All About Attachment Disorders

What is Attachment Disorder?

Attachment disorder is a broad term used to describe a mental health difficulty where a child fails to develop a healthy emotional bond with their caregivers during childhood, often due to severe neglect, inconsistent care or abuse in early childhood. This can lead to emotional and behavioural difficulties, such as difficulties trusting others and managing emotions later in life.

When a child forms a healthy attachment with their primary caregiver, they learn to rely on their caregivers to provide them with food, shelter, safety and emotional support. This gives the child the base and confidence to explore their environment, develop healthy relationships with others, learn how to manage their emotions and feel safe and secure in their environment and relationships. A strong bond with a caregiver is essential to help a child develop their social, emotional and intellectual needs and intelligence. If a child is deprived of this healthy attachment, it can affect their emotional and social development and impact many areas of their life in both childhood and adulthood. Attachment disorders typically develop by the age of 5.

Attachment disorder is relatively uncommon in the general population of children and young people but is much higher in the care population. In 2022-2023, approximately 107,000 children were looked after (CLA) by a local authority in the UK. Also known as children in care, this can include children living with foster carers, a residential children’s home, friends or relatives, or a residential setting, such as a school or secure unit.

CLA can also include children who live with their parents but are under the local authority’s care. Many looked after children have experienced abuse, neglect or other trauma, which puts them at significantly higher risk of attachment disorder. Research has identified that 2.5% of looked after children in the UK display pervasive symptoms of attachment disorder and an additional 18% of looked after children display some symptoms of attachment disorder.

Further research has identified a higher-than-average prevalence of attachment disorder in young offenders, with one study, conducted in the UK by Moran, et al. (2017) finding that 52% of young offenders had a total or borderline attachment disorder. This indicates a relationship between attachment disorder and anti-social behaviour.

Secure and Insecure Attachments

Two main attachment styles develop due to our early childhood experiences:

Secure Attachment

Consistent positive experiences with the primary caregiver help infants and young children develop a secure attachment. For example, if a baby cries and an adult consistently responds by offering comfort or addressing a physical need, such as feeding or changing, the infant learns they can trust the adult to keep them safe and cared for. This helps the child form relationships with others, manage their emotions, have less extreme responses to stress and become more willing to explore new things. A person with a secure attachment feels safe, valued and confident in relationships, primarily because their caregiver is consistently responsive, loving and supportive.

Characteristics of secure attachment include:

• Comfortable with closeness and independence.
• Trusts others and forms healthy relationships.
• Can express emotions and seek support when needed.
• Recovers well from conflicts in relationships.
• Feels worthy of love and connection.

Insecure Attachment

Insecure attachment develops when a child experiences inconsistent, neglectful or unresponsive caregiving. This can lead to difficulties in trusting others, regulating emotions and forming healthy relationships. Insecure attachment is not an official type of attachment disorder but instead represents attachment difficulties that can still impact behaviour and relationships.

There are three main types of insecure attachment:

Avoidant Attachment

This type of attachment difficulty can develop when caregivers are emotionally distant, unresponsive or dismissive of a child’s needs, which can lead the child to become self-reliant and emotionally detached.

Signs of avoidant attachment in childhood include:

• Prefers to spend time alone.
• Doesn’t seek comfort or help from others.
• Avoids showing emotions.
• Resists physical affection.

The signs of avoidant attachment in adulthood include:

• Difficulties with emotional intimacy.
• Valuing independence to an extreme.
• Avoids deep emotional connections.
• Feels uncomfortable being vulnerable.

Anxious attachment

An anxious attachment style develops when a child experiences inconsistent caregiving, where sometimes their needs are met and other times they are ignored. This can create a fear of abandonment and an excessive need for reassurance.

Signs of anxious attachment in childhood include:

• Very clingy and anxious when apart from caregivers.
• Struggles with self-soothing.
• Overreacts to perceived rejection.

Signs of an anxious attachment style in adulthood include:

• Constantly seeks validation and reassurance.
• Fear of being abandoned or not loved enough.
• Overthinks and overanalyses relationships.
• Can be emotionally intense or jealous.

Disorganised attachment

Disorganised attachment is often a result of trauma, abuse or neglect, which can lead to conflicted behaviours such as wanting closeness but also fearing it and avoiding it.

