.
Pediatricians are often the first health professionals to assess and raise suspicions of RAD in children with the disorder. The initial presentation varies according to the child’s developmental and chronological age, although it always involves a disturbance in social interaction. Infants up to about 18–24 months may present with non-organic failure to thrive and display abnormal responsiveness to stimuli. Laboratory investigations will be unremarkable barring possible findings consistent with malnutrition or dehydration, while serum growth hormone levels will be normal or elevated.
The core feature is severely inappropriate social relating by affected children. This can manifest itself in three ways:
- Indiscriminate and excessive attempts to receive comfort and affection from any available adult, even relative strangers (older children and adolescents may also aim attempts at peers). This may oftentimes appear as a denial of comfort from anyone as well.
- Extreme reluctance to initiate or accept comfort and affection, even from familiar adults, especially when distressed.
- Actions that otherwise would be classified as conduct disorder, such as mutilating animals, harming siblings or other family members, or harming themselves intentionally.
While RAD occurs in relation to neglectful and abusive treatment, automatic diagnoses on this basis alone cannot be made, as children can form stable attachments and social relationships despite marked abuse and neglect. However, the instances of that ability are rare.
There is as yet no universally accepted diagnostic protocol for reactive attachment disorder. Often a range of measures is used in research and diagnosis. Recognized assessment methods of attachment styles, difficulties or disorders include the Strange Situation Procedure (devised by developmental psychologist Mary Ainsworth), the separation and reunion procedure and the Preschool Assessment of Attachment, the Observational Record of the Caregiving Environment, the Attachment Q-sort and a variety of narrative techniques using stem stories, puppets or pictures. For older children, actual interviews such as the Child Attachment Interview and the Autobiographical Emotional Events Dialogue can be used. Caregivers may also be assessed using procedures such as the Working Model of the Child Interview.,
Other research also uses the Disturbances of Attachment Interview (DAI) developed by Smyke and Zeanah (1999). The Disturbances of Attachment Interview (DAI) 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 caregiver,” “reticence with unfamiliar adults,” “willingness to go off with relative strangers,” “self-endangering behavior,” “excessive clinging,” “vigilance/hypercompliance,” and “role reversal.” This method is designed to pick up not only RAD but also the proposed new alternative categories of disorders of attachment.
In children ages zero to three, research has shown high rates of comorbidity with RAD and speech/language developmental disorders as well as autism. Additionally, ADHD was found to be common among those with RAD, in children aged seven to nine and for non-psychological disorders, respiratory and digestive diseases were found to be fairly common as well.
Causes of RAD
Although increasing numbers of childhood mental health problems are being attributed to genetic defects, reactive attachment disorder is by definition based on a problematic history of care and social relationships. Abuse can occur alongside the required factors, but on its own does not explain attachment disorder. It has been suggested that types of temperament, or constitutional response to the environment, may make some individuals susceptible to the stress of unpredictable or hostile relationships with caregivers in the early years. In the absence of available and responsive caregivers, it appears that most children are particularly vulnerable to developing attachment disorders.
While similar abnormal parenting may produce the two distinct forms of the disorder, inhibited (RAD) and disinhibited (DSED), studies show that the abuse and neglect was far more prominent and severe in the cases of disinhibited social engagement disorder.
Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. Play therapy and expression therapy, even nonverbal therapy, can be used to help children form attachments.
Mainstream practitioners and theorists have presented significant criticism of the diagnosis and treatment of attachment disorders within the controversial form of psychotherapy commonly known as attachment therapy. Attachment therapy has a scientifically unsupported theoretical base and uses diagnostic criteria or symptom lists markedly different from criteria under ICD-10 or DSM-5, or to attachment behaviors. A range of treatment approaches are used in attachment therapy, some of which are physically and psychologically coercive, and considered to be antithetical to attachment theory.
The Controversy of Attachment Therapy
Attachment therapy is not the same as attachment-based family therapy. These are two different concepts that must not be confused.
