Elsevier

Child Abuse & Neglect

Volume 65, March 2017, Pages 77-87
Child Abuse & Neglect

A study of Attachment Disorders in young offenders attending specialist services

https://doi.org/10.1016/j.chiabu.2017.01.009Get rights and content

Abstract

Attachment disorders, specifically Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) are disorders associated with neglect and abuse in which people have significant difficulties relating to others. This study aims to explore Attachment Disorder symptoms and diagnoses in young offenders and factors that may be associated with them such as mental health problems. A cross-sectional design was used with 29 young people who were known to Intensive Services, aged 12–17 (M = 16.2, SD = 1.3), 29 carers and 20 teachers. They completed measures investigating symptoms of Attachment Disorders and psychopathology. Eighty-six percent of the young people had experienced some form of maltreatment and the rates of an actual or borderline Attachment Disorder was 52%. A positive correlation between Attachment Disorder symptoms and other mental health problems (as rated by carer-report Strengths and Difficulties Questionnaire Total Difficulties Score), accounting for 36% of the variance was found, with a large effect size (rs = 0.60). Attachment Disorder symptoms were associated with hyperactivity and peer relationship problems.

Introduction

RAD and DSED are characterized by ‘markedly disturbed and developmentally inappropriate social relatedness in most contexts; beginning before age five’ (Diagnostic and statistical manual of mental disorders fifth edition, DSM 5, APA, 2013). The behaviors are thought to arise from persistent caregiver neglect, physical or emotional abuse or a lack of continuity in caregivers that prevents the formation of stable attachments, for example frequent changes in foster care. Throughout the paper the term “attachment disorder” will be used to refer to both RAD and DSED collectively, unless otherwise specified.

The origins of attachment theory stemmed from Bowlby’s (1944) work with young offenders. Fourteen out of 44 teenage ‘thieves’ were identified as showing a lack of affection and little guilt towards their victims. More than 80% of these “affectionless” children (n = 12), had experienced maternal separation of over six months in their first two years. Of the 44 non offending controls only two (five percent) had experienced maternal separation. Bowlby concluded that maternal separation could have an adverse effect on development in terms of emotions, behaviour, social relationships and intellect.

Follan and Minnis (2010) re-interpreted Bowlby’s findings by suggesting that the “affectionless” group could be classified as displaying symptoms of an Attachment Disorder: they struggled to establish relationships and showed behaviors that were socially inappropriate. They noticed that many of the “affectionless” children were neglected during separation and suggested that these problems may have arisen from neglect by the parent rather than the stress of the separation. However, both nature and nurture may impact on the development of such problems (Minnis et al., 2007).

Attachment disorder is a relatively new diagnosis; RAD was first included in the DSM in 1980 (Potter et al., 2009). In the DSM- IV two subsets of RAD are identified; an inhibited (IRAD) and a disinhibited (DRAD) type. The inhibited child does not initiate suitable social interactions and if approached responds inappropriately. In the disinhibited type the child exhibits an active involvement in close social interactions with numerous people, failing to discriminate between suitable attachment figures. Although two distinct subtypes are outlined, research shows that they can occur together (Smyke, Dumitrescu, & Zeanah, 2002). Recently the DSM 5 (APA, 2013) divided the two types into distinct disorders; the inhibited form continues to be known as RAD whereas the disinhibited form was redefined as Disinhibited Social Engagement Disorder (DSED). Research by Lehmann, Breivik, Heiervang, Havik and Havik (2016) found support for the DSM-5 conceptualisation of the disorders as distinct dimensions of child psychopathology. They noted that assessment of both yields information beyond other mental health problems. The criteria within the two disorders remains largely the same as in the DSM-IV and they are discussed in greater detail in the following section. They are also available to view in Appendix A. As mentioned above, for ease of reference the term Attachment Disorders will be used to refer to both RAD and DSED within this paper. In any of the classification systems, the diagnosis can only be made if there has been a history of maltreatment (abuse or neglect).

Skovgaard (2010) estimated the rates of Attachment disorders in 211 Danish one and a half year olds to be 0.9%. Minnis et al. (2013) found the prevalence of Attachment disorders in 1646 six to eight-year-old children in a deprived area of the UK to be 1.4%. More specifically, Kay, Green and Sharma (2016) found the prevalence of Disinhibited Attachment Disorder which is now known as Disinhibited Social Engagement Disorder (DSED) in 60 adopted children (aged 6–11) from UK out of home care to be 49%. Seven-two percent of this sample had suffered maltreatment. They noted the prevalence to be 4% in 26 clinic-referred children with externalizing disorder but no history of maltreatment or disrupted care; and 6% in 55 matched low-risk comparison controls.

