148 Chapter 17
which is only reliable under the age of 2 years anyway. It is important
to take a careful history from multiple informants and observe the child
in several settings. It may also help to get the carer to keep a diary of
the child’s behaviour, especially focusing on times of stress when a child
might be expected to turn to their attachment figure, for example, when
very tired, ill, upset or frightened. The main focus is on various aspects of
attachment:
1 A safe haven?Does the child have a narrow range of people to turn to
in times of distress, in order to obtain comfort and renew confidence?
Children with an attachment disorder may not seek comfort, or may
seek it from whoever is around at the time (disinhibited type), or may
seek comfort in obviously odd ways, for example, by backing into the
caregiver rather than walking forward and making eye contact.
2 A secure base?Can the child venture out to explore the world, returning
to the attachment figure for security when necessary? The child with
an attachment disorder may be excessively inhibited about exploring,
or may be a disinhibited explorer without due regard for his or her own
safety.
3 An affectionate bond?The child with an attachment disorder may show a
lack of affection or promiscuous affection.
4 Selectivity?Does the child make use of fairly unfamiliar adults as attach-
ment figures, turning to them for comfort, clinging to them, or showing
them inappropriate affection? Does the child become over-familiar with
strange adults, for example, sitting on their lap at first meeting?
A full assessment also needs to determine the age of onset of problems
and establish the type and quality of current and previous caregiving.
Wider social impairments also need to be considered. For example, how
well does the child relate to other children? Does he or she tend to ignore
or attack other children when they are distressed? It is also essential to
look for evidence of autistic impairments and severe intellectual disability.
These are possible differential diagnoses and need to be excluded if the
diagnostic criteria for an attachment disorder are to be met. ADHD or
brain injury may also need to be considered as an alternative explanation
for over-familiarity with adults, disinhibited exploration and poor peer
relationships. However, neither ADHD nor brain injury would account for
failure to seek comfort from attachment figures when distressed.
Assessment of the care received
A careful history should be taken from birth onwards. The focus should
be on the constancy of the chief caregivers versus the number of changes,
and on the quality of care given, including warmth, emotional availability,
neglect, and hostility or abuse. Informants who know the child well should
be questioned closely. These may include health visitors and relatives as
well as the immediate caregivers. Direct observation of the interaction