In brief, when children are unable to securely attach to a primary caregiver, they may develop an attachment disorder, or at the very least, have difficulty understanding proper relationships. These issues need to be addressed in a sensitive therapeutic setting and treatment such as ABFT can be helpful. Therapists trained in ABFT understand attachment theory and work with families to improve their bonding via psychotherapy. For more information on ABFT, watch this short video.
Attachment therapy (also known as Coercive Restraint Therapy) is much different. In sum, it is used by therapists to treat children diagnosed with RAD in an attempt to repair attachment issues that began with earlier caregivers. Rising in popularity in the 80s and 90s, it’s often used to treat adoptive and foster care children and still in practice today. The idea behind it is this: the tantrums; rage; and inappropriate, uncontrollable behavior often seen in children with RAD is a result from early neglect and mistreatment, thus they must be provoked in order to “release” this rage and form better attachments, which result in affection and obedience.
Three main techniques are holding, rebirthing, and therapeutic foster parenting. In holding therapy, the therapist (or trained parent) restrains the child in an attempt to trigger the rage. In rebirthing, the child is wrapped and/or covered in pillows and held down until they can force themselves out, hence the term “rebirth.” The latter is illegal in Colorado after 10-year-old Candace Newmaker suffocated to death during a “rebirthing.” Therapy may also involve placing children in a totally controlled and structured environment, like a boot-camp, in attempts to break them into becoming more obedient.
Unfortunately, attachment therapy has resulted in injuries—even death—for many children who’ve been through this treatment. For a list of real examples of victims, visit Advocates for Children in Therapy. Research into its efficacy has concluded that there’s no empirical evidence showing this type of intervention to be valid.
In 2005, the American Academy of Child and Adolescent Psychiatry laid down guidelines (devised by N.W. Boris and C.H. Zeanah) based on its published parameters for the diagnosis and treatment of RAD. Recommendations in the guidelines include the following:
- Clinicians should ensure the child has an emotionally available attachment figure.
- While RAD is a diagnosis for symptoms displayed by a child, it’s also important to assess the caregiver’s attitude about the child.
- Treatment should focus on creating positive interactions with caregivers.
- Children with RAD should also display aggressive or oppositional behavior should be provided with additional treatment.
Undoubtedly, identifying RAD and DSED while overlooking other common disorders may be detrimental due to missed treatment of other treatable disorders. Yet, neglecting to properly diagnose RAD or DSED may be equally damaging, as an incomplete or incorrect case formulation may reduce the likelihood of adequate developmental support for a child. In cases with RAD or DSED, caregivers may need specialized interventions, aiming to enhance their sensitivity, emotional availability, and commitment to the child.
Pharmacological interventions are under scrutiny and there is little supporting evidence to show efficacy. For one, it is difficult to assess in very young children with ongoing development of the liver and the kidneys. It has been observed that psychotropic medications in children have shorter half-lives (Kearns et al.), which would require use of higher doses for body weight in comparison to adults for same plasma level. Unfortunately, that in turn significantly increases the likelihood and severity of potential side effects. There is also a question on effects of early exposure to antipsychotics on neurodevelopment. In particular, in the first three years of life, there are many changes in developing brains, such as an increase in synaptic density, pruning, and an increase in neuronal myelination to list just a few.
If at all possible, prevention is key. Once a diagnosis of RAD or DSED is established, then measures should be taken to provide as much emotional stability as possible, while considering appropriate therapeutic interventions.
Research and RAD
Research by Rachel Pritchett and others took a closer look at the nuanced nature of RAD and its comorbidity with other disorders. They described their results as follows:
This study was part of a population-based study investigating the prevalence of reactive attachment disorder (RAD) in 6–8 years old children from a sector of a UK city characterized by high levels of deprivation.
