What is an attachment disorder
Attachment is seen as a motivational, vital need of human beings. A distinction is made between organized (secure and insecure) and disorganized attachment qualities. In addition, different types of attachment disorders can be differentiated clinically in the psychiatric classification systems. These attachment disorders are associated with an early emotional disturbance in the child, with far-reaching consequences for the entire development, including adult psychopathology. In this article, the etiology, the basics of diagnostics and the effects of the disorder are presented. The treatment options are then shown.
Attachment is a motivational force that is important in the survival needs of human beings. A distinction is made between organized (securely and insecurely) and disorganized attachment qualities. In addition, psychiatric classification systems enable us to diagnose clinically different types of attachment disorders. These attachment disorders are associated with early childhood emotional disorders that have far-reaching consequences for the complete personal development up to psychopathology in adults. The article examines the etiology, fundamentals of the diagnostics and effects of the disorder. Finally, treatment modalities are considered.
After reading this post ...
you know the division and the development of the bonding pattern.
you are able to recognize attachment disorders.
know how to go about diagnosing attachment disorders.
you know differential diagnoses of attachment disorders.
you know the interdisciplinary procedure in the event of an attachment disorder.
According to John Bowlby (1907–1990), the founder of the attachment theory, the development of attachment is a genetic one motivational needwhich is absolutely necessary for the survival of a child as well as an adult. When children with a secure attachment quality experience fear, they try to use their attachment behavior - such as B. Protest, following the adult, shouting, crying and clinging - to draw the attention of your attachment figure to you and to create closeness to you in order to experience protection and security in this way. This secure attachment pattern is generally considered to be a resilience factor in attachment research. It protects against the development of a psychopathology.
On the other hand, insecure-avoidant and insecure-ambivalent attachment patterns represent risk factors. Children with a insecure-avoidant attachment pattern show a behavioral strategy with which they adapt to the rejecting behavior of their parents, which followed their attachment signals, by avoiding them. They have learned that signaling a desire for closeness is more likely to be answered by their parents with rejection. On the other hand, children with insecure-ambivalently bound ties know that their signals and their search for protection and security are answered with fearful behavior by the attachment figures. In a current meta-analysis of parent-child bonding and the transgenerational relationships , 52.2%Footnote 1 of children a safe and 24.6%1 children have one of the two insecure attachment patterns. The organized patterns (safe, avoidant, ambivalent) are considered strategies with which the children have adapted to the reactions of their attachment figures in the first year of life.
The disorganized attachment behavior (23.2%1 ), on the other hand, can no longer be viewed as an adaptive strategy; it is definitely not an attachment disorder yet. In the case of the children in situations that frighten them and activate their attachment behavior, contradicting behaviors - such as walking towards the attachment figure, stopping, turning around, freezing of movement, motor stereotypes - can be observed. These have the same effect on an outside observer "Confused" behavior. This behavior is observed, on the one hand, in the case of a child at risk (e.g. in premature babies or in children with individual traumatic experiences) and, on the other hand, in the case of parental risk (e.g. in the case of unresolved trauma or unresolved loss of parents).
If, on the other hand, there has been long-lasting, frequent traumatisation of the child by his attachment figures as early as infancy and toddlerhood, children often develop attachment disorders in the further course. They are called early emotional psychopathology viewed.
The development of attachment disorders is etiologically traced back to trauma - such as the child's early experiences of mistreatment, abuse, violence and extreme neglect by attachment figures.
In clinical samples, profound changes and deformations in the development of attachment are found in attachment disorders. The most comprehensive insights into the development and formation of attachment disorders come from longitudinal studies of the emotional development of infants and preschoolers. These were harder under the conditions earlier Deprivation Grew up in Romanian homes and then were adopted by English and Canadian families. The longitudinal studies show that, even many years later, these children still suffered from symptoms of pronounced reactive attachment disorders with additional disorders related to attention deficit and hyperactivity disorder (ADHD) as well as behaviors that resembled an autism spectrum disorder  .
