CLINICAL PERSPECTIVES

The Clinical Assessment of Attachment in Children Under Five

This Practice Parameter is a revision of a previous Parameter addressing reactive attachment disorder that was published in 2005. It reviews the current status of reactive attachment disorder (RAD) and disinhibited social engagement disorder (DESD) with regard to assessment and treatment. Attachment is a central component of social and emotional development in early childhood, and disordered attachment is defined by specific patterns of abnormal social behavior in the context of “insufficient care” or social neglect. Assessment requires direct observation of the child in the context of his or her relationships with primary caregivers. Treatment requires establishing an attachment relationship for the child when none exists and ameliorating disturbed social relatedness with non-caregivers when evident.

This parameter reviews the current status of reactive attachment disorder with regard to assessment and treatment. Attachment is a central component of social and emotional development in early childhood, and disordered attachment is defined by specific patterns of abnormal social behavior in the context of “pathogenic care.” Clinically relevant subtypes include an emotionally withdrawn/inhibited pattern and a socially indiscriminate/disinhibited pattern. Assessment requires direct observation of the child in the context of his/her relationships with primary caregivers. Treatment requires establishing an attachment relationship for the child when none exists and ameliorating disturbed attachment relationships with caregivers when they are evident. Coercive treatments with children with attachment disorders are potentially dangerous and not recommended.

To determine whether published subtypes of attachment disorder can be reliably identified by trained clinicians reviewing data from high-risk populations and to investigate the relationship between disorder classification and standardized measures of attachment behavior.

Twenty or more children aged 18 to 48 months and their primary caregivers were recruited from three sites: a treatment team for maltreated young children (n = 20), a homeless shelter (n = 25), and Head Start centers (n = 24). All dyads completed a semistructured clinical assessment and laboratory and home-based attachment measures.

All but one type of attachment disorder could be identified reliably by clinician raters (κ range = 0.62–0.74, depending on subtype). Children from the maltreatment sample were significantly more likely to meet criteria for one or more attachment disorders than children from the other groups (p < .001). As predicted, children without an attachment disorder were more likely to be classified as securely attached than those with an attachment disorder (p = .03); however, children classified as having disorganized attachment were not more likely to receive an attachment disorder diagnosis.

Attachment disorders can be reliably diagnosed in young children, though research on refining disorder criteria should precede intervention trials.