Signs of disorganised attachment in childhood include:

• Being fearful of caregivers but also attempting to seek comfort from them.
• Unpredictable or aggressive behaviour.
• Difficulties regulating emotions.

Signs of disorganised attachment in adulthood:

• Pushes people away but fears being alone.
• Struggles with trust and emotional stability.
• May experience mood swings and self-sabotage relationships.
• Has high levels of anxiety and fear of rejection.

Types of Attachment Disorder

Many people have heard of the three types of insecure attachment styles: avoidant, anxious, and disorganised. However, these attachment styles refer to attachment difficulties, rather than diagnosable attachment disorders.

The DSM-5 criteria categorise attachment disorder into two different types:

Reactive Attachment Disorder

Reactive Attachment Disorder (RAD) is a serious condition that occurs when a child does not form a healthy emotional bond with caregivers, usually due to severe neglect, abuse or frequent changes in caregivers during early childhood.

RAD usually develops due to early-life trauma or neglect, particularly when a child’s basic emotional and physical needs are not met. Some key risk factors include:

• Severe neglect, including a lack of emotional or physical care.
• Frequent changes in caregivers (e.g., living in multiple foster homes).
• Abuse.
• Long-term separation from parents.
• Institutionalised care (e.g., growing up in a neglectful children’s home).

When a child does not experience consistent, loving caregiving, their ability to develop trust and emotional bonds becomes impaired.

Key features of reactive attachment disorder include:

• Difficulty forming emotional connections.
• Avoids seeking comfort or responding to affection.
• Emotional withdrawal and lack of social engagement.
• Trouble trusting others or forming meaningful relationships.
• Appears indifferent or emotionally shut down.
• Outbursts of anger or resistance to authority.
• Unresponsive to praise or affection.

Adults with RAD may either avoid intimacy (emotional detachment) or display intense fear of rejection (clingy behaviour).

Disinhibited Social Engagement Disorder (DSED)

Disinhibited social engagement disorder (DSED) is a condition where children show an unusually friendly, overly trusting or inappropriate approach toward strangers. It develops when a child lacks a stable, consistent caregiver in early life, which leads to difficulty understanding social boundaries. Risk factors include:

• Severe neglect (e.g., caregivers not responding to the child’s needs).
• Frequent changes in caregivers (e.g., frequent foster care placements).
• Institutionalised care (e.g., growing up in an impersonal setting, such as a children’s home).
• Long-term separation from parents

Unlike reactive attachment disorder, which leads to emotional withdrawal, DSED causes overly familiar and indiscriminate social behaviour. When a child does not form a secure, stable bond with a primary caregiver, they fail to develop normal caution around unfamiliar people.

Key features of disinhibited social engagement disorder include:

• Overly friendly or trusting with strangers.
• Lack of appropriate social boundaries.
• No hesitation to approach unfamiliar adults.
• Willingness to leave with a stranger without concern.
• Impulsive or attention-seeking behaviour.

DSED is not simply being sociable or extroverted. Children with DSED struggle to differentiate between safe and unsafe interactions. Unlike RAD, people with DSED are not emotionally withdrawn. Instead, they struggle with excessive friendliness and poor judgment in social interactions.

It can sometimes be difficult to differentiate between a child who is friendly and a child with disinhibited social engagement disorder. The key differences are:

DSED requires early intervention to help children learn safe social behaviour.

Causes of Attachment Disorders

Attachment disorders can develop for a variety of reasons, with some children being at higher risk of attachment difficulties than others. Attachment difficulties and the associated emotional and behavioural difficulties can develop when a child doesn’t feel safe and secure. The most common cause of attachment disorder is being unable to form a bond with a caregiver or the bond being disrupted, which can occur for several reasons.

The risk factors of attachment disorders include:

Experiencing physical, emotional or sexual abuse

Physical, emotional or sexual abuse in early childhood can disrupt the child’s trust in caregivers and damage the child’s ability to form healthy relationships. For example:

• Physical abuse: This can result in fear or avoidance of caregivers.
• Emotional abuse: This can result in a lack of emotional regulation and self-worth issues.
• Sexual abuse: This can result in extreme distrust, difficulties with boundaries and emotional detachment.

