What Are Attachment Issues In Children, And How Are They Treated?

When children are reared in a loving and caring environment, they are more likely to develop healthy, secure attachments to their parents or caregivers. Attachment issues can arise, however, if children experience multiple traumas or severe neglect of their needs. This can negatively affect how the child develops and functions physically, socially, and emotionally.

Attachment disorders may be rare, but they are serious conditions that can have emotionally and socially debilitating effects for children and adolescents. The child's best possible outcome is achieved when the disorder is identified and treated with evidence-based treatment methods as early as possible. What follows is an in-depth look at these disorders, from insecure attachment types, causes, and symptoms to diagnosis, treatment, and outlook for affected children.

We will also highlight some conditions that tend to occur alongside an attachment disorder and tips for caregivers to help children build secure and nurturing attachment bonds. Steps that can prevent attachment disorders from developing in babies and young children will also be looked at.

We will begin by explaining attachment theory, and the role attachment plays in child development.

The attachment theory

Attachment theory was first proposed by John Bowlby, a British psychologist, psychiatrist, psychoanalyst, and child development specialist. The theory suggests that an infant who is loved, has their needs attended to in a timely fashion, and feels a sense of security will naturally develop an attachment to their primary caregiver (in most cases, a parent).

Attachment to a primary caregiver typically occurs in infancy, before the child reaches their first birthday. When attachment occurs, the child typically dislikes being separated from the primary caregiver and may cry in protest when this happens. They also display what is considered to be a healthy level of stranger anxiety around people with whom they are unfamiliar.

The child sees the caregiver as a reassuring constant in their life and comes to expect that that person will always be there to provide care, attention, and protection from harm. This, in turn, helps to build the child's confidence in exploring and experiencing the world. Attachment bonds also help the child in developing positive self-esteem and self-reliance. 

What are attachment disorders?

Attachment disorders occur when a child & adolescent experiences severe or prolonged emotional and physical neglect. An attachment disorder can also arise when the child experiences trauma or abuse or when a child has no consistent caregiver early in life, like in an orphanage or foster care. Attachment disorders prevent a child from forming loving and trusting emotional attachment bonds with a primary caregiver.

Attachment disorders can have adverse effects on a child's moods, emotions, ability to socialize normally, decision-making ability, and behavior. Signs that an attachment disorder is present are usually evident from around the age of nine months and up. According to the American Academy of Child & Adolescent Psychiatry, depending on the child's symptoms, their attachment disorder may be diagnosed as one of two distinct types: Reactive Attachment Disorder (RAD) or Disinhibited Social Engagement Disorder (DSED).

The two types of attachment disorders

NOTE: Although this article deals exclusively with the two attachment disorders in children, it must be emphasized that attachment issues can affect adults, as well. Generally, Adult Attachment Disorder (AAD) is the result of an untreated childhood attachment disorder.

Reactive attachment disorder (RAD)

A child with RAD displays inhibited (reserved and withdrawn) behaviors toward their primary caregiver, other adult caregivers, and adults in general. They typically will not reach out to others to start social relationships and may appear to be lacking in empathy toward others.

Disinhibited social engagement disorder (DSED)

As suggested by its name, disinhibited social engagement disorder causes a child to be overly familiar or overly friendly with strangers. Since a child with DSED has no inhibitions around strangers and shows little or no preference for a caregiver's company over that of a stranger, there is a valid concern that this puts the child's safety at risk.

In the past, both RAD and DSED were categorized into two forms of a single condition called reactive attachment disorder. The first was Reactive Attachment Disorder - Inhibited Type, and the second was known as Reactive Attachment Disorder - Disinhibited Type or Disinhibited Attachment Disorder (DAD). They have since been reclassified as two separate conditions requiring separate diagnoses. The first retains the name Reactive Attachment Disorder, while the second was assigned the name Disinhibited Social Engagement Disorder.

What causes attachment issues in children?

The root causes of attachment disorders are not yet fully understood. For instance, research is still ongoing into why, in the same or similar situations, one child develops an attachment disorder while another child does not; and why one child develops RAD while the other develops DSED.

Mental health professionals have, however, identified several contributing factors to the development of an attachment disorder. These include:

• Absence of a single, long-term primary caregiver - This might arise when the child is moved repeatedly from one foster care situation to another. It also can occur in orphanages or in institutions where the caregiver-to-child ratio is high. The child does not benefit from having a primary caregiver who is focused on their needs, so they do not have the opportunity to form important attachment bonds.
• An inattentive primary caregiver - The caregiver is present but is consistently unresponsive to the child's needs. The child may, for instance, endure long periods of being hungry or needing a soiled diaper changed before they are attended to. Caregiver inattentiveness also includes situations where the child is not played with, or there is very little eye contact, physical contact, or emotions (such as smiling) even when the caregiver is close by.
• Separation from a primary caregiver - This can include the death of one or both parents, as well as situations in which the parent is incarcerated or relocates without the child, and no stable caregiver remains.
• Excessive early physical or sexual abuse - The child may begin to view the world as an unsafe place where they need to be always on their guard.
• Parental substance abuse - Alcohol and drug abuse can take away from a parent's ability to focus on and cater to the child's needs.
• Parental mental health issues - Conditions such as depression or personality disorders can impede the parent's ability to cater to the child's needs adequately.
• Prolonged hospitalization - A child hospitalized for a long period may have grossly insufficient contact with a parent or other primary caregiver. The child may therefore be unable to bond successfully with them.

