Attachment disorder

Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers between 6 months and three years of age, frequent change or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts resulting in a lack of basic trust.[1] A person's attachment style is permanently established before the age of three. A problematic history of social relationships occurring after about age three may be distressing to a child, but does not result in attachment disorder.

The term attachment disorder is used to describe emotional and behavioral problems of young children, and also applied to school-age children, teenagers and adults. The specific difficulties implied depend on the age of the individual being assessed, and a child's attachment-related behaviors may be very different with one familiar adult than with another, suggesting that the disorder is within the relationship and interactions of the two people rather than an aspect of one or the other personality.[2] No list of symptoms can legitimately be presented but generally the term attachment disorder refers to the absence or distortion of age appropriate social behaviors with adults. For example, in a toddler, attachment-disordered behavior could include a failure to stay near familiar adults in a strange environment or to be comforted by contact with a familiar person, whereas in a six-year-old attachment-disordered behavior might involve excessive friendliness and inappropriate approaches to strangers.

There are currently two main areas of theory and practice relating to the definition and diagnosis of attachment disorder, and considerable discussion about a broader definition altogether. The first main area, based on scientific enquiry, is found in academic journals and books and pays close attention to attachment theory. It is described in ICD-10 as reactive attachment disorder, or "RAD" for the inhibited form, and disinhibited attachment disorder, or "DAD" for the disinhibited form. In DSM-IV-TR both comparable inhibited and disinhibited types are called reactive attachment disorder or "RAD".[3]

The second area is controversial and considered pseudoscientific.[4] It is found in clinical practice, on websites and in books and publications, but has little or no evidence base. It makes controversial claims relating to a basis in attachment theory.[5] The use of these controversial diagnoses of attachment disorder is linked to the use of pseudoscientific attachment therapies to treat them.[3][4]

Some authors have suggested that attachment, as an aspect of emotional development, is better assessed along a spectrum than considered to fall into two non-overlapping categories. This spectrum would have at one end the characteristics called secure attachment; midway along the range of disturbance would be insecure or other undesirable attachment styles; at the other extreme would be non-attachment.[6] Agreement has not yet been reached with respect to diagnostic criteria.[7]

Finally, the term is also sometimes used to cover difficulties arising in relation to various attachment styles which may not be disorders in the clinical sense.

Attachment disorder

Attachment and attachment disorder

Attachment theory is primarily an evolutionary and ethological theory. In relation to infants, it primarily consists of proximity seeking to an attachment figure in the face of threat, for the purpose of survival.[8] Although an attachment is a "tie," it is not synonymous with love and affection, despite their often going together and a healthy attachment is considered to be an important foundation of all subsequent relationships. Infants become attached to adults who are sensitive and responsive in social interactions with the infant, and who remain as consistent caregivers for some time. Parental responses lead to the development of patterns of attachment which in turn lead to 'internal working models' which will guide the individual's feelings, thoughts and expectations in later relationships.[9]

A fundamental aspect of attachment is called basic trust. Basic trust is a broader concept than attachment in that it extends beyond the infant-caregiver relationship to "... the wider social network of trustable and caring others."[10] and "... links confidence about the past with faith about the future."[10] "Erikson argues that the sense of trust in oneself and others is the foundation of human development"[11] and with a balance of mistrust produces hope.

In the clinical sense, a disorder is a condition requiring treatment as opposed to risk factors for subsequent disorders.[12] There is a lack of consensus about the precise meaning of the term 'attachment disorder' although there is general agreement that such disorders only arise following early adverse caregiving experiences. Reactive attachment disorder indicates the absence of either or both the main aspects of proximity seeking to an identified attachment figure. This can occur either in institutions, or with repeated changes of caregiver, or from extremely neglectful primary caregivers who show persistent disregard for the child's basic attachment needs after the age of 6 months. Current official classifications of RAD under DSM-IV-TR and ICD-10 are largely based on this understanding of the nature of attachment.

The words attachment style or pattern refer to the various types of attachment arising from early care experiences, called secure, anxious-ambivalent, anxious-avoidant, (all organized), and disorganized. Some of these styles are more problematic than others, and, although they are not disorders in the clinical sense, are sometimes discussed under the term 'attachment disorder'.

Discussion of the disorganized attachment style sometimes includes this style under the rubric of attachment disorders because disorganized attachment is seen as the beginning of a developmental trajectory that will take the individual ever further from the normal range, culminating in actual disorders of thought, behavior, or mood.[13] Early intervention for disorganized attachment, or other problematic styles, is directed toward changing the trajectory of development to provide a better outcome later in the person's life.

Zeanah and colleagues proposed an alternative set of criteria (see below) of three categories of attachment disorder, namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". These classifications consider that a disorder is a variation that requires treatment rather than an individual difference within the normal range.[14]

Boris and Zeanah's typology

Many leading attachment theorists, such as Zeanah and Leiberman, have recognized the limitations of the DSM-IV-TR and ICD-10 criteria and proposed broader diagnostic criteria. There is as yet no official consensus on these criteria. The APSAC Taskforce recognised in its recommendations that "attachment problems extending beyond RAD, are a real and appropriate concern for professionals working with children", and set out recommendations for assessment.[15]

Boris and Zeanah (1999),[16] have offered an approach to attachment disorders that considers cases where children have had no opportunity to form an attachment, those where there is a distorted relationship, and those where an existing attachment has been abruptly disrupted. This would significantly extend the definition beyond the ICD-10 and DSM-IV-TR definitions because those definitions are limited to situations where the child has no attachment or no attachment to a specified attachment figure.

Boris and Zeanah use the term "disorder of attachment" to indicate a situation in which a young child has no preferred adult caregiver. Such children may be indiscriminately sociable and approach all adults, whether familiar or not; alternatively, they may be emotionally withdrawn and fail to seek comfort from anyone. This type of attachment problem is parallel to Reactive Attachment Disorder as defined in DSM and ICD in its inhibited and disinhibited forms as described above.

Boris and Zeanah also describe a condition they term "secure base distortion". In this situation, the child has a preferred familiar caregiver, but the relationship is such that the child cannot use the adult for safety while gradually exploring the environment. Such children may endanger themselves, may cling to the adult, may be excessively compliant, or may show role reversals in which they care for or punish the adult.

