Attachment disorders and relational trauma

Overview & Definition

A foster carer brings a four-year-old, placed six weeks ago after neglect, who will not look at her, pushes her away when hurt, yet wanders off with any adult in the waiting room. The question is not "is he attached?" but "has grossly pathogenic care produced a disorder of social relatedness, and which one?" Most children in substitute care settle as their carer becomes reliable; the minority who do not are the ones your assessment must find. [1] [13]

A reactive attachment disorder (RAD) is a pattern of emotionally withdrawn and inhibited behaviour toward adult caregivers: the child minimally seeks comfort when distressed and minimally responds to comfort when it is offered, with persistent social and emotional disturbance. A disinhibited social engagement disorder (DSED) is the mirror behavioural pattern — overly familiar, culturally inappropriate approach to unfamiliar adults, with reduced or absent social reserve. Both share one aetiological root: a history of grossly pathogenic care, through neglect, deprivation, or repeated disruption of the primary caregiver, that prevented a selective attachment from forming. [1] [2]

In children the picture is developmental and easy to misread. A preschooler with RAD looks withdrawn, vacant, or watchful rather than "shy." A child with DSED looks charmingly friendly, hugging strangers and wandering off with them, which families mistake for good adjustment. Because the behaviours overlap with autism, intellectual disability, and the wider relational-trauma picture, attachment disorders are over-diagnosed by those who skip the caregiving history and under-diagnosed by those who never ask about early care. [2] [3]

Deep technique for the single-incident trauma-response continuum lives on the PTSD leaf, autism recognition on the autism leaf, and acute self-harm risk on the suicide-and-self-harm leaf. This page owns the two attachment disorders and the relational-trauma spine that runs from recognition to closed-loop care. [13] [14]

References14Show ledgerHide ledger

1. [1]Zeanah CH, Scheeringa M, Boris NW, Heller SS, Smyke AT, Trapani J Reactive attachment disorder in maltreated toddlers. Child Abuse Negl, 2004.PMID 15350771
2. [2]Gleason MM, Fox NA, Drury S, Smyke A, Egger HL, Nelson CA 3rd, et al Validity of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types. J Am Acad Child Adolesc Psychiatry, 2011.PMID 21334562
3. [3]Gleason MM, Fox NA, Drury SS, Smyke AT, Nelson CA 3rd, Zeanah CH Indiscriminate behaviors in previously institutionalized young children. Pediatrics, 2014.PMID 24488743
4. [4]Smyke AT, Zeanah CH, Gleason MM, Drury SS, Fox NA, Nelson CA, et al A randomized controlled trial comparing foster care and institutional care for children with signs of reactive attachment disorder. Am J Psychiatry, 2012.PMID 22764361
5. [5]Zeanah CH, Smyke AT, Koga SF, et al. Attachment in institutionalized and community children in Romania. Child Dev, 2005.PMID 16149999
6. [6]Sheridan MA, Fox NA, Zeanah CH, McLaughlin KA, Nelson CA 3rd Variation in neural development as a result of exposure to institutionalization early in childhood. Proc Natl Acad Sci U S A, 2012.PMID 22826224
7. [7]Dozier M, Peloso E, Lewis E, Laurenceau JP, Levine S Effects of an attachment-based intervention on the cortisol production of infants and toddlers in foster care. Dev Psychopathol, 2008.PMID 18606034
8. [8]Dozier M, Lindhiem O, Lewis E, Bick J, Bernard K, Peloso E Effects of a Foster Parent Training Program on Young Children's Attachment Behaviors: Preliminary Evidence from a Randomized Clinical Trial. Child Adolesc Social Work J, 2009.PMID 22065891
9. [9]Lieberman AF, Ghosh Ippen C, Van Horn P Child-parent psychotherapy: 6-month follow-up of a randomized controlled trial. J Am Acad Child Adolesc Psychiatry, 2006.PMID 16865033
10. [10]Lieberman AF, Van Horn P, Ippen CG Toward evidence-based treatment: child-parent psychotherapy with preschoolers exposed to marital violence. J Am Acad Child Adolesc Psychiatry, 2005.PMID 16292115
11. [11]Rutter ML, Kreppner JM, O'Connor TG Specificity and heterogeneity in children's responses to profound institutional privation. Br J Psychiatry, 2001.PMID 11483469
12. [12]McGoron L, Gleason MM, Smyke AT, Drury SS, Nelson CA 3rd, Gregas MC, et al Recovering from early deprivation: attachment mediates effects of caregiving on psychopathology. J Am Acad Child Adolesc Psychiatry, 2012.PMID 22721591
13. [13]Zeanah CH, Chesher T, Boris NW Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. J Am Acad Child Adolesc Psychiatry, 2016.PMID 27806867
14. [14]Bourne SV, Korom M, Dozier M Consequences of Inadequate Caregiving for Children's Attachment, Neurobiological Development, and Adaptive Functioning. Clin Child Fam Psychol Rev, 2022.PMID 35201540