As pointed out earlier, not all children exposed to the situations described here will develop an attachment disorder. Child psychiatrists and psychologists point out that children in general are very resilient, and the majority of children who face any or some of the hardships described above will not go on to develop an attachment disorder.

Institutionalization as a risk factor for developing attachment disorders

Children in institutions such as children's homes and orphanages are at the greatest risk of developing an attachment disorder. This does not mean that all children in these institutions will have attachment issues or that attachment disorders are common.

Research has discovered that while attachment disorders are extremely rare in the general population, their occurrence in institutionalized children is comparatively high.

What effects can attachment disorders have on a child now and in the future?

The onset of an attachment disorder usually happens before the age of five years but, if left untreated, its effects can last through adolescence and into adulthood. Commonly seen effects include:

• Delay in attaining developmental milestones
• Eating difficulties which may develop into eating disorders
• Stunted physical growth resulting from eating difficulties
• Learning and behavioral problems in school
• The disposition toward lying, stealing, and cruelty
• Difficulty with anger management
• Getting into trouble with the law
• Anxiety, depression, and other emotional issues
• Unstable employment
• Relationship issues in adulthood
• Inappropriate sexual behavior
• Abuse of drugs and alcohol possibly leading to addiction
• Development of personality disorders in adulthood

What are the symptoms associated with attachment disorders?

Attachment disorders are disorders of social functioning. As such, most of the symptoms are seen in how the child reacts to and behaves around others. These symptoms vary greatly depending on whether the child has RAD or DSED.

Here are the symptoms caregivers will typically see in each case.

A child with reactive attachment disorder

• Rarely smiles or seems happy
• Will most likely not react when a caregiver attempts to play with them
• Displays detachment
• Shows no interest in interactive games
• Does not reach out when a caregiver moves to pick them up
• Does not like being touched and is unlikely to seek out comfort when distressed
• Will typically not respond favorably to comfort offered to them
• Recovers from distress much quicker by self-soothing than if an adult attempts to comfort them
• Is often irritable and fearful in interactions with adults
• Holds back their emotions

A child with disinhibited social engagement disorder

• Is extremely excited at meeting strangers
• Willingly leaves a safe place with a stranger
• Shows no fear or concern in strange places or situations
• Does not first check with caregivers before leaving a safe place or going off with a stranger
• Does not mind being picked up by a stranger
• Will hug persons they do not know
• Shows poor judgment in their choice of attachment figures

The symptoms displayed in RAD and DSED can be viewed as adaptations or coping mechanisms. The infant or young child develops them in response to the stressful situation, which prevented them from bonding with an adult. For this reason, attachment disorders are sometimes compared to post-traumatic stress disorder (PTSD).

Distinguishing attachment disorders from healthy behavior

Some children may seem to prefer their own company for long periods while another child often does not display much reservedness around strangers. These alone do not mean that an attachment disorder is present. They could be indications that one child is naturally introverted while the other is naturally outgoing.

Also, delayed development alone is not sufficient for a diagnosis of an attachment disorder. A child may appear to be delayed when, in fact, they are hitting their skill and behavior milestone within the specified window of time identified by doctors and researchers, just not as quickly as another child is doing.

How are attachment disorders diagnosed?

The diagnosis for RAD or DSED can be made when the child is at least nine months old. Furthermore, the diagnosis is not made after the child reaches five years old unless it is based on present symptoms before the child's fifth birthday.

The caregiver will often take the child in to see a doctor once they notice worrying symptoms. After reviewing the child's medical history, the doctor may conduct tests to rule out physical illness or medication to cause the child's symptoms. Once these have been eliminated, the doctor will likely refer the child to a psychiatrist or psychologist to assess a possible mental health condition.

That evaluation normally takes place throughout several visits and includes observation of caregiver-child interactions, interviews with the child and caregiver, and the use of specially designed evaluation tools. These can help the mental health professional to ascertain:

• The child's living situation since birth
• Their progress through developmental milestones
• How the child typically behaves in different situations
• Parental styles and abilities

The psychiatrist or psychologist may compare the information gathered with the guidelines set out in the American Psychiatric Association's DSM-V. This comprehensive diagnostic tool details all the criteria which must be met before a diagnosis of any recognized mental health condition can be made.

Conditions with symptoms similar to those in attachment disorders

Use of the DMS-V is important to avoid a misdiagnosis. That is because several other conditions have symptoms like those displayed in an attachment disorder. These can include:

• Adjustment disorders
• Mood disorders
• Cognitive disabilities
• Autism spectrum disorder (ASD)
• Post-traumatic stress disorder (PTSD)

Comorbidities - Other issues which typically occur with attachment disorders

Research has shown a high incidence of comorbidity of mental illnesses in children in high-risk situations such as being institutionalized. Furthermore, although attachment disorders are rare, a high percentage of children with an attachment disorder are also diagnosed with a comorbid condition.