The third type of disorder discussed by Boris and Zeanah is termed "disrupted attachment". This type of problem, which is not covered under other approaches to disordered attachment, results from an abrupt separation or loss of a familiar caregiver to whom attachment has developed. The young child's reaction to such a loss is parallel to the grief reaction of an older person, with progressive changes from protest (crying and searching) to despair, sadness, and withdrawal from communication or play, and finally detachment from the original relationship and recovery of social and play activities.

Most recently, Daniel Schechter and Erica Willheim have shown a relationship between maternal violence-related posttraumatic stress disorder and secure base distortion (see above) which is characterized by child recklessness, separation anxiety, hypervigilance, and role-reversal.[17]

Problems of attachment style

The majority of 1-year-old children can tolerate brief separations from familiar caregivers and are quickly comforted when the caregivers return. These children also use familiar people as a "secure base" and return to them periodically when exploring a new situation. Such children are said to have a secure attachment style, and characteristically continue to develop well both cognitively and emotionally.

Smaller numbers of children show less positive development at age 12 months. Their less desirable attachment styles may be predictors of poor later social development. Although these children's behavior at 12 months is not a serious problem, they appear to be on developmental trajectories that will end in poor social skills and relationships. Because attachment styles may serve as predictors of later development, it may be appropriate to think of certain attachment styles as part of the range of attachment disorders.

Insecure attachment styles in toddlers involve unusual reunions after separation from a familiar person. The children may snub the returning caregiver, or may go to the person but then resist being picked up. They may reunite with the caregiver, but then persistently cling to him/her, and fail to return to their previous play. These children are more likely to have later social problems with peers and teachers, but some of them spontaneously develop better ways of interacting with other people.

A small group of toddlers show a distressing way of reuniting after a separation. Called a disorganized/disoriented style, this reunion pattern can involve looking dazed or frightened, freezing in place, backing toward the caregiver or approaching with head sharply averted, or showing other behaviors that seem to imply fearfulness of the person who is being sought.[18] Disorganized attachment has been considered a major risk factor for child psychopathology, as it appears to interfere with regulation or tolerance of negative emotions and may thus foster aggressive behavior.[19] Disorganized patterns of attachment have the strongest links to concurrent and subsequent psychopathology, and considerable research has demonstrated both within-the-child and environmental correlates of disorganized attachment.[20]

Possible mechanisms

One study has reported a connection between a specific genetic marker and disorganized attachment (not RAD) associated with problems of parenting.[21] Another author has compared atypical social behavior in genetic conditions such as Williams syndrome with behaviors symptomatic of RAD.[22]

Typical attachment development begins with unlearned infant reactions to social signals from caregivers. The ability to send and receive social communications through facial expressions, gestures and voice develops with social experience by seven to nine months. This makes it possible for an infant to interpret messages of calm or alarm from face or voice. At about eight months, infants typically begin to respond with fear to unfamiliar or startling situations, and to look to the faces of familiar caregivers for information that either justifies or soothes their fear. This developmental combination of social skills and the emergence of fear reactions results in attachment behavior such as proximity-seeking, if a familiar, sensitive, responsive, and cooperative adult is available. Further developments in attachment, such as negotiation of separation in the toddler and preschool period, depend on factors such as the caregiver's interaction style and ability to understand the child's emotional communications.[23]

With insensitive or unresponsive caregivers, or frequent changes, an infant may have few experiences that encourage proximity seeking to a familiar person. An infant who experiences fear but who cannot find comforting information in an adult's face and voice may develop atypical ways of coping with fearfulness such as the maintenance of distance from adults, or the seeking of proximity to all adults. These symptoms accord with the DSM criteria for reactive attachment disorder.[24] Either of these behavior patterns may create a developmental trajectory leading ever farther from typical attachment processes such as the development of an internal working model of social relationships that facilitates both the giving and the receiving of care from others.[25][26]

Atypical development of fearfulness, with a constitutional tendency either to excessive or inadequate fear reactions, might be necessary before an infant is vulnerable to the effects of poor attachment experiences.[27]

Alternatively, the two variations of RAD may develop from the same inability to develop "stranger-wariness" due to inadequate care. Appropriate fear responses may only be able to develop after an infant has first begun to form a selective attachment. An infant who is not in a position to do this cannot afford not to show interest in any person as they may be potential attachment figures. Faced with a swift succession of carers the child may have no opportunity to form a selective attachment until the possible biologically-determined sensitive period for developing stranger-wariness has passed. It is thought this process may lead to the disinhibited form.[28]

In the inhibited form infants behave as if their attachment system has been "switched off". However the innate capacity for attachment behavior cannot be lost. This may explain why children diagnosed with the inhibited form of RAD from institutions almost invariably go on to show formation of attachment behavior to good carers. However children who suffer the inhibited form as a consequence of neglect and frequent changes of caregiver continue to show the inhibited form for far longer when placed in families.[28]

Additionally, the development of Theory of Mind may play a role in emotional development. Theory of Mind is the ability to know that the experience of knowledge and intention lies behind human actions such as facial expressions. Although it is reported that very young infants have different responses to humans than to non-human objects, Theory of Mind develops relatively gradually and possibly results from predictable interactions with adults. However, some ability of this kind must be in place before mutual communication through gaze or other gesture can occur, as it does by seven to nine months. Some neurodevelopmental disorders, such as autism, have been attributed to the absence of the mental functions that underlie Theory of Mind. It is possible that the congenital absence of this ability, or the lack of experiences with caregivers who communicate in a predictable fashion, could underlie the development of reactive attachment disorder.[29][30]


Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation procedure (Mary Ainsworth),[31][32][33] the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA"),[34] the Observational Record of the Caregiving Environment ("ORCE")[35] and the Attachment Q-sort ("AQ-sort").[36] More recent research also uses the Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah, (1999).[37] This is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely having a discriminated, preferred adult, seeking comfort when distressed, responding to comfort when offered, social and emotional reciprocity, emotional regulation, checking back after venturing away from the care giver, reticence with unfamiliar adults, willingness to go off with relative strangers, self endangering behavior, excessive clinging, vigilance/hypercompliance and role reversal.