One can assume that attachment disorders with a very low prevalence occur. In the first epidemiological study by Pritchett et al.  found a general prevalence of 1.4% for attachment disorders in a sample of 1,600 children aged 5 to 8 years. These were screened for attachment disorders in a very differentiated manner with the help of various instruments. In almost all children diagnosed with attachment disorder, further diagnostics revealed neglect and abuse in the life history. In studies and samples of children who grew up under extremely negligible conditions in nursing homes, the prevalence of signs of attachment disorders rises to 40% and more . However, in some studies the term and diagnosis of attachment disorder have been used unspecifically and undifferently for many forms of emotional difficulties.
In child psychiatric clinics, outpatient clinics, orphanages, child and youth welfare institutions, the percentage of children with severe early emotional neglect and abuse and the resulting attachment disorders is likely to be high. In the patient collective of the MOSES study, which is made up of children who were traumatized early and severely traumatized, the clinical diagnosis “attachment disorder” almost always applies before treatment begins .
In the International Statistical Classification of Diseases and Related Health Problems (ICD-10), a “reactive attachment disorder in childhood (type I, F94.1)” is differentiated from a “disinhibited attachment disorder in childhood (type II, F94.2)”. The diagnosis “reactive attachment disorder in childhood” (Type I F94.1) in the ICD-10 describes children who are very inhibited in their willingness to bond towards adults and who react to attachment persons with ambivalence and fearfulness, e. B. run away from them when they are scared. In type II (F 94.2 - attachment disorder of childhood with disinhibition), children show a contrary clinical picture with disinhibited, open-minded sociability even to completely strangers to them. This behavior appears in the DSM-5 classification under “symptoms of disinhibited social engagement disorder” (DSED). Both types of attachment disorder are viewed as a direct result of extreme emotional and / or physical neglect and abuse or as a result of constant changes in caregivers. Thus, both subtypes of attachment disorder should in principle be called “reactive”.
There is no superordinate explanatory model in any of the diagnostic systems. This is astonishing, because in earlier years typologies of attachment disorders were described against the background of attachment theory, but these have not yet found a comprehensive entry into the above-mentioned classification systems. Brisch  has described an expanded typology of attachment disorders in order to capture clinically highly conspicuous attachment behavior in a more differentiated manner. The benefit of this more differentiated additional classification is that the clinician can think of attachment problems and traumatisation of the child if the symptoms are appropriate. These include children who show no signs of attachment behavior at all (even when they are maximally stressed and in panic), children with accident-risk behavior, excessive attachment behavior, aggressive attachment behavior, attachment behavior with role reversal, attachment disorder with addictive behavior and children with psychosomatic reactions to extreme attachment trauma .
In children with an attachment disorder, very significant changes in behavior towards different caregivers are observed. These behaviors do not only occur situationally, but are as stable behavior pattern Observed as pathological behaviors over a long period of time in various situations.
An attachment disorder should not be diagnosed before the age of 8 months. Children this age usually show that "Strangers", and their attachment behavior cannot yet be validly investigated. It is suggested that psychopathological abnormalities exist for at least a period of 6 or more months with different attachment persons and that the pathological attachment behavior must appear before the age of 5 .
In principle, close cooperation in diagnostics between pediatricians, child and adolescent psychiatrists, pedagogues and child and adolescent psychotherapists is urgently required.
Differential diagnoses and comorbidities
In a study by Pritchett et al. , 85% of children with attachment disorders received at least one additional diagnosis using screening tools. B. ADHD (52%), oppositional defiance (29%), disorder of social behavior (29%), "posttraumatic stress disorder" (PTSD, 19%), autism spectrum disorder (14%), specific phobias (14, 3%) and tic disorder (5%).
Symptoms of Autism Spectrum Disorders may be confused with the pattern of reactive attachment disorder with inhibition of attachment behavior. Anamnestic information about the beginning of the behavior disorder and its occurrence - only in attachment-relevant situations such as attachment disorders or more generalized occurrence as with autistic disorders - are required for differentiation. They can be collected in a combination of a clinical interview with the parents as well as additional questionnaires. With some children, however, it is difficult to differentiate and requires clinically experienced examiners and one Follow-upwhich sometimes has to take place over several months.
There are various diagnostic options for determining attachment behavior and attachment patterns . Pediatricians could discover the first signs and indications of an attachment disorder. The specific diagnostics, possibly with the aid of appropriate methods of attachment diagnostics, should be carried out by specialists such as B. child and adolescent psychiatrists and child psychotherapists or in socio-pediatric centers.
