Attachment Disorders 149between the child and his or her current caregiver should be carried out,
looking for insensitive and inappropriate responding and unusual child
behaviours.
Management
The principal objective of management is to improve the children’s care-
giving environment. The main contribution of child and adolescent mental
health professionals is often to provide appropriate advice on this to
social services and the courts. If a child is currently being maltreated,
an alternative placement is obviously needed if the current caregivers
cannot be helped to change. If the child has passed through a succession
of brief foster placements or has grown up in an institution with rapidly
changing staff, he or she needs to be given the opportunity to form
lasting attachments, ideally with permanent foster or adoptive parents.
Though attachment-based interventions have been developed for the
treatment of a variety of severe relationship difficulties and have proved
to be moderately successful at reducing insecure patterns of attachment in
infancy, there is less evidence whether these approaches benefit children
with attachment disorders. Two observational studies of young children
adopted from severely depriving Romanian orphanages (one to parents
in Canada, one to England) converge in suggesting that while symptoms
of both the inhibited and disinhibited type reduced as the children grew
up into late middle childhood and the teenage years, they persisted to
a marked degree in around half. One study of children in depriving
Hungarian institutions randomised the children to continuing care in the
institution or foster care. Those remaining in the institution continued to
show both types of disorder, whereas those allocated to foster care showed
virtual elimination of the inhibited type of disorder and reduction but not
elimination of the disinhibited type.
In conclusion, on both theoretical grounds and on practical empirical
evidence, the best treatment for attachment disorders is long-term good-
quality parental-type care with sensitive responding to the child’s needs.
This needs emphasising as fosterers and adopters of maltreated children
with attachment problems or disorders may get desperate and instead of
seeking sensible advice from a skilled child and adolescent mental health
professional, may fall into the hands of eccentric and potentially dangerous
practitioners. Controversial therapies include: regression therapy; holding
therapy; rebirthing therapy; corrective attachment therapy; holding time
and rage-reduction therapy. The names change frequently and carers do
not know if their attachment therapy is ‘controversial’.
Course and prognosis
A number of cohorts of children raised in depriving circumstances have
now been followed-up over the longer term. In general, early attachment