An inability of an infant or small child to form a healthy emotional attachment with a parent or parental figure, which experts believe impedes future relationships. The term bonding refers to the process by which the attachment is formed. An attachment disorder may result from physical and/or psychological harm caused by a parent or other primary caregiver. It may also result from neglect; for example, infants and children reared in orphanages with constantly changing caregivers may not have an opportunity to develop an attachment to one or two individuals.

Some experts say that even when parents exhibit normal and healthy responses to their children, sometimes children will fail to develop an attachment to the parent, for unknown reasons.

Said Klaus Minde in his article on attachment disorders in Attachment & Human Development in 2003, "In my personal clinical experience with some 150 biologically and cognitively fragile small premature infants I have observed at least three children who had bewildered yet 'good enough' parents but nevertheless showed the signs of 'disordered attachment,' i.e., they displayed significant and pervasive role reversal and/or excessive clinging at age 4."

Bonding and the Age of the Child

Most children form an emotional attachment to their parents or other caregivers during infancy or their toddler years. Psychoanalyst John Bowlby first wrote about bonding and attachment in 1951, based on his research with institutionalized children. Bowlby believed that children needed to form a close attachment to a parent by the age of about two and a half, and if attachment did not occur by that time, then the child's future character was in jeopardy.

British researcher and psychiatrist Michael Rutter has said that although the concept of "sensitive periods" when environmental factors are critical to bonding has some validity, the upper age limits of sensitive periods may be older than believed in the past. Rutter has studied adoptive parents and their children, and he found that children adopted before the age of four bonded well with their parents, while children adopted when they were older than four experienced many of the same problems as orphaned children who had remained in an institution. Despite this finding, Rutter said that it was possible for children adopted after the age of four years to bond with their adoptive parents.

Reactive Attachment Disorder

The sole type of attachment disorder that is recognized by the American Psychiatric Association is reactive attachment disorder. This attachment disorder occurs as a result of receiving pathological care before the child is five years old. There are several types of this disorder, including the inhibited and disinhibited types. If the child has the inhibited type of reactive attachment disorder, he or she is resistant to being comforted and also exhibits hyper-vigilance. If the child has the disinhibited type, then he or she is extremely sociable and is equally friendly to total strangers as to their parents.

According to authors Gregory Keck and Regina Kupecky in their book Parenting the Hurt Child: Helping Adoptive Parents Heal and Grow, it can be difficult for caregivers to help children with reactive attachment disorder, but therapy can help. Said the authors, "Therapy with hurt children needs to include high energy and intense focus, close physical proximity, frequent touch, confrontation, movement, much nurturing and love, almost constant eye contact, and fast-moving verbal exchanges."

Other Forms of Attachment Disorders

Some therapists believe that there are other forms of attachment disorders beyond reactive attachment disorder. For example, clinical social worker Deborah Gray wrote about attachments in Attaching in Adoption: Practical Tools for Today's Parents. Gray believed that attachments could be secure (normal) or insecure, and she further subdivided insecure attachments into avoidant, ambivalent and disorganized attachments. According to Gray, children with avoidant attachments feel a connection with their caregiver, but they are insecure about how the caregiver will react to them, not knowing whether their behavior will elicit hugs or hits.

Children with ambivalent attachments may alternate between clinging to their parents and then pushing them away--behavior that is usually very frustrating and confusing to the parents.

Children with disorganized attachments may exhibit fear or rage. According to Gray, the original caregivers of such children had "set the child up for overwhelming situations and then responded in a rejecting, frightening, or abandoning manner. Children with disorganized attachments tend to have a sense of helplessness about their relationship with parents."

Symptoms and Diagnostic Path

Some symptoms of attachment disorders may include the following behaviors:

-           Self-destructive behavior

-           Stealing from parents

-           Cruelty to animals

-           Sleep disorders

-           Intense rage, especially toward female caregivers

-           Above or below-average response to pain

-           Little or no eye contact with others

-           Inappropriate emotional responses, such as laughing when someone is hurt

Children with possible attachment disorder should be screened for attention-deficit/hyperactivity disorder, autism spectrum disorders and social phobias, among other possible diagnoses.

Treatment Options and Outlook

There are no known consistent and validated treatments for attachment disorders, although therapy is available, according to experts such as O'Connor and Zeanah. Parents can often be trained to identify and respond to the subtle indications of a developing attachment in children with attachment disorders.

In addition, new caregivers need to appreciate that disciplinary measures that may be effective in healthy children may be very counterproductive when it is used with children who have attachment disorders. For example, according to experts such as Lieberman, the use of "time outs" is inappropriate among children with attachment disorders, because they are perceived as a form of rejection. Few experts recommend spanking as a form of discipline for any children, but spanking is particularly harmful for children who have attachment disorders, especially among children who have been abused in the past.

Lieberman also stated that parents of children with attachment disorders may help children to understand the emotional responses of others by exaggerating their own responses to the child, such as showing an exaggerated joy when the parent and child are reunited or exhibiting simulated excessive sadness when they must be separated.

Risk Factors and Preventive Measures

Abuse and neglect are risk factors for the development of attachment disorders in children. Although abuse and neglect cannot always be prevented, the next best preventive measure to avoid any continuing or further psychological damage is to help children be placed with loving, caring and secure adults, whether the adults are related to the child or not. Whenever possible, the placement should be made before the child is five or six years old, to increase the chances for a successful attachment. This action is more possible today in the United States, because of passage of the Adoption And Safe Families Act, which is meant to prevent children from remaining in foster care from infancy until they age out at 18 years.

References:

1)         Adamec, Christine, and Laurie C. Miller, M.D. The Encyclopedia of Adoption. 3rd ed. New York: Facts On File, 2007.

2)         American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition, Text Revision. (DSM-IV-R). Washington, D.C.: American Psychiatric Association, 2000.

3)         Bowlby, John. Maternal Care and Mental Health. Geneva, Switzerland: World Health Organization, 1951.

4)         Gray, Deborah D. Attaching in Adoption: Practical Tools for Today's Parents. Indianapolis, Ind.: Perspective Press, 2002.

5)         Keck, Gregory C., and Regina M. Kupecky. Parenting the Hurt Child: Helping Adoptive Parents Heal and Grow. Colorado Springs, Colo.: Pinon Press, 2002.

6)         Lieberman, Alicia F. "The Treatment of Attachment Disorder in Infancy and Early Childhood: Reflections from Clinical Intervention with Later-adopted Foster Care Children." Attachment & Human Development 5, no. 3 (September 2003): 279-282.

7)         Minde, Klaus. "Attachment Problems as a Spectrum Disorder: Implications for Diagnosis and Treatment." Attachment & Human Development 5, no. 3 (September 2003): 289-296.

8)         O'Connor, Thomas G., and Charles H. Zeanah. "Attachment Disorders. Assessment Strategies and Treatment Approaches." Attachment & Human Development 5, no. 3 (September 2003): 223-244.

9)         Rutter, Michael. "Family and School Influences on Behavioural Development." Journal of Child Psychology and Psychiatry 26, no. 3 (1985): 349-368.

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