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Disorders of attachment and social engagement related to deprivation

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Abstract

The study of attachment disorders has evolved over the last decades and a number of systematic studies have begun to illuminate the salient characteristics. Psychiatric nosologies have specified a variety of criteria for the disorder over the last 30 years, but there is emerging consensus regarding the disorders, their association with attachment, and ways in which to intervene with children affected by the disorder. In this chapter we review issues associated with defining attachment and attachment disorders, describe the typical development of attachment and examine the relationship between attachment classification, disorganized attachment, and attachment disorders. We discuss the history of attachment disorders including landmark studies by Tizard and colleagues, describe the progression of attachment disorders in the nosologies, and touch on the newest description to be found in the DSM-5. Finally, we examine measurement issues, review clinical course, and touch on interventions which address the amelioration of attachment disorders.

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... The first is the emotional withdrawn/inhibited subtype, where children persistently respond to social interactions in developmentally inappropriate ways. This can include lack of attachment-related behaviors in times of stress, irritability that is out of proportion to the situation, episodes of fear and hypervigilance, and severe emotional dysregulation (Zeanah et al., 2015). The indiscriminate social/disinhibited subtype is categorized by a child displaying a lack of selectivity in choice to attachment figures (APA, 2000). ...
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Children diagnosed with reactive attachment disorder (RAD) have been reported to exhibit a multitude of symptoms and behaviors that are not captured by the Diagnostic and Statistical Manual of Mental Disorders criteria. One behavior in particular that has been the source of much argument and controversy is aggression. Although limited research on this topic does support an association between aggression and RAD behaviors, the exact nature of this link remains unclear. This study aims to fill this gap by reporting data from a study that examined the behavioral processes that occur in adopted children with RAD. Guided by the principles of grounded theory, this study employed a multi-stage semi-structured interview design. The sample consisted of 5 adoptive families, and included both adult and child participants, including the adopted children with RAD. The findings revealed 5 prominent themes: The adopted children are reported to engage in extreme and prolonged tantrums, known as rages; children were often inconsolable during these rages; these rages are perceived as uncontrollable by children with RAD; these rages are directed toward a discriminate caregiver; and the impetus for these rages appears to be associated with difficulties in adapting to environmental demands. An in-depth discussion that draws a theoretical connection between these rages and possible deficits in brain-based processes responsible for emotional regulation is presented.
... Dating back to the mid-20th century, descriptive, cross-sectional studies demonstrated that children raised in institutions exhibited unusual social behaviors, including social inhibition and unresponsiveness and social disinhibition and boundary violations (Goldfarb, 1945;Levy, 1947;Provence & Lipton, 1962;Tizard & Rees, 1975;Wolkind, 1974). These unusual behaviors are what we now define as reactive attachment disorder and disinhibited social engagement disorder Zeanah & Smyke, 2015). More recently, several groups have reported that young children living in institutions have similar signs of disturbances in their attachment and social behaviors (Dobrova-Krol, Bakermans-Kranenburg, van IJzendoorn, & Juffer, 2010;Smyke, Dumitrescu, & Zeanah, 2002;Zeanah, Smyke, Koga, & Carlson, 2005). ...
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Two disorders of attachment have been consistently identified in some young children following severe deprivation in early life: reactive attachment disorder and disinhibited social engagement disorder. However, less is known about whether signs of these disorders persist into adolescence. We examined signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years in 111 children who were abandoned at or shortly after birth and subsequently randomized to care as usual or to high-quality foster care, as well as in 50 comparison children who were never institutionalized. Consistent with expectations, those who experienced institutional care in early life had more signs of reactive attachment disorder and disinhibited social engagement disorder at age 12 years than children never institutionalized. In addition, using a conservative intent-to-treat approach, those children randomized to foster care had significantly fewer signs of reactive attachment disorder and disinhibited social engagement disorder than those randomized to care as usual. Analyses within the ever institutionalized group revealed no effects of the age of placement into foster care, but number of caregiving disruptions experienced and the percentage of the child's life spent in institutional care were significant predictors of signs of attachment disorders assessed in early adolescence. These findings indicate that adverse caregiving environments in early life have enduring effects on signs of attachment disorders, and provide further evidence that high-quality caregiving interventions are associated with reductions in both reactive attachment disorder and disinhibited social engagement disorder.
