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Chapter 27: Attachment Disorders in Early Childhood CHAPTER 27 Attachment Disorders in Early Childhood Julianna Finelli Charles H. Zeanah, Jr. Anna T. Smyke “Attachment” describes the human infant’s century that “essential for mental health is that tendency to seek comfort, support, nurturance, an infant and young child should experience and protection selectively from a small number a warm, intimate and continuous relationship of caregivers. Based on experiences of regular with his mother (or mother substitute . ) in interactions with adult caregivers, infants learn which both find satisfaction and enjoyment.” gradually to seek comfort and protection not The propensity for human infants to form se- from just anyone but selectively, from caregiv- lective attachments is believed to be so strong ers on whom they have learned they can rely. that only in highly unusual and maladaptive According to attachment theory, infants’ behav- caregiving environments do attachments fail to iors with these caregivers are guided by their develop. For young children raised in species- “internal working models” of relationships, a atypical rearing conditions, however, seriously heuristic term describing a set of tendencies to disturbed and developmentally inappropri- experience and behave in intimate relationships ate ways of relating may evolve. Examples of in particular ways; that is, as early as the first atypical environments include institutions (i.e., year of life, infants begin to construct expec- orphanages), frequent changes of caregivers (as tations about how they and others with whom sometimes happens in foster care), neglectful they interact will feel and behave. The internal or abusive caregiving, or being raised by insen- working model is more than a set of expecta- sitive or unresponsive caregivers. In these ex- tions, however, as it includes selective attention treme situations, young children may develop to incoming social information and salient so- clinical disorders of attachment. cial cues, feelings elicited during intimate inter- In this chapter, we review the construct of actions with others, memories of similar feel- attachment disorders, with an emphasis on re- ings in previous interactions and relationships, active attachment disorder and disinhibited and the infant’s own behavioral responses to social engagement disorder. Although derived others. Attachment is considered a vital compo- from descriptive studies dating back at least to nent of social and emotional development in the the 1940s, these disorders have been subjected early years, and individual differences in the to systematic study only in the past decade or quality of attachment relationships are believed so, and are still often misunderstood (Chaffin to be important early indicators of infant mental et al., 2006). Therefore, we review developmen- health. John Bowlby (1952, p. 11), who elaborat- tal perspectives on attachment, as well as the Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. ed attachment theory, declared in the mid-20th phenomenology, correlates, epidemiology, and 452 EBSCO : eBook Collection (EBSCOhost) - printed on 7/2/2019 3:16 PM via TUFTS UNIV AN: 1843598 ; Zeanah, Charles H..; Handbook of Infant Mental Health, Fourth Edition Account: s3579704.main.ehost 27. Attachment Disorders in Early Childhood 453 course of reactive attachment disorder and dis- those to whom they are attached. Bowlby (1969) inhibited social engagement disorder. Finally, emphasized that play partners are not necessar- we consider assessment and treatment of reac- ily attachment figures. We may think of a con- tive attachment disorder and disinhibited social tinuum of infants’ behavior with caregivers, be- engagement disorder. ginning with recognition/familiarity, followed by familiarity/comfort, then comfort/pleasure, then pleasure/reliance and finally reliance/pref- Developmental Perspectives on Attachment erence (see Figure 27.1). Only at the level of reli- ance/preference may we say infants have fully The capacity to form an attachment is not pres- formed attachments to caregivers. ent at birth but develops gradually over the first Though older children can sustain attach- year of life. For the first 2 months after birth, in- ment relationships over time and space, in the fants are not well developed socially, spending first 3 years or so of life, the young child needs most of their time sleeping, eating, and crying. actual interaction with caregivers in order to At around 2 months of age, they become dra- become attached to them. This has important matically more social, exhibiting a responsive implications both for custody and visitation and “social” smile, as well as cooing responsively for infants