We described the characteristics of 22 children with a suspected, borderline, or definite diagnosis of RAD. We found that they have a high level of comorbidity with other disorders, had lower IQs than population norms, had a higher level of disorganized attachment than has been found in general population studies, more problem behaviors, and had lower social skills than would be found in the general population. These findings are in line with previous research about children coming from institutions. This study shows that those children in the general population with RAD also have these additional problems, providing further evidence that a multidisciplinary approach is needed when working with these children.
We found that over half of our sample had a secure attachment; this offers support to the growing body of research showing that RAD and insecure attachment are not the same thing. We did, however, also find that there was a higher rate of disorganized attachment than would be found in the general population. This is not surprising as research has previously shown that those with a history of maltreatment have a greater chance of having a disorganized attachment in later development.
Key Takeaways: RAD and DSED
attachment style: these refer to the various types of attachment arising from early care experiences, which are secure, insecure-avoidant, resistant, or disorganized
attachment theory: the belief that young children need to develop a secure and/or healthy bond with at least one primary caregiver for normal social and emotional development
attachment therapy: a pseudoscientific child mental health intervention intended to treat attachment disorders through techniques like holding or rebirthing
proximity seeking: these are behaviors (by the infant) that are intended to keep the caregiver close (or whoever the infant is attached to); this is usually exhibited by actions such as crawling/walking to the person or climbing in their lap, lifting their arms to be held, etc.
avoidant attachment (or insecure-avoidant): the child is unresponsive to the parent, does not use the parent as a secure base, and does not care if the parent leaves
disinhibited social engagement disorder (DSED): a stressor-related disorder caused by childhood neglect and considered the “uninhibited form” of RAD, which manifests as a lack of inhibitions or externalizing behavior
disorganized attachment: this type of attachment is seen most often in kids who have been abused or severely neglected; research has shown that abuse disrupts a child’s ability to regulate their emotions
reactive attachment disorder (RAD): a stressor-related disorder caused by social neglect during childhood (meaning a lack of adequate caregiving) that manifests as inhibited, emotionally withdrawn behavior toward adult caregivers
resistant attachment (or insecure-resistant/ambivalent): children tend to show clingy behavior, but then they reject the attachment figure’s attempts to interact with them
secure attachment: considered the “healthiest” style, a child with this attachment has a caregiver that is sensitive and responsive to their needs; the parent is a “secure base” for them and the child will seek them when in stress
strange situation: a study conducted in 1970 in which researchers observed attachment between mothers and their infants
- Boris, Neil W.; Zeanah, Charles H.; Work Group on Quality Issues (November 2005). "Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood". Journal of the American Academy of Child and Adolescent Psychiatry. 44 (11): 1206–19. doi:10.1097/01.chi.0000177056.41655.ce. PMID 16239871. ↵
- Mercer, J. (2002). The Scientific Review of Mental Health Practice. https://www.srmhp.org/0102/attachment-therapy.html. ↵
- Boris, Neil W.; Zeanah, Charles H.; Work Group on Quality Issues (November 2005). "Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood". Journal of the American Academy of Child and Adolescent Psychiatry. 44 (11): 1206–19. doi:10.1097/01.chi.0000177056.41655.ce. PMID 16239871 ↵
- Seim, A.R., Jozefiak, T., Wichstrøm, L. et al. Validity of reactive attachment disorder and disinhibited social engagement disorder in adolescence. Eur Child Adolesc Psychiatry (2019). https://doi.org/10.1007/s00787-019-01456-9 ↵
- Romanowicz, M., McKean, A.J. & Vande Voort, J. A case of a four-year-old child adopted at eight months with unusual mood patterns and significant polypharmacy. BMC Psychiatry 17, 330 (2017). https://doi.org/10.1186/s12888-017-1492-y ↵
- Pritchett, R., Pritchett, J., Marshall, E., Davidson, C., & Minnis, H. (2013, April 18). Reactive Attachment Disorder in the General Population: A Hidden ESSENCE Disorder. https://www.hindawi.com/journals/tswj/2013/818157/. ↵