Attachment Disorders in Couple and Family Therapy
Name of Concept
Attachment Disorders in Couple and Family Therapy.
Attachment disorders have several meanings in the field of couple and family therapy. The first refers to the relatively rare, diagnosable disorders of Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) which are seen exclusively in maltreated children. The second refers to commonly enduring attachment styles of parent-child interactions that were first identified by John Bowlby (1969) and Ainsworth et al. (1978) for children and later expanded to adults (Hazan and Shaver 1987). The third meaning of “attachment disorder” is a pseudo-diagnostic term with criteria ambiguous enough to include most developmentally appropriate child behavior such as lying, persistent questions, or triangulation of caregivers. This entry focuses on RAD and DSED. Both RAD and DSED have particular relevance to field of Couple and Family Therapy as the disorders result from severe and persistent neglect, and caregivers often experience intense challenges with raising these children.
Theoretical Context for Concept
Attachment theory posits that children are biologically wired to form close, long-term, and dependent relationship with their caregivers from infancy. Four infant styles of attachment (secure, avoidant, resistant-ambivalent, and disorganized-disoriented) has been identified. Infants that have a secure bond with their caregiver experience distress when the caregiver leaves and seek reunion upon the caregivers return. Infants with an insecure bond either do not attempt reunion with caregiver upon return or do so ineffectively. While insecure attachment styles are related to Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED), the relationship is not causal and the appropriateness of classifying these disorders as attachment disorders is increasingly questioned.
There are several major questions that should be considered with the RAD or DSED diagnoses. First, given that RAD and DSED are almost entirely seen with institutionalized children, we must question if the disorders can be generalized to other developmental experiences. The lack of information about their prevalence also severely limits the generalizability of what we do know about the disorders. Second, although RAD and DSED are considered relational disorders, they are primarily defined by the individual symptoms of a child (attachment) rather than the relational dynamics at play. Namely, the role of caregivers failing to bond with RAD/DSED children is essential to the development of the disorders and is absent from literature on the disorders. This leaves the main conceptualization of the disorders as the child’s problematic behaviors as the problem rather than the systemic pattern of neglect in which the child was raised. Although there is question about the caregivers’ role in the development of the disorder that may never be answered due to ethical limitations, some caregivers may be less likely to bond with children that are less likely to seek comfort. Third, attachment styles and several of integral aspects of attachment theory, like internal working models, are missing from the discussion of RAD and DSED. In fact, many have suggested that an attachment framework may not be appropriate for these disorders (Allen 2016; Lyons-Ruth 2015). Perhaps most importantly, the disconnect between attachment theory and RAD/DSED is confusing the public and may encourage caregivers that are have exhausted all other options to consider “attachment therapies” that include dangerous and controversial tactics that have no established evidence of efficacy. These “attachment therapies” are typically marketed as treatments designed for attachment disorders.
Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) manifest through disturbed and developmentally inappropriate social behaviors. Children that have been severely neglected, maltreated, or abused are more likely to be diagnosed with RAD or DSED, but no epidemiological studies have examined their prevalence. Children at risk for RAD and DSED are those who have been placed in foster care or raised in institutions such as orphanages, hospitals, or long-term care facilities. The development of these attachment disorders is rooted in both biological factors (e.g., temperament) and contextual factors (e.g., parent ability to bond). A stress-diathesis model may be useful to understand the development of these disorders. This model assumes that most people have some level of diathesis (predisposition) for any disorder that is then activated by stress. People with high levels of diathesis require lower levels of stress but no amount of stress can activate the disorder in people with no amount of diathesis. Given that even within extremely maltreated populations few children develop these disorders, it appears be that some biological factor underlies the disorder.
Children with RAD demonstrate contradictory or ambivalent social responses at reunions or partings with attachment figures. Essentially, this manifests through children rarely turning to an attachment figure for comfort. These children may approach others without making eye contact or stare into the distance while being held or embraced. RAD children respond to social and parenting cues inconsistently – sometimes appearing welcoming or accepting and other times showing avoidance or resistance. When experiencing their own distress or in proximity of others in distress, RAD children are typically unresponsive, withdraw entirely, or sometimes become physically aggressive. They are noted for displaying hypervigilance and fearfulness. For complete diagnostic criteria and further discussion of differential diagnoses (autism spectrum disorder, intellectual disability, and depressive disorders), we recommend consulting the DSM-5; the diagnosis cannot be made before the age of 9 months and should be made with caution after the age of five.
