5.2.1 Attachment and Conduct Disorders
Attachment disorders and conduct disorders are common mental health conditions in children and adolescents that can have significant long-term consequences for social and emotional development.
Attachment theory, founded by John Bowlby, emphasizes the importance of early relationships with attentive and consistent caregivers for an infant’s brain development and emotional well-being. These relationships help shape a child’s identity, exploration, and understanding of relationships.
Mary Ainsworth’s Strange Situation experiment studied 12-18 month-old infants’ attachment styles, categorizing them into secure, insecure-avoidant, and insecure ambivalent groups. Later, Mary Main added a fourth category, disorganized. The experiment assessed infants’ responses during separation and reunion with their caregivers.
| Attachment style | Percentage of children | Features in Strange Situation experiment | |
| 1 | Secure | 60-70% | Distress during separation is easily soothed upon reunion; related to attuned parenting. |
| 2 | Insecure-avoidant | 15-20% | Indifference during separation and reunion; linked to unresponsive parenting. |
| 3 | Insecure-ambivalent | 10-15% | Distress during separation resists comfort upon reunion; connected to inconsistent parenting. |
| 4 | Disorganized | 5-10% | Confused behaviour; is often tied to maltreatment or parental trauma. |
It’s crucial to note that attachment classification is based on relationships rather than individual children, as a child may have varying attachment styles with different caregivers.
Attachment Disorders
Attachment disorders are a group of disorders that are characterized by disturbances in the ability to form appropriate attachments with caregivers or peers. There are two main types of attachment disorders: reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED). The prevalence of attachment disorders is estimated to be between 1% and 10% in the general population, and the conditions are more commonly diagnosed in children who have experienced early childhood trauma, such as neglect, abuse, or multiple caregiver transitions.
| Attachment Disorders | Information |
| Prevalence | 1%-10% of the general population |
| Aetiology | Early childhood trauma, such as neglect, abuse, or multiple caregiver transitions |
| Presentation | Difficulty forming appropriate attachments with caregivers or peers may exhibit symptoms such as withdrawal, lack of responsiveness to others, indiscriminate friendliness, and aggressive behaviour |
| Treatments | Psychotherapy, attachment-based interventions, improving the quality of relationships with caregivers and others in the child’s environment |
| Outcomes | Improved social and emotional functioning with early intervention, early intervention is critical for improving outcomes for children with attachment disorders |
Children with attachment disorders may exhibit a range of symptoms, including withdrawal, lack of responsiveness to others, indiscriminate friendliness, and aggressive behaviour. These symptoms can persist into adulthood and can result in difficulties in forming and maintaining relationships. Treatments for attachment disorders typically involve psychotherapy and attachment-based interventions that focus on improving the quality of relationships with caregivers and others in the child’s environment. Early intervention is critical for improving outcomes for children with attachment disorders.
Reactive attachment disorder:
Reactive attachment disorder (RAD) is an often overlooked and misdiagnosed condition that involves considerable psychiatric comorbidity. It is characterized by challenges in social interaction and functioning, frequently linked to maltreatment. The ICD-10 identifies two RAD forms: the inhibited type, which is emotionally withdrawn and hypervigilant, and the disinhibited type, which is indiscriminately friendly. Some children may exhibit both types. DSM-5 distinguishes between RAD (inhibited form) and disinhibited social engagement disorder, both classified under the new chapter “Trauma- and stressor-related disorders,” while ICD-11 categorizes them under “Disorders specifically associated with stress.”
As awareness of attachment difficulties increases, so does the availability of evidence-based attachment interventions. Examples of these interventions include video interaction guidance, attachment and bio-behavioural catch-up, circle of security, parent-child/infant psychotherapy, and therapeutic play.
Conduct Disorders
Conduct disorders are a group of disorders characterized by persistent patterns of aggressive and antisocial behaviour that violate the rights of others and societal norms. The prevalence of conduct disorders is estimated to be between 5% and 7% in the general population, and the conditions are more commonly diagnosed in boys than girls. The aetiology of conduct disorders is multifactorial and includes both genetic and environmental factors, such as exposure to violence, parental conflict, and poor parenting practices.
| Conduct Disorders | Information |
| Prevalence | More common in boys and urban populations. Prevalence 5–7% in the UK. |
| Aetiology | Multifactorial, including genetic and environmental factors such as exposure to violence, parental conflict, and poor parenting practices |
| Presentation | Persistent patterns of aggressive and antisocial behaviour that violate the rights of others and societal norms, may exhibit behaviours such as physical aggression, destruction of property, theft, and violation of rules |
| Treatments | Psychotherapy, behavioural interventions, and medication depending on the severity of symptoms and the specific needs of the child |
| Outcomes | Improved social and emotional functioning with early intervention, early intervention is critical for improving outcomes for children with conduct disorders |
Depending on the age or stage of a child, various problematic behaviours can emerge, such as aggression, cruelty, property destruction, bullying, deceit, theft, fire setting, truancy, defiance, forced sexual activity, or weapon use. These behaviours can significantly affect family dynamics, peer relationships, and educational performance. In ICD-10, a diagnosis requires three or more severe features, with one persisting for at least six months. Subtypes include confined to family context, unsocialized, and socialized. DSM-5 necessitates three characteristic features over 12 months, with one lasting at least six months, and includes the specifier “limited pro-social emotions,” referring to a callous and unemotional interpersonal style across various settings and relationships, often associated with severe conduct disorder (CD).
