Attachment disorders in children

Also known as Reactive attachment disorder · RAD · Disinhibited social engagement disorder · DSED · Indiscriminate friendliness · Attachment disorder · Emotionally withdrawn attachment disorder · Disinhibited attachment disorder

Exam-exhaustive fellowship reference on childhood attachment disorders — DSM-5-TR/ICD-11 RAD versus DSED, extremes of insufficient care, BEIP and ERA evidence, differential from ASD and ADHD, AACAP caregiving-first management, and explicit rejection of coercive attachment therapies. FRANZCP-primary, globally tagged.

high16 referencesUpdated 26 July 202612 min readVerification in progress

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10 MCQs

Meet the patient

A six-year-old adopted at three from institutional care is brought by her adoptive parents. In the waiting room she climbed onto your registrar's lap, asked her name afterwards, and offered to go home with her.^[1]^[12]

At school she is described as "everyone's friend". Twice she has left the playground with an unfamiliar adult. Her parents have been told by a private practitioner that she has "attachment issues" and needs holding therapy.^[4]^[15]

Three exam questions are live: which disorder is this?, what actually treats it?, and what will you refuse to endorse? This topic answers all three at consultant depth.^[1]^[4]^[12]

References16Show

[1]Zeanah CH, Chesher T, Boris NW; AACAP Committee on Quality Issues 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
[2]Boris NW, Zeanah CH; Work Group on Quality Issues Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood J Am Acad Child Adolesc Psychiatry, 2005.PMID 16239871
[3]Gleason MM, Fox NA, Drury S, Smyke A, 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of evidence-derived criteria for reactive attachment disorder: indiscriminately social/disinhibited and emotionally withdrawn/inhibited types J Am Acad Child Adolesc Psychiatry, 2011.PMID 21334562
[4]Chaffin M, Hanson R, Saunders BE, Nichols T, et al. Report of the APSAC task force on attachment therapy, reactive attachment disorder, and attachment problems Child Maltreat, 2006.PMID 16382093
[5]Fox NA, Nelson CA 3rd, Zeanah CH The Effects of Psychosocial Deprivation on Attachment: Lessons from the Bucharest Early Intervention Project Psychodyn Psychiatry, 2017.PMID 29244624
[6]Nelson CA 3rd, Zeanah CH, Fox NA, Marshall PJ, et al. Cognitive recovery in socially deprived young children: the Bucharest Early Intervention Project Science, 2007.PMID 18096809
[7]O'Connor TG, Rutter M; English and Romanian Adoptees Study Team Attachment disorder behavior following early severe deprivation: extension and longitudinal follow-up J Am Acad Child Adolesc Psychiatry, 2000.PMID 10846304
[8]Rutter ML, Kreppner JM, O'Connor TG; English and Romanian Adoptees study team Specificity and heterogeneity in children's responses to profound institutional privation Br J Psychiatry, 2001.PMID 11483469
[9]Zeanah CH, Smyke AT, Dumitrescu A Attachment disturbances in young children. II: Indiscriminate behavior and institutional care J Am Acad Child Adolesc Psychiatry, 2002.PMID 12162634
[10]Smyke AT, Dumitrescu A, Zeanah CH Attachment disturbances in young children. I: The continuum of caretaking casualty J Am Acad Child Adolesc Psychiatry, 2002.PMID 12162633
[11]O'Connor TG, Marvin RS, Rutter M, Olrick JT, et al. Child-parent attachment following early institutional deprivation Dev Psychopathol, 2003.PMID 12848433
[12]Bruce J, Tarullo AR, Gunnar MR Disinhibited social behavior among internationally adopted children Dev Psychopathol, 2009.PMID 19144228
[13]McGoron L, Gleason MM, Smyke AT, Drury SS, et al. Recovering from early deprivation: attachment mediates effects of caregiving on psychopathology J Am Acad Child Adolesc Psychiatry, 2012.PMID 22721591
[14]Yarger HA, Lind T, Raby KL, Zajac L, et al. Intervening With Attachment and Biobehavioral Catch-Up to Reduce Behavior Problems Among Children Adopted Internationally: Evidence From a Randomized Controlled Trial Child Maltreat, 2022.PMID 33882710
[15]Kay C, Green J, Sharma K Disinhibited Attachment Disorder in UK Adopted Children During Middle Childhood: Prevalence, Validity and Possible Developmental Origin J Abnorm Child Psychol, 2016.PMID 26857922
[16]King LS, Guyon-Harris KL, Valadez EA, Radulescu A, et al. A Comprehensive Multilevel Analysis of the Bucharest Early Intervention Project: Causal Effects on Recovery From Early Severe Deprivation Am J Psychiatry, 2023.PMID 37211832