Attachment disorder
Encyclopedia
Attachment disorder is a broad term intended to describe disorders of mood
, behavior
, and social relation
ships arising from a failure to form normal attachments
to primary care giving figures
in early childhood
, resulting in problematic social expectations and behaviors. Such a failure would result from unusual early experiences of neglect
, abuse
, abrupt separation from caregivers after about six months but before about three years, frequent change of caregivers or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts. 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 most often used to describe emotion
al and behavior
al problems of young children, but is sometimes applied to school-age children or even to 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. No list of symptom
s 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 is 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".
The second area is controversial and considered pseudoscientific
. It is found in clinic
al 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. The use of these controversial diagnoses
of attachment disorder is linked to the use of pseudoscientific attachment therapies
to treat them.
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. Agreement has not yet been reached with respect to diagnostic criteria.
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.
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. Although an attachment is a "tie" it is not synonymous with love and affection although they often go 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.
In the clinical
sense, a disorder
is a condition requiring treatment
as opposed to risk factors for subsequent disorders. 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. 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.
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:
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 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.
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.
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.
Boris and Zeanah (1999), 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.
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. 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. 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. 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.
(Mary Ainsworth
), the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA"), the Observational Record of the Caregiving Environment ("ORCE") and the Attachment Q-sort
("AQ-sort").
More recent research also uses the Disturbances of Attachment Interview
or "DAI" developed by Smyke and Zeanah, (1999). 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.
. 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. Such approaches include 'Watch, wait and wonder,' manipulation of sensitive responsiveness, modified 'Interaction Guidance,'. 'Preschool Parent Psychotherapy,'. 'Circle of Security', Attachment and Biobehavioral Catch-up (ABC), the New Orleans Intervention, and Parent-Child psychotherapy. 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 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.
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. .
and disorganized attachment (not RAD) associated with problems of parenting. Another author has compared atypical social behavior in genetic conditions such as Williams syndrome
with behaviors symptomatic of RAD.
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.
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. 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.
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.
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 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 biological-determined sensitive period for developing stranger-wariness has passed. It is thought this process may lead to the disinhibited form.
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.
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 respond differently to humans and 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.
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. Although there are no studies examining diagnostic accuracy, concern is expressed as to the potential for over-diagnosis based on broad checklists and 'snapshots'. 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. It has been described as potentially abusive and a pseudoscientific
intervention, that has resulted in tragic outcomes for children.
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". 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."
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
. The theoretical base is broadly a combination of regression
and catharsis
, accompanied by parenting methods which emphasise obedience
and parental control. These therapies concentrate on changing the child rather than the caregiver. 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.
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. 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.
Mood (psychology)
A mood is a relatively long lasting emotional state. Moods differ from emotions in that they are less specific, less intense, and less likely to be triggered by a particular stimulus or event....
, behavior
Behavior
Behavior or behaviour refers to the actions and mannerisms made by organisms, systems, or artificial entities in conjunction with its environment, which includes the other systems or organisms around as well as the physical environment...
, and social relation
Interpersonal relationship
An interpersonal relationship is an association between two or more people that may range from fleeting to enduring. This association may be based on limerence, love, solidarity, regular business interactions, or some other type of social commitment. Interpersonal relationships are formed in the...
ships arising from a failure to form normal attachments
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
to primary care giving figures
Primary caregiver
A primary caregiver is the person who takes primary responsibility for someone who cannot care fully for themselves. It may be a family member, a medical professional or another trained professional. Depending on culture there may be other members of the family engaged in care. This concept is very...
in early childhood
Attachment in children
Newborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
, resulting in problematic social expectations and behaviors. Such a failure would result from unusual early experiences of neglect
Neglect
Neglect is a passive form of abuse in which a perpetrator is responsible to provide care for a victim who is unable to care for himself or herself, but fails to provide adequate care....
, abuse
Child abuse
Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...
, abrupt separation from caregivers after about six months but before about three years, frequent change of caregivers or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts. 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 most often used to describe emotion
Emotion
Emotion is a complex psychophysiological experience of an individual's state of mind as interacting with biochemical and environmental influences. In humans, emotion fundamentally involves "physiological arousal, expressive behaviors, and conscious experience." Emotion is associated with mood,...
al and behavior
Behavior
Behavior or behaviour refers to the actions and mannerisms made by organisms, systems, or artificial entities in conjunction with its environment, which includes the other systems or organisms around as well as the physical environment...
al problems of young children, but is sometimes applied to school-age children or even to 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. No list of symptom
Symptom
A symptom is a departure from normal function or feeling which is noticed by a patient, indicating the presence of disease or abnormality...
s can legitimately be presented but generally the term attachment disorder refers to the absence or distortion of age appropriate
Age appropriate
Age appropriate refers to a developmental concept whereby certain activities may be deemed appropriate or inappropriate to a child's "stage" or level of development....