The DSED diagnosis was originally a subtype of RAD but is now considered distinct disorder. Given that there are differences in how DSED and RAD symptoms respond to in-home placement after institutionalization, this separation appears to be appropriate. Children with DSED are seen to have inappropriate or overly familiar relationships with people unknown to the child. This manifests through comfortable and intimacy with strangers. These children are often overly clingy as infants but become indiscriminately friendly as older children. Children with DSED are comfortable sitting on the laps of strangers and leaving the presence of caregivers with a stranger. They also have extreme difficulty in creating close relationships with peers and commonly have emotional and behavioral disturbances. Many DSED children also suffer from cognitive delays and developmental delays.
Although the prevalence of RAD in the general population is unknown, some literature suggests that approximately 1 out of every 100 children in foster care or other placement outside of a home will be diagnosed with RAD (Gleason et al. 2011); the DSM-5 reports the prevalence of RAD to be about 10% and of DSED to be about 20% in extremely neglected populations. Though RAD is more likely to develop in cases of maltreatment, many children are able to subsequently form a stable attachment relationship and only 40% of children diagnosed with RAD spent time in foster homes or orphanages. There is no standard diagnostic protocol for either attachment disorders, though the Disturbances of Attachment Interview has effectively been able to identify both RAD and DSED (Smyke and Zeanah 1999). Children typically do not develop attachment disorders from a mild history of maltreatment or disrupted attachment although there is some connection between mild maltreatment and the RAD/DSED disorders (Lionetti et al. 2015).
Most of the foundational research on RAD and DSED has come from or has been inspired by two longitudinal projects which tracked a group of institutionalized children in the United Kingdom and children from Romanian Orphanages. Barbara Tizard et al. (1972) followed a group of children from the UK who were placed outside of a home or in an institution. Tizard and colleagues first identified the emotionally withdrawn and socially disinhibited categories that have been utilized as bases for RAD and DSED, respectively. The other project involved the study of Romanian orphans in the 1990s (O’Connor et al. 2000). O’Connor and colleagues found that some DSED behaviors are likely to persist in-home placement. Fortunately, there has been a sizable increase in research to attachment disorders in the last decade (cf. Zeanah and Gleason 2015). Perhaps the most hopeful and striking finding from recent research is that children placed into homes, and receive care adequate to their needs show significant (or complete) remission of their RAD/DSED symptoms in most cases. However, it appears that DSED symptoms are more persistent post in-home-placement than RAD symptoms; the most important factor predicting reduction of symptoms appears to be the amount of time the child has spent in an institution (Guyon-Harris et al. 2018). Specifically, the less time in an institution, the greater the reduction in symptoms has been found.
Application of Concept in Couple and Family Therapy
The primary interventions RAD and DSED focus on enhancing caregiver sensitivity or finding new caregivers when current caregivers are unable or unwilling to meet the heightened and intense needs of the child (Bakermans-Kranenburg et al. 2003). Enhancing caregiver sensitivity requires observation of a caregiver providing care for their child to accurately assess caregiver sensitivity patterns. The therapeutic target is how the parent and child interact and specifically, how the caregiver responds to the child. Much of this work involves psychoeducation about the development of attachment disorders and the child’s inability to just get over it. This involves building a belief within the caregivers that it is their responsibility to help the child learn to be a more functional and normative adult. This belief fits very well with most family-based interventions that believe that the parent/caregiver plays an integral role in the child’s development. The child’s behaviors are not the focus; rather, treatment focuses on teaching the parent to better understand and be able to respond to the child’s needs.
Interventions also aim to help parents and caregivers develop greater empathy for their child through helping caregivers better understand their own attachment history. When parents are able to increase their understanding and empathy of their child, they are then able to comfort and provide care more effectively. Because of the severity and persistence of attachment disorders, when efforts to increase the caregiver’s capacity to be sensitive to the child’s needs and behaviors is not possible – due to unwillingness or inability of the caregiver – it may be appropriate to work on finding a new caregiver that is capable of the increased level of sensitivity needed. Though there is no model that specifically addresses RAD and DSED attachment disorders, both RAD and DSED appear to be responsive to enhanced and stable caregiving (cf. Zeanah and Gleason 2015).
Maria was 5 years old when her foster parents sought additional help to understand some of the challenges they were facing with Maria. Maria had been severely neglected by her biological parents. She was found alone when she was 12 months old by her parents’ landlord after a neighbor reported a noise disturbance and the parents were not home. This started a process several years long of bouncing between systems-of-care and short-term placements before she was placed in a more stable foster home with her older sister.