The diagnostic process always includes:
detailed anamnesis of the type, duration, beginning, expression, variation and context of the child's behavior,
Behavioral observation with various attachment figures in the exploration, e.g. B. in joint play and in attachment-specific contexts, for example in a separation situation, and, if possible,
diagnostic clarification of child trauma.
At all points are External anamnestic information, both from the attachment figures themselves and possibly from the caregivers of the child in kindergarten, school, after-school care and possibly from youth welfare workers. Furthermore, a physical examination by the pediatrician is required to rule out physical illnesses, such as a neurological disability or a metabolic disorder as well as a severe mental handicap, as the cause of the behavior. All of these can lead to developmental delays or behavioral problems, as can also be observed in children with attachment disorders.
The diagnosis of attachment disorder can be made in children as early as 12 months of age; However, further observations and examinations of the child in the second year of life are still necessary to confirm the diagnosis. The disordered behavior is already evident at 12 months in frightening everyday situations.
Precursors of attachment disorders
Very noticeable disorders of the parental sensitivity in the early interactions with their infants can be precursors of attachment disorders, as longitudinal studies show .
Disorders in parent-child interaction can best be diagnosed with the help of video recordings. The diagnosis of parental sensitivity with the Ainsworth scale  is a qualitative assessment that can be carried out if necessary microanalytical methods can be added. The assessments can also be made using the Emotional Availabilty Scale (EAS) by Biringen et al.  are evaluated.
Parents can get through during pregnancy primary prevention programs, such as “Safe Education for Parents” (SAFE), should be trained .
Age-specific diagnostic examinations
Infancy and toddler age.
The quality of bond development is measured using the methods described by Ainsworth et al.  analyzed the "strange situation procedure". This can be carried out from about the 12th month of life and is valid until the 19th month of life. It consists of different episodes of separation and reunion. The behavior of the child can be analyzed in the respective modes of reaction to the attachment person and classified in the form of the described attachment qualities (secure, insecure-avoiding, insecure-ambivalent, disorganized). However, there is no specific evaluation classification for attachment disorders. For diagnosis, however, the clinical abnormalities in the child's behavior in the unfamiliar situation can be used.
The “strange situation” provides the following regular procedure: A stranger joins the mother or father and child. The attachment person briefly leaves the room and the child remains with the stranger. If the child behaves in the separation situation z. B. sociable and friendly towards the stranger, even seeks physical contact with him, allows himself to be comforted and reassured by him very well, on the other hand reacts very anxiously to frightened when the attachment person returns and runs away from him and towards the stranger, this is a very noticeable behavior that is not described in any of the attachment categories as safe, unsafe-avoiding, unsafe-ambivalent. In the “strange situation”, significant signs can be seen even in toddlerhood, which are often classified as disorganized behavior, but already the suspicion of one incipient attachment disorder can arise and require further diagnostics.
This “strange situation” method, however, requires one specific training for the implementation and analysis of the attachment behavior. The examination cannot be carried out in the everyday practice of a pediatrician.
Nevertheless, pediatricians - knowing the classic child behavior from the "strange situation" - can assess the different behavior of children in fearful situations, especially with regard to their reaction to their attachment figure. If z. B. a child in the 2nd year of life cries inconsolable after a vaccination or blood sample on the arm of the mother, finally, crying, reaches out his arms for the office hours and can be calmed down quickly by this. B. not for a secure attachment to the mother, but rather for a disorganized attachment or even an incipient attachment disorder with inhibition.
Kindergarten through the end of elementary school age.
A modified "strange situation" for the preschool age was developed by Marvin and Britner . In the respective separation situations, behavior disrupted can also be observed and assigned to the aforementioned ICD-10 codes. An attachment disorder with inhibition is z. B.recognizable when the child flees from the attachment person when they return, shows clear fear of them or even expresses them verbally and seeks protection and security in the stranger who is still in the room.
There are various diagnostic tools for this age group Puppet showsthat offer the children stories with clues that are relevant to their attachment . In the puppet show, the children then have to supplement the beginnings of stories relevant to their attachment to them and play how the story continues and comes to an end. On the basis of transcriptions and video recordings, the child's attachment pattern can be validly evaluated . Under the tie pattern or the "Inner work model" By attachment we understand that over the years the child has created an internal pattern of how it will react in fear-inducing situations that activate its need for attachment.