ADHD has been shown to be the condition most likely to occur alongside an attachment disorder. Other common comorbidities with attachment disorder include:

• Anxiety disorders
• Depressive disorders
• Conduct disorders
• Oppositional defiant disorder
• Phobias

Treatment for attachment issues

Treatment for attachment disorder focuses on the child and the family, aiming to strengthen the caregiver-child attachment bond and help the child develop healthy attachments with others. Attachment disorders are not treated with medication. However, a doctor might prescribe medication for a condition arising from or comorbid with the child's RAD or DSED, such as problems sleeping, mood imbalance, or depression.

Treatment is highly individualized and may include:

• Removing the child from an uncaring environment or the cycle of frequent foster home changes.
• Ensuring that the child is in a stable home environment with a consistent caregiver who is sensitive to their needs.
• Educating the caregiver about the child's condition.
• Counseling for the caregiver to better enable them to cope with their behaviors and reactions to them.
• Parental skill classes to help the caregiver in providing a nurturing environment where the child can build trust.
• Play therapy where both child and caregiver use play to work through their concerns, fears, and thoughts.
• Art therapy is an outlet of expression for the child.
• Talk therapy or psychotherapy for child and caregiver, done separately or together.
• Cognitive Behavior Therapy for the child to teach them coping skills.
• Addressing caregiver issues such as substance abuse, which prevents them from adequately meeting their child's needs.

Controversial treatments for attachment disorders

Several non-traditional techniques have been used in the past as therapy for attachment disorders. Examples include "rebirthing" and "holding" strategies, which involve physical restraint of the child. Their use is controversial, especially after they have resulted in children's deaths, and at least one, rebirthing, has been banned in several U.S. states, and its use is condemned by the U.S. Congress.

Furthermore, both the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP) warn against the use of physically coercive therapies in children. The AACAP also labels as "dangerous" the use of "hunger or thirst or forcing food or water upon the child" as a therapy for attachment disorders.

Outlook - What are the likely results of treatment?

Caregivers can be reassured that approved attachment disorder therapy provided by a trained mental health professional works - even in cases where the child has faced extreme neglect or has never had a stable primary caregiver. With therapy and help from experts specializing in child & adolescent psychiatry, children can develop trust, become more open, and learn to display age-appropriate behaviors in their interactions with adults.

How quickly a child shows improvement will depend on several factors, such as the child's age, living situation, personality, and comorbidities the child may be experiencing, as well as caregiver issues, which may affect how readily they implement the recommended strategies. It is also not uncommon for a child to initially show improvement then become resistant and regress before improving again and moving toward overcoming the disorder.

Caregivers are encouraged to be diligent and persist in using the nurturing techniques they are exposed to strengthen the attachment between them and their child.

Preventing the development of attachment issues in children

Caregivers can reduce a child's risk of developing an attachment disorder by providing opportunities for a loving and trusting relationship to grow between them. They can do this by:

• Providing a stable and loving environment for the child to grow up in.
• Being sensitive to the needs of the child and responding to them in a timely fashion.
• Interacting, making eye contact, playing, smiling, and cuddling with their child often.
• Taking advantage of feedings, bath time, diaper changes, and other routine activities by using them to bond with the child.
• Being aware of the possible early warning signs that a child is having an attachment issue.
• Getting help for their child as soon as warning signs are detected.
• Learning about childhood developmental milestones so that they are aware if the child is slow in achieving any of them.

Tips for developing healthy bonds with a child who has an attachment disorder

If you are already caring for with a child who has been diagnosed with an attachment disorder, you can help build attachment in the following ways:

• Set reasonable limits and apply them consistently.
• Ensure the child knows what rules and limits are in place and reiterate them whenever necessary, calmly and lovingly.
• Remain calm when the child displays anger, rebelliousness, or other undesirable behaviors, and refrain from disciplining your child while you are upset.
• After disciplining your child, maintain loving and caring interactions to specific behaviors and not the issue; they’ve already been disciplined for the latter.
• Never punish your child by withholding love and affection. Instead, help your child to realize that you will love them at all times.

Learn more about attachment in online therapy

Watching a child struggle with an attachment disorder or any other kind of mental health issue can be deeply distressing for parents and caregivers. Attachment disorders are preventable, but if they do develop, they are treatable. They will not go away or improve on their own, but implementing interventions as soon as possible after symptoms are noticed can help. There are mental health professionals and support services to reach out to for help. You and your child can begin building the loving and trusting relationship you deserve.

Online therapy allows for flexible scheduling – sessions can be held via phone call, video chat, or secure instant in-app messaging anywhere you have a reliable internet connection. Many of our therapists can and do operate outside of traditional office hours, which can be particularly helpful for parents and caregivers.