Five Ways of Looking at "Attachment Disorders"

What is a syndrome of behavior and/or causes that leads to a mental health diagnosis? When we talk about mental health diagnoses, we are trying to use an analogy to diagnoses of physical illnesses and injuries. Like mental health diagnoses, classifications of physical health problems have to place people into categories for which they meet some, but not necessarily all, of the criteria. These diagnoses may in both cases also involve symptoms that can be found among the criteria for more than one category of problems. But--  there is one big difference between mental health and physical health diagnoses. For problems of physical health, there is a physical cause that may be hard to ascertain but is certainly there; without a specific physical cause, a specific diagnosis will not be made.

In the case of mental health diagnoses, physical causes are rarely present in detectable forms. Genetic factors may play important roles in causing mental illness, but although there is much ongoing research in this area, the complexity of the human genome makes it difficult to isolate genes and genetic events that may be at work. Occasionally criteria for mental health diagnoses  include  causes in the form of experiences (for example, post-traumatic stress disorders), but such causes have not been demonstrated for most mental health disorders, and it may be very difficult to trace histories of experience in early life. 

Our lack of understanding of causes of mental illness means that criteria for a diagnosis generally depend on systematic observation of many cases and the establishment of evidence that certain symptoms tend to be found together in ways that may overlap somewhat with other diagnostic categories but that can be regarded as having their own unique pattern. Our understanding of these patterns changes with new information, and that is why lists of diagnostic categories and their criteria change over time, and categories may be added or deleted.

In the 2013 edition of the American Psychiatric Association’s Diagnostic and statistical manual of mental disorders (DSM-5), changes were made in the description and criteria for Reactive Attachment Disorder, a diagnostic category that had been changing over the years since 1980, when it was classed as a disorder of feeding. This category had involved two potentially problematic patterns of social interaction by young children, one in which the child was anxious about separation and clung to caregivers, and one in which the child appeared interested in adults but indifferent to particular people, with no preference for familiar caregivers. In DSM-5, two separate categories were used. In one, Reactive Attachment Disorder, the child does not seek comfort from caregivers or respond to it when distressed; the child is not responsive to others and shows little positive emotion; the child may be irritable, sad, or fearful when interacting with an adult, even when there seems to be no evident threat to the child. For this diagnosis, there must also be a history of extremes of inadequate care, the child must be at least 9 months old because attachment does develop sufficiently before that age, and the child must be less than five years old when the problematic behavior begins.

The second DSM-5 category, Disinhibited Social Engagement Disorder, involves behavior rather different from the typical responses of young children to separation from familiar people or to the approach of strangers. Children with DSED readily approach strangers and are overly familiar with them in physical and verbal ways (as compared to what is typical of young children). They are less likely than typical children to “check back” by looking at or speaking to a familiar caregiver when exploring unfamiliar settings. They show little hesitation about going with an unfamiliar adult. To receive the DSED diagnosis, the child must also have experienced extremes of inadequate care and be at least 9 months old. There is no upper limit for when the  behavior begins, no doubt for the reason that such friendly, non-anxious behavior is much more typical of older children and should not be seen as problematic; what is “overly familiar” also changes with age.

DSM-5 is often treated as the “last word’ about mental health diagnoses, but in fact there are other sets of diagnostic categories. One of these is the one your insurance carrier is likely to use: the World Health Organization’s International classification of diseases and related health problems (ICD-10). ICD-10 includes the diagnostic category Reactive Attachment Disorder of Childhood and describes this as involving persistent abnormalities in the child’s pattern of social relationships, including fearfulness and hypervigilance, poor social interaction with peers, aggression toward self and others, misery, and possible growth reduction or growth failure. This syndrome is said probably to occur as a result of serious neglect, abuse, or mishandling, but unlike DSM-5, such a history is not required for the diagnosis. It’s notable that although the term “attachment” is found in the name of the diagnosis, the criteria do not particularly mention social interactions with adult caregivers.

ICD-10 also includes Disinhibited Attachment Disorder of Childhood, which is essential described in the same way as DSM-5 described DSED. The interesting difference is that ICD-10 says that depending on circumstances there may be associated emotional or behavioral disturbance.

ICD-10 dates back to an initial publication in 1992, and there is an ICD-11 in the works. Drafts of proposed material for ICD-11 are available. For Reactive Attachment Disorder, the draft proposes that the disorder occurs in cases of grossly negligent child care and involves grossly abnormal attachment behaviors. The child does not seek comfort from familiar caregivers or other adults and does not respond to offered comfort. The disorder cannot be diagnosed before one year of age or 9 months developmental age. The draft notes that there are normal variations in selective attachment behavior and these should not be confused with Disinhibited Attachment Disorder.

The ICD-11 draft uses the term Disinhibited  Social Engagement Disorder instead of Disinhibited Attachment Disorder, and again proposes that this problem must occur in the context of a history of inadequate care. The criteria are similar to the DSED criteria. The disorder is not to be diagnosed before age one year and must begin before age 5 years.

But ICD-10 and ICD-11 are not the “last words” either. Because diagnosis of early childhood mental health problems may be quite a different task than diagnosis of adults, the Diagnostic Classification of Mental Health and Development Disorders of Infancy and Early Childhood (Revised edition; DC:0-3R) has been developed. DC:0-3R has dropped the term Reactive Attachment Disorder and instead refers to Deprivation or Maltreatment Disorder of Infancy. This may appear in three patterns. The first, an emotionally withdrawn or inhibited pattern, may be characterized by failing to seek comfort when stressed, showing few attachment behaviors (cooperating, seeking help from others), appearing emotionally blunted, showing frozen watchfulness, avoiding and failing to initiate social interactions, or actively resisting comforting. The second pattern, an  indiscriminate or disinhibited pattern, involves a lack of the usual shyness about interacting with strangers, seeking comfort and proximity even with strangers, and even resisting comforting by familiar people. In a third pattern, there may be a combination of features from the first two. As its title suggest, DC:0-3R is a classification system for infants, toddlers, and preschoolers, and would not be used for older children.

What’s the fifth way of looking at ‘attachment disorders”? I’m only mentioning this one because I want readers to compare it to the legitimate attempts to define the diagnosis. Here’s part of a list of symptoms given by Nancy Thomas, the well-known proponent of  an alternative theory of child development,  at www.attachment.org/reactive-attachment-disorder/ : superficially engaging and charming, lack of eye contact on parents’ terms, indiscriminately affectionate with strangers, cruel to animals, etc. etc. If anyone reading this has been exposed to this view of “attachment disorders”, let me suggest that you compare it carefully to the DSM-5, ICD-10/11, and DC:0-3R efforts. Keep in mind that that the first four were based on careful observation and ongoing discussion by people trained in research methodology. The last one was borrowed from the old Hare Psychopathy Checklist, slightly revised to bring in some alternative beliefs about eye contact and some behaviors related to conduct disorders—also, to give parents a good scare.

It’s evident that professionals are still refining their formulations of “attachment disorders”. However, none of these efforts so far have included the list at www.attachment.org, and I am quite certain that they never will.