Disorders of Attachment in Infancy

Fast facts

• A secure and robust relationship with a small number of warm, caring and emotionally responsive adults is fundamental to infant wellbeing and development.
• The single most effective ‘intervention’ is to ensure that the infant has reliable access to an emotionally responsive caregiver.
• Video feedback programmes and parent-child psychotherapy are also useful interventions for attachment difficulties.

Interventions that work – at a glance

This table represents a compilation of information from several different sources (Zeanah et al., (2016), O’Hara et al., (2016), and The Matrix (2015)) and is designed to provide an overview only. Directly consulting these sources will provide considerable additional information. The Evidence-Based Interventions (EBI) page has more detail on these categories.

The fine print

1. Video feedback programmes delivered in the family home by a trained health or social care worker are an effective intervention for attachment difficulties in children who remain with their original family but are at risk of entering the care system (NICE, 2015). Video feedback is a generic term which describes interventions that utilise video recordings of interactions between parents and their children to enhance parental sensitivity. Interventions may be delivered one-to-one or in group settings, such as the Circle of Security intervention (O’Hara et al., 2016). A Cochrane review of the effectiveness of video feedback interventions is underway and will provide further clarification in due course (see O’Hara et al., 2016).
2. Respected guidelines recommend that parent-child psychotherapy ought to be considered as an intervention for parents who have maltreated, or are at risk of maltreating their children (NICE, 2015). However results are mixed, as a recent Cochrane review suggested that while parent-infant psychotherapy is promising, and deserving of further study, it was no more effective than no intervention or treatment as usual (Barlow et al., 2015).
3. While it is certainly not the role of mental health services to determine care arrangements for children, even the most sound clinical intervention is unlikely to succeed if the child is in a care environment where there is not an emotionally available attachment figure present. And professionals working in mental health services are often well placed to contribute information and raise awareness of the child’s needs in the process of care being evaluated or arranged. It has been said that the single most influential intervention for a child with attachment difficulties is having a secure care arrangement with an emotionally responsive, warm and nurturing adult or adults (Zeanah et al., 2016).
4. Pharmacological interventions are not recommended for the treatment of attachment difficulties, however may be useful in treating co-morbid difficulties (Zeanah et al., 2016).
5. Attachment interventions that involve physical holding, coercion, “reworking” of trauma such as “rebirthing” or promoting regression in order to “reattach” have no research support and have been associated with serious harm (including death in several cases in the United States) and should not be used (Zeanah et al., 2016).

Description and demographics

The phrase ‘infant mental health’ was developed in the 1960s to describe the social, cognitive and emotional wellbeing of an infant within the context of a caregiving relationship (Fraiberg et al., 1987; cited in Ministry of Health, 2011). Parents or caregivers of young children can present in primary care settings with concerns involving feeding and sleeping difficulties, speech delay, social eccentricities, or aggressive and/or non-compliant behaviour (Guy, 2011). Despite the variety of infant presentations, the focus of interventions within the infant mental health field is usually on the relationships which provide a scaffold for the child’s cognitive, social and relational development (The Matrix, 2015). This parent (or caregiver) – child attachment relationship is designed to provide comfort when the infant is distressed, and to provide warmth and nurture, emotional availability and emotion regulation, and physical and emotional safety (Zeanah, 1993; cited in O’Hara et al., 2016). When this attachment relationship is compromised, there may be wide-ranging effects on the infant’s development, including emotion regulation abilities which in turn affect executive functioning, such as planning, decision-making abilities, and judgement (Merry et al., 2009).

It is beyond the scope of this summary to explore all interventions in the infant mental health domain. Given that attachment relationships are fundamental to a young child’s wellbeing and development, a focus on effective, evidence-based interventions for attachment difficulties has been adopted here.

There are two categories in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association) that relate to the attachment relationship. Reactive Attachment Disorder describes a child with inhibited, emotionally withdrawn behaviour and persistent social and emotional disturbance as a result of having experienced extremes of insufficient care (American Psychiatric Association, 2013). And Disinhibited Social Engagement Disorder describes a child who approaches and interacts with unfamiliar adults in a socially disinhibited manner as a result of an experience (or series of experiences) of extremes of insufficient care. The Diagnostic Classification of Mental Health and Developmental Disorders of Infancy and Early Childhood (DC:0-3R) system is also often used to describe and diagnose developmental and mental health disorders in 0-3 year old children.

Several documents have been published that relate to the assessment and treatment of infant mental health issues, including attachment, in the New Zealand context and it is recommended that these are consulted for more information:

• Ministry of Health (2011). Healthy Beginnings: Developing perinatal and infant mental health services in New Zealand. Wellington: Ministry of Health.
• Merry, S. N., Wouldes, T., Elder, H., Guy, D., Faleafa, M., & Cargo, T. (2009). Kua whakawhenua te purapura ka puawai te taonga: Addressing the social and emotional needs of infants in Counties Manukau District Health Board. Auckland: Counties Manukau District Health Board.
• Merry, S. N. (2009). Interventions for infants and pre-schoolers with mental health problems: A summary of reviews. Auckland: The University of Auckland.

References

• American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V). Arlington, VA: American Psychiatric Association.
• Barlow, J., Bennett, C., Midgley, N., Larkin, S. K., & Wei, Y. (2015). Parent-infant psychotherapy for improving parental and infant mental health. Cochrane Database Syst Rev. CD010534.
• Guy, D. (2011). Infant mental health and child protection. Best Practice Journal 39, 4-9.
• Merry, S. N., Wouldes, T., Elder, H., Guy, D., Faleafa, M., & Cargo, T. (2009). Kua whakawhenua te purapura ka puawai te taonga: Addressing the social and emotional needs of infants in Counties Manukau District Health Board. Auckland: Counties Manukau District Health Board.
• Ministry of Health (2011). Healthy Beginnings: Developing perinatal and infant mental health services in New Zealand. Wellington: Ministry of Health.
• The Matrix (2015). A Guide to Delivering Evidence-based Psychological Therapies in Scotland. Scotland: NES.
• National Institute for Health and Care Excellence (NICE) (2015). Children’s attachment: attachment in children and young people who are adopted from care, in care or at high risk of going into care. NICE Guideline [NG26].
• O’Hara, L., Barlow, J., Livingstone, N., & MacDonald, G. (2016). Video feedback for improving parental sensitivity and attachment. Cochrane Database of Systematic Reviews. Issue 9, Article CD012348.
• Zeanah, C. H., Chester, T., Boris, N. W. & the American Academy of Child and Adolescent Psychiatry (AACAP) Committee on Quality Issues (CQI). Practice Parameter for the Assessment and Treatment of Children and Adolescents With Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. Journal of the American Academy of Child and Adolescent Psychiatry 55(11), 990-1003.