Symptoms of RAD include failure to seek comfort, avoiding eye contact, frozen watchfulness, hypervigilance and unpredictable reunion responses. Symptoms of DSED include seeking comfort from strangers, indiscriminate friendliness, demanding and attention seeking behaviour, minimal checking in unfamiliar settings, cuddliness with strangers, asking personal questions of strangers, invading social boundaries (Minnis et al., 2013). They are also shown in Table 1 below.

Previous research has indicated Attachment Disorders may be more likely in specific environments. Many studies of Attachment Disorders have been conducted with ex-institutionalized children. Tizard and Rees (1975) investigated institutionalized rearing, behavioural problems and disrupted relationships for 26 children aged four to 16 compared with an adopted and a non-institutionalized group. They found that the institutionalized children had slightly higher levels of behaviour problems, clinginess and struggled to form an attachment relationship. In a study of 165 Romanian and 52 UK adoptees (age six), symptoms of severe attachment disorder were noted for six percent of those that had experienced less than six months’ parental deprivation and 31% of those that had experienced over two years’ parental deprivation (O’Connor & Rutter, 2000). Failure to discriminate appropriately between adults, showing a lack of wariness with strangers and a lack of physical boundaries was found amongst institutionalized Romanian children (Zeanah, Smyke, & Dumitrescu, 2002).

Two studies explored Attachment Disorders in children in care (Millward, Kennedy, Towlson, & Minnis, 2006; Minnis, Everett, Polosi Dunn, & Knapp, 2006). Higher scores on measures of Attachment Disorders were found compared to children not in care. Minnis, Everett et al. (2006) also found higher symptom scores for Attachment Disorders in children in care compared to the school population.

A potential association between maltreatment, Attachment disorders, mental health and offending becomes clear from the literature, although this has not previously been empirically explored: for example, there is no previous research exploring Attachment Disorders among young offenders. Millward et al. (2006) found a high correlation (r = 0.84) between Attachment Disorders and other mental health problems. Kocovska et al’s (2012) study of 34 adopted children with indiscriminate friendliness and early maltreatment found that most displayed symptoms of Attachment disorders, they also had other disorders such as attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), anxiety disorders and conduct disorder. This cluster of disorders suggests that in such cases what emerges is a complexity of needs as proposed by Gilberg (2010). In his work with children under six he noted that some could be classified as showing “early symptomatic syndromes eliciting neurodevelopmental clinical examination (ESSENCE)”. Gilberg (2010) suggested that a child with an Attachment Disorder may also display the symptoms of ADHD and depression, for example, and importantly these should not be looked upon in isolation.

Minnis (2013) acknowledges this concept of overlapping neurodevelopmental difficulties when introducing the idea of maltreatment associated psychiatric problems (MAPP), reflecting studies which demonstrate that indiscriminately friendly children may also have other disorders such as ADHD and Conduct Disorder. An association for boys between maltreatment, harsh parenting and conduct disorder was noted by Rutter, Giller and Hagell (1998). Here it was suggested that many boys who experienced harsh, physically or verbally abusive punitive parenting could develop conduct disorder and violent criminal behaviour in later years.

Other studies have also identified a strong association between maltreatment and later criminal behaviour (Smith, Thornberry, & Ireland, 2004; Trentacosta and Shaw, 2008, Widom and Maxfield, 2001). Ryan, Williams and Courtney (2013) confirmed this association and reported the level of maltreatment to be 30% amongst a sample of young offenders. Further studies expanded this association relative to the specific type of offence (Lansford et al., 2007; Topitzes, Mersky, & Reynolds, 2012). In the first case an association between maltreatment and adolescent violent offences was noted and in the second a link between maltreatment and both violent and nonviolent offences in adolescence was found. This research leads on to an emerging profile of young offenders. A survey of 300 offenders, aged 13–18, found that a third had experienced foster care, 36% had educational needs, 48% had difficulties with social relationships and 31% had mental health problems (Chitsabesan et al., 2006).

