Reactive Attachment Disorder and Attachment Therapy
By Kim Cross LSCSW
May 2003
The Importance of Secure Attachment
Over the years, research findings have shown the importance of the parent/child relationship in the early
years, the stability of the early attachment style throughout the years and the long lasting impact upon
behaviors and relationships. (Shaw, et al., 1996 & Moss et al 1999)
1) Children with secure attachment were more likely to have close friends, be more socially
competent, more accepted by their peer group, have more empathy for others, more self reliant,
better problem solvers and be able to read emotional cues. Secure attachment is thought to be
one of the protective factors involved in the development of resiliency.
2) Children with (anxious) insecure attachment histories were found to be less confident and more
reliant on others to have their needs met, and more at risk for psychosocial malfunctioning, such
as somatic complaints, social withdrawal, depression and anxiety disorders.
3) Avoidant children exhibit different forms of social incompetence - they are often identified as the
bullies by their peers and are hostile and aggressive.
Schore (1994, 2001), Perry (1997), Greenspan (1997), Siegel (1999, 2001) and LeDoux (2002) among
others have written about how the early relationship between the primary caretaker and the infant
influences the child's developing cognitive processes, ability to recognize and manage emotions and
empathize with the feelings of others and even determines the shape and functioning of the brain.
Reactive Attachment Disorder
“Insecure attachments become psychiatric disorders when emotions and behaviors displayed in
attachment relationships are so disturbed as to indicate, or substantially increase the risk for, persistent
distress or disability. An attachment disorder, thus, represents behavior at the most extreme ends of
attachment relationships, reflecting serious distortions in the child's use of the caregiver as a secure
base.” (Center for Adoption Research).
Reactive Attachment Disorder as defined by the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders is characterized by the breakdown of social ability of a child
beginning before age five. The child may treat all people as if they were his/her best friend or mistrust
of nearly everyone. A history of pathological disregard for the child’s emotional and physical needs or
multiple caregivers is required for diagnosis.
Attachment Therapy
In the 1970s, a therapeutic technique was developed for older children with attachment problems called
“holding” or “rage reduction” therapy. In the following years, as new research emerged in the fields of
attachment, trauma, child development, neurological functioning, sensory integration, etc. treatment
methods or new methods were developed including Welch Method Regulatory Bonding Therapy,
Corrective Attachment Therapy, Dyadic Developmental Psychotherapy and Theraplay. In 1990, the
Association for Treatment and Training in the Attachment of children (ATTACh) was created to “help
families and society deal with critical attachment and bonding issues”. This organization is made up of
mental health professionals, educators and other experts, as well as parents of children with attachment
disorders. Several years later it developed a registration process of clinicians and Practice and Safety
Standards.
The basic principles of attachment therapy, as cited by ATTACh includes:
Attachment therapy is a therapeutic process that is designed to promote, develop, or enhance a
reciprocal attachment relationship and meets the criteria of that therapeutic process as defined
and developed by ATTACh. Attachment and bonding therapy includes an array of treatment
strategies, which continue to evolve and expand. A rich diversity of therapeutic approaