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Attachment Theory and Reactive Attachment Disorder

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on 2 October 2014

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Transcript of Attachment Theory and Reactive Attachment Disorder

Attachment Theory and Reactive Attachment Disorder
Attachment at birth
Attachment at birth
Secure Attachments
Secure Attachments
Movie Clip
John Bowlby (1907-1990)
Bowlby formed attachment theory.

He was born in a family with 6 children.

His primary caregiver was a nanny.

From an upper class British family.

Studied at Trinity College in Cambridge then went on to University College Hospital.

Reactive Attachment Disorder
Insecure attachment styles can lead to the formulation of reactive attachment disorder (RAD). This disorder yields emotionally withdrawn behaviors toward the primary caregiver.

Children who have RAD struggle in making interpersonal relationships because they never formed a secure attachment to their caregiver.

The disturbance in social functioning comes from never having their basic emotional needs met.
Some of the diagnostic criteria for this disorder would be the behavior from child to caregiver
neglecting to seek comfort and resisting comfort

will have little emotional response to others and they may show signs of sadness, fearfulness and irritability when there is no threatening stimuli

moods can not be explained because they aren't in relation to the interaction they have with their caregiver
4 different types of attachment
First is the secure attachment style which is when the child objects the caregivers leaving and welcomes the caregiver upon reunion.
When the caregiver comes back a secure child will try to become close again, this form of attachment is seen as healthy and beneficial.

The avoidant attachment style is when the child rejects care and affection from the caregiver.
When the caregiver departs the child will normally ignore their departure and when they return the child will actively avoid the caregiver.


Bowlby describes attachment as a process that happens over time between the child and their primary caregiver.

Bowlby suggested that a child would initially form only one primary attachment and that the attachment figure acted as a secure base for exploring the world.

The attachment relationship acts as a prototype for all future social relationships so disrupting it can have severe consequences.

Insecure Attachments
Research shows that insecure attachments between the child and the caregiver are related to low self-esteem, aggressive behavior and poor coping skills.

Children who have insecure attachments have poor interpersonal relationships throughout their lifespan and have issues with intimacy.

People who have a negative view of themselves have a harder time reaching out to others for relationship.
unhealthy behaviors
Bowlby defines attachment theory as, “a way of conceptualizing the propensity of human beings to make strong affectional bonds to particular others and of explaining the many forms of emotional distress and personality disturbance, including anxiety, anger, depression, and emotional detachment, to which unwilling separation and loss give rise” (Seligman, pg. 103).

Immediately when they’re born the child will try to seek comfort from their caregiver.

The caregiver should respond when the child is showing comfort seeking behavior in order to provide a sense of security for the child.
4 different types of attachment
(Hardy, 2007)
(Seligman, 2013)
Studies show that attachments were most likely to form with those who responded accurately to the baby's signals (smiling, crying).
Infants look for attachment figures when confronted with new and different stimuli.
They are evolutionary primed to form bonds through close and frequent contact with their primary caregiver.
As they grow older and start developing they will continue to come back to the caregiver for to be physically close in proximity for comfort.
(Seligman, 2013)
(Hardy, 2007)
The resistant-ambivalent style of attachment looks like the obsession and fixation coming from the infant to caregiver but when the child seeks comfort they end up decking it.

The disorganized attachment style looks like the child showing conflicting behaviors because the caregiver is supposed to be the source of comfort.
This happens most often in kids who have been abused in some form they seek comfort from the source of their distress.
(Hardy, 2007)
Attachment is correlated with the infants biological maturation and causes the ability for a child to regulate their emotions dependent on whether or not they have a secure attachment with their primary caregiver.

Studies have revealed results showing that secure attachment with the caregiver in the early years of life yields to the development of self-image, security and healthy relationships through the rest of their life.

(Paredes, 2014)
There is a development of an internal framework that happens when the primary caregiver responds appropriately to the child’s physical and psychological needs.

The internal framework is the mental scheme a person has about themselves and others.

The mental scheme a person has forms their behaviors and builds their self esteem making it easier for a child to have intimate relationships if they have a secure attachment to their caregiver.
(Paredes, 2014)
(Paredes, 2014)
(Seligman, 2013)
little consistency in the role of their primary caregiver or has not had their basic emotional needs me

comfort and stimulation that the child needs from the caregiver has been lacking

characterized by the infant rarely seeking comfort, protection or nurturing from caregiver and they have inappropriate attachment seeking behaviors

developmental criterion states that these symptoms must be present before the age of 5 years old and the child must be at least 9 months in order to be considered for RAD
At risk
(APA, 2013)
(APA, 2013)
Children who are at risk for developing RAD are those who have experienced some sort of severe trauma or those who have been placed in foster care.
These children generally show the characteristic called ‘indiscriminate sociability’ with adults whom they are familiar with and adults who are strangers.
(Kay & Green, 2013)
Children with this seek attention from any form of caregiver and they fail to show any behaviors towards making a selective attachment.

