Children who have had breaks from their primary caregiver, unmitigated pain, abuse, neglect or in other ways have not had their needs met can often be impaired in their ability to develop healthy emotional attachments. This is currently called by many names, such as insecure attachment. These less-than-healthy ways of attaching are often not diagnosed as disorders, but are common in children who have backgrounds of abuse or neglect or who are no longer with their biological parents, who have had the loss of one or more parents, who are in foster care, who have had several medical procedures or who have been adopted. Attachment is on a spectrum – from healthy to insecure to disorganized (often diagnosed as an attachment disorder). Some of the basic signs/characteristics that a person struggles with attachment are:
- History of abandonment, neglect, abuse, and/or multiple placements
- Indiscriminately seeks affection and/or comfort from strangers (i.e., pseudo-attachments)
- Anti-social behaviors (e.g., lying, stealing, manipulating, destructiveness, cruelty, fire-setting, aggression)
- Lack of authenticity, spontaneity, flexibility, and empathy
- Lack of physical affection and closeness and/or inappropriate clinginess
- Poor eye contact
- Problems with learning, attending, self-regulating, self-monitoring
- Abnormal eating and elimination patterns (e.g., wetting, soiling, hoarding food)
The children exhibiting the most severe symptoms are sometimes diagnosed with Reactive Attachment Disorder (RAD), or the newer diagnosis — Disinhibited Social Engagement Disorder (DSED). All disorders/impairments of attachment are serious, because they impede the child’s emotional health and ability to have meaningful relationships.
Reactive Attachment Disorder
The DSM-5 gives the following criteria for Reactive Attachment Disorder:
A. A consistent pattern of inhibited, emotionally withdrawn behavior toward adult caregivers, manifested by both of the following:
- The child rarely or minimally seeks comfort when distressed.
- The child rarely or minimally responds to comfort when distressed.
B. A persistent social or emotional disturbance characterized by at least two of the following:
- Minimal social and emotional responsiveness to others
- Limited positive affect
- Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers.
C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caring adults
- Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., frequent changes in foster care)
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios)
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the lack of adequate care in Criterion C).
E. The criteria are not met for autism spectrum disorder.
F. The disturbance is evident before age 5 years.
G. The child has a developmental age of at least nine months.
Specify if Persistent: The disorder has been present for more than 12 months.
Specify current severity: Reactive Attachment Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.
Disinhibited Social Engagement Disorder
The DSM-5 gives the following criteria for Disinhibited Social Engagement Disorder:
A. A pattern of behavior in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of the following:
- Reduced or absent reticence in approaching and interacting with unfamiliar adults.
- Overly familiar verbal or physical behavior (that is not consistent with culturally sanctioned and with age-appropriate social boundaries).
- Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings.
- Willingness to go off with an unfamiliar adult with little or no hesitation.
B. The behaviors in Criterion A are not limited to impulsivity (as in Attention-Deficit/Hyperactivity Disorder) but include socially disinhibited behavior.
C. The child has exhibited a pattern of extremes of insufficient care as evidenced by at least one of the following:
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation and affection met by caregiving adults.
- Repeated changes of primary caregivers that limit ability to form stable attachments (e.g., frequent changes in foster care).
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions with high child to caregiver ratios).
D. The care in Criterion C is presumed to be responsible for the disturbed behavior in Criterion A (e.g., the disturbances in Criterion A began following the pathogenic care in Criterion C).
E. The child has a developmental age of at least nine months.
Specify if Persistent: The disorder has been present for more than 12 months.
Specify current severity: Disinhibited Social Engagement Disorder is specified as severe when a child exhibits all symptoms of the disorder, with each symptom manifesting at relatively high levels.
The behaviors (symptoms) of attachment disorders can be very challenging to parent. Providing safety for these children and the rest of the family is a major concern. Families need continuous support and education to help these children heal.
Most professionals agree that attachment disorders are the result of early childhood trauma, so it’s important to understand how trauma affects a developing brain.
The APA further is recognizing that disorders of attachment are trauma-related and has designed a new category of Trauma and Stressor-Related Disorders, under which both attachment diagnoses will be found.
Links:
- Facts for Families – Attachment Disorders – American Academy of Child & Adolescent Psychiatry
- DSM5 313.89 – DSED