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
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
of attachment disorder, and considerable discussion about a broader definition altogether. The first main area is based on scientific enquiry, is found in academic journals and books and pays close attention to attachment theory
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
. It is described in ICD-10
ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
as reactive attachment disorder
Reactive attachment disorder
Reactive attachment disorder 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...
, or "RAD" for the inhibited form, and disinhibited attachment disorder
Disinhibited attachment disorder
Disinhibited attachment disorder of childhood according to the International Classification of Diseases , is defined as:Disinhibited attachment disorder is a subtype of the ICD-10 category F94, "Disorders of social functioning with onset specific to childhood and adolescence"...
, or "DAD" for the disinhibited form. In DSM-IV-TR both comparable inhibited and disinhibited types are called reactive attachment disorder or "RAD".
The second area is controversial and considered pseudoscientific
Pseudoscience
Pseudoscience is a claim, belief, or practice which is presented as scientific, but which does not adhere to a valid scientific method, lacks supporting evidence or plausibility, cannot be reliably tested, or otherwise lacks scientific status...
. It is found in clinic
Clinic
A clinic is a health care facility that is primarily devoted to the care of outpatients...
al 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. The use of these controversial diagnoses
Medical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
of attachment disorder is linked to the use of pseudoscientific attachment therapies
Attachment Therapy
Attachment therapy is the most commonly used term for a controversial category of alternative child mental health interventions intended to treat attachment disorders. The term generally includes accompanying parenting techniques...
to treat them.
Some authors have suggested that attachment, as an aspect of emotional development
Child development
Child development stages describe theoretical milestones of child development. Many stage models of development have been proposed, used as working concepts and in some cases asserted as nativist theories....
, 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. Agreement has not yet been reached with respect to diagnostic criteria.
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 and attachment disorder
Attachment theoryAttachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
is primarily an evolutionary
Adaptation
An adaptation in biology is a trait with a current functional role in the life history of an organism that is maintained and evolved by means of natural selection. An adaptation refers to both the current state of being adapted and to the dynamic evolutionary process that leads to the adaptation....
and ethological theory
Ethology
Ethology is the scientific study of animal behavior, and a sub-topic of zoology....
. In relation to infants, it primarily consists of proximity seeking to an attachment figure in the face of threat, for the purpose of survival. Although an attachment is a "tie" it is not synonymous with love and affection although they often go 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.
In the clinical
Clinical psychology
Clinical psychology is an integration of science, theory and clinical knowledge for the purpose of understanding, preventing, and relieving psychologically-based distress or dysfunction and to promote subjective well-being and personal development...
sense, a disorder
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
is a condition requiring treatment
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
as opposed to risk factors for subsequent disorders. 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
Reactive attachment disorder
Reactive attachment disorder 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...
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
Reactive attachment disorder
Reactive attachment disorder 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...
under DSM-IV-TR and ICD-10
ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
are largely based on this understanding of the nature of attachment.
The words attachment style
Attachment in children
Newborn humans infants cannot survive without a caregiver to provide food and protection, and will not thrive without other types of support as well. While infants have relatively few inborn behaviors—such as crying, rooting, and sucking—they also come with many behavioral systems ready to be...
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. 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
Charles H. Zeanah
Charles H. Zeanah Jr., M.D. is a child and adolescent psychiatrist who is a member of the Council of the American Academy of Child and Adolescent Psychiatry .-Professional:...
and colleagues proposed an alternative set of criteria
Criterion validity
A valid measure actually measures what it says it will measure. To define a measure as valid, one can assess different types of validity. The type of validity of measurement assessed depends on what the researcher wants to know...
(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.
Classification
ICD-10ICD-10
The International Statistical Classification of Diseases and Related Health Problems, 10th Revision is a medical classification list for the coding of diseases, signs and symptoms, abnormal findings, complaints, social circumstances, and external causes of injury or diseases, as maintained by the...
describes Reactive Attachment Disorder of Childhood
Reactive attachment disorder
Reactive attachment disorder 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...