... Despite expectations that children adopted from institutions would display dysregulation in the form of marked increases in clinical levels of internalizing and externalizing problems, this has not been readily observed in childhood (Gunnar and van Dulmen 2007;Juffer and Van Ijzendoorn 2005), although it may emerge in adolescence . Unlike internalizing and externalizing disorders, dysregulation in the form of symptoms of disinhibited social engagement disorder (DSED; Lawler et al. 2014;Zeanah and Smyke 2015) and attention-deficit/hyperactivity disorder (ADHD) are readily observed during childhood in postinstitutionalized (PI) children (Pollak et al. 2010;Roy et al. 2004;Rutter et al. 2001). These problems are so prevalent among PI children that some have suggested these excessive approach Tahl I. Frenkel and Kalsea J. Koss contributed equally to this work. ...
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A randomly selected sample of 165 children from Romania (of whom 144 had been reared in institutions) who were adopted by UK families, with placement before the age of 42 months, was studied at 4, 6, and 11 years of age. Comparisons were made with a sample of 52 non-institutionalized UK children adopted before the age of 6 months, who were studied in the same way. The paper briefly summarizes circumstances at the time of adoption and then reports findings at age 11, focusing on changes between 6 and 11. Marked catch-up in psychological functioning was evident following adoption, but significant problems continued in a substantial minority of the children placed after the age of 6 months. The theoretical implications of the findings are considered, and the policy implications are noted.
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The authors examined signs of emotionally withdrawn (inhibited type) and indiscriminately social (disinhibited type) reactive attachment disorder in Romanian children enrolled in a randomized trial of foster care compared with institutional care and in a comparison group of never-institutionalized children. At baseline and when children were ages 30, 42, and 54 months and 8 years, caregivers were interviewed with the Disturbances of Attachment Interview to assess changes in signs of reactive attachment disorder in three groups of children: those receiving care as usual (including continued institutional care) (N=68); those placed in foster care after institutional care (N=68); and those who were never institutionalized (N=72). The impact of gender, ethnicity, and baseline cognitive ability was also examined. On the Disturbances of Attachment Interview, signs of the inhibited type of reactive attachment disorder decreased after placement in foster care, and scores were indistinguishable from those of never-institutionalized children after 30 months. Signs of the disinhibited type were highest in the usual care group, lower in the foster care group, and lowest in the never-institutionalized group. Early placement in foster care (before age 24 months) was associated with fewer signs of the disinhibited type. Lower baseline cognitive ability was associated with more signs of the inhibited type in the usual care group and more signs of the disinhibited type in both groups. Signs of the inhibited type of reactive attachment disorder responded quickly to placement in foster care; signs of the disinhibited type showed less robust resolution with foster placement. Lower baseline cognitive ability was linked to signs of reactive attachment disorder.
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A growing literature demonstrates that early clinical intervention can reduce risks of adverse psychosocial outcomes. A first step necessary for developing early intervention services is to know the prevalence of clinical disorders, especially in systems that are rebuilding, such as Romania, where the mental health system was dismantled under Ceausescu. No epidemiologic studies have examined prevalence of psychiatric disorders in young children in Romania. The objective of this study was to determine the prevalence of psychiatric disorders in Romanian children 18-60 months in pediatric settings. Parents of 1,003 children 18-60 months in pediatric waiting rooms of two pediatric hospitals completed background information, the Child Behavior Checklist (CBCL). A subgroup over-sampled for high mental health problems were invited to participate in the Preschool Age Psychiatric Assessment. Rates of mental health problems were similar to the US norms on the CBCL. The weighted prevalence of psychiatric disorders in these children was 8.8%, with 5.4% with emotional disorders and 1.4% with behavioral disorders. Comorbidity occurred in nearly one-fourth of the children with a psychiatric disorder and children who met diagnostic criteria had more functional impairment than those without. Of children who met criteria for a psychiatric disorder, 10% of parents were concerned about their child's emotional or behavioral health. This study provides prevalence rates of psychiatric disorders in young Romanian children, clinical characteristic of the children and families that can guide developing system of care. Cultural differences in parental report of emotional and behavioral problems warrant further examination.