ICD-10 describes Reactive Attachment Disorder of Childhood, known as RAD, and Disinhibited Disorder of Childhood, less well known as DAD. DSM-IV-TR also describes Reactive Attachment Disorder of Infancy or Early Childhood. It divides this into two subtypes, Inhibited Type and Disinhibited Type, both known as RAD. The two classifications are similar and both include:

  • markedly disturbed and developmentally inappropriate social relatedness in most contexts,
  • the disturbance is not accounted for solely by developmental delay and does not meet the criteria for Pervasive Developmental Disorder,
  • onset before 5 years of age,
  • requires a history of significant neglect, and
  • implicit lack of identifiable, preferred attachment figure.

ICD-10 includes in its diagnosis psychological and physical abuse and injury in addition to neglect. This is somewhat controversial, being a commission rather than omission and because abuse in and of itself does not lead to attachment disorder.

The inhibited form is described as "a failure to initiate or respond ... to most social interactions, as manifest by excessively inhibited responses" and such infants do not seek and accept comfort at times of threat, alarm or distress, thus failing to maintain 'proximity', an essential element of attachment behavior. The disinhibited form shows "indiscriminate sociability ... excessive familiarity with relative strangers" (DSM-IV-TR) and therefore a lack of 'specificity', the second basic element of attachment behavior. The ICD-10 descriptions are comparable. 'Disinhibited' and 'inhibited' are not opposites in terms of attachment disorder and can co-exist in the same child. The inhibited form has a greater tendency to ameliorate with an appropriate caregiver whilst the disinhibited form is more enduring.[38]

While RAD is likely to occur following neglectful and abusive childcare, there should be no automatic diagnosis on this basis alone as children can form stable attachments and social relationships despite marked abuse and neglect. Abuse can occur alongside the required factors but on its own does not explain attachment disorder. Experiences of abuse are associated with the development of disorganised attachment, in which the child prefers a familiar caregiver, but responds to that person in an unpredictable and somewhat bizarre way. Within official classifications, attachment disorganization is a risk factor but not in itself an attachment disorder. Further although attachment disorders tend to occur in the context of some institutions, repeated changes of primary caregiver or extremely neglectful identifiable primary caregivers who show persistent disregard for the child's basic attachment needs, not all children raised in these conditions develop an attachment disorder.[39]


There are a variety of mainstream prevention programs and treatment approaches for attachment disorder, attachment problems and moods or behaviors considered to be potential problems within the context of attachment theory. All such approaches for infants and younger children concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver.[40][41][42] Such approaches include 'Watch, wait and wonder,'[43] manipulation of sensitive responsiveness,[44][45] modified 'Interaction Guidance,'.[46] 'Preschool Parent Psychotherapy,'.[47] Circle of Security',[48][49] Attachment and Biobehavioral Catch-up (ABC),[50] the New Orleans Intervention,[51][52][53] and Parent-Child psychotherapy.[54] Other known treatment methods include Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders[55] Some of these approaches, such as that suggested by Dozier, consider the attachment status of the adult caregiver to play an important role in the development of the emotional connection between adult and child. This includes foster parents, as children with poor attachment experiences often do not elicit appropriate caregiver responses from their attachment behaviors despite 'normative' care.[50]

Treatment for reactive attachment disorder for children usually involves a mix of therapy, counseling, and parenting education. These must be designed to make sure the child has a safe environment to live in and to develop positive interactions with caregivers and improves their relationships with their peers.

Medication can be used as a way to treat similar conditions, like depression, anxiety, or hyperactivity; however, there is no quick fix for treating reactive attachment disorder. A pediatrician may recommend a treatment plan. For example, a mix of family therapy, individual psychological counseling, play therapy, special education services and parenting skills classes.[56]

Pseudoscientific diagnoses and treatment

In the absence of officially recognized diagnostic criteria, and beyond the ambit of the discourse on a broader set of criteria discussed above, the term attachment disorder has been increasingly used by some clinicians to refer to a broader set of children whose behavior may be affected by lack of a primary attachment figure, a seriously unhealthy attachment relationship with a primary caregiver, or a disrupted attachment relationship.[57] Although there are no studies examining diagnostic accuracy, concern is expressed as to the potential for over-diagnosis based on broad checklists and 'snapshots'.[58] This form of therapy, including diagnosis and accompanying parenting techniques, is scientifically unvalidated and is not considered to be part of mainstream psychology or, despite its name, to be based on attachment theory, with which it is considered incompatible.[59][60] It has been described as potentially abusive and a pseudoscientific intervention, that has resulted in tragic outcomes for children.[4]

A common feature of this form of diagnosis within attachment therapy is the use of extensive lists of "symptoms" which include many behaviours that are likely to be a consequence of neglect or abuse, but are not related to attachment, or not related to any clinical disorder at all. Such lists have been described as "wildly inclusive".[61] The APSAC Taskforce (2006) gives examples of such lists ranging across multiple domains from some elements within the DSM-IV criteria to entirely non-specific behavior such as developmental lags, destructive behaviors, refusal to make eye contact, cruelty to animals and siblings, lack of cause and effect thinking, preoccupation with fire, blood and gore, poor peer relationships, stealing, lying, lack of a conscience, persistent nonsense questions or incessant chatter, poor impulse control, abnormal speech patterns, fighting for control over everything, and hoarding or gorging on food. Some checklists suggest that among infants, "prefers dad to mom" or "wants to hold the bottle as soon as possible" are indicative of attachment problems. The APSAC Taskforce expresses concern that high rates of false positive diagnoses are virtually certain and that posting these types of lists on web sites that also serve as marketing tools may lead many parents or others to conclude inaccurately that their children have attachment disorders."[62]

There is also a considerable variety of treatments for alleged attachment disorders diagnosed on the controversial alternative basis outlined above, popularly known as attachment therapy. These therapies have little or no evidence base and vary from talking or play therapies to more extreme forms of physical and coercive techniques, of which the best known are holding therapy, rebirthing, rage-reduction and the Evergreen model. In general these therapies are aimed at adopted or fostered children with a view to creating attachment in these children to their new caregivers. Critics maintain these therapies are not based on an accepted version of attachment theory.[63] The theoretical base is broadly a combination of regression and catharsis, accompanied by parenting methods which emphasise obedience and parental control.[64] These therapies concentrate on changing the child rather than the caregiver.[65] An estimated six children have died as a consequence of the more coercive forms of such treatments and the application of the accompanying parenting techniques.[66][67][68]