, known as RAD, and Disinhibited Disorder of Childhood, less well known as DAD
Disinhibited attachment disorder
Disinhibited attachment disorder of childhood according to the International Classification of Diseases , is defined as:Disinhibited attachment disorder is a subtype of the ICD-10 category F94, "Disorders of social functioning with onset specific to childhood and adolescence"...
. 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 DisorderPervasive developmental disorderPervasive developmental disorders is a diagnostic category refers to a group of disorders characterized by delays or impairments in communication, social behaviors, and cognitive development.Pervasive developmental disorders include Autism, Asperger's syndrome, Rett's syndrome, Childhood...
, - 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
Child abuse
Child abuse is the physical, sexual, emotional mistreatment, or neglect of a child. In the United States, the Centers for Disease Control and Prevention and the Department of Children And Families define child maltreatment as any act or series of acts of commission or omission by a parent or...
and injury in addition to neglect. This is somewhat controversial, being a commission rather than omission and because abuse 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.
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.
Boris and Zeanah's typology
Many leading attachment theorists, such as ZeanahCharles H. Zeanah
Charles H. Zeanah Jr., M.D. is a child and adolescent psychiatrist who is a member of the Council of the American Academy of Child and Adolescent Psychiatry .-Professional:...
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.
Boris and Zeanah (1999), 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
Daniel Schechter
Daniel S. Schechter is an American psychiatrist currently living in Geneva, Switzerland. He is known for his clinical work and research on intergenerational transmission or "communication" of violent trauma and related psychopathology involving parents and very young children...
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.
Problems of attachment style
The majority of 12-month-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. 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. 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. 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.
Diagnosis
Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation procedureAttachment measures
Attachment measures refer to the various procedures used to assess attachment in children and adults.Researchers have developed various ways of assessing patterns of attachment in children. A variety of methods allow children to be classified into four attachment pattern groups: secure,...
(Mary Ainsworth
Mary Ainsworth
Mary Dinsmore Salter Ainsworth was a Canadian developmental psychologist known for her work in early emotional attachment with "The Strange Situation" as well as her work in the development of Attachment Theory.-Life:...
), the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA"), the Observational Record of the Caregiving Environment ("ORCE") and the Attachment Q-sort
Attachment measures
Attachment measures refer to the various procedures used to assess attachment in children and adults.Researchers have developed various ways of assessing patterns of attachment in children. A variety of methods allow children to be classified into four attachment pattern groups: secure,...
("AQ-sort").
More recent research also uses the Disturbances of Attachment Interview
Attachment measures
Attachment measures refer to the various procedures used to assess attachment in children and adults.Researchers have developed various ways of assessing patterns of attachment in children. A variety of methods allow children to be classified into four attachment pattern groups: secure,...
or "DAI" developed by Smyke and Zeanah, (1999). 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.
Treatment
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 theoryAttachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
. 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. Such approaches include 'Watch, wait and wonder,' manipulation of sensitive responsiveness, modified 'Interaction Guidance,'. 'Preschool Parent Psychotherapy,'. 'Circle of Security', Attachment and Biobehavioral Catch-up (ABC), the New Orleans Intervention, and Parent-Child psychotherapy. Other known treatment methods include Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as Floor Time) by Stanley Greenspan
Stanley Greenspan
Stanley Greenspan was a clinical professor of Psychiatry, Behavioral Science, and Pediatrics at George Washington University Medical School and a practicing child psychiatrist...
, although DIR is primarily directed to treatment of pervasive developmental disorders 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.
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. .
Possible mechanisms
One study has reported a connection between a specific genetic markerGenetic marker
A genetic marker is a gene or DNA sequence with a known location on a chromosome that can be used to identify cells, individuals or species. It can be described as a variation that can be observed...
and disorganized attachment (not RAD) associated with problems of parenting. Another author has compared atypical social behavior in genetic conditions such as Williams syndrome
Williams syndrome
Williams syndrome is a rare neurodevelopmental disorder characterized by a distinctive, "elfin" facial appearance, along with a low nasal bridge; an unusually cheerful demeanor and ease with strangers; developmental delay coupled with strong language skills; and cardiovascular problems, such as...
with behaviors symptomatic of RAD.
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.
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. 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.
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.
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 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 biological-determined sensitive period for developing stranger-wariness has passed. It is thought this process may lead to the disinhibited form.
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.
Additionally, the development of Theory of Mind
Theory of mind
Theory of mind is the ability to attribute mental states—beliefs, intents, desires, pretending, knowledge, etc.—to oneself and others and to understand that others have beliefs, desires and intentions that are different from one's own...