in foster care. and making more sustained eye-to-eye contact. They seem more interested in social interaction Classifications of Attachment and are willing to interact readily with adults. Although infants in the first 6 months are able Attachment is most often assessed in the early to distinguish among different interactive part- years of life with a procedure known as the ners, they do not express an obvious preference Strange Situation Procedure (SSP). This obser- for one caregiver over another. vational paradigm involves a series of interac- This lack of obvious preference changes at tions between a young child, an attachment fig- around 7–9 months of age. At that point, in- ure, and a stranger (Ainsworth, Blehar, Waters fants begin to exhibit stranger wariness and & Wall, 1978). The procedure was designed to separation protest, two behaviors that herald examine the young child’s balance between at- the onset of “focused” or “selective” attach- tachment and exploratory behaviors, primarily ment. “Stranger wariness” varies from mild through comparing the child’s behavior with the reticence to outright distress, but it contrasts attachment figure and with the unfamiliar adult. with the infant’s selective seeking of comfort, Because separation from the attachment figure support, nurturance, and protection. “Separa- activates the young child’s need for closeness tion protest” describes the infant’s reaction to and comfort, the SSP includes two brief separa- actual or anticipated separation from an attach- tions and reunions that allow direct observation ment figure. Once infants have developed the of the child making use of the caregiver to regu- cognitive capacity to exhibit separation protest late his or her emotions during this moderately and stranger wariness, they may form new at- stressful experience. tachments with any caregivers with whom they Based on the organization of child’s attach- have significant and sustained interactive expe- ment behaviors and the balance between the riences. child’s tendency to seek proximity to the at- It is important to emphasize that infants are tachment figure and to move away from the likely to recognize and may even be comfort- attachment figure and explore, it is possible to able with a larger number of caregivers than derive an overall classification of attachment Recogni�on/ Familiarity/ Comfort/ Pleasure/ Reliance/ familiarity comfort pleasure reliance preference FIGURE 27.1. Continuum of behaviors relevant to development of attachment relationships. Copyright @ 2019. The Guilford Press. All rights reserved. May not be reproduced in any form without permission from the publisher, except fair uses permitted under U.S. or applicable copyright law. EBSCO : eBook Collection (EBSCOhost) - printed on 7/2/2019 3:16 PM via TUFTS UNIV AN: 1843598 ; Zeanah, Charles H..; Handbook of Infant Mental Health, Fourth Edition Account: s3579704.main.ehost 454 IV. Psychopathology between the child and caregiver. Ainsworth and mary caregivers (Deklyen & Greenberg, 2016; colleagues (1978) described three major pat- Lyons-Ruth & Jacobvitz, 2016). Thus, SSP clas- terns of attachment. Children who expressed sifications of secure, avoidant, resistant, and distress directly, sought comfort unhesitatingly, disorganized are risk and protective factors for and responded to comfort readily were classi- disorders rather than diagnostic entities them- fied as “securely” attached to their caregivers. selves. Secure attachment appears to be espe- Children who showed little distress on sepa- cially important as a protective factor in high- ration and little need for closeness or comfort risk samples (e.g., Tharner et al., 2012). Still, on reunion were classified as “avoidantly” at- it seems increasingly clear that taken alone, tached to their caregivers. Finally, children classifications of attachment have more limited who showed intense distress but could not be long-term predictive power, whereas when con- comforted on reunion were classified as “resis- sidered with other variables, they appear to be tantly” (sometimes referred to as “ambivalent- important, if not vital, considerations (Sroufe, ly”) attached to their caregivers. Essentially, 2005). these patterns represent balanced (“secure”), Given the ubiquity of attachment for human diminished (“avoidant”) and excessive (“resis- infants, an important clinical challenge is to tant”) activation of the child’s need for comfort distinguish between typically appearing vari- when stressed. A fourth classification was later ants of attachment and actual clinical disorders added by Main and colleagues (Main & Hesse, of attachment. For this, we turn to a consider- 1990; Main & Solomon, 1990). They described
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