Two of the most well-known cases are those of Candace Newmaker in 2001 and the Gravelles in 2003 through 2005. Following the associated publicity, some advocates of attachment therapy began to alter views and practices to be less potentially dangerous to children. This change may have been hastened by the publication of a Task Force Report on the subject in January 2006, commissioned by the American Professional Society on the Abuse of Children (APSAC) which was largely critical of attachment therapy, although these practices continue.[69] In April 2007, ATTACh, an organisation originally set up by attachment therapists, formally adopted a White Paper stating its unequivocal opposition to the use of coercive practices in therapy and parenting.[70]

See also


  1. ^ Fonagy, Peter. Attachment Theory and Psychoanalysis. Other Professional, 2010. Print.
  2. ^ Zeanah, 2005
  3. ^ a b Chaffin et al. (2006) p78
  4. ^ a b c Berlin LJ, et al. (2005). "Preface". In Berlin LJ, Ziv Y, Amaya-Jackson L, Greenberg MT (eds.). Enhancing Early Attachments: Theory, Research, Intervention and Policy. Duke series in child development and public policy. Guilford Press. pp. xvii. ISBN 978-1-59385-470-6.
  5. ^ Prior & Glaser p 183
  6. ^ O'Connor & Zeanah, (2003)
  7. ^ Chaffin et al. p. (2006)
  8. ^ Bowlby (1970) p 181
  9. ^ Bretherton & Munholland (1999) p 89
  10. ^ a b Newman, Barbara M., and Philip R. Newman. Development through Life: A Psychosocial Approach. 12th ed. Stamford: Cenage Learning, 2015. 177. Print. ISBN 9781285459967
  11. ^ Kail, Robert V., and John C. Cavanaugh. Human Development: A Life-span View. 5th ed. Australia: Wadsworth Cengage Learning, 2010. 168. Print.
  12. ^ AACAP 2005, p1208
  13. ^ Levy K.N. et al. (2005)
  14. ^ Prior & Glaser (2006) p 223
  15. ^ Chaffin (2006) p 86
  16. ^ Boris & Zeannah (1999)
  17. ^ Schechter DS, Willheim E (2009). Disturbances of attachment and parental psychopathology in early childhood. Infant and Early Childhood Mental Health Issue. Child and Adolescent Psychiatry Clinics of North America, 18(3), 665-687.
  18. ^ Mercer, J (2006) p 107
  19. ^ VanIJzendoorn & Bakermans-Kranenburg (2003)
  20. ^ Zeanah et al. (2003)
  21. ^ Van Ijzendoorn MH, Bakermans-Kranenburg MJ (2006). "DRD4 7-repeat polymorphism moderates the association between maternal unresolved loss or trauma and infant disorganization". Attach Hum Dev. 8 (4): 291–307. doi:10.1080/14616730601048159. PMID 17178609.
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  23. ^ Dozier M, Stovall KC, Albus KE, Bates B (2001). "Attachment for infants in foster care: the role of caregiver state of mind". Child Dev. 72 (5): 1467–77. doi:10.1111/1467-8624.00360. PMID 11699682.
  24. ^ DSM-IV American Psychiatric Association 1994
  25. ^ Mercer J, Sarner L and Rosa L (2003) Attachment Therapy on Trial: The Torture and Death of Candace Newmaker. Westport, CT: Praeger ISBN 0-275-97675-0, pp. 98–103.
  26. ^ Mercer (2006), pp. 64–70.
  27. ^ Marshall, P.J.; Fox, N.A. (2005). "Relationship between behavioral reactivity at 4 months and attachment classification at 14 months in a selected sample". Infant Behavior and Development. 28 (4): 492–502. doi:10.1016/j.infbeh.2005.06.002.
  28. ^ a b Prior and Glaser p.
  29. ^ Mercer (2006) p.
  30. ^ Fonagy P, Gergely G, Jurist EL, Target M (2006). Affect Regulation, Mentalization, and the Development of Self. Other Press (NY) ISBN 1-892746-34-4
  31. ^ Ainsworth (1978),
  32. ^ Main & Solomon (1986), pp.95-124.
  33. ^ Main & Solomon (1990), pp. 121-160.
  34. ^ Crittenden (1992)
  35. ^ National Institute of Child Health and Human Development(1996)
  36. ^ Waters and Deane (1985)
  37. ^ Smyke and Zeanah (1999)
  38. ^ Prior & Glaser 2006, p. 220-221.
  39. ^ Prior & Glaser (2006) p218-219
  40. ^ Prior & Glaser (2006), p. 231.
  41. ^ AACAP (2005) p. 17-18.
  42. ^ BakermansKranenburg et al. (2003) A meta-analysis of early interventions.
  43. ^ Cohen et al. (1999)
  44. ^ van den Boom (1994)
  45. ^ van den Boom (1995)
  46. ^ Benoit et al. (2001)
  47. ^ Toth et al. (2002)
  48. ^ Marvin et al. (2002)
  49. ^ Cooper et al. (2005)
  50. ^ a b Dozier et al. (2005)
  51. ^ Larrieu & Zeanah (1998)
  52. ^ Larrieu & Zeannah (2004)
  53. ^ Zeannah & Smyke (2005)
  54. ^ Leiberman et al. (2000), p. 432.
  55. ^ Interdisciplinary Council on Developmental & Learning Disorders. (2007). Dir/floortime model Archived 2008-02-25 at the Wayback Machine.
  56. ^ "Archived copy". Archived from the original on 2011-11-26. Retrieved 2011-12-01.CS1 maint: Archived copy as title (link), '', 2011.
  57. ^ Chaffin et al., (2006) p 81
  58. ^ Chaffin et al. (2006) p 82
  59. ^ O'Connor TG, Zeanah CH (2003). "Attachment disorders: assessment strategies and treatment approaches". Attach Hum Dev. 5 (3): 223–44. doi:10.1080/14616730310001593974. PMID 12944216.
  60. ^ Ziv Y (2005). "Attachment-Based Intervention programs: Implications for Attachment Theory and Research". In Berlin LJ, Ziv Y, Amaya-Jackson L, Greenberg MT (eds.). Enhancing Early Attachments. Theory, Research, Intervention and Policy. Duke series in child development and public policy. Guilford Press. p. 63. ISBN 978-1-59385-470-6.
  61. ^ Prior & Glaser (2006) p186-187
  62. ^ Chaffin (2006) p 82
  63. ^ Prior & Glaser (2006) p 262
  64. ^ Chaffin et al. 2006, p. 79–80. The APSAC Taskforce Report.
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  66. ^ Boris 2003
  67. ^ Mercer, Sarner & Rosa 2003
  68. ^ Zeanah 2003
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  70. ^ "ATTACh White paper on coercion" (PDF). ATTACh. 2007. Archived from the original (PDF) on 2007-09-28. Retrieved 2008-03-16.


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  • Lieberman, A.F., Silverman, R., Pawl, J.H. (2000). Infant-parent psychotherapy. In C.H. Zeanah, Jr. (ed.) Handbook of infant mental health (2nd ed.) (p. 432). New York: Guilford Press. ISBN 1-59385-171-5
  • Main, M. and Solomon, J. (1986). Discovery of an insecure disorganized/disoriented attachment pattern: procedures, findings and implications for the classification of behavior. In T. Braxelton and M.Yogman (eds) Affective development in infancy, (pp. 95–124). Norwood, NJ: Ablex ISBN 0-89391-345-6
  • Main, M. and Solomon, J. (1990). Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation. In M. Greenberg, D. Cicchetti and E. Cummings (eds) Attachment in the preschool years: Theory, research and intervention, (pp. 121–160). Chicago: University of Chicago Press. ISBN 0-226-30630-5.
  • Mercer, J., Sarner, L., & Rosa, L. (2003). Attachment therapy on trial: The torture and death of Candace Newmaker. Westport, CT: Praeger Publishers/Greenwood Publishing Group, Inc. ISBN 0-275-97675-0
  • Mercer, J (2006) Understanding Attachment: Parenting, child care and emotional development. Westport, CT: Praeger ISBN 0-275-98217-3
  • Marvin, R., Cooper, G., Hoffman, K. and Powell, B. The Circle of Security project: Attachment-based intervention with caregiver – pre-school child dyads. Attachment & Human Development Vol 4 No 1 April 2002 107–124.
  • Health Child, Human (1996). "Characteristics of infant child care: Factors contributing to positive caregiving". Early Childhood Research Quarterly. 11 (3): 269–306. doi:10.1016/S0885-2006(96)90009-5.
  • O'Connor TG, Zeanah CH (2003). "Attachment disorders: assessment strategies and treatment approaches". Attach Hum Dev. 5 (3): 223–44. doi:10.1080/14616730310001593974. PMID 12944216.
  • Prior, V., Glaser, D. Understanding Attachment and Attachment Disorders: Theory, Evidence and Practice (2006). Child and Adolescent Mental Health Series. Jessica Kingsley Publishers London ISBN 1-84310-245-5 OCLC 70663735
  • Schechter, D.S., Willheim, E. (2009). Disturbances of attachment and parental psychopathology in early childhood. Infant and Early Childhood Mental Health Issue. Child and Adolescent Psychiatry Clinics of North America, 18(3), 665-687.
  • Smyke, A. and Zeanah, C. (1999). Disturbances of Attachment Interview. Available on the Journal of the American Academy of Child and Adolescent Psychiatry website at [3]
  • Toth S.; Maughan A.; Manly J.; Spagnola M.; Cicchetti D. (2002). "The relative efficacy of two in altering maltreated preschool children's representational models: implications for attachment theory". Development and Psychopathology. 14 (4): 877–908. doi:10.1017/S095457940200411X. PMID 12549708.
  • van den Boom, D. (1994). The influence of temperament and mothering on attachment and exploration: an experimental manipulation of sensitive responsiveness among lower-class mothers with irritable infants. Child Development 65, 1457–1477. doi:10.2307/1131277
  • van den Boom DC (1995). "Do first-year intervention effects endure? Follow-up during toddlerhood of a sample of Dutch irritable infants". Child Dev. 66 (6): 1798–816. doi:10.2307/1131911. JSTOR 1131911. PMID 8556900.
  • Van Ijzendoorn M, Bakermans-Kranenburg M. Attachment disorders and disorganized attachment: Similar and different Attachment & Human Development, Volume 5, Number 3, September 2003 , pp. 313–320(8) doi:10.1080/14616730310001593938 [4]
  • Waters, E. and Deane, K (1985). Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behavior in infancy and early childhood. In I. Bretherton and E. Waters (Eds) Growing pains of attachment theory and research: Monographs of the Society for Research in Child Development 50, Serial No. 209 (1–2), 41–65 [5]
  • O'Connor TG, Zeanah CH (2003). "Attachment disorders: assessment strategies and treatment approaches". Attach Hum Dev. 5 (3): 223–44. doi:10.1080/14616730310001593974. PMID 12944216.
  • Zeanah CH, Keyes A, Settles L (2003). "Attachment relationship experiences and childhood psychopathology". Ann. N. Y. Acad. Sci. 1008: 22–30. doi:10.1196/annals.1301.003. PMID 14998869.
  • Zeanah, C., H. and Smyke, A., T. "Building Attachment Relationships Following Maltreatment and Severe Deprivation" In Berlin, L., J., Ziv, Y., Amaya-Jackson, L. and Greenberg, M., T. Enhancing Early Attachments; Theory, research, intervention, and policy The Guilford Press, 2005 pps 195-216 ISBN 1-59385-470-6 (pbk)