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While effects of institutional care on behavioral development have been studied extensively, effects on neural systems underlying these socioemotional and attention deficits are only beginning to be examined. The current study assessed electroencephalogram (EEG) power in 18-month-old internationally adopted, postinstitutionalized children (n = 37) and comparison groups of nonadopted children (n = 47) and children internationally adopted from foster care (n = 39). For their age, postinstitutionalized children had an atypical EEG power distribution, with relative power concentrated in lower frequency bands compared with nonadopted children. Both internationally adopted groups had lower absolute alpha power than nonadopted children. EEG power was not related to growth at adoption or to global cognitive ability. Atypical EEG power distribution at 18 months predicted indiscriminate friendliness and poorer inhibitory control at 36 months. Both postinstitutionalized and foster care children were more likely than nonadopted children to exhibit indiscriminate friendliness. Results are consistent with a cortical hypoactivation model of the effects of early deprivation on neural development and provide initial evidence associating this atypical EEG pattern with indiscriminate friendliness. Outcomes observed in the foster care children raise questions about the specificity of institutional rearing as a risk factor and emphasize the need for broader consideration of the effects of early deprivation and disruptions in care.
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Describes a comparative study of children who were adopted, placed in foster homes, or returned to their natural parents after spending up to 7 yrs under institutional care. The special problems of mixed-race children adopted by White couples and the difficulties of children in long-term foster homes were also examined. It is suggested that attempts to restore the child to his/her natural family may not be in the best interest of the child. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This chapter presents conclusions, trends, conceptual analyses, hypotheses, and speculations regarding some fundamental issues of research, practice, and policy that are largely unsettled or controversial. As such, the chapter is not a summary of Chapters I–VIII, but rather contains interpretations and opinions of the author intended to elevate the priority of certain issues, suggest hypotheses to be studied, and propose practice and policy steps to be considered.
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The stability and predictive validity of Classifications of mothers' representations of their infants as determined by the Working Model of the Child Interview (WMCI) were examined. Concordance between mothers' representations of their infants assessed prenatally and again one year later and infant Strange Situation (SS) attachment classifications at 12 months was also examined. WMCI classifications were stable over 12 months in 80% of mothers, compared to 51 % expected by chance alone. Pregnancy WMCIs predicted infant SS classifications in 74% of cases, compared to 54% expected by chance. Concordance between 11-month WMCI and 12-month SS classifications was 73 % (vs. 55% expected by chance). Problems with the skewed distribution of the sample, the low concordance between pregnancy and 11 months for one of the three classifications, and future directions for research are discussed.
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Children exposed to early institutional rearing are at risk for developing psychopathology. The present investigation examines caregiving quality and the role of attachment security as they relate to symptoms of psychopathology in young children exposed to early institutionalization. Participants were enrolled in the Bucharest Early Intervention Project (BEIP), a longitudinal intervention study of children abandoned and placed in institutions at or shortly after birth. Measures included observed caregiving when children were 30 months of age, observed attachment security at 42 months, and caregiver reports of children's psychopathology at 54 months. At 54 months, some children remained in institutions, others were in foster care, others had been adopted domestically, and still others had been returned to their biological families. Thus, the children had experienced varying amounts of institutional rearing. After controlling for gender, quality of caregiving when children were 30 months old was associated with symptoms of multiple domains of psychopathology at 54 months of age. Ratings of security of attachment at 42 months mediated the associations between quality caregiving at 30 months and fewer symptoms of psychopathology at 54 months. Among deprived young children, high-quality caregiving at 30 months predicted reduced psychopathology and functional impairment at 54 months. Security of attachment mediated this relationship. Interventions for young children who have experienced deprivation may benefit from explicitly targeting caregiver-child attachment relationships.
