Attachment disorder

Attachment disorder is based on the psychological theories that

1. normal mother-child attachment forms in the first two years of life; and
2. if a normal attachment is not formed during the first two to three years, attachment can be induced later.

This theory is used, for example, to explain the behavioral difficulties of adopted children.

Attachment theory was developed by John Bowlby in the 1940s and 1950s and is the leading theory used in the fields of Infant Mental Health, Child Development, and related fields. It is a well researched theory that describes how the attachment relationship develops, why it is crucial to later healthy development, and what are the effects of early maltreatment or other disruptions in this process.

Attachment therapy is a broad term that covers a multitude of interventions. It is a term that has lost utility since it is used to cover so many interventions. Reputable approaches to treatment based on theory and research evidence include Theraplay, Dyadic Developmental Psychotherapy. However, the use of coercive interventions has no basis in theory and is not supported by any reputable professional organization, including The Association for The Treatment and Training in the Attachment of Children, APSAC, APA, NASW, or AMA. Neither Theraplay nor Dyadic Developmental Psychotherapy use coercive interventions and are in full compliance with the above referenced standards.

Signs of attachment problems

Attachment is fundamental to healthy development, normal personality, and the capacity to form healthy and authentic emotional relationships. How can one determine whether a child has attachment issues that require attention? What is normal behavior, and what are the signs of attachment issues? When adopting an infant, will attachment problems develop? These and other related questions are often at the forefront of adoptive parents’ minds.

Attachment is the base of emotional health, social relationships, and one's worldview. The ability to trust and form reciprocal relationships affects the emotional health, security, and safety of the child, as well as the child's development and future inter-personal relationships. The ability to regulate emotions, have a conscience, and experience empathy all require secure attachment. Healthy brain development is built on a secure attachment relationship.

Children who are adopted after the age of six months are at risk for attachment problems. Normal attachment develops during the child's first two to three years of life. Problems with the mother-child relationship during that time, orphanage experience, or breaks in the consistent caregiver-child relationship interfere with the normal development of a healthy and secure attachment. There are wide ranges of attachment difficulties that result in varying degrees of emotional disturbance in the child. One thing is certain; if an infant's needs are not met consistently, in a loving, nurturing way, attachment will not occur normally and this underlying problem will manifest itself in a variety of symptoms.

When the attachment-cycle is undermined and the child’s needs are not met, and normal socializing shame is not resolved, mistrust begins to define the perspective of the child and attachment problems result. The cycle can become undermined or broken for many reasons:

• Multiple disruptions in care giving
• Post-partum depression causing an emotionally unavailable mother
• Hospitalization of the child causing separation from the parent and/or unrelieved pain. For example, stays in a NICU or repeated hospitalizations during infancy.
• Parents who have experienced their own relational trauma, leading to neglect, abuse (physical/sexual/verbal), or inappropriate parental responses not leading to a secure/predictable relationship
• Genetic factors
• Pervasive developmental disorders
• Caregivers whose own needs are not met, leading to overload and lack of awareness of the infants needs

The child may develop basic mistrust (Erikson), impeding effective attachment behavior. The developmental stages following these first three years continue to be distorted and/or retarded, and common symptoms emerge. It is very important to realize that when one is trying to parent a child with attachment difficulties one must focus on the cause of the behaviors and not on the symptoms or surface behaviors. Furthermore, the following behaviors can be indicators of a variety of problems. A child exhibiting several of these behaviors should receive a comprehensive evaluation by a licensed mental health professional to determine the cause of these symptoms. Many of these symptoms can be seen in children who have experienced complex trauma, attachment difficulties and other issues.

• Superficially engaging and charming behavior, phoniness
• Avoidance of eye contact
• Indiscriminate affection with strangers
• Lack of affection in a reciprocal manner
• Destructiveness to self, others, and material things
• Cruelty to animals
• Crazy lying (lying in the face of the obvious)
• Poor impulse control
• Learning lags
• Lack of cause/effect thinking
• Lack of conscience
• Abnormal eating patterns
• Poor peer relationships
• Preoccupation with fire and/or gore
• Persistent nonsense questions and chatter indicating a need to control
• Inappropriate clinginess and demandingness
• Inappropriate sexuality

It is important to get a thorough evaluation as one symptom can have many causes. There are a variety of evidence-based methods to assess a child's pattern and style of attachment such as Strange Situation Protocol developed by Mary Ainsworth and a variety of narrative methods. Among adults, the Adult Attachment Interview is a frequently used research method.

Causes

What are the underlying causes of these various symptoms? The cause is some break in the early attachment relationship that results in difficulties trusting others. The child experiences a fear of close authentic emotional relationships because early maltreatment or other difficulties has "taught" the child that adults are not trust worthy and that the child is unloved and unlovable. Fundamentally, the cause is a developmental delay. The child may be chronologically six, ten, or fifteen, but developmentally these children are much younger. It is often useful to consider, "at what age would this behavior be normal?" Frequently you will find that the child’s behavior would be normal for a toddler.