Further reading

  • Mills, Jon. (2005). Treating Attachment Pathology. Lanham, MD: Aronson/Rowman & Littlefield. ISBN 978-0765701305
  • Holmes, J (2001). The Search for the Secure Base. Philadelphia: Brunner-Routledge. ISBN 1-58391-152-9
  • Cassidy, J; Shaver, P (eds.) (1999). Handbook of Attachment: Theory, Research, and Clinical Applications. New York: Guilford Press. ISBN 1-57230-087-6.
  • Zeanah, CH (ed.) (1993). Handbook of Infant Mental Health. New York: Guilford Press. ISBN 1-59385-171-5
  • Bowlby, J (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. London: Routledge; New York: Basic Books. ISBN 0-415-00640-6.
Adult Attachment Disorder

Adult Attachment disorder (AAD) is the result of untreated Attachment Disorder, or Reactive Attachment Disorder, that develops in adults when it goes untreated in children. It begins with children who were unable to form proper relationships early in their youth, or were abused by an adult in their developmental stages in life. Belonging to the study of attachment theory, causes and symptoms are rooted in human relationships over the course of one's lifetime, and how these relationships developed and functioned. Symptoms typically focus around neglect, dysfunction, abuse, and trust issues in all forms of their relationships. These symptoms are similar to those of other attachment disorders, but focus more on relationships later in life rather than those in earlier years. To be considered to be suffering from AAD, you must demonstrate at least 2-3 of its symptoms. These symptoms include: impulsiveness, desire for control, lack of trust, lack of responsibility, and addiction. While the DSM-V does not recognize it as an official disorder, Adult Attachment disorder is currently being studied by several groups and treatment is being developed. Some of these studies suggest splitting AAD into two groups, avoidance and anxious/ambivalent.

Advocates for Children in Therapy

Advocates for Children in Therapy (ACT) is a U.S. advocacy group founded by Jean Mercer and opposed to attachment therapy and related treatments. The organization opposes a number of psychotherapeutic techniques which it considers potentially or actually harmful to children who undergo treatment. The group's mission is to provide advocacy by "raising general public awareness of the dangers and cruelty" of practices related to attachment therapy. According to the group, "ACT works to mobilize parents, professionals, private and governmental regulators, prosecutors, juries, and legislators to end the physical torture and emotional abuse that is Attachment Therapy."

Attachment-based therapy (children)

Attachment-based therapy applies to interventions or approaches based on attachment theory, originated by John Bowlby. These range from individual therapeutic approaches to public health programs to interventions specifically designed for foster carers. Although attachment theory has become a major scientific theory of socioemotional development with one of the broadest, deepest research lines in modern psychology, attachment theory has, until recently, been less clinically applied than theories with far less empirical support. This may be partly due to lack of attention paid to clinical application by Bowlby himself and partly due to broader meanings of the word 'attachment' used amongst practitioners. It may also be partly due to the mistaken association of attachment theory with the pseudo-scientific interventions misleadingly known as attachment therapy. The approaches set out below are examples of recent clinical applications of attachment theory by mainstream attachment theorists and clinicians and are aimed at infants or children who have developed or are at risk of developing less desirable, insecure attachment styles or an attachment disorder.

Attachment theory

Attachment theory is a psychological model attempting to describe the dynamics of long-term and short-term interpersonal relationships between humans. "Attachment theory is not formulated as a general theory of relationships; it addresses only a specific facet": how human beings respond in relationships when hurt, separated from loved ones, or perceiving a threat.Provided any caregiver, all infants become attached—however, individual differences in the quality of the relationships remain significant.

In infants, attachment as a motivational and behavioral system directs the child to seek proximity with a familiar caregiver when they are alarmed, with expectation they will receive protection and emotional support.

John Bowlby believed that the tendency for primate infants to develop attachments to familiar caregivers was the result of evolutionary pressures, since attachment behavior would facilitate the infant's survival in the face of dangers such as predation or exposure to the elements.The most important tenet of attachment theory is an infant needs to develop a relationship with at least one primary caregiver for the child's successful social and emotional development, and in particular for learning how to regulate their feelings. Any caregiver is likely to become the principal attachment figure if they provide most of the child care and related social interaction. In the presence of a sensitive and responsive caregiver, the infant will use the caregiver as a "safe base" from which to explore.

This relationship can be dyadic, as in the mother-child dyad often studied in Western culture, or it can involve a community of caregivers (siblings/extended family/teachers) as can be seen in areas of Africa and South America.It should be recognized "even sensitive caregivers get it right only about fifty per cent of the time. Their communications are either out of sync, or mismatched. There are times when parents feel tired or distracted. The telephone rings or there is breakfast to prepare. In other words, attuned interactions rupture quite frequently. But the hallmark of a sensitive caregiver is that the ruptures are managed and repaired."Attachments between infants and caregivers form even if this caregiver is not sensitive and responsive in social interactions with them. This has important implications. Infants cannot exit unpredictable or insensitive caregiving relationships. Instead they must manage themselves as best they can in such relationships.

Based on her established Strange Situation Protocol, research by developmental psychologist Mary Ainsworth in the 1960s and 1970s found children will have different patterns of attachment depending on how they experienced their early caregiving environment. Early patterns of attachment, in turn, shape — but do not determine — the individual's expectations in later relationships.Four different attachment classifications have been identified in children:

Secure attachment occurs when children feel they can rely on their caregivers to attend to their needs of proximity, emotional support and protection. It is considered to be the most advantageous attachment style.

Anxious-ambivalent attachment occurs when the infant feels separation anxiety when separated from the caregiver and does not feel reassured when the caregiver returns to the infant.

Anxious-avoidant attachment occurs when the infant avoids their parents.

Disorganized attachment occurs when there is a lack of attachment behavior.In the 1980s, the theory was extended to attachment in adults. Attachment applies to adults when adults feel close attachment to their parents, their romantic and platonic partners and their friends.

Attachment theory has become the dominant theory used today in the study of infant and toddler behavior and in the fields of infant mental health, treatment of children, and related fields.

