Attachment disorders in children — structured clinical viva

This is a looked-after preschooler with severe early insufficient care and mixed social presentation requiring careful mapping to RAD (inhibited) versus DSED (disinhibited) — not a casual "attachment issues" label and not insecure style alone.^[1][3]

Assessment priorities. Confirm extremes of insufficient care; multi-setting observation with familiar carer and stranger; full criteria; ASD/ADHD/language/cognition screen; safeguarding status and placement stability; stranger-related absconding risk.^[1]

Management. AACAP-aligned: stable sensitive caregiving, reduce placement moves, carer coaching (ABC/sensitivity models), psychoeducation that residual DSED can persist without meaning current carers are failing, treat comorbidity, multiagency review.^[1][4][6]

Hard refusal. Coercive holding/"attachment holding programmes" are contraindicated — APSAC task force: unproven and potentially dangerous. Offer written rationale and evidence-based alternatives.^[2]

Prognosis talk. ERA/BEIP framing: environment matters; inhibited features often improve; disinhibited social engagement may be stickier; earlier quality care better — hope with realistic timelines.^[4][5]