Chronic Maltreatment (abuse or neglect) or other disruptions to the normal attachment relationship cause:

• Fear of intimacy
• Overwhelming feelings of shame (not guilt... shame causes a person to want to hide and not be seen. So, for example, some children’s chronic lying can be seen as a manifestation of this pervasive sense of shame. A lie is then another way to hide.)
• Chronic feelings of being unloved
• Chronic feelings of being unlovable
• A distorted view of self, other, and relationships based on past maltreatment
• Lack of trust
• Feeling that nothing the child does can make a difference; hence, low motivation and poor academic performance
• A core sense of being Bad
• Difficulty asking for help
• Difficulty relying on others in a cooperative and collaborative manner

How can the difference between a child who "looks" attached and a child who really is making a healthy, secure attachment be distinguished? This question becomes important for adoptive families because some adopted children will form an almost immediate dependency bond to their adoptive parents. To mistake this as secure and healthy attachment can lead to many problems down the road. Just because a child calls someone Mom or "Dad," snuggles, cuddles, and says, I love you," does not mean that the child is attached or even attaching. Saying, "I love you", and knowing what that really feels like, can be two different things. Attachment is a process. It takes time. The key to its formation is trust, and trust becomes secure only after repeated testing. Generally attachment develops during the first two to three years of life. The child learns that he or she is loved and can love in return. The parents give love and learn that the child loves them. The child learns to trust that his needs will be met in a consistent and nurturing manner. The child learns that he/she "belongs" to his family and they to him/her. It is through these elements that a child learns how to love, and how to accept love.

Older adopted children need time to make adjustments to their new surroundings. They need to become familiar with their caregivers, friends, relatives, neighbors, teachers, and others with whom they will have repeated contact. They need to learn the ins and outs of new household routines and adapt to living in a new physical environment. Some children have cultural or language hurdles to overcome. Until most of these tasks have been accomplished, they may not be able to relax enough to allow the work of attachment to begin. In the meantime, behavioral problems related to insecurity and lack of attachment, as well as to other events in the child's past, may start to surface. Some start to get labels, like "manipulative," "superficial," or "sneaky". On the inside, this child is filled with anxiety, fear, grief, loss, and often a profound sense of being bad, defective, and unlovable. The child has not developed the self-esteem that comes with feeling like a valued, contributing member of a family. The child cares little about pleasing others since his relationships with them are quite superficial.

When are problems first apparent? Children who have experienced physical or sexual abuse, physical or psychological neglect, or orphanage life will begin to show difficulties as young as six-months of age. For example, the signs of difficulties for an infant include the following:

• Weak crying response or rageful and/or constant whining; inability to be comforted
• Tactile defensiveness
• Poor clinging and extreme resistance to cuddling: seems stiff as a board
• Poor sucking response
• Poor eye contact, lack of tracking
• No reciprocal smile response
• Indifference to others
• Failure to respond with recognition to parents
• Delayed physical motor skill development milestones (creeping, crawling, sitting, etc.)
• Flaccid

Subtle signs of attachment problems

An example: Gail tells her seven-year-old daughter, Sally, to pick up the napkin Sally has dropped. As Sally crosses her arms a sad and angry pout darkens her face. Gail says, "Sally, I told you to pick up the napkin and throw it away." Sally stomps over to the napkin, picks it up, and throws it away. Crying and whining, Sally stands with her back to Gail.

Sally, angry and unhappy, is exhibiting one of the subtle signs of attachment sensitivity that nearly all children adopted after six-months demonstrate. Attachment is an interpersonal, interactive process that results in a child feeling safe, secure, and able to develop healthy, emotionally meaningful relationships. The process requires a sensitive, responsive parent who is capable of emotional engagement and participation in contingent collaborative communication (responsive communication) at nonverbal and verbal levels. The parent’s ability to respond to the child’s emotional state is what will prevent attachment sensitivities from becoming problems of a more severe nature.

What are the subtle signs of attachment issues?