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 respond differently to humans and 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
Autism
Autism is a disorder of neural development characterized by impaired social interaction and communication, and by restricted and repetitive behavior. These signs all begin before a child is three years old. Autism affects information processing in the brain by altering how nerve cells and their...
, 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.
Pseudoscientific diagnoses and treatment
In the absence of officially recognized diagnosticMedical diagnosis
Medical diagnosis refers both to the process of attempting to determine or identify a possible disease or disorder , and to the opinion reached by this process...
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. Although there are no studies examining diagnostic accuracy, concern is expressed as to the potential for over-diagnosis based on broad checklists and 'snapshots'. This form of therapy
Therapy
This is a list of types of therapy .* Adventure therapy* Animal-assisted therapy* Aquatic therapy* Aromatherapy* Art and dementia* Art therapy* Authentic Movement* Behavioral therapy* Bibliotherapy* Buteyko Method* Chemotherapy...
, including diagnosis and accompanying parenting techniques, is scientifically unvalidated and is not considered to be part of mainstream psychology
Psychology
Psychology is the study of the mind and behavior. Its immediate goal is to understand individuals and groups by both establishing general principles and researching specific cases. For many, the ultimate goal of psychology is to benefit society...
or, despite its name, to be based on attachment theory
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
, with which it is considered incompatible. It has been described as potentially abusive and a pseudoscientific
Pseudoscience
Pseudoscience is a claim, belief, or practice which is presented as scientific, but which does not adhere to a valid scientific method, lacks supporting evidence or plausibility, cannot be reliably tested, or otherwise lacks scientific status...
intervention, that has resulted in tragic outcomes for children.
A common feature of this form of diagnosis within attachment therapy
Attachment Therapy
Attachment therapy is the most commonly used term for a controversial category of alternative child mental health interventions intended to treat attachment disorders. The term generally includes accompanying parenting techniques...
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". 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."
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
Attachment Therapy
Attachment therapy is the most commonly used term for a controversial category of alternative child mental health interventions intended to treat attachment disorders. The term generally includes accompanying parenting techniques...
. 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
Attachment theory
Attachment theory describes the dynamics of long-term relationships between humans. Its most important tenet is that an infant needs to develop a relationship with at least one primary caregiver for social and emotional development to occur normally. Attachment theory is an interdisciplinary study...
. The theoretical base is broadly a combination of regression
Age regression
-Age Regression in Myths and Mainstream Fiction :Age regression is a popular theme in transformation fiction involving the physical and/or mental reduction in age. This age regression often occurs via magic, including potions or the legendary fountain of youth, or from a science fiction plot device...
and catharsis
Catharsis
Catharsis or katharsis is a Greek word meaning "cleansing" or "purging". It is derived from the verb καθαίρειν, kathairein, "to purify, purge," and it is related to the adjective καθαρός, katharos, "pure or clean."-Dramatic uses:...
, accompanied by parenting methods which emphasise obedience
Obedience (human behavior)
In human behavior, obedience is the quality of being obedient, which describes the act of carrying-out commands or being actuated. Obedience differs from compliance, which is behavior influenced by peers, and from conformity, which is behavior intended to match that of the majority. Obedience can...
and parental control. These therapies concentrate on changing the child rather than the caregiver. 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.
Two of the most well-known cases are those of Candace Newmaker
Candace Newmaker
Candace Elizabeth Newmaker was a victim of child abuse, killed during a 70-minute attachment therapy session to allegedly treat reactive attachment disorder. The treatment used that day included a rebirthing script, during which Candace was suffocated...
in 2001 and the Gravelles
Michael and Sharen Gravelle
Michael and Sharen Gravelle are known for having adopted eleven special needs children in Clarksfield Township, Ohio, United States. In 2003 they were indicted for child abuse for, among other things, keeping the children in cage-like enclosures...
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
American Professional Society on the Abuse of Children
American Professional Society on the Abuse of Children is an organization in the USA started by David Corwin. The APSAC website states its mission is "mission is to enhance the ability of professionals to respond to children and their families affected by abuse and violence." Membership is open to...
(APSAC) which was largely critical of attachment therapy, although these practices continue. 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.
Further reading
- Holmes, J (2001). The Search for the Secure Base. Philadelphia: Brunner-Routledge. ISBN 1583911529
- 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 1593851715
- Bowlby, J (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. London: Routledge; New York: Basic Books. ISBN 0-415-00640-6.