They don’t respond to the efforts made by the caregiver to show comfort, support and nurturance.

Children with RAD commonly are prone to have little impulse control, developmental delays and may partake in inappropriate sexual behavior.
(Hall & Geher, 2013)
Some of the goals when considering intervention strategies for children who struggle with RAD would be to improve the relationships between the child and the primary caregiver

The goal would be to work with the child and the caregiver in order to make for powerful and positive interactions.

It is of utmost importance that the child has a caregiver that is emotionally available to form an attachment with.
(Seligman, 2011)
"The caregiver’s ability to modulate and process affective states and provide this structure to the infant is the most important factor in the infant’s early brain development,”
(Hardy, 2007)
The consequences for regulatory systems failing can form a sense of helplessness and hopelessness.

Interventions should be focused on primary prevention in order to prevent insecure attachments later in life.

Addressing behaviors that hinder the formulation of making attachments is more important then addressing just the symptoms.
Treatment for children with disordered attachment should be more focused on the formulation of new attachments in their current relationships.

Cognitive behavioral management of mood symptoms is a preferred intervention when treating patients with RAD.

Children with RAD need support and healthy relationships to improve heir functioning.
consistent, reflective interaction
Hardy, 2007
Hardy, 2007
Interventions should be focused not only the child but also training the caregivers in sensitive responsiveness.
improving the mothers’ ability to monitor the infant’s signals and respond to them accurately

It’s important that there is an alternative arrangement for a child that has no primary caregiver to give them some type of support.
at least one reliable long-term relationship
it may take time for the child to gain a sense of belonging and security to develop
Seligman, 2007
Diagnosis is 313.89 Reactive Attachment Disorder.

Objectives for treatment would be to improve relationship between the child and caregiver. It’s important to address the behavior that is hindering the child from developing secure attachments.
help increase self-esteem and self-worth is crucial
main objective would be to make sure the child has a consistent and sensitive caregiver so that they can form a healthy attachment

Assessments that can be given for children with RAD would be The Child Behavior Checklist, the Behavior Assessment for Children, the Sutter-Eyeberg Student Behavior Inventory-Revised.

Clinician characteristics should be a clinician who is educated on the disorder and knows a lot about attachments.
should be kind, warm, supportive and patient while also working with their caregivers in an empathetic way.
The therapist should be able to make appropriate boundaries between the child and the caregiver while also being able to provide a team of medical professionals to help.
It is important for the therapist to be skilled at building interpersonal relationships
Location of treatment should be in the therapist’s office and foster care homes.

Interventions would be working on the child to caregiver relationship.
Cognitive behavioral management of mood
help in recognizing the root of behaviors
work with the caregiver on sensitivity
make sure the child has a consistent, caring relationship

Emphasis of treatment is structured but supportive.

Numbers for treatment would be individual therapy and therapy between the child and caregiver.
Time should be long-term treatment, weekly sessions.

Medication treatment should be referred to clinician.

Adjunct services would be parent education, possible involvement in a mentor program.

Prognosis is good with parental (or caregiver) cooperation
American Psychiatric Association. (2013). Diagnostic and
statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Cornell, Tonya, RN, MSN,A.R.N.P., B.C., & Hamrin, Vanya, RN, MSN,A.P.R.N., B.C. (2008). Clinical interventions for children with attachment problems. Journal of Child and Adolescent Psychiatric Nursing, 21(1), 35-47. Retrieved from http://0-search.proquest.com.library.trevecca.edu/docview/232962604?accountid=29083

Kay, C., & Green, J. (2013). Reactive attachment disorder following early maltreatment: Systematic evidence beyond the institution. Journal of Abnormal Child Psychology, 41(4), 571-81. doi:http://dx.doi.org/10.1007/s10802-012-9705-9

Hall, S. E. K., & Geher, G. (2003). Behavioral and personality characteristics of children with reactive attachment disorder. The Journal of Psychology, 137(2), 145-62. Retrieved from http://0-search.proquest.com.library.trevecca.edu/docview/213825651?accountid=29083

Hardy, L. T. (2007). Attachment theory and reactive attachment disorder: Theoretical perspectives and treatment implications. Journal of Child and Adolescent Psychiatric Nursing, 20(1), 27-39. Retrieved from http://0-search.proquest.com.library.trevecca.edu/docview/232962773?accountid=29083

Paredes, A. C., Ferreira, G., & Pereira, M. D. G. (2014). Attachment to parents: the mediating role of inhibition of exploration and individuality on health behaviors. Families, Systems & Health, 32(1), 43

Smyke, A. T., Zeanah, C. H., Gleason, M. M., Drury, S. S., Fox, N. A., Nelson, C. A., & Guthrie, D. (2012). A randomized controlled trial comparing foster care and institutional care for children with signs of reactive attachment disorder. The American Journal of Psychiatry, 169(5), 508-14. Retrieved from http://0-search.proquest.com.library.trevecca.edu/docview/1022030861?accountid=29083

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