1. Sensitivity to rejection and to disruptions in the normally attuned connection between mother and child
2. Avoiding comfort when the child’s feelings are hurt, although the child will turn to the parent for comfort when physically hurt
3. Difficulty discussing angry feelings or hurt feelings
4. Over valuing looks, appearances, and clothes
5. Sleep disturbances, not wanting to sleep alone
6. Precocious independence - a level of independence that is more frequently seen in slightly older children
7. Reticence and anxiety about changes
8. Picking at scabs and sores
9. Secretiveness
10. Difficulty tolerating correction or criticism

Internationally adopted children experience at least two significant changes during the first few months of life that can have a profound impact on later development and security. Birth mother to orphanage or foster care and then orphanage to adoptive home are two transitions. It is known from extensive research that prenatal, post-natal, and subsequent experiences create lasting impressions on a child. During the first few minutes, days, and weeks of life, the infant clearly recognizes the birth mother’s voice, smell, and taste. Changes in caregivers are disruptive. The new caregivers look different, smell different, sound different, taste different. In the orphanage there are often many care givers but no one special caregiver. Adoption brings with it a whole new, strange, and initially frightening world. These moves and disruptions have profound effects on a child's emotional, interpersonal, cognitive, and behavioral development. The longer a child is in alternate care, the more these subtle signs become pervasive.

There are effective ways for a parent to help his or her child. Parents and the right parenting are vital to preventing subtle signs from becoming anything more than sensitivities. Parenting consistently with clear and firm limits is essential. Discipline should be enforced with an attitude of sensitive and responsive empathy, acceptance, curiosity, love, and playfulness. This provides the most healing and protective way to correct a child.

The example continued: As Sally walks away to pout, Gail comes up behind her, scoops her up, and begins rocking her gently while crooning in Sally's ear. Gail sings songs and tells Sally she loves her and understands Sally is angry at being told what to do. Gail expresses sadness that Sally is so unhappy. At first Sally resists a bit, but she soon calms down and listens as Gail tells her how much she loves Sally. Sally is sensitive to feelings of rejection and abandonment that are evoked by her mother’s displeasure, so Gail brings Sally closer to reassure Sally nonverbally. It is by experience that the subtle signs are addressed and managed. Nonverbal experience is much more powerful than verbal experience since most of the subtle signs have their origin in nonverbal experience and nonverbal memory. Finally, Sally eventually did what she was asked to do and praised for doing what was expected. In this manner, Sally experiences acceptance of who she is while becoming socialized.

These sensitivities do not constitute a mental illness or Reactive Attachment Disorder. They are subtle signs of attachment sensitivities. So, what can be done?

First, the most important thing one can do is maintain an attuned emotionally close and positive relationship with the child even when the child is being nasty or pushing buttons... it is at those times that the child most needs to feel loved and loveable, even if the behavior is unacceptable. First, a connection with the child must be created, and then the child must be disciplined.

Second, bringing the child in close is better than allowing the child to be alone or isolate him or her self.

Third, talking for the child is required - putting words to what the child is feeling. This allows the child to feel understood by the parent, maintains a connection, and helps assuage the fear of rejection and abandonment. It also helps the child become self-aware, models verbal behavior, and facilitates a sense of emotional attunement between parent and child.

Fourth, food shouldn't be made a battle. A child who steals food or hoards food usually has sound emotional reasons for this. Providing the child with food so that the child experiences the parent as provider is often the solution. Putting a bowl of fruit (which is kept filled) in the child’s room, or providing the child with a fanny pack and keeping it stocked with snacks might be useful, ending hoarding and stealing of food.

Fifth, for the child who is overly independent, doing for the child and not encouraging precocious independence is helpful. So, making a game of brushing the six-year old’s teeth, dressing the seven-year-old, or playing at feeding a nine-year-old, are all ways to demonstrate that the parent will care for the child. Keeping it playful and light allows the child to experience what the child needs and helps eliminate hurtful battles.

Sixth, Time-In rather than Time-out. When the child is becoming dysregulated, they need the parents to regulate their emotions. They do that by reflecting the child’s emotions back to the child; putting into words what they think the child may be feeling. In this manner they demonstrate that they can accept what the child is feeling, that feelings can be tolerated and discussed; even if the behavior will be disciplined at a later time. Remember; first connect with the child, then discipline.

Seventh, reducing shame. Shaming parenting methods and interactions that might be harsh or punitive should be avoided. If the child is already experiencing too much shame, increasing that will only be destructive to the child and the relationship with the parents. The parents set the emotional tone for the relationship, so keeping things positive is important. So, as an example, a seven year old has just screamed at the parent, "I hate you," because he or she said it's time to go to bed. //////// I’d start by reflecting the child’s feelings back to the child as you walk the child to bed with your arm around the child, "Boy, you are really mad that you have to go to bed now." "You sure don’t want to go to bed now. I wonder what you think is making me send you to bed now? … Maybe you just think I’m being mean?" Through this sort of dialogue you are demonstrating your acceptance of the child's feelings and your interest in the child's thinking and feeling…you are showing the child how to reflect on one’s inner life. The model suggested for parents is to create a healing PLACE (being Playful, Loving, Accepting, Curious, and Empathic). ////////

In conclusion, these subtle signs are important reminders that the children have ongoing sensitivities that must be addressed by the parents. Responsive and sensitive communication is essential. Attachment is a function of reciprocal communication; attachment does not reside in the child alone. It is very important for the parent to manage and facilitate this attuned connection within a framework of clear limits and boundaries, natural consequences, and firm loving discipline.