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Fifty-one children who had spent their first 2–7 years in institutions, and who had been previously visited at the age of 41/2 years, were reassessed at the age of 8. Seven children had never left the institutions, the rest had been adopted, fostered, or restored to their biological parent. The children's behaviour during psychological testing was assessed, and information was obtained from their parents and teachers. According to the parents’ reports, the ex-institutional children did not present any more problems than the comparison groups. The teachers, however, found many differences between the ex-institutional children and their classmates. Despite very frequent staff changes, the institutional children were not retarded. The adopted children had the highest mean I. Q, and reading achievements; this finding appears to be related to the higher social class of the adoptive parents and the poorer emotional adjustment of the children restored to their biological families.
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Evidence that gene×environment interactions can reflect differential sensitivity to the environmental context, rather than risk or resilience, is increasing. To test this model, we examined the genetic contribution to indiscriminate social behavior, in the setting of a randomized controlled trial of foster care compared to institutional rearing. Children enrolled in the Bucharest Early Intervention Project (BEIP) were assessed comprehensively before the age of 30 months and subsequently randomized to either care as usual (CAUG) or high quality foster care (FCG). Indiscriminate social behavior was assessed at four time points, baseline, 30 months, 42 months and 54 months of age, using caregiver report with the Disturbances of Attachment Interview (DAI). General linear mixed-effects models were used to examine the effect of the interaction between group status and functional polymorphisms in Brain Derived Neurotrophic Factor (BDNF) and the Serotonin Transporter (5htt) on levels of indiscriminate behavior over time. Differential susceptibility, relative to levels of indiscriminate behavior, was demonstrated in children with either the s/s 5httlpr genotype or met 66 BDNF allele carriers. Specifically children with either the s/s 5httlpr genotype or met66 carriers in BDNF demonstrated the lowest levels of indiscriminate behavior in the FCG and the highest levels in the CAUG. Children with either the long allele of the 5httlpr or val/val genotype of BDNF demonstrated little difference in levels of indiscriminate behaviors over time and no group×genotype interaction. Children with both plasticity genotypes had the most signs of indiscriminate behavior at 54 months if they were randomized to the CAUG in the institution, while those with both plasticity genotypes randomized to the FCG intervention had the fewest signs at 54 months. Strikingly children with no plasticity alleles demonstrated no intervention effect on levels of indiscriminate behavior at 54 months. These findings represent the first genetic associations reported with indiscriminate social behavior, replicate previous gene×gene×environment findings with these polymorphisms, and add to the growing body of literature supporting a differential susceptibility model of gene×environment interactions in developmental psychopathology.
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Study of attachment in the 1970s and 1980s focused on operationalizing and validating many of the tenets of attachment theory articulated in Bowlby’s landmark trilogy, Attachment and Loss (Bowlby, 1982, 1973, 1980), robustly underscoring the central role of child to parent attachment in the child’s development and mental health. Attachment theory and its implications have long interested clinicians, though determining how best to translate complex theoretical constructs and research methods into the clinical arena has been challenging. Nevertheless, well-defined landmarks in early childhood attachment are clinically useful, and the emergence of interventions drawn from systematic research is promising. The purpose of this paper is to summarize salient issues from attachment theory and research and discuss how these issues inform clinical work with infants and young children. We recognize that there is a range of clinical settings in which child–parent attachment will be important. Likewise, among practitioners serving young children and their families, there is a broad range of familiarity with and expertise in attachment principles and attachment-based treatment. We assert that all clinical services for young children and their families will be enhanced by providers’ understanding of attachment theory and research. We further assert that in some clinical contexts understanding child–parent attachment is essential. We begin by reviewing developmental research on attachment to describe how attachments develop, how individual differences in selective attachments manifest, and the characteristics of clinical disorders of attachment. Next, we turn to assessment of attachment in clinical settings. Then, we describe selected specialized clinical contexts in which assessing attachments are uniquely important. Finally, we describe four interventions for young children and their families, all of which are closely derived from attachment theory, supported by rigorous evaluations, and designed to support directly the developing child–parent relationship.