Maria’s foster parents reported erratic and unpredictable moods with behaviors that would escalate quickly from hugging to biting and yelling. According to the foster parents, Maria had no friends at school. They also reported frequent physical altercations, lying, and a lack of remorse after acting aggressively. Most recently, the foster parents reported an incident in which Maria followed an unknown adult male and tried to get into his car. Many elements of DSED appear present with Maria, particularly the early and sustained neglect, difficulty in mood regulation, and the willingness to wander off with an unfamiliar adult. An integral aspect that distinguishes DSED from RAD is the pattern of overly familiar and inappropriate social behavior with strangers. While Maria’s pattern of indiscriminate behavior of nonselective attachment behavior is a clear indicator of DSED, utilizing the Disturbances of Attachment Interview (Smyke and Zeanah 1999) may be useful during assessment.
Perhaps most important in Maria’s treatment is the inclusion of the caregiving system (and parents should reunification ever take place). The development of secure attachment can occur in the foster-care family environment but only if the foster parents also demonstrate more secure attachment patterns for Maria. The mains goals for treatment are to help Maria’s foster-parents (1) learn how to increase their empathy for Maria, (2) increase their ability to be emotionally available and respond sensitively to Maria, and (3) to help them feel confident and capable of loving a child that may, at times, be challenging. Perhaps most important is that Maria has a stable and consistent home to live in – good enough but consistent caregivers are key.
An integral aspect of both these goals involves psychoeducation with the caregivers regarding the DSED diagnosis and some of the history that Maria, and her sister, has experienced. When the caregivers better understand the context in which Maria has lived, they are more able to forgive the difficulties they are dealing with currently. Given that many DSED children also are developmentally or cognitively delayed, it may be useful help the caregivers learn how to listen and speak with toddlers and young children. This may occur through play-therapy or sandbox treatments due to Maria’s age.
Given the increased effort that parenting a DSED child takes, it is likely the caregivers experience frustration and may even wonder if they should continue to try as foster parents. Empathizing with the caregivers about their frustrations will help the caregivers to feel competent and revitalize their efforts to parent a difficult child. Structured sessions in which the therapist helps the caregivers to identify and respond to Maria’s needs may be useful. Most important is that the caregivers find the support, the need, and the belief that they themselves are good enough to provide consistent care.
Several changes identify when termination of treatment with Maria and family should be considered: (1) Maria is able to consistently turn to her caregivers (reunited parents or foster parents) when she has questions or difficulties, (2) when Maria’s parents (foster or reunited) are able to consistently be emotionally available and respond to Maria’s concerns rather than their own reactions to her, and (3) Maria’s caregivers feel revitalized and confident in parenting on their own and seeking additional help when they need it. Though treatment duration may vary between cases, what little outcome data does exist on children diagnoses with RAD or DSED suggest that almost all youth that are placed in a home show few differences when compared to non-neglected or institutionalized youth.
- Ainsworth, M. D., Blehar, M. C., Waters, E., & Wall, S. (1978). Patterns of attachment: A psychological study of the strange situation. Hillsdale, NJ: Erlbaum.Google Scholar
- Bowlby, J. (1969). Attachment and loss: Attachment. New York: Basic Books.Google Scholar
- Guyon-Harris, K. L., Humphreys, K. L., Fox, N. A., Nelson, C. A., & Zeanah, C. H. (2018). Course of disinhibited social engagement disorder from early childhood to early adolescence. Journal of the American Academy of Child & Adolescent Psychiatry, 57, 329–335. https://doi.org/10.1016/j.jaac.2018.02.009.CrossRefGoogle Scholar
- O’Connor, T. G., Rutter, M., & English and Romanian Adoptees Study Team. (2000). Attachment disorder behavior following early severe deprivation: Extension and longitudinal follow-up. Journal of the American Academy of Child and Adolescent Psychiatry, 39, 703–712. https://doi.org/10.1097/00004583-200006000-00008.CrossRefPubMedGoogle Scholar
- Prior, V., & Glaser, D. (2006). Understanding attachment and attachment disorders: Theory, evidence and practice. Philadelphia: Jessica Kingsley Publishers.Google Scholar
- Smyke, A., & Zeanah, C. H. (1999). Disturbances of attachment interview. New Orleans, LA: Tulane University School of Medicine, Department of Psychiatry.Google Scholar