Management of conduct disorders: is case-specific and requires multi-agency collaboration. Possible components:
- Parent management training (PMT), such as group-based parent training/education programs for children aged 12 or younger
- Functional family therapy
- Multisystem therapy, involving family, school, and community
- Child interventions, including social skills, problem solving, anger management, and confidence building
- Treatment of comorbidities, such as ADHD
- Educational support through school liaison
- Addressing child protection concerns
- Medication is not routinely prescribed, but risperidone may be considered for short-term management of severe aggressive behaviour if psychosocial interventions fail; discontinue if no improvement in 6 weeks
Oppositional defiant disorder:
Oppositional defiant disorder (ODD) is a persistent pattern of negative, hostile, and defiant behaviour in children under 10 years old, without significant violations of societal norms or others’ rights. DSM-5 identifies three types: angry/irritable mood, argumentative/defiant behaviour, and vindictiveness. There are no exclusion criteria for conduct disorder (CD); the behaviour must occur most days for 6 months (if under 5 years) or once a week for at least 6 months (if over 5 years). Mild, moderate, and severe forms are recognized. The behaviour may be limited to specific situations (e.g., home) and more evident with familiar adults or peers.
ODD is more prevalent in boys and during childhood rather than adolescence, affecting 2-5% of the population. Around 25% do not exhibit symptoms later in life, but many progress to CD and/or substance abuse. The management of ODD follows the same principles as for CD.
In summary, attachment disorders and conduct disorders are significant mental health conditions that can have long-term consequences for social and emotional development. Early intervention, including psychotherapy, attachment-based interventions, and behavioural interventions, is critical for improving outcomes for children with these conditions.
An Understanding of How Attachment and Conduct Disorders Relate to Behaviours (e.g. Self-harm, Refusal to Attend School etc.) and Contexts (e.g. Pre-school Behaviours)
Attachment and conduct disorders play a significant role in shaping a child’s behavior and response to various contexts, such as self-harm, school refusal, and preschool behaviors. These disorders stem from early relationships and experiences, impacting the child’s ability to interact with others and function in different settings.
Attachment disorders, such as reactive attachment disorder (RAD) and disinhibited social engagement disorder, arise from inadequate or disrupted caregiving during a child’s early years. When a child lacks a secure attachment with caregivers, it can result in difficulties forming healthy relationships, regulating emotions, and understanding the emotions of others. Insecure attachment can manifest in various behaviors, such as self-harm, as a way for the child to cope with overwhelming emotions or as an attempt to gain control or express feelings they may not understand. Additionally, children with attachment disorders may struggle with school refusal, as they might find it difficult to trust and engage with unfamiliar adults, peers, and environments.
Conduct disorders, on the other hand, are characterized by a persistent pattern of aggressive, defiant, or disruptive behavior that violates societal norms and others’ rights. These behaviors can have a significant impact on a child’s relationships, academic performance, and overall well-being. For example, children with oppositional defiant disorder (ODD) may exhibit anger, irritability, and defiance, which can be particularly evident in preschool settings. They might refuse to follow instructions, argue with teachers, or engage in negative interactions with peers. Similarly, conduct disorder (CD) may involve more severe behaviors, such as aggression, destruction of property, or deceit, further impacting a child’s ability to function in social and academic settings, including school refusal.
In conclusion, attachment and conduct disorders have a profound influence on a child’s behavior and their ability to navigate different contexts. Early identification and intervention are crucial to address these challenges and promote healthier emotional development and functioning. Through appropriate therapy, family support, and educational accommodations, children struggling with attachment and conduct disorders can build coping skills and resilience, enabling them to better adapt to various situations and relationships.
References:
- Minnis, H., Marwick, H., Arthur, J., & McLaughlin, A. (2019). Attachment and conduct disorders. In R. E. Tremblay, M. Boivin, & R. D. Peters (Eds.), Encyclopedia on Early Childhood Development [online]. Centre of Excellence for Early Childhood Development. Retrieved from https://www.child-encyclopedia.com/attachment/according-experts/attachment-and-conduct-disorders
- Groh, A. M., Roisman, G. I., van Ijzendoorn, M. H., Bakermans-Kranenburg, M. J., & Fearon, R. P. (2012). The significance of attachment security for children’s social competence with peers: A meta-analytic study. Attachment & Human Development, 14(3), 185-205. doi: 10.1080/14616734.2012.672262
- Hawes, D. J., & Dadds, M. R. (2006). Stability and malleability of callous-unemotional traits during treatment for childhood conduct problems. Journal of Clinical Child and Adolescent Psychology, 35(2), 347-355. doi: 10.1207/s15374424jccp3502_13