146 Chapter 17
frequent changes in foster placement, or rearing in a group home with
a high turnover of staff.
2 Inhibited. This clinical picture is called ‘reactive attachment disorder’
by ICD-10 and ‘reactive attachment disorder, inhibited type’ by DSM-
IV. Core features include lack of social and emotional responses, an
absence of attachment behaviours even in times of stress, and marked
problems with emotional regulation. There is a striking lack of positive
emotional responses. In contrast, negative emotional reactions, espe-
cially fear and irritability are frequently seen, despite there being no
or only minimal discernible triggers. Social and emotional reciprocal
interactions are almost totally absent. Inhibited attachment disorders
are usually associated with either severe abuse in the first years of life,
or with being raised in institutions. It is worth remembering, however,
that most children who are severely abused and the majority raised in
institutions do not develop an inhibited attachment disorder. Whether
it arises from an interaction between pathogenic care and, for example,
a neurodevelopmental predisposition remains to be discovered. The fact
that the disinhibited type responds less well to intervention (see below)
and is less associated with pathogenic care at a critical, early period has
led some to suggest it is a form of neurodevelopmental disorder.
Diagnosis
According to the ICD-10 and DSM-IV classifications, the following diag-
nostic criteria are relevant:
1 Severity. The children are not attached in any meaningful sense. They do
not have enduring relationships with people who provide them with a
‘secure base’ and a ‘safe haven’.
2 Pervasiveness. A seriously troubled relationship with one particular par-
ent or other caregiver is insufficient. The attachment problems must be
evident across a number of different caregivers.
3 Distress or disability. Attachment disorders cause the child persistent
distress or social disability, partly as a consequence of the lack of
normal attachment relationships, and partly as a consequence of a
wider range of associated social difficulties (for example, with poor peer
relationships).
4 Onset before the age of 5 years. Along with autism, it is one of the
psychiatric disorders that is often first diagnosed in a child of 3 or under.
5 Not autistic. The child’s impaired social relationships are not attributable
to an autistic spectrum disorder (see Chapter 4). Relevant evidence is
the lack of other autistic impairments, such as ritualistic and repetitive
behaviours, or communication difficulties. In addition, some capacity
for social reciprocity and responsiveness is usually evident in interac-
tions with normal adults. In extreme cases, though, the child’s social
potential may not be apparent for as long as he or she lives in adverse
social circumstances. The response to a more favourable caregiving en-
vironment is then of diagnostic value. For example, the rapid emergence