These methods, too, cannot simply be used quickly in pediatric practice, but require training and training in reliable evaluation. Nevertheless, knowing the behavior of the children during these diagnostic methods is helpful because a pediatrician could recognize more quickly in the practice if a child - for example during an examination - shows clear signs of fear towards his attachment figure or - in a frightening situation - hurt yourself, have a tantrum or aggressively attack the attachment figure instead of seeking protection and security from them. These behaviors, in turn, are rather signs of disorganized attachment or incipient reactive attachment disorder of the type with inhibition of attachment behavior.
From an age of about 7 years this can be Child attachment interview (CAI ) and from around the age of 17 the adult attachment interview (AAI, ) to record the mental attachment patterns (“attachment representations”).
Brisch  developed a questionnaire on attachment abnormalities for kindergarten age. In a pilot study carried out with this questionnaire, positive correlations were found between the traumas experienced by the children and high values for behavioral disorders .
For a complete diagnosis, it is also necessary to examine the child’s attachment figures, e.g. mother and father. There are various questionnaire tools to examine the attachment patterns of attachment figures. Some also combine interviews and questionnaires to assess attachment .
After thorough physical examinations and the exclusion of physical causes - and if necessary, if their treatment is available - the psychotherapy the child, his parents and the entire family in the foreground. This applies to all age groups listed below.
Infants and young children
If infants or toddlers already show signs of an incipient attachment disorder, the sensitive interaction treatment of the infant with the involvement of the caregivers top priority. Therefore, the most important consideration is an early intervention, possibly a change of milieu by removing the child from the family and introducing it to attachment figures who can act emotionally sensitive and bond-oriented in contact. Admission of the mother (father) with the baby in a mother (father) child home or in a parent-child ward and psychotherapy for the attachment figures are very helpful everywhere.
Sometimes the development of an attachment disorder shows up in kindergarten age. Here it is z. B. recognizable through indifferent attachment behavior of the child towards all caregivers in kindergarten. In this case, diagnostic work-up and intensive psychotherapeutic treatment of the child, for example as a Play therapy, indexed.
Elementary school age
It is to be expected that the early attachment disorders in elementary school age - in addition to the abnormality in attachment behavior - can manifest themselves with a variety of comorbid symptoms, such as ADHD, speech development delay or disorder of social behavior.
Here, too, the individual child psychotherapeutic treatment of the child is of the greatest importance for the experience of new, as secure as possible, relationships in play therapy. The intensive pedagogical work in the discussions with the attachment figures of the child is urgently required. A removal of the child from his family and his further care by Foster parents must also be considered.
The most severe attachment disorders with massive problems in group behavior in elementary school children and children in puberty are often an indication for inpatient treatment settings social interaction disorders, aggressive and dissociative developments, school failure and school refusal.
Drug treatments with psychotropic drugs can curb affective outbreaks in the child in the short term, but ultimately do not lead to a cure for the early attachment disorder. This requires more intensive psychotherapeutic inpatient treatment methods, such as those developed and successfully applied in the concept of MOSES intensive therapy [18, 19].
The inpatient treatments within the framework of the MOSES therapy model are carried out completely without the use of psychotropic drugs. The children currently being examined in the ongoing MOSES study show clinically clear progress in development after treatment. In addition to changes on the emotional and behavioral level, there were also increases in connectivity in the individual cases analyzed so far trauma-specific brain areas (e.g. amygdala, hippocampus, prefrontal cortex) seen in functional magnetic resonance imaging (fMRI) and changes at the hormonal level (cortisol, oxytocin, vasopressin in response to a stress stimulus).
A similarly intensive approach would also be required for the treatment of adolescents with attachment disorders. Some youth welfare institutions have now started to introduce modifications to the MOSES intensive therapy concept, in the hope that a combination of therapeutic and educational work can provide support for the development of these seriously ill young people.
conclusion for practice
Attachment disorders are an expression of severe early emotional developmental disorders.
They can occur in the context of traumatic experiences with attachment figures. Early diagnosis and early intervention increase the chance of positive development.
