WHAT WE KNOW ABOUT “ATTACHMENT DISORDERS” IN CHILDHOOD

Современата носологија опишува реактивно нарушување во приврзувањето претставено од два различни видa нарушувања: реактивно нарушување на приврзувањето, што се карактеризира со значително воздржано и емоционално повлечено однесување кон возрасните старатели, минимално барање поддршка или минимално реагирање на поддршката во време на вознемиреност, и невоздржано нарушување на социјалното вклучување што е претставено со неселективно социјално однесување кое не е во рамките на конвенционалната култура и ги поминува социјалните граници во присуство на непознати возрасни лица. И двете нарушувања, без оглед на нивните различни фенотипи, се предизвикани од патогената средина на растење, повторливи промени на облиците за приврзување, социјално запоставување и лишување во првите години од животот. Оваа студија ги испитува современите дијагностички критериуми наведени во литературата што ги споредува дијагностичките класификации и се обидува да ја разбере етиологијата на нарушувањето. Постојат нерешени прашања во современата носологија, што значи дека квалитетот на доказите што ги подржуваат дијагностичките критериуми треба да се подобри. Овој труд заклучува дека, и покрај достапните современи дијагностички класификации, Current nosology describes reactive attachment disorder as represented by two distinct disorders: reactive attachment disorder, characterized by markedly inhibited and emotionally withdrawn behavior toward adult caregivers, minimally seeking comfort or minimally responding to comfort in time of distress, and disinhibited social engagement disorder, which is represented by an indiscriminate social behavior, sanctioned from culture and which crosses social boundaries, in the presence of unfamiliar adults. Both disorders, despite their different phenotypes, are caused by a pathogenic caregiving environment, repeated changes of attachment figures, social neglect and deprivation in the first years of life. The article examines recent diagnostic criteria reported in the literature comparing diagnostic classifications and attempting to understand the etiology of the disorder. Unresolved questions exist in current nosology, which means that the quality of the evidence supporting the diagnostic criteria needs to be improved. This review concludes that, despite the currently available diagnostic classifications, future longitudinal studies


Резиме Abstract
Современата From the 1940s to the 1980s, the theoretical framework of attachment theory provided essential empirical findings regarding the social and affective behavior of children (1,2).In particular, attachment theory focuses on the tendency of infants to seek proximity to a specific attachment figure (a secure base) in order to gain protection and comfort.The secure base is a selected attachment figure that is available to respond in a sensible way to the child's needs for comfort and protection and to whom the child returns periodically.From this perspective, the quality of infant attachment is directly related to the quality of care giving that the infant experiences.
Securely attached children feel safe and able to depend on their adult caregivers.These children know that their caregivers will provide comfort and reassurance, so they are comfortable to seek the caregivers in times of need.In contrast, insecurely attached children deal with their caregivers' unavailability or unpredictability. in middle childhood; and superficial and conflicted relationships with peers in adolescence (10).As Zeanah and Gleason (11) have argued, the major limits of the DSM are that it is more focused on defining this disorder as a tendency to violate culturally sanctioned social boundaries in interactions with others rather than considering that the core of the disorder is the reaction of a child who is developmentally able to form an attachment bond but does not because of a harsh and the neglecting care giving environment.In conclusion, one may argue that, in this case, the DSM provides a description of visible behavior without highlighting the adaptive meaning of the disorder (12).Axis II, among other relational disorders.Indeed, the DC:0-3R focuses on the specificity of the parent-child Axis II, providing a description that focuses more on the parents' interaction behaviors than on the child's attachment behaviors.

РНП во други дијагностички класифика
Comparing the DC:0-3R with the DSM-V, the main evidence of the differences between the two can be identified in the different perspectives they assume when describing the disorder.
While the latter focuses entirely on the disease within the individual (i.e., children are disturbed if they are not able to form a selective attachment), the former places the responsibility on the child-caregiver relationship, rather than solely on the child's difficulties in establishing an attachment bond.Thus, the DC:0-3R aims to consider the contributions that each partner in the dyadic interaction makes to the relationship.In this relational perspective, it is possible a child to be involved in a pathological relationship with a caregiver, who is affected by a psychopathological disorder of his own, without the existence of an attachment disorder per se.Therefore, the first step is to identify whether behavioral problems are caused by a RAD or whether they are the result of neglect and maltreatment in the relationship with the caregiver.
For this reason, diagnosis should require a deep and accurate assessment of the child's abilities to interact with different social partners in order to draw a clear picture of the environment where the child lives and of the contributions of the multiple relationships in which it is involved (11,15,16).(17).Interestingly, no relationship between the length of institutionalization and the signs of RAD, either emotionally withdrawn/inhibited or indiscriminately social/disinhibited, were highlighted.These findings are most likely related to the fact that the participating children were still living in the adverse caregiving environment of the orphanages, so it was not possible to assess properly the magnitude of this correlation.Previously, scholars have demonstrated that early deprivation seems to be correlated with the severity of the disorder, but the outcomes are not so evident when the deprivation is limited to the first month of life and if the child has the subsequent opportunity to develop a selective attachment bond.Therefore, this study a) confirmed the distinction between two subtypes of RAD, b) highlighted the possibility of distinguishing children affected by RAD from children with ADHD or other early psychopathologies, and c) showed that RAD predicts social impairment and is stable over time, with a peak from 42 to 52 months of age and stabilization after 30 months for the disinhibited pattern.The findings from this study proved that institutionalized children had more psychiatric disorders compared to the children in foster care, who also showed a reduction in internalizing disorders.However, the finding that many children with disinhibited RAD show an organized attachment pattern at 54 months supports the fact that neither the attachment insecurity nor the disorganization is at the core of RAD, a finding in line with the previous findings of the BEIP (17).Taken together, these longitudinal results should focus clinicians' and policymakers' attention on the existence of a sensitive period for the many children currently living in orphanages world- In previous decades, as well as considering the importance of the care giving environment at a general level, scholars also focused on the type of deprivation that children experienced to distinguish between the possible effects of material deprivation and affective deprivation.