Given the link between maltreatment and young offending and the fact that Attachment Disorders are the only diagnoses specifically related to a history of maltreatment, the hypothesis was that a group of young offenders might have a higher rates of Attachment Disorders. This study will, for the first time, examine the rates of Attachment Disorders within this population and consider factors that may be associated with higher levels of Attachment Disorder symptoms within this group. It is recognised that the term “young offender” is a simplistic definition however, after much discussion, a commonly used clinical definition was employed, i.e. young people who have been involved in criminal activity and are known to youth offending services.

Hypotheses and Research Questions

The hypothesis is that there will be high rates of Attachment Disorders among young offenders and that Attachment Disorder symptoms will be associated with other mental health problems. Research Questions are:

  • 1.

    What is the rate of Attachment Disorder diagnoses among young offenders?

  • 2.

    Is there a correlation between Attachment Disorder symptoms and other mental health problems?

Section snippets

Design

A cross-sectional study, which involves the analysis of data collected from a population at one specific point in time, was undertaken to examine the rate of Attachment Disorders among young offenders. A correlational design was used to address hypotheses including the association between Attachment Disorders and other mental health problems which will form the basis of the main analysis. The aim of the study design was to identify and target the entire eligible population.

Participants

The study aimed to

Results

Preliminary analysis indicated that the data was normally distributed for the carer and teacher SDQ; however, it was positively skewed for the carer and teacher RPQ and therefore violated the assumptions required for parametric tests. As such, in all analysis non-parametric tests were selected. The majority of the statistics are descriptive as there is no way of controlling for error rate and power.

Discussion

A high rate of Attachment Disorder or borderline Attachment Disorder (52%) was found in this population who has a high incidence of offending behaviour. This greatly exceeds what previous research estimated the rates to be in one and a half year olds (0.9%; Skovgaard, 2010) and in a materially deprived school aged population (1.4%; Minnis et al., 2013). Specifically considering DSED, the rate of 21% in this study is less than what was found by Kay, Green and Sharma (42%, 2016) in a sample of UK

Limitations

The cross-sectional nature of the study may be seen as a limitation as it does not allow for any assertions about the direction of causality for associations between Attachment Disorders and other factors. As some of the target population was lost, an element of bias may have been introduced. For example, the young people who workers thought were too unwell or chaotic to be involved in the study may well have been more likely to have an Attachment Disorder, so the finding on rates may be an

Conclusion

Overall there was high rates of Attachment Disorders found within a population of high risk young offenders attending specialist services. Attachment Disorders were also found to be strongly associated with other mental health problems. Further research is warranted to examine the generalizability to other groups of young offenders. It might also be interesting to explore associations between an Attachment Disorder and other variables such as the type, prevalence and severity of offending

Acknowledgements

This research was partly funded by NHS Education Scotland. We would like to thank Dr Aileen Blower for comments helpful to the design of this study.

References (36)

  • M. Follan et al.

    Forty-four juvenile thieves revisited: from bowlby to reactive attachment disorder

    Child: Care, Health & Development

    (2010)
  • C. Gilberg

    The ESSENCE in child psychiatry: Early symptomatic syndromes eliciting neurodevelopmental clinical examinations

    Research in Developmental Disabilities

    (2010)
  • R. Goodman et al.

    Comparing the Strengths and Difficulties questionnaire and the Child Behaviour Checklist: Is small beautiful?

    Journal of Abnormal Child Psychology

    (1999)
  • R. Goodman et al.

    The Strengths and Difficulties Questionnaire: A pilot study on the validity of the self-report version

    European Child & Adolescent Psychiatry

    (1998)
  • R. Goodman et al.

    Using the Strengths and Difficulties Questionnaire (SDQ) to screen for child psychiatric disorders in a community sample

    International Review of Psychiatry

    (2003)
  • C. Kay et al.

    Disinhibited attachment disorder in UK adopted children during middle childhood: Prevalence, validity and possible developmental origin

    Journal of Abnormal Child Psychology

    (2016)
  • D.N. Klein et al.

    Test-retest reliability of team consensus best-estimate diagnoses of axis I and II disorders in a family study

    American Journal of Psychiatry

    (1994)
  • J.E. Lansford et al.

    Early physical abuse and later violent delinquency: A prospective longitudinal study

    Child Maltreatment

    (2007)
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