Intensive psychotherapy for the child and accompanying work with the attachment figures, which is always indicated, are urgently needed.
Pediatricians could at least identify attachment disorders very early and make a suspected diagnosis. Afterwards, further diagnostics in close cooperation with child and adolescent psychiatrists as well as child and adolescent psychotherapists and educators are required.
A joint planning of all those involved in the treatment of the child, together with the attachment figures and the youth welfare office, is necessary in order to discuss and coordinate the further procedure in helper groups.
These percentages result from the number of cases in the individual cells (, crosstab no. 7, p. 351). The percentages were confirmed by Marije Verhage on September 11th, 2017 in a personal communication to the authors of this article.
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Institute for Early Life Care, Paracelsus Medical Private University PMU Salzburg, Salzburg, Austria
Prof. PD Dr. K. H. Brisch
Pediatric Psychosomatics and Psychotherapy, Dr. von Haunersches Kinderspital, LMU Munich, Pettenkoferstr 8a, 80336, Munich, Germany
Prof. PD Dr. K. H. Brisch, C. Hilmer, L. Oberschneider & L. Ebeling
Correspondence to Prof. PD Dr. K. H. Brisch.
Conflict of interest
K.H. Brisch, C. Hilmer, L. Oberschneider and L. Ebeling state that they have no conflict of interest.
All investigations on humans described were carried out with the consent of the responsible ethics committee, in accordance with national law and in accordance with the Helsinki Declaration of 1975 (in the current, revised version). A declaration of consent is available from all participating patients.
R. Berner, Dresden
B. Koletzko, Munich
W. Sperl, Salzburg
A. Muntau, Hamburg
Which parent-child interaction pattern is particularly typical for the development of an insecure-avoidant child-like attachment pattern?
Projection of parental needs and needs onto the child
Autistic behaviors of the child that express a clear disinterest in attachment to the parents
Rejecting and / or ignoring the attachment signals displayed by the child in situations that activate the child's attachment system
Fearful tendencies of the parents not to be able to give the child freedom in play and exploration
Sensitive interaction between attachment person and child, especially in fearful situations
What subdivision of the weave patterns can be made?
The classification for children up to the age of 3 years is based on the assessment of parental sensitivity in interactions with the child.
Division into organized (secure, insecure) and disorganized attachment patterns.
Division into organized (safe) and disorganized attachment patterns (these include insecure patterns and attachment disorders).
According to ICD-10 and DSM-5, there is a division into a reactive type and a type with disinhibition.
In addition to attachment disorders, organized and disorganized attachment patterns are diagnosed and further subdivided using ICD-10 criteria.
What is the clinical significance of the diagnosis of an attachment disorder?
Attachment disorders correspond to functional adaptations to parental behavior.
In contrast to disorganized attachment patterns, attachment disorders represent a psychopathology per se.
Attachment disorders can only be diagnosed as psychopathology from the age of 8, so only a suspected diagnosis should be made in younger children.
Attachment disorders can only be diagnosed in the ICD-10 on the basis of accompanying and secondary diseases that are not attachment-specific.
In developmental psychology, attachment disorders are to be viewed as an unfavorable path of development which, due to lower resilience, can lead to the development of psychopathologies.
Which anamnestic or differential diagnostic factor plays a role in the assessment of a questionable attachment disorder least Role?
Autism Spectrum Disorder
Psychological and / or physical trauma
An observation period of at least 6 months with different attachment figures
The educational level of the parents
Which temporal and situational criteria of behavior should be met in order to diagnose an attachment disorder?
The behavior should occur over at least 6 months in different situations and with different caregivers.
The behavior should be due to early childhood trauma.
The observable behavior occurs independently of the situation only in relation to the main reference person and not in other people.
The behavior should be limited to the family setting and should not be observable in clearly structured environments such as school.
Main caregivers should be significantly less affected by the child's aggressive or dismissive behavior than other people.
Which area should be the focus of therapy for severely disturbed attachment development?
Because of the impairment of psychological, social and physical areas, interdisciplinary therapy should be carried out.
The therapy should mainly be medicated in order to minimize negative influences of the social environment.
Whenever possible, treatment should be carried out on an outpatient basis so that the children can be left in their familiar surroundings.
