Children who showed secure patterns of attachment behaviour in infancy (compared to insecure or disorganised patterns of behaviour) are typically more socially competent with peers, better able to regulate their own emotions and control their behaviour; providing they continue to receive good quality care.
Typically, children become more cognitively sophisticated to negotiate their needs and communicate them to their carers through language as well as behaviour. Therefore, even by 3 years of age the attachment system is already changing the way it works. Children also become more autonomous, beginning to apply the rules and learning from their primary relationships to other relationships, contexts and environments. With development, secure and insecure forms of attachment start to look different.
Secure attachment in a six-year-old may be manifested by an easy and flexible capacity to communicate about distressing things with a caregiver, rather than a direct display of proximity-seeking as in infancy. Insecure forms of attachment also diversify, in ways shaped by cognitive maturation, culture and context, as well as the specific dynamics of the family. However, attachment theorists presume that the different and more developed forms of insecurity in later childhood are nonetheless built on the ground-plan of the patterns seen in the Strange Situation. Forms of insecure-avoidance will downplay attachment needs, and direct attention away from potential sources of distress. Though, when overwhelmed and the avoidant strategy breaks down, these infants may show poorly modulated forms of anger or unhappiness (Moss et al, 2004). Forms of insecure-ambivalence/resistance will intensify behaviours that keep the attention of the caregiver, with some drama always going on or threatening. Other non-normative forms of insecure attachment may also develop. These include the use of aggressive behaviour by the child to control a parent; or the use of solicitous, caregiving behaviour by the child to try to prop up their own caregiver.
Adoption and Fostering
Some children will experience dramatic changes in who looks after them. Children who enter the care system, or who are adopted, may have experienced a disruption in their primary attachment relationship. Children respond to this in different ways. They may need help to begin to trust their new parents or carers as attachment figures. This takes time and the child may need lots of new positive experiences to begin to develop a new and robust attachment relationship. Depending on their early history, they may also keep an attachment relationship to their previous carers who remain important to them.
The best support to help these children is being raised by sensitive parents in a stable home where their needs and signals about distress are noticed and responded to. New families may need some help to treat specific disorders, to free up the therapeutic potential of being parented in a new family. Other families may need some additional help with building the attachment relationship specifically, in terms of helping caregivers provide a “safe haven” that children can feel confident that they can go to and receive support when distressed, and knowing how to respond to expectations and behaviours a child may bring to this new relationship from their past experience. There is evidence that respite, as part of an overall parent training and support package, is effective with looked-after children who have previously been traumatised. It can reduce the likelihood of a placement being disrupted and placement stability can potentially increase attachment security (NICE, 2015).
Important things to remember
- Attachment is just one factor influencing development and is subject to change depending on changes in the individual and family environment.
- The quality of care continues to be very important across development, and this is one of the reasons why stable and responsive adoption or fostering arrangements can have such a positive impact on attachment quality.
- For children placed into foster care, who can stay in a stable placement, research shows that the attachment security to their foster carers is similar to typically brought up children, suggesting that children have the capacity to form new trusting attachment relationships despite early adversity (NICE, 2015).
Psychiatric diagnostic systems recognise two types of rare disorders that manifest in early childhood in which the attachment system has failed to develop properly. These are to be firmly distinguished from insecure and disorganised/disoriented attachment. Both forms of attachment disorder can only be assigned by clinicians to children who meet the diagnostic criteria before the age of five years and after nine months of age (i.e., when an attachment has usually formed) under current ICD-10 guidelines.
The ICD-10 describes a Reactive Attachment Disorder (RAD) (WHO, 2016). The infant’s attachment system appears inhibited, as if the system has not had the opportunity to grow. In situations in which the attachment system might be expected to be active, these children will not show attachment behaviours, such as seeking comfort when distressed.
The ICD-10 also describes a Disinhibited Attachment Disorder (DAD) in which the infant’s attachment system has failed to develop specificity. The infant seeks comfort from a range of carers, including strangers. These infants may rush up to unfamiliar adults to seek proximity and contact and show little fear separating from their primary carer. This type of disorder is strongly related to children raised in institutions or who have had a very large number of changes in carers over a short period. Zeanah et al. (2016, p. 992) have recently questioned whether Disinhibited Attachment Disorder should be considered an “attachment” disorder at all, as it “may occur in the absence of attachment, in an aberrant attachment or in a healthy attachment to a subsequent foster or adoptive parent”. Indeed, the DSM-5 classification system takes this new research into account and has added a new disorder, without attachment in its name, Disinhibited Social Engagement Disorder (DSED) to replace the idea of disinhibited attachment.
Both RAD and DAD are difficult to diagnose and it is not clear how common they are, but they are typically thought to be rare (less than 1%; Moran, 2017), and almost non-existent outside of institutionalised care or significant maltreatment. Expert assessments by a specialist team, including observing the infant or young child’s behaviour across different contexts, with attachment figures and unfamiliar adults, are recommended to make reliable diagnoses of RAD/DAD. To meet diagnostic criteria for an attachment disorder, it is never enough that an infant has had a very poor upbringing or been raised in a family with maltreatment or mental health problems.
Research recommends that when discussing or reporting attachment disorders these should always be specified as RAD or DAD/DSED (and never as generic attachment problems or attachment disorder) because the origins, presentation and outcomes differ so markedly between RAD and DAD/DSED, to ensure that the child’s difficulties are accurately communicated and the most suitable treatment can be identified (Woolgar & Baldock, 2015).
The most important intervention for young children diagnosed with RAD or DAD is ensuring that they are provided with an emotionally available attachment figure (Zeanah, Chesher & Boris, 2016, p.999). In fact, placement stability with sensitive carers leads to the spontaneous recovery of RAD, without the need for psychological intervention.
Clinicians should not administer interventions designed to enhance attachment that involve non-contingent physical restraint or coercion, or promotion of regression because they have no empirical support and have been associated with significant harm (Zeanah, Chesher & Boris, 2016, p.1000).
The NICE Guidance outlines the appropriate treatments to consider, based on the best evidence-supported approaches for benefitting families with insecure and disorganised attachment relationships, including Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline (VIPP-SD); the Attachment and Bio-behavioural Catch-up (ABC) program and Parent Child Psychotherapy.
Important things to remember
- Attachment insecurity and disorganisation are not disorders, but they may be risk factors for later life problems. There are only two psychiatric attachment disorders associated with pathology of the attachment system and these are rare.
- For young children with a history of foster care, adoption, or institutional rearing, clinicians should inquire routinely about a) whether the child demonstrates attachment behaviours and b) whether the child is reticent with strangers (Zeanah, Chesher & Boris, 2016, p.996).
- If someone describes a child as having ‘attachment problems’ it is essential to ask them to explain what they mean in everyday language (e.g., what they observe happening with the caregiver and strangers, in situations when the attachment system is likely to be active, such as during separations and reunions) and what help they think the child needs as a result. Other problems (such as challenging behaviour or anxiety) may be seen in the child’s attachment relationships, e.g., with their primary caregivers, but which are not about dysfunction within their attachment system, and so may be more helpfully understood as other, more common disorders to ensure evidence-based treatments are accessed without delay.
- There are some established interventions that target attachment insecurity and disorganisation discussed by NICE and Zeanah, Chesher & Boris (2016).
- Psychopharmacological interventions are not indicated for the core features of RAD or DSED (Zeanah, Chesher & Boris, 2016, p.1000).
- Individual psychotherapy is of uncertain value. Although the use of creative and non-directive therapies is a popular intervention, there is no evidence that any form of individual therapy done with primary school-age children works (NICE, 2016).