Attachment therapy

Attachment disorder is a broad term intended to describe disorders of mood, behavior, and social relationships arising from a failure to form normal attachments to primary care giving figures in early childhood. Such a failure would result from unusual early experiences of neglect, abuse, abrupt separation from caregivers after about age 6 months but before about age 3 years, frequent change of caregivers or excessive numbers of caregivers, or lack of caregiver responsiveness to child communicative efforts. A problematic history of social relationships occurring after about age 3 may be distressing to a child, but does not result in attachment disorder.

Attachment disorder is a term 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.

Attachment disorder is a term that is often seen in the research literature (O'Connor & Zeanah) but which is much broader than the clinical diagnosis of Reactive attachment disorder, which is described in the Diagnostic & Statistical Manual, 4th Edition, Technical Revision, of the American Psychiatric Association.

This theory ( Attachment Theory ) is used, for example, to explain the behavioral difficulties of children who have experienced chronic early maltreatment, such as foster and adopted children.

Attachment therapy is a broad term with no generally agreed-upon meaning, as it covers a wide variety of interventions. As such, some believe the term has lost utility.

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 (Zeanah, C., 1999). 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 and attachment disorder
Attachment theory is an evolutionary theory. In relation to infants, it primarily consists of proximity seeking to an attachment figure in the face of threat, for the purpose of survival. Although an attachment is a "tie" it is not synonymous with love and affection. There are two main aspects to attachment behaviour. The first is maintaining proximity to another and the second is the specificity of the other (Bowlby 1969, p181). A disurbance of attachment indicates the absence of either or both. This can occur either in institutions, or with repeated changes of caregiver, or from extremely neglectful primary caregivers who show persistent disregard for the child's basic attachment needs. Current official classifications under DSM-IV-TR and ICD-10 are largely based on this understanding of the nature of attachment.

In the clinical sense, a disorder is a condition requiring treatment as opposed to risk factors for subsequent disorders.(AACAP 2005, p1208 ) There is a lack of consensus about the precise meaning of the term 'attachment disorder' although there is general agreement that such disorders only arise following early adverse caregiving experiences.

The words 'attachment style' refer to the various types of attachment arising from early care experiences, called 'secure', 'anxious-ambivalent', 'anxious-avoidant', (all organized), and 'disorganized'. Some of these styles are more problematical than others, and although they are not disorders in the clinical sense, are sometimes discussed under the term 'attachment disorder'.

Discussion of 'disorganized attachment' style sometimes includes this style under the rubric of attachment disorders because disorganized attachment is seen as the beginning of a developmental trajectory that will take the individual ever farther from the normal range, culminating in actual disorders of thought, behavior, or mood. Early intervention for disorganized attachment, or other problematic styles, is directed toward changing the trajectory of development to provide a better outcome later in the person's life.

Zeanah and colleagues proposed an alternative set of criteria (see below) of three categories of attachment disorder, namely "no discriminated attachment figure", "secure base distortions" and "disrupted attachment disorder". These classifications retain the basis that a disorder is such as to require treatment.

Diagnosis
Recognised assessment methods of attachment styles, difficulties or disorders include the Strange Situation procedure (Mary Ainsworth), the separation and reunion procedure and the Preschool Assessment of Attachment ("PAA", Crittenden 1992), the Observational Record of the Caregiving Environment ("ORCE") and the Attachment Q-sort ("AQ-sort" ) More recent research also uses the Disturbances of Attachment Interview or "DAI" developed by Smyke and Zeanah, (1999). This is a semi-structured interview designed to be administered by clinicians to caregivers. It covers 12 items, namely having a discriminated, preferred adult, seeking comfort when distressed, responding to comfort when offered, social and emotional reciprocity, emotional regulation, checking back after venturing away from the care giver, reticence with unfamiliar adults, willingness to go off with relative strangers, self endangering behavior, excessive clinging, vigilance/hypercompliance and role reversal. Most research will use a combination of measures.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 the Strange situation developed by Mary Ainsworth and a variety of narrative methods. Among adults, the Adult Attachment Interview is a frequently used research method.

Causes of attachment disorders
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 may be younger. It is often useful to consider, "at what age would this behavior be normal?" Frequently one may find that the child’s behavior would be normal if the child were of a younger age.

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

Older adopted children (see Adoption article for additional details.) 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.

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.)
 * Flaccidity

Treatment
There is a variety of effective prevention programs and treatment approaches for attachment disorder based on Attachment theory. All approaches concentrate on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, changing the caregiver. Approaches with a sound evidential and theoretical base include the following:
 * 1) 'Circle of Security' (Marvin et al, 2002)
 * 2) Dyadic Developmental Psychotherapy
 * 3) 'Watch, wait and wonder' (Cohen et al, 1999),
 * 4) manipulation of sensitive responsiveness, (van den Boom 1994 and 1995), # modified 'Interaction Guidance' (Benoit et al, 2001),
 * 5) 'Preschool Parent Psychotherapy' (Toth et al, 2002)
 * 6) Parent-Child psychotherapy (Leiberman et al 2000).
 * 7) Developmental, Individual-difference, Relationship-based therapy (DIR) (also referred to as Floor Time) by Stanley Greenspan, although DIR is primarily directed to treatment of pervasive developmental disorders.

There are a variety of evidence-based and effective prevention programs and treatment approaches for attachment disorder. Nearly all mainstream programs for the prevention and treatment of disorders of attachment use attachment theory. Programs include: the Circle of Security Program, (Dr. Robert Marvin, University of VA), 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. This treatment is consistent with the general principles for the treatment of trama (Briere & Scott, 2006).

Attachment therapy is a term with little or no agreed upon meaning. It is not a term that is used in generally accepted texts on psychotherapy. 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).

Additional Reading and References

 * Becker-Weidman, A., & Shell, D., (Eds.) (2005) Creating Capacity For Attachment, Wood 'N' Barnes, OK. ISBN 1-885473-72-9
 * 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, 2nd. Edition by Daniel Hughes, Ph.D., Guilford Press, 2006.
 * "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 1-885473-72-9
 * O'Connor and Zeanah (2003) "Attachment disorders and assessment approaches Attachment and Human Development 5(3)223-244:Taylor and Francis
 * Hughes, Daniel, (2006) Building the Bonds of Attachment, 2nd. Edition. 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.
 * Holmes, J., The Search for the Secure Base, (2001), Brunner-Routledge, Philadelphia, PA.
 * Bowlby, J., A Secure Base, (1988), Basic Boosk, NY.
 * Briere, J., and Scott, C., (2006) Principles of Trauma Therapy: A guide to symptoms, evaluation, and treatment. Thousand Oaks, CA: Sage.