Tuesday, 1 June 2010

Attachment Disorder

I am often asked about “attachment disorder”. This term is sometimes loosely applied to children or young people with attachment difficulties. I think this is unfortunate because it has specific meaning and, in my opinion, we need to be clear about its use. Attachment disorder is a psychiatric diagnosis and would usually refer to classifications form either the Diagnostic Statistical Manual version IV (DSM IV) or the International Classification of Disease 10 (ICD 10), and would therefore be, respectively, Reactive Attachment Disorder (RAD) with a subset of inhibited or disinhibited, or Reactive Attachment Disorder (RAD) / Disinhibited Attachment Disorder (DAD). These diagnoses are based on clinically assessing a range of social functioning observable before age 5, but do not consider the relationship specific behaviours that are usually associated with attachment, and are therefore at odds with attachment theory and research, which emphasizes the relationship context of attachment patterns.

Attachment theory (the best explanation we currently have of how the parent-child primary bond functions) considers the security of the relationship (secure or insecure) and the organization (organized/disorganized). Some insecurely attached children, although they may be avoidant or resistant, do have organized patterns of attachment, however, children with disorganized
attachment are always insecurely attached and have no coherent way of getting their attachment needs met.

Securely attached children develop an internal working model of themselves as worthy and loveable, the attachment figure as loving and available, and the relationship as a secure base from which to explore the world. Children who are insecurely attached lack this confidence.

Patterns of attachment tend to be stable over time, and of course, the conditions that promoted the attachment patterns in infancy are often continued in the family dynamic over the child's life. Disorganized attachment is over-represented in clinical groups.

Attachment theory posits developmental pathways. The child is at the point they are now, and recovery (earned security) happens in relationships. Recovery is not found in regression (Bowlby specifically rejected regression therapy). Work that is founded on attachment theory requires that we develop understanding with the child of their current difficulties, especially interpersonal relations, and allow the relationship with us to become a secure base, building enough trust to explore current relationships. It is important to recognize that the child's difficulties are rooted in real-life experiences, not fantasies, and to support exploration and review of earlier experiences to improve interpersonal relationships in here-and-now.

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