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Attachment Disorders Pratibha Reebye, MBBS, FRCPC, Terry Kope, MD, FRCPC Attachment disorders Several effective interventions for disturbed attachment relation- ships rely on a developmental rather than psychiatric classification approach. ABSTRACT: Attachment disorders ttachment behaviors em- encounter a clearly disturbed attach- are serious disorders that have po- body what an infant does ment relationship. tentially deleterious effects on a to promote proximity to developing child. Identification of What is not an attachment A a caregiver and ensure attachment disorders is best done disorder? safety, security, and survival. Warm, by direct observation of the child in sensitive, and responsive parenting In identifying attachment disorders we the context of the child's relation- generally contributes to secure attach- look at what is happening to individ- ship with the primary caregivers by and ment. In order for an infant to be ual partners what is happening trained early childhood clinicians. attached, an attachment figure or ob- within their relationship. An attach- Diagnosis involves complex issues. ject must, of course, be available. The ment disorder is not defined solely in The point of entry for interventions attachment figure needs to have an terms of an infant’s behavioral distur- can be the infant, the mother or ongoing emotional investment in the bances. Day-to-day parenting errors are other caregiver, dyadic interactions, 1,2 child. In some situations caregivers commonplace anddo not contribute to triadic interactions, or group work. other than parental figures, often out an attachment or relationship disorder. Physicians can also help their pa- of necessity, act as temporary attach- A typical parent-infant relationship is tients by utilizing a variety of clinical ment figures; not all of these will not always optimal; repairing mis- resources. become attachment objects. Certain matches or interactive errors is an situations may preclude the develop- essential part of the ongoing negotia- 3 ment of relational stability and secure tion within the dyad. attachment. Children placed in emer- Secure attachment facilitates in- gency foster homes, children placed in fant mental health andcan mitigate the orphanages with multiple care- effects of other social-emotional risk givers, and children displaced by envi- factors, thus operating as a protective ronmental and other disasters are at factor. However, not all atypical risk. When attachment falls outside of attachment patterns (insecure, disorga- a normative range and into extremes, nized) described previously in this BC Med J mental health clinicians commonly theme issue ( 2007; use the term “attachment disorder.” 49[3]:117) give rise to an attachment Unfortunately, this term is sometimes disorder or future psychopathology. usedin an imprecise manner to refer to Dr Reebye is a clinical professor at the general relationship disturbances in University of British Columbia and clinical early infancy. Empirical data through head of the Infant Psychiatry Clinic at BC longitudinal and cross-sectional stud- Children’s Hospital. Dr Kope is a clinical ies is emerging but is fraught with assistant professor at the University of methodological constraints. Here we British Columbia and a psychiatric consul- will address the current clinical under- tant to the Alan Cashmore Centre, Vancou- standing of what an attachment disor- ver Community Mental Health Services. der represents andwhat to do when you VOL. 49 NO. 4, MAY 2007 BC MEDICAL JOURNAL 187 Attachment disorders Nor do social deprivations necessarily develop healthy attachment relation- ment disorder (reactive attachment dis- 6 give rise directly to an attachment dis- ships and are not always destined to order) in 1980, earlier versions of the International Statistical Classifica- order. However, research findings indi- experience disordered attachment. tion of Diseases9 Diagnostic cate that those in the social high-risk Attachment cannot be quantified and the and Statistical Manual of Mental Dis- sample who also have insecure attach- and every dyad has unique qualities. orders10 ICD-9 DSM-III ment often develop psychopathology Measurement of attachment security ( and ) 4 when followed to adolescence. Even is complex and includes variables that required an age of onset before 8 disorganizedattachment is best viewed are sometimes difficult to decipher on months, failure to thrive, and a perva- 7,8 as a vulnerability factor for adverse clinical observation alone. Tradition- sive lack of social responsivity. De- 5 social and emotional outcomes. ally, clinicians have depended upon spite revisions, newer versions of both Parents who plan to adopt may observable attachment behaviors in manuals continue to be less than ade- approach