Attachment therapy

Attachment therapy (also called "the Evergreen model", "holding time", "rage-reduction", "compression therapy", "rebirthing", "corrective attachment therapy" and Coercive Restraint Therapy) ) is a pseudoscientific child mental health intervention intended to treat attachment disorders. It is found primarily in the United States, and much of it is centered in about a dozen clinics in Evergreen, Colorado, where Foster Cline, one of the founders, established his clinic in the 1970s.The practice has resulted in adverse outcomes for children, including at least six documented child fatalities. Since the 1990s there have been a number of prosecutions for deaths or serious maltreatment of children at the hands of "attachment therapists" or parents following their instructions. Two of the most well-known cases are those of Candace Newmaker in 2000 and the Gravelles in 2003. Following the associated publicity, some advocates of attachment therapy began to alter views and practices to be less potentially dangerous to children. This change may have been hastened by the publication of a Task Force Report on the subject in January 2006, commissioned by the American Professional Society on the Abuse of Children (APSAC) which was largely critical of attachment therapy. In April 2007, ATTACh, an organization originally set up by attachment therapists, formally adopted a White Paper stating its unequivocal opposition to the use of coercive practices in therapy and parenting, promoting instead newer techniques of attunement, sensitivity and regulation.

Candace Newmaker

Candace Elizabeth Newmaker (born Candace Tiara Elmore, November 19, 1989 – April 18, 2000) was a child who was killed during a 70-minute attachment therapy session purported to treat reactive attachment disorder. The treatment used that day included a rebirthing script, during which Candace was suffocated.

Charles H. Zeanah

Charles H. Zeanah Jr. is a child and adolescent psychiatrist who is a member of the Council (Board) of the American Academy of Child and Adolescent Psychiatry (AACAP).

Child of Rage

Child of Rage is a 1992 CBS Television movie starring Ashley Peldon and Mel Harris. The film is based on the true story of Beth Thomas, who had severe behavioral problems as a result of being sexually abused as a child. The film was shot in Vancouver, British Columbia, Canada, with classroom scenes being filmed at Mary Hill Elementary School.

Disinhibited attachment disorder

Disinhibited attachment disorder (DAD) according to the International Classification of Diseases (ICD-10), is defined as:

"A particular pattern of abnormal social functioning that arises during the first five years of life and that tends to persist despite marked changes in environmental circumstances, e.g. diffuse, nonselectively focused attachment behaviour, attention-seeking and indiscriminately friendly behaviour, poorly modulated peer interactions; depending on circumstances there may also be associated emotional or behavioural disturbance." – F94.2 of the ICD-10.Disinhibited attachment disorder is a subtype of the ICD-10 category F94, "Disorders of social functioning with onset specific to childhood and adolescence". The other subtype of F94 is reactive attachment disorder of childhood (RAD – F94 .1).

Synonymous or similar disorders include Affectionless psychopathy and Institutional syndrome.

Within the ICD-10 category scheme, disinhibited attachment disorder specifically excludes Asperger syndrome (F84.5), hospitalism in children (F43.2), and hyperkinetic disorders (F90.-).

Disinhibited social engagement disorder

Disinhibited social engagement disorder (DSED) or disinhibited attachment disorder of childhood is an attachment disorder that consists of "a pattern of behavior in which a child actively approaches and interacts with unfamiliar adults." and which "...significantly impairs young children’s abilities to relate interpersonally to adults and peers." For example, sitting on the lap of a stranger or peer, or leaving with a stranger. DSED is exclusively a childhood disorder and is not diagnosed before the age of nine months or if symptoms did not appear until after the age of five. Infants and very young children are at risk if they receive inconsistent or insufficient care from a primary caregiver.

Dyadic developmental psychotherapy

Dyadic developmental psychotherapy is a psychotherapeutic treatment method for families that have children with symptoms of emotional disorders, including complex trauma and disorders of attachment. It was originally developed by Daniel Hughes as an intervention for children whose emotional distress resulted from earlier separation from familiar caregivers. Hughes cites attachment theory and particularly the work of John Bowlby as theoretical motivations for dyadic developmental psychotherapy.Dyadic developmental therapy principally involves creating a "playful, accepting, curious, and empathic" environment in which the therapist attunes to the child's "subjective experiences" and reflects this back to the child by means of eye contact, facial expressions, gestures and movements, voice tone, timing and touch, "co-regulates" emotional affect and "co-constructs" an alternative autobiographical narrative with the child. Dyadic developmental psychotherapy also makes use of cognitive-behavioral strategies. The "dyad" referred to must eventually be the parent-child dyad. The active presence of the primary caregiver is preferred but not required.A study by Arthur Becker-Weidman in 2006, which suggested that dyadic developmental therapy is more effective than the "usual treatment methods" for reactive attachment disorder and complex trauma, has been criticised by the American Professional Society on the Abuse of Children (APSAC). According to the APSAC Taskforce Report and Reply, dyadic developmental psychotherapy does not meet the criteria for designation as "evidence based" nor provide a basis for conclusions about "usual treatment methods". A 2006 research synthesis described the approach as a "supported and acceptable" treatment, but this conclusion has also proved controversial. A 2013 review of research recommended caution about this method of therapy, arguing that it has "no support for claims of effectiveness at any level of evidence" and a questionable theoretical basis.

Emotional dysregulation

Emotional dysregulation (ED) is a term used in the mental health community to refer to an emotional response that is poorly modulated, and does not fall within the conventionally accepted range of emotive response.

Possible manifestations of emotional dysregulation include angry outbursts or behavior outbursts such as destroying or throwing objects, aggression towards self or others, and threats to kill oneself. These variations usually occur in seconds to minutes or hours. Emotional dysregulation can lead to behavioral problems and can interfere with a person's social interactions and relationships at home, in school, or at place of employment.

Emotional dysregulation can be associated with an experience of early psychological trauma, brain injury, or chronic maltreatment (such as child abuse, child neglect, or institutional neglect/abuse), and associated disorders such as reactive attachment disorder. Emotional dysregulation may be present in people with psychiatric disorders such as attention deficit hyperactivity disorder, autism spectrum disorders, bipolar disorder, borderline personality disorder, and complex post-traumatic stress disorder. In such cases as borderline personality disorder and complex post-traumatic stress disorder, hypersensitivity to emotional stimuli causes a slower return to a normal emotional state. This is manifested biologically by deficits in the frontal cortices of the brain.


