Guide to attachment disorder

The first of a monthly series of articles offering guidance on important issues in children’s social work practice. This month we look at attachment disorder among looked-after children

What is attachment disorder?

Some children and young people in care – in children’s homes, in foster families or in adoptive families – have difficulties in managing close relationships. The closeness of caring relationships that would normally be considered to be crucial for healthy social, emotional and personality development seem to be rejected or resisted.

When this type of pattern emerges, without effective help, support and understanding, the situation can spiral out of control and lead to the breakdown of the care setting. Good information and some understanding of the complexity of such difficulties are therefore very important for professionals trying to provide help.

There are several ways of thinking about and understanding these difficulties and the different ways of trying to address the problems they can lead to. One approach involves a medical diagnosis of attachment disorder – also known as reactive attachment disorder.

But there remains considerable disagreement about what this diagnosis actually entails, and what types of assessments and interventions should be used with these children and families.

Different types of attachment disorder

Under this diagnosis, two types or sets of chronic and persistent symptoms are described: the “inhibited and emotionally withdrawn” type, and the “disinhibited and indiscriminate” type.

With the “inhibited” type, close relationships, usually associated with comfort and security, seem to be actively avoided. With the “uninhibited” type, the search for closeness is described as somewhat superficial and can cause concern because the child can fail to discriminate in relationships and can form inappropriate ones.

Where the medical diagnosis converges with other approaches is in the criteria that identify the roots of such problems occurring before the age of five in the context of grossly negligent or seriously inconsistent care and/or other chronically neglectful or abusive experiences in infancy.

One of the problems of diagnosis, however, is that the symptoms described under the category of reactive attachment disorder are likely to coexist with a range of other behavioural and relationship-based difficulties also associated with traumatic early experiences. It is therefore important to have an understanding of the term “attachment” in the first place.

The painful reality for looked-after children

Many children in alternative care have to live their lives with several mostly unanswerable and troubling questions, which reside at a deep unconscious level. These include: why did my family relationships fail me so badly what led adults who were my only recourse in the world to abandon or abuse me and why does it continue to hurt so much?

There are further, perhaps more fundamental, questions which help children shape their identity and their sense of self: who am I, will I ever belong anywhere or to anyone, why didn’t my parents want me enough, and was I ever meant to exist?

The fact that these and other irresolvable questions are too huge and too immensely painful for children to face alone underlies much of the behaviour described as symptoms of attachment disorder.

Therapies and interventions

It is easy to leap from the use of terms such as “attachment disorder” into a search for a targeted therapy or intervention. But Baaf Adoption and Fostering urges caution, flagging up the complexity of defining and tracking the development of attachment disorder and the difficulty in identifying the longer term consequences.

There are sometimes grounds for exploring how appropriate an individual therapy is for a child with attachment difficulties, but the assessment for such intervention must be carried out by a suitably qualified practitioner and is best approached from the context of a multi-disciplinary team.

The aim for the professional network responsible for children with attachment problems, especially foster carers and adoptive parents, is to be able to survive. What can really help is involving carers and children in a sustained process of trying to understand what has happened, possibly through regular reviews with carers.

Group consultations involving a network of those most closely involved with the child and maintained as a therapeutic process in itself have been found to be invaluable.

This article is an abridged version of the Guide To Attachment Disorder written by Peter Toolan, consultant child and adolescent psychotherapist at Foster Care Associates, and published on the CC Inform web site. CC Inform is an online subscription information service specifically for social care professionals working with children, young people and their families. It has been designed to enable practitioners to be better informed to be more reflective in their practice and to better evidence their decisions.

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