Physical or emotional neglect

Emotional and physical neglect is one of the most common causes of attachment disorder. If a child’s physical and emotional needs are ignored or inconsistently met, this can lead to withdrawal and attachment difficulties. Examples include caregivers failing to respond to a child’s cries or signs of distress, having minimal or no physical interaction, eye contact or comfort and a lack of engagement (e.g., verbal interaction, physical touch and play).

Frequent changes in caregivers

A stable caregiver is crucial for healthy attachment. When children experience multiple placements in foster care, children’s homes or adoption, they struggle to form lasting emotional bonds. Moving between different caregivers disrupts attachment formation and uncertainty about caregivers can lead to mistrust and emotional detachment.

Being separated from the main caregiver

Prolonged separation from a primary caregiver (e.g., due to hospitalisation, a prison sentence or military deployment) can disrupt the attachment process, particularly if the main caregiver is unable to care for the child.

Lack of early stimulation and interaction

Babies need social and sensory stimulation to develop secure attachment. Without it, their emotional and cognitive growth is affected. For example, infants who experience a lack of touch, eye contact and verbal interaction, minimal playtime or time spent on engaging activities and those left in prolonged isolation without affection are more likely to develop attachment difficulties. For example, infants who are hospitalised for many months and are unable to be held by their caregiver may lack consistent bonding time and may struggle to form attachments.

Parental attachment issues

Parents who struggled with their own attachment issues may unknowingly repeat the cycle with their children. For example, emotionally distant parents may fail to show love or affection to their child, overly anxious parents may pass on their fear of abandonment and parents who struggle to form relationships with other people may be emotionally neglectful to their children.

Parental mental health difficulties

Parents with severe mental health conditions may struggle to provide the emotional stability a child needs. For example:

• Depression: A depressed parent may be emotionally distant or unresponsive.
• Substance abuse: Addiction can lead to inconsistent caregiving and neglect.
• Severe anxiety or post-traumatic stress disorder (PTSD): A caregiver’s emotional instability can affect the child’s sense of security.

It is important to note that although parental mental health can raise the risk of attachment disorder, many parents or caregivers with mental health difficulties create a strong emotional bond with their child and their children grow up with a healthy attachment.

Signs of Attachment Disorders

Attachment disorder can occur on a spectrum, with some children experiencing severe symptoms that significantly affect many areas of their lives and contribute to their emotional trauma. This type of attachment difficulty is more likely to develop into a more serious attachment disorder that can affect the child into adulthood. Other children are only minimally affected by having low attachment and the symptoms may be addressed, helping the child to overcome their attachment difficulties.

Multiple signs and characteristics could indicate that a child has an attachment disorder. The characteristics of attachment disorder can differ depending on:

• The type of attachment disorder.
• The cause of the attachment disorder.
• The person’s age.
• Their personality.
• Whether they have developed healthy attachments later on in childhood.

One of these characteristics alone is unlikely to indicate attachment difficulties but multiple signs together could indicate a child is experiencing attachment difficulties. The most common signs and characteristics of attachment difficulties in children include:

• Engaging in anti-social behaviours, such as lying, stealing, manipulating others or being destructive.
• Aggressive behaviour, including being quick to anger and lash out and having tantrums.
• Engaging in passive-aggressive behaviour or hiding their anger through socially acceptable behaviours (such as gripping someone’s hand so tight it hurts or hurting someone and passing it off as a joke).
• Bullying, hurting or being cruel to others.
• Inability to self-regulate their emotions.
• Inability to self-monitor or regulate their behaviour.
• No fear of strangers and/or indiscriminately seeking affection from strangers (also known as pseudo-attachments).
• A strong need to be in control.
• Using extreme measures to get attention from others.
• No affection towards caregivers (particularly in insecure attachments).
• Not going to the parent or caregiver for reassurance or help if they are sad or scared.
• Seeming uncomfortable with being touched or comforted.
• Lack of impulse control.
• Oppositional behaviours, including being disobedient and argumentative.
• An underdeveloped conscience, for example, not showing any remorse or regret.
• Lack of empathy for others.
• Being inflexible in thoughts and behaviours.
• Being inappropriately clingy with others, OR
• Lack of physical affection or emotional closeness with others.
• Lack of smiling and laughter, particularly when interacting with others.
• Engaging in self-destructive behaviours.
• Being withdrawn.
• Avoiding interacting with others, for example, watching other children play and socialise but not joining in, even when invited.
• Lack of eye contact.
• Abnormal eating habits (such as hoarding food).
• Difficulties in the school environment, including difficulties concentrating, disruptive behaviour and poor relationships with others.

