Attachment Disorders 147of social responsiveness and reciprocity in a foster placement points to
an attachment disorder rather than an autistic disorder.
6 Mental age over 10–12 months. Children with severe intellectual disabil-
ity may lack selective attachments simply because they have not yet
reached a mental age when these would normally emerge. This does
not warrant an additional diagnosis of an attachment disorder.
7 Pathogenic care. DSM-IV criteria require an abnormal caregiving context,
involving either repeated changes of primary caregiver, preventing the
formation of stable attachments, or persistent disregard of the child’s
basic emotional or physical needs. ICD-10 also makes it clear that an
attachment disorder is usually associated with pathogenic care but does
not make this a diagnostic requirement. This allows the diagnosis to be
made in those transnationally adopted children who meet all the other
criteria without much being known of their care history.
Differential diagnosis
Disinhibition and indiscriminate friendliness can also be seen in ADHD,
mania and after frontal lobe damage, for example, following severe closed
head injuries. Inhibition can also be seen in social phobia and shyness –
while it is usually evident that shy or socially anxious children are attached
to their parents, this can be hard to establish in the presence of severe
intellectual disability.
Attachment disorders v. insecure attachment
Attachment has been one of the key themes in developmental research for
decades, with much being written about secure and insecure attachment
patterns (see Chapter 32). How do attachment disorders differ from inse-
cure attachment patterns? First, the rates are dramatically different, with
about 40% of children being classified as insecurely attached, whereas
attachment disorders appear to be rare. Second, a child may be insecurely
attached to one key caregiver (for example, the mother) but not to others
(for example, the father), whereas attachment disorders involve problems
that are pervasive as well as severe. Third, an insecure attachment pattern
does not necessarily result in distress or social impairment, whereas an
attachment disorder does. Finally, the characteristic symptoms of attach-
ment disorders (particularly disinhibited attachment disorders) do not
correspond to any of the recognised subtypes of insecure attachment,
including insecure-disorganised attachment (type D).
Assessment of the child
When evaluating a child who may have an attachment disorder, it is not
sufficient to carry out one of the standard assessments of attachment secu-
rity, such as the Ainsworth Strange Situation Procedure (see Chapter 32),