Фокусирање на емпириските податоци
A sample of 52 children aged between six months and two years who experienced institutional upbringing and were later adopted into the United Kingdom was compared to a sample of 111 institutionalized Romanian children (19)(20) aged between six months and two years.The latter group had lived without the opportunity to turn to a preferred caregiver and under conditions of material deprivation; the British children had better medical care but did not have the opportunity to interact with a specific caregiver.The children were observed from four years to six years of age.The results clearly showed the presence of attachment disorders in both groups of children, and the severity and impairments in behavioral and social relationships were directly proportional to the length of the deprivation period.The attachment disorders showed strong stability.
Investigating the behavior of the last aspect over time in post-adoption Romanian children, the same authors (19,20)  Although the prevalence of RAD is unclear, the disorder can be observed in populations of children reared in orphanages or in severely deprived environments (21).
Recently, the DSM-V reported that findings estimate that the prevalence is approximately 0.9% (8,21) in populations of severely neglected children.According to one of the first studies conducted in 1990 in Eastern Europe orphanages, children who did not develop the disorder showed a higher level of disorganization and insecure attachment.In a threeyear follow-up, compared to the control group, affected children continued to show a higher level of indiscriminate sociability.In another study conducted in Budapest, the diagnostic criteria of both the DSM and the ICD-10 were partially disconfirmed because the study proved that symptoms of the inhibited and indiscriminate sub-types of RAD could coexist in the same child (17).
Even if this disorder tends to occur within the context of the orphanages and in the presence of repeated changes of the primary attachment figure, some empirical findings show that not all children who experienced these conditions, or at least not the majority of them, develop RAD (11,15,17).Other empirical studies have been conducted in the United States using the diagnostic criteria for the DSM and the ICD.In one of these studies (17), children from a clinical sample of maltreated children met the criteria for one or more attachment disorders according to the new classification of disrupted attachment disorders and not the diagnostic criteria proposed by the DSM and the ICD.In another study (22), which aimed to assess the prevalence of RAD and whether it could be properly identified in a sample of maltreated versus neglected children, 35% of maltreated children in foster care were diagnosed with RAD (ICD) and 22% with DAD (ICD), while 38% did not satisfy the DSM criteria for RAD.Additionally, in this study, the two sub-types seemed to coexist in the same child.
Although the DSM-IV and V state that RAD cannot be diagnosed unless there has been maltreatment, some scholars have underlined that the two problems -RAD and severe child maltreatment or abuse -shared similar symptoms, but this should not lead us to think that child maltreatment will necessarily lead to the development of RAD (15) It should be clear that despite the many comorbid conditions described below, RAD is not an exhaustive explanation for the behavioral and relational problems of maltreated, abused or adopted children because individual resilience can occur and because, as attachment theory and the diathesis-stress model have also stressed, changes in the developmental pathways can always happen.

Заклучок Conclusions
Земајќи First, the DSM-V and the ICD-10 have an individual-centered perspective rather than taking a relational perspective, as some attachment theorists state (11,12,15,41) and as the DC:0-3R (14) diagnostic classification highlights.Instead, considering RAD and DSED as relational disorders and taking into account both the characteristics of caregivers and the specific quality of the interaction between the child and the parent is useful for understanding the transmission of the intergenerational psychopathology, based on the premise that children's current mental health is influenced across generations by the persistence of maladaptive relationship patterns.Second, another significant criticism of the available diagnostic classifications of RAD is that, although the actual RAD is an attachment disorder, the phenotype is insufficiently supported by research in this field, as it could be important to define the ubiquity of such a relationship.
It could be particularly useful, however, to distinguish whether the attachment is a primary clinical problem that impairs the child's interactions with people other than the attachment figure, or whether the attachment is one of the few developmental domains associated with other psychopathology that has been indicated.Third, the RAD diagnostic criteria proposed in current diagnostic classifications do not seem to grasp the evolution of the disorder and its behavioral phenotype across the lifespan, and we have few empirical findings to address hypotheses about the prognosis of the disorder.Another important missing piece in defining the picture of RAD and its diagnostic and prognostic characteristics across the lifespan is the paucity of longitudinal studies that cover the ages between four and eight years to examine the developmental outcomes or impairments related to RAD beyond the critical peak of 54 months.Differently, for DSED, ERA and Tizard and Hodges (38) studies examined the developmental outcomes over the 54 month threshold.However a related critical point is that if, on one hand, some symptoms overlap with ADHD, conduct disorders, disorganized attachment and autistic spectrum disorders in a way that could lead to misinterpretation by a nonexpert clinician, on the other hand, several empirical findings highlight the presence of a wide range of different representational and observational assessment measures suitable for early infancy and middle childhood (23, 39 -41).Therefore, it seems important to stress the value of early interventions during sensitive periods of a child's development for clinicians and policymakers.As it was previously highlighted, not all institutionalized, maltreated and fostered children develop RAD; inner coping strategies and the later caregiving environment can provide children with the opportunity to revise and repair their distorted internal working models of attachment relationships, allowing a marked change in the developmental trajectory (42).
Authorѕ declare no conflict of interest.