Some people who experience an attachment disorder in childhood are able to overcome this, particularly if they go on to create a healthy attachment with a caregiver in middle or later childhood and if they receive support with their attachment difficulties. However, for some people, attachment disorder continues to affect them throughout adulthood. The signs and characteristics of attachment disorder in adulthood include:

• Difficulties forming emotional connections and positive relationships with others.
• A lack of understanding of boundaries.
• Extreme independence or extreme clinginess.
• Engaging in risk-taking behaviours.
• Difficulties forming or maintaining romantic relationships.
• Difficulties trusting others.
• Difficulties showing affection or feeling uncomfortable if others show affection or attempt physical touch.
• Feelings of anxiety in friendships and romantic relationships.
• Constant need for reassurance.
• Sabotaging relationships to prevent themselves from becoming too attached.
• Disliking change.
• An overwhelming need to be in control.
• Low self-esteem and feeling unworthy of love.
• Engaging in self-destructive behaviours, such as drug and alcohol use and self-harm.

Many of the signs of attachment disorder could also indicate another mental health or behavioural difficulty or another disorder. For example, some of the characteristics may also be consistent with autism spectrum condition (ASC), attention deficit hyperactivity disorder (ADHD) or anxiety.

A thorough assessment is necessary to ensure the individual receives the correct diagnosis. The psychologist or psychiatrist who performs the assessment will need access to all relevant information, particularly in relation to the individual’s background, their attachments and their relationships. It is, therefore, essential to be honest with the person performing the assessment to ensure the child or adult gets the support they need.

Recognising the signs of attachment difficulties can help adults to address them quickly. The earlier attachment difficulties are addressed, the less likely it is that the child will develop a full attachment disorder.

Attachment Disorder Treatments

In the UK, treating attachment disorders involves a combination of therapeutic interventions and supportive measures tailored to the individual’s needs. Early intervention is crucial to address the emotional and behavioural challenges associated with these disorders.

Treatment options include:

Attachment-based therapy

This therapeutic approach focuses on building or rebuilding a trusting, supportive relationship between the individual and their caregiver. It aims to address and repair the disruptions in attachment that may have occurred during early development. Therapists work to improve the caregiver’s sensitivity and responsiveness to the individual’s needs to help create a secure attachment bond.

Play therapy

Utilised primarily with children, play therapy provides a safe environment where they can express their emotions and experiences through play. This method helps therapists understand the child’s internal world and address attachment-related issues effectively.

Family therapy

This approach involves working with both the individual and their family members to improve communication, resolve conflicts and strengthen the family unit. Family therapy addresses patterns of interaction that may contribute to attachment difficulties and promotes healthier relationships.

Video interaction guidance (VIG)

VIG is an intervention where caregivers are filmed interacting with their child. A trained practitioner then reviews the footage with the caregiver, highlighting positive interactions and areas for improvement. This method can help improve caregivers’ awareness and promote more attuned responses to the child’s needs.

Cognitive analytic therapy (CAT)

CAT combines cognitive and analytic approaches to help individuals understand the patterns of behaviour and thinking that stem from early attachment experiences. Through this understanding, individuals can develop healthier ways of relating to others.

Supporting a loved one with an attachment disorder can be challenging. It is essential for caregivers to seek support and education to understand the disorder and learn effective strategies. Family therapy and support groups can provide valuable assistance in navigating these challenges. Early and appropriate intervention can significantly improve outcomes for individuals with attachment disorders, help nurture healthier relationships and improve emotional well-being.

The NHS provides mental health services that can address attachment disorders. Access typically begins with a referral from a GP to Child and Adolescent Mental Health Services (CAMHS) or adult mental health services, depending on the individual’s age. Alternatively, you can choose to seek private therapy. Numerous private practitioners and clinics specialise in attachment-related issues. Organisations such as the Counselling Directory offer a list of certified counsellors and therapists across the UK who deal with attachment disorders.

There are also multiple charities in the UK that provide resources and support for individuals and families dealing with attachment difficulties. They offer guidance on understanding attachment and accessing appropriate help.