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This study examined the validity of criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited reactive attachment disorder (RAD). As part of a longitudinal intervention trial of previously institutionalized children, caregiver interviews and direct observational measurements provided continuous and categorical data used to examine the internal consistency, criterion validity, construct validity, convergent and discriminant validity, association with functional impairment, and stability of these disorders over time. As in other studies, the findings showed distinctions between the two types of RAD. Evidence-derived criteria for both types of RAD showed acceptable internal consistency and criterion validity. In this study, rates of indiscriminately social/disinhibited RAD at baseline and at 30, 42, and 54 months were 41/129 (31.8%), 22/122 (17.9%), 22/122 (18.0%), and 22/125 (17.6%), respectively. Signs of indiscriminately social/disinhibited RAD showed little association with caregiving quality. Nearly half of children with indiscriminately social/disinhibited RAD had organized attachment classifications. Signs of indiscriminately social/disinhibited RAD were associated with signs of activity/impulsivity and of attention-deficit/hyperactivity disorder and modestly with inhibitory control but were distinct from the diagnosis of attention-deficit/hyperactivity disorder. At baseline, 30, 42, and 54 months, 6/130 (4.6%), 4/123 (3.3%), 2/125 (1.6%), and 5/122 (4.1%) of children met criteria for emotionally withdrawn/inhibited RAD. Emotionally withdrawn/inhibited RAD was moderately associated with caregiving at the first three time points and strongly associated with attachment security. Signs of this type of RAD were associated with depressive symptoms, although two of the five children with this type of RAD at 54 months did not meet criteria for major depressive disorder. Signs of both types of RAD contributed independently to functional impairment and were stable over time. Evidence-derived criteria for indiscriminately social/disinhibited and emotionally withdrawn/inhibited RAD define two statistically and clinically cohesive syndromes that are distinct from each other, shows stability over 2 years, have predictable associations with risk factors and attachment, can be distinguished from other psychiatric disorders, and cause functional impairment.
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The rearing environment of human immunodeficiency virus (HIV)-infected children is often compromised, putting these children at additional risks. Positive caregiving may ameliorate the impact of adverse circumstances and promote attachment security. The goal of the present study was to examine the attachment relationships of HIV-infected children in biological families and institutions; to examine the effects of HIV infection and institutional rearing on attachment security and indiscriminate friendliness; and to assess the role of caregiving in the face of HIV-related adversities. We studied 64 Ukrainian uninfected and HIV-infected children reared in families and institutions (mean age 50.9 months). Physical and cognitive development of children as well as attachment-related domains and indiscriminate friendliness were assessed. Institutional care but not the presence of HIV was associated with lower levels of attachment security and higher levels of indiscriminate friendliness. On average, the level of indiscriminate friendliness among institution-reared children was more than twice as high as among family-reared children. Only 24% of institution-reared children had clearly developed attachment patterns, as opposed to 97% among family-reared children. Controlling for physical and cognitive development, type of care (institution or family), and HIV status, positive caregiving was associated with higher levels of attachment security. Indiscriminate friendliness was associated with lower levels of attachment security among family-reared children, but with higher levels of positive caregiving among institution-reared children. Etiology and function of indiscriminate friendliness may differ for family-reared versus institution-reared children. The findings of this study suggest the necessity of early interventions improving the quality of care for HIV-infected children.
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