Chapter Two: Literature Review

Attachment Disorders

     Boundaries in the field of attachment disorders are still being defined. The therapeutic community acknowledges both severe disorders and reactive disorders as serious problems which need treatment. Therapists speak of a line that is crossed in attachment disorders, a line whereby the children's attachment issues become the primary focus of treatment and where all other treatment is futile unless the problems within the attachment relationships are addressed (Goble & Jones, 2000). Nonattached children and those with disorganized attachments are most likely to fit in the definition of having reactive attachment disorders (O'Connor, Bredenkamp, Rutter, & the ERA Study Team, 1999). The definition of Reactive Attachment Disorder, given in Chapter I of this thesis, is a good point of origin, but too narrow for the purpose of defining the scope of attachment disorders (Sroufe, 2000a; Goble & Jones, 2000). It deals only with the most severe cases of attachment disorders, those where the child has little or no ability to form relationships. These cases, generally caused by clearly pathological parental care of the infant or young child (Reber, 1996), are only the tip of the attachment disorder iceberg. Also, the DSM-IV definition does not take into account that in most cases the effects of early attachment relationship dysfunction take the form of gradually-appearing, but long-lasting, childhood disturbances which may not present themselves before the DSM-IV required age of five (Sroufe et al., 1999).
     Children suffering from severe attachment disorders are cut off from their humanity and from true relationship with others. Unable to give or receive genuine affection, and destructive both toward themselves and others, they are likely both victim and victimizer. Symptoms of attachment disorder range from mild to severe maladaptation in six areas of development: behavioral, cognitive, physical, moral/spiritual, social, and affective (Levy & Orlans, 1998). Individual children will have various symptoms to different degrees. Children with attachment disorders often manifest an artificially charming personality, inability to accept external limits, underresponsibility, and manipulative and defiant behavior, as well as poor hygiene and extremes of physical reactions to pain. Spiritually and morally, attachment disordered children are usually crippled. Since these children have usually experienced either abandonment or abuse by their first authority figure, it is not surprising they are unable to believe in a loving God who will not punish or disappoint them. Children with severe attachment disorders identify with evil and have a lack of remorse or conscience. Their ethical development has also been stunted. The common behaviors of older children with severe disorders of attachment are overwhelming for the uninitiated. They include: cruelty to animals; pathological lying; lack of conscience or cause and effect thinking; preoccupation with fire, blood, and gore; abnormal eating patterns; learning difficulties; and poor peer relationships (Reber, 1996). Because of the variety of symptoms and their tendency to intensify if left untreated, parents struggling with children with attachment disorders, oftentimes adoptive or foster parents, find themselves challenged beyond all expectations.
     This literature review seeks to address all serious disorders of attachment, not only those of the magnitude labeled Reactive Attachment Disorders. Sroufe et al. (1999) caution against classifying all insecurely attached children as suffering from psychopathology, but instead stress that early anxious attachment begins a path of disturbances in development which, without intervention, will likely lead to future pathology. Despite their warning, it is very easy to be tempted to consider all children who lack secure attachments to be disordered after learning about the benefits of secure attachment and the consequences of insecure attachment. Clearly disorganized attachment is more disruptive than stable anxious attachment. Levy and Orlans (1998) note that most severe attachment disorders occur among children with disorganized-disoriented attachment and that this pattern exists at an alarming rate (more than 80% of children) in maltreating, high-risk families.

Causes of Attachment Disorders

The specific causes of attachment disorders are as diverse as the common characteristics, but the common thread is abuse or neglect during infancy. Emotional neglect has been found to be more damaging to attachment relationships than either physical neglect or other types of maltreatment, with the exception of sexual abuse (Levy & Orlans, 1998). Attachment disorders in infancy are seen as significant changes or omissions of behavior from the normal sequential development of attachment (Call, 1984). The infants' failure to thrive without a physical cause is a symptom of the abuse, neglect, and hostility that is common in mother-infant dyads that involved severe disorders of attachment. Unfortunately, in some families normal infant distress behaviors such as crying, flailing, turning away from the bottle, or thumb sucking, have been interpreted by the parent to be manipulative, hostile, disobedient, or immature (Call, 1984). These distorted views of infant development lead to assaults or emotional deprivation which further damage the attachment relationship. Disorganized patterns of attachment in infancy are believed to be the result of various types of trauma or frightening behavior, including maltreatment and intrusive caregiving. They are also correlated with prenatal exposure to alcohol and drugs, maternal depression and/or unresolved mourning of a death, divorce, or other loss, and caregivers who were known to have lapsed into dissociated states (Carlson, 1998).

