Paediatrics: Attachment disorder

Attachment disorder

Definition and diagnostic criteria

The key feature of attachment disorders is a pattern of abnormal social functioning that is apparent during first 5yrs of life, and is associated with a significant disturbance in emotional functioning. These patterns persist into later childhood and adolescence in spite of changes in the child or young person’s environment. Two patterns of attachment disorders are described;

Disinhibited attachment disorder

Associated with an ‘institutional’ style of care in early life, with care being provided by a number carers and the absence of a specific primary care giver. The child is unduly friendly with strangers, does not seem to mind who looks after her/him, and forms superficial relationships easily. Such children may be overactive, aggressive, show emotional liability, or poor-ly tolerate frustration. The incidence of disinhibited attachment disorder is not well characterized, but is relatively low in the general population. Significant rates of disinhibited attachment disorder are however, report-ed in children raised in institutional care from birth.

Reactive attachment disorder

These children fail to respond appropriately to social interactions and dis-play a fearfulness and hypervigilance which is not responsive to reassur-ance. Contradictory or ambivalent social responses may also be present. Parental abuse, neglect, and severe maltreatment are highly significant aetiological factors. The severity and duration of abuse or neglect influ-ences the severity of the disorder. The prevalence of inhibited attachment disorder is low and not all children who experience significant abuse and neglect will develop an inhibited attachment disorder.

Differential diagnosis 

Includes autism spectrum disorder, PTSD, ADHD, anxiety disorders, and selective mutism.

Treatment

The focus of interventions is to ensure a secure nurturing care set-ting which provides consistent behavioural management and emotional responses. Infants and young children often have the capacity to alter their behaviour in response to sensitive and emotionally responsive parenting. There is less evidence for significant change in older children.

Children with severe attachment disorders may require placement in a therapeutic residential unit.

Prognosis

Children with attachment disorders have significant difficulties with inter-personal relationships and are at greater risk of developing mental health problems in adolescence and adulthood. Duration of inadequate care is linked to outcome. Children who are placed with appropriate carers before age two have a better outcome.