The therapy plan should only actively involve the current attachment figures if they indicate their own need for therapy.
The therapy manual “Emotional Availability Scales (EAS)” by Biringen et al. contains most of the necessary steps and is considered the gold standard for the treatment of such disorders.
Which therapeutic approach should be preferred, if possible, for infants and toddlers with signs of incipient attachment disorder?
Removing the child from the family is usually the most promising measure.
At this age, the early parallel treatment of child and attachment person with a focus on interactions and therapy of the attachment person - e. B. in a mother / father-child home - to be preferred.
Psychotherapeutic treatment with stabilization of the attachment person (s) is in the foreground, whereby an improvement in the interaction pattern can be expected.
After referral to a pediatric clinic, in addition to somatic examinations, cooperation with the parents should be started and, if necessary, the child protection team should be called in.
Suitable therapy places are very rare for this early age, which is why the family should be looked after on an outpatient basis and the child's psychological development should be monitored.
What role do childhood traumas play in the development of attachment disorders?
In most cases, trauma in early childhood leads to attachment disorders, which can only be prevented with rapid professional help.
Child trauma can be found equally often in all attachment patterns.
Child trauma must be ruled out before an attachment disorder is diagnosed, as PTSD should be diagnosed in such cases.
Traumas in early childhood - especially those caused by attachment figures - are seen as a crucial factor in the development of attachment disorders.
Such traumas are only of importance for the development of the bond if they do not originate from the attachment person, but the attachment person is also affected by the trauma (e.g. natural disasters).
The parents of 7-year-old Marcel report that their son missed a large part of the previous school year. For this are z. T. recurring gastrointestinal complaints, e.g. Sometimes, however, refusal to attend school for no particular reason is also responsible. Marcel's parents disagree on whether they are too strict or too indulgent towards him. On the basis of known history of visits to several mother-child facilities, you suspect that Marcel's bond development could have been difficult. What are you most likely to do to learn more about Marcel's attachment style?
They should find out more about the stays in the mother-child facilities and the findings there in order to assess Marcel's development of bonds.
Since it is obviously a school phobia, you should refer him to a child and adolescent psychiatrist for assessment.
Due to the required training in attachment diagnostics and the corresponding equipment, you cannot observe attachment behavior, but only obtain information from someone else's anamnestic and inform Marcel's parents about the importance of attachment and attachment development.
You should call Marcel and his two parents into your practice in order to receive informative information about the prevailing attachment styles and interaction patterns in the family and possibly even options for intervention about the interactions of this triad in conversation.
In addition to further information about the patient's history and questions to Marcel about the relationship with his parents, you could use the upcoming vaccination as a stress-inducing situation and observe his interactions with his parents as well as with you and your office hours assistant.
Marie, who is almost 4 years old, is presented to her mother for the first time in her pediatric practice for U8. Despite the premature birth, Marie has developed well except for a feeding disorder. In conversation with the worried mother, she reported in a relaxed manner: "Marie still doesn't want to eat anything, and I really have to force her to eat anything at all!" During the conversation you notice that Marie is pulling herself away from her mother's lap in the room walks around, seems to run back to the mother again and again, but remains frozen and then turns back again. They are irritated that the mother does not seem to notice. When the office assistant enters the room unannounced, Marie is frightened, throws herself to the floor and repeatedly hits the floor with her head. How do you rate Marie's behavior?
Marie's behavior suggests a disorganized attachment pattern that should be diagnosed as an attachment disorder with disinhibition (ICD-10 F94.2).
Marie's behavior and the mother's lack of reactivity suggest a reactive attachment disorder (ICD-10 F94.1). Further clarification is not indicated until U9.
Marie's behavior is typical of children with disorganized attachment patterns. The exclusion of an attachment disorder is not yet possible and should therefore be pursued further.
Marie's behavior suggests an insecure-avoidant attachment pattern that is typically based on a traumatic experience.
Marie's behavior seems to be age-appropriate defiant behavior. Further diagnostic clarification of the feed disorder should be prioritized.
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Brisch, K.H., Hilmer, C., Oberschneider, L. et al. Attachment disorders. Monthly childcare166, 533-544 (2018). https://doi.org/10.1007/s00112-018-0465-7
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