Adoption and Attachment Disorders

The most striking cases of attachment disorder are demonstrated by children who spent a large portion of their infancy in large institutions such as orphanages. These children did not receive the basic nurturing human infants need to develop a positive internal working model. In a study of Romanian infant adoptees by O'Connor, Bredenkamp, Rutter, and the ERA Study Team (1999), it was found that children exposed to early severe deprivation were predisposed to attachment disorders including disorders of nonattachment. Furthermore, the extent of the attachment disorders for adoptees was affected by the duration of the deprivation before the adoption and the availability of a sensitive caregiver once the child was adopted. Case examples cited by Lieberman and Zeanah (1995) show that nonattachment is not exclusive to institutionalized children. It can also be found among children who experience mediocre or emotionally unavailable foster care and frequent changes in placement.

Prevention of Attachment Disorders

     Researchers involved in the longitudinal attachment research at the University of Minnesota (Egeland & Erickson, 1999) continue to work on improving and adapting their parenting intervention program, Steps Toward Effective, Enjoyable Parenting [STEEP]. They focus on improving parental sensitivity among at-risk first-time parents to promote responsive caregiving in an effort to foster secure attachment relationships. Recognition of the ramifications of attachment disorders has led to the creation of many prevention programs that have focused on early intervention efforts to help create healthy child rearing patterns and to redirect at-risk families. Some of these programs, like STEEP, involve caseworkers who facilitate educational and support aspects (Erickson & Egeland, 1999), while other programs have included prenatal and early child medical care (Levy & Orlans, 1998).
     Studies evaluating the effect of attachment status of adults on their ability to parent responsively are increasingly becoming available. As the children studied in the early 1970s are now becoming parents themselves, researchers have noted a high degree of consistency between the nurturing they received from their mothers and the care they are now giving their babies (Egeland & Erickson, 1999). Adults in other studies (e.g., Cowan et al., 1996) have been classified by their attachment history along with their current beliefs about attachment. Secure-autonomous adults are the most likely to provide a secure relationship for their children (Levy & Orlans, 1998). They have a clear concept of the meaning and importance of attachment. Most had a secure relationship with at least one of their parents. Others have already worked through a painful past and have achieved some level of forgiveness towards their parents. All of these adults have a realistic view of their own childhoods, recognizing the positive and negative qualities of their parents, and are comfortable talking about attachment issues. They also are able to rely on the important relationships in their adult lives. In contrast, parents with anxious and disorganized attachment histories are at an increased risk of abusing or neglecting their own children (Levy & Orlans, 1998).
     Some parents are able, despite troubled attachment relationships with their own parents, to recognize the importance of providing a secure base for their own children and also maintain an objective understanding of their own attachment history. These are the adults from whose experience researchers have concluded that support and education can change intergenerational patterns of attachment through effective interventions (Egeland & Erickson, 1999). Interventions and changes in social and emotional support to prevent the development of attachment disorders and other emotional and behavioral disorders are most effective when implemented early in the developmental process (Sroufe et al., 1999). Problems such as aggressive behavior are increasingly difficult to change as the child ages, with change after the elementary years arduous (Sroufe, 2000b).
     The focus on early intervention with at-risk parents and their babies is admirable, but it begs the question of why parenting skills are not taught to all children. There has been little recent focus on early education about parenting, as opposed to sexual education, for school children. Child development is sometimes taught from an Ericksonian perspective, but little is taught about the ramifications of parental behavior on the emotional well being of their children. Child care is usually addressed from the prospective of babysitting training rather than at a level commensurate with preparing the parents of our next generation. The repertoire of attachment disorder intervention strategies needs to be extended to include early education. Explaining the importance of secure attachment relationships to all potential future parents, not just those teens who are already expecting or raising babies, is the logical next phase of prevention.

Back to the Main Page On to the Next Section