Grandiosity refers to an unrealistic sense of superiority, a sustained view of oneself as better than others that causes one to view others with disdain or as inferior, as well as to a sense of uniqueness: the belief that few others have anything in common with oneself and that one can only be understood by a few or very special people.Grandiosity is chiefly associated with narcissistic personality disorder, but also commonly features in antisocial personality disorder, and the manic or hypomanic episodes of bipolar disorder. It also occurs in reactive attachment disorder.

Jane E. Ryan

Jane Elizabeth Ryan is a writer/producer who works to familiarize the public with Reactive Attachment Disorder (RAD). She retired from a career as a Registered Nurse and counselor and currently lives in Grand Island, Nebraska.Ryan is the author of Broken Spirits Lost Souls, a non-fiction book that details the effects of bonding interruptions caused by neglect and/or abuse. Ryan then wrote a novel and the award-winning screenplay, The Boarder, which portrays Reactive Attachment Disorder (RAD) within a family trying to understand and help their disturbed son.The book and screenplay are based on Ryan's experiences adopting two children who were disturbed. The lack of parental support and education about their children's pasts and behaviors hindered their development. A film based on this book, Disturbed Child, based on The Boarder, was released in 2012 for which Ryan wrote the screenplay and executive produced.

List of diseases (R)

This is a list of diseases starting with the letter "R".

Obsessive love

Obsessive love is a condition in which one person feels an overwhelming obsessive desire to possess and protect another person toward whom one feels a strong attraction, with an inability to accept failure or rejection. Symptoms, if such a term is applicable, include an inability to tolerate any time spent without that person, obsessive fantasies surrounding the person, and spending inordinate amounts of time seeking out, making, or looking at images of that person. Although it is not categorized specifically under any specific mental diagnosis by the DSM-5, some people argue that obsessive love is considered to be a mental illness similar to attachment disorder, borderline personality disorder, and erotomania. Depending on the intensity of their attraction, obsessive lovers may feel entirely unable to restrain themselves from extreme behaviors such as acts of violence toward themselves or others. Obsessive love can have its roots in childhood trauma and may begin at first sight; it may persist indefinitely, sometimes requiring psychotherapy.

Reactive attachment disorder

Reactive attachment disorder (RAD) is described in clinical literature as a severe and relatively uncommon disorder that can affect children. RAD is characterized by markedly disturbed and developmentally inappropriate ways of relating socially in most contexts. It can take the form of a persistent failure to initiate or respond to most social interactions in a developmentally appropriate way—known as the "inhibited form". Due to recent revision in the DSM-5 the "disinhibited form" is now considered a separate diagnosis named "disinhibited attachment disorder".

RAD arises from a failure to form normal attachments to primary caregivers in early childhood. Such a failure could result from severe early experiences of neglect, abuse, abrupt separation from caregivers between the ages of six months and three years, frequent change of caregivers, or a lack of caregiver responsiveness to a child's communicative efforts. Not all, or even a majority of such experiences, result in the disorder. It is differentiated from pervasive developmental disorder or developmental delay and from possibly comorbid conditions such as intellectual disability, all of which can affect attachment behavior. The criteria for a diagnosis of a reactive attachment disorder are very different from the criteria used in assessment or categorization of attachment styles such as insecure or disorganized attachment.

Children with RAD are presumed to have grossly disturbed internal working models of relationships that may lead to interpersonal and behavioral difficulties in later life. There are few studies of long-term effects, and there is a lack of clarity about the presentation of the disorder beyond the age of five years. However, the opening of orphanages in Eastern Europe following the end of the Cold War in the early-1990s provided opportunities for research on infants and toddlers brought up in very deprived conditions. Such research broadened the understanding of the prevalence, causes, mechanism and assessment of disorders of attachment and led to efforts from the late-1990s onwards to develop treatment and prevention programs and better methods of assessment. Mainstream theorists in the field have proposed that a broader range of conditions arising from problems with attachment should be defined beyond current classifications.Mainstream treatment and prevention programs that target RAD and other problematic early attachment behaviors are based on attachment theory and concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. Most such strategies are in the process of being evaluated. Mainstream practitioners and theorists have presented significant criticism of the diagnosis and treatment of alleged reactive attachment disorder or the theoretically baseless "attachment disorder" within the controversial form of psychotherapy commonly known as attachment therapy. Attachment therapy has a scientifically unsupported theoretical base and uses diagnostic criteria or symptom lists markedly different to criteria under ICD-10 or DSM-IV-TR, or to attachment behaviors. A range of treatment approaches are used in attachment therapy, some of which are physically and psychologically coercive, and considered to be antithetical to attachment theory. Many constitute abuse.

Richard A. Cohen

Richard A. Cohen, M.A. (born 1952) is an author and a proponent of Sexual Orientation Therapy. Cohen founded the International Healing Foundation (dissolved in 2015), through which he promoted his ideas on sexual orientation change efforts for lesbian, gay, bisexual, and transgender (LGBT) people. Cohen, who was gay in his youth, underwent years of psychotherapy in an attempt to heal childhood issues which he felt had led to his homosexuality. He says that his therapy and personal growth helped him to understand his same-sex attractions, and to eventually transition to heterosexuality.

Cohen lives in Washington, D.C., with his wife and has three adult children. His earlier foundation, the International Healing Foundation, offered psychotherapy, coaching, teleconferencing classes, and healing seminars for members of the LGBT community and those with unwanted same-sex attraction.

Sumiko Hennessy

Sumiko Tanaka Hennessy (born November 8, 1937) is a Japanese-American social worker, trauma therapist, academic, and activist for the Asian-American community in Denver, Colorado. Born in Yokohama, Japan, she earned her Master of Social Work degree at Fordham Graduate School of Social Service and her doctorate at the University of Denver. She was a founding board member and later executive director of the Asian Pacific Development Center, which provides mental health services, counseling, education, and youth activities for the Asian immigrant community in the Denver metropolitan area. In 2000 she helped inaugurate the Tokyo University of Social Welfare and is presently a professor emeritus of that institution. In 2004 she and her husband founded Crossroads for Social Work, LLC, a training program for mental health professionals in Japan and the United States. The recipient of numerous awards, she was inducted into the Colorado Women's Hall of Fame in 1989.

Mental and behavioral disorders (F00–F99 & 290–319)
Notable theorists
Clinical applications

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