physicians with questions relation to a particular attachment fig- quate in that they do not describe the regarding attachment disorders. They ure, the caregiver’s accessibility and full range of observed difficulties. should be told that attachment securi- responsiveness to the child, and the Also, children with attachment diffi- ty has been related to the timing of the constancy of this relationship over culties may not show problems across placement and adoptive caregiving time, especially in situations where all relationships. A child may experi- quality. Research suggests that infants Diagnosticthe infant is distressed. classification ence an attachment difficulty with the adoptedearly in the first year of life are primary caregiver but not with other 11 just as likely as non-adoptedinfants to For the formal diagnosis of an attach- adults or peers. Finally, attachment Cases of attachment disorder seen at the Infant Psychiatry Clinic at BC Children’s Hospital Referral criteria The important parts of therapy rec- ommended for Mary included: Patients who are acceptedto the Infant Psychiatry Clinic range in age from • Working with the stepmother regard- birth to 5 years. ing her feelings of guilt and her con- Patients are assessedfor a the full range of concerns, including (but not cern about not being a good parent. limited to) attention deficit hyperactivity disorder (ADHD), anxiety disor- • Framing the child’s behavior as adap- ders, attachment disturbances, autism, behavior problems, developmental tive to the previously experienced delays, mood disturbances, and regulatory difficulties. neglectful environment. After patients are assessed, families that require long-term intervention • Empowering the stepmother and are directed to resources in the community. father to act as secure bases and pro- vide a safe haven. Case 1 The empowerment of the parents “Mary,” a 16-month-old girl, was with a smile, and participate in inter- was the most important strategy. This brought to the clinic by her step- active games. This was in contrast to was achieved through parent-infant mother and natural father. This child Mary’s previous behavior, while in her psychotherapy. was previously caught in a bitter mother’s care, when she seemed with- Case 2 custody battle andwas removedfrom drawn and uninterested in adults. The her biological mother because of stepmother took Mary’s behavior as a “Roger,” a 21/2-year-old boy, was re- extreme neglect. She was subse- rebellion against her new parental fig- ferredto theADHD clinic. He was con- quently placed with her father. ures and sought psychiatric advice sidereda hyperactive, aggressive child, The stepmother did not have regarding what she should do. andwas seen as destructive andaggres- children of her own and had no pre- During assessment Mary’s indis- sive during play. vious parenting experience. She criminate social behavior continued His impulsive behaviors included became very alarmed by Mary’s de- with the examiners, with the resident leaving home in the middle of night mands on male andfemale strangers. trainees, and the patients waiting in and darting into heavy traffic. He had Mary would follow any stranger the reception area. been lost in the local supermarket on 188 BC MEDICAL JOURNAL VOL. 49 NO. 4, MAY 2007 Attachment disorders relational 16 disorders are disorders and Table 1. Types of attachment disorders. do not conform to nosological sys- • Infant has no preferred attachment figure tems that characterize the disorder as DSM- • Can be associated with the infant's emotional withdrawal or indiscriminate sociability and extend to all social interactions residing in the individual. The Disorder of IV-TR • Behaviors highly suggestive of emotional withdrawal: comfort seeking and describes reactive attachment nonattach- displays of affection are remarkably restricted; emotional blunting is observed disorder that can manifest as either ment • Behaviors highly suggestive of indiscriminate sociability: seek proximity or inhibited or disinhibited behavior. DC: 0-3R12 comfort from strangers, with an absence of usual social reticence with The is somewhat more unfamiliar adults useful when classifying attachment • There is a discriminated attachment figure, but the infant does not have disorders but also limited. The advan- secure base, which is created when the caregiver allows infant to explore Secure base tage of this system over that of the the world while being available to the infant if he or she feels insecure DSM-IV-TR distortion is the introduction of a • Behaviors highly suggestive of secure base distortion: self-endangerment, relationship measure on axis 2, with clinging, inhibition, vigilance, hypercompliance, role reversal no relationship disorder at one end and • Involves
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