Treatment

There are a variety of evidence based and effective prevention programs and treatment approaches for attachment disorder. Attachment theory is the basis for these and other treatment approaches. Several evidence-based and effective treatments are based on attachment theory including Theraplay and Dyadic Developmental Psychotherapy. Nearly all mainstream programs for the prevention and treatment of disorders of attachment attachment disorder use attachment theory. For example, the Circle of Security Program, (Dr. Robert Marvin, University of VA) is one such early intervention program with demonstrated effectiveness. Dr. Marvin and Dr. Siegel (University of California) both also endorse Dyadic Developmental Psychotherapy Other promising treatment methods include the Circle of Security Program of Dr. Robert Marvin at the University of Virginia, Developmental, Individual-difference, Relationship-based therapy (DIR or Floor Time) by Stanley Greenspan.

Dyadic developmental psychotherapy is an evidence-based ("Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy" Child and Adolescent Social Work Journal. 12(6), December 2005) treatment approach for the treatment of attachment disorder and reactive attachment disorder. Children who have experienced pervasive and extensive trauma, neglect, loss, and/or other dysregulating experiences can benefit from this treatment. Dyadic Developmental Psychotherapy is based on principles derived from Attachment theory and Research; see the work of Bowlby. The treatment meets the standards of the American Professional Society on Child Abuse, The American Academy of Child Psychiatry, American Psychological Association, American Psychiatric Association, National Association of Social Workers, and various other groups' standards for the evaluation and treatment of children and adolescents. This is a non-coercive treatment.

Attachment therapy is a term with little agreed upon meaning. Components of "attachment therapy" have been disapproved by a task force of the American Professional Society on Abuse of children. (Chaffin et al.,2006, PMID 16382093). However, the Circle of Security Program, Dyadic developmental psychotherapy, Developmental, Individual-difference, Relationship-based therapy (DIR or Floor Time) by Stanley Greenspan, and Theraplay are not considered controversal and meet the standards of the American Professional Society on Abuse of Children, as well as various other professional association standards for practice.

See also

• Attachment theory
• Attachment Therapy
• Bowlby
• Dyadic Developmental Psychotherapy
• Reactive attachment disorder
• Stanley Greenspan
• Theraplay

Additional Reading and References

• Creating Capacity for Attachment, edited by Arthur Becker-Weidman, Ph.D., & Deborah Shell, MA, Wood 'N' Barnes, OK (2005).
• Handbook of Infant Mental Health, edited by Charles Zeanah, MD, Guilford Press, 1993, NY.
• Handbook of Attachment: Theory, Research, and Clinical Applications, edited by Jude Cassidy, Ph.D., & Phillip Shaver, Ph.D, Guilford Press, NY (1999).
• Building the Bonds of Attachment by Daniel Hughes, Ph.D., Guilford Press, 1999.
• "Treatment for Children with Trauma-Attachment Disorders: Dyadic Developmental Psychotherapy" Child and Adolescent Social Work Journal. 12(6), December 2005.
• Creating Capacity For Attachment, (Eds.) Arthur Becker-Weidman, Ph.D., and Deborah Shell, MA, Wood 'N' Barnes, OK: 2005.ISBN 1885473729
• O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244:Taylor and Francis
• Hughes, Daniel, (1999) Building the Bonds of Attachment, NY: Guilford Press.
• Hughes, D. (2004). An attachment-based treatment of maltreated children and young people. Attachment & Human Development, 3, 263–278.
• Hughes, D. (2003). Psychological intervention for the spectrum of attachment disorders and intrafamilial trauma. Attachment & Human Development, 5, 271–279.

External links

• Support for Parents - The Attachment Disorder Site

• "Association for Treatment and Training in the Attachment of Children"

• "Center For Family Development, Information about effective treatment for this disorder"

• American Professional Society on the Abuse of Children, Task Force Report on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems

• "The use of Neurofeedback in treating Attachment Disorders"

• Support for Parents - The Attachment Disorder Site

Critics

• American Professional Society on the Abuse of Children, Task Force Report on Attachment Therapy, Reactive Attachment Disorder, and Attachment Problems

• "Be Wary of Attachment Therapy" by Shannon-Bridget Maloney, on QUACKWATCH

• Advocates for Children in Therapy

• "Coercive Restraint Therapies: A Dangerous Alternative Mental Health Intervention" by Jean Mercer, PhD, on *Medscape*

• "Reader's Response to 'Coercive Restraint Therapies" by Arthur Becker-Weidman, Ph.D., *Medscape*

• "Author's Response to 'Reader's Response'" by Jean Mercer, PhD, on *Medscape*

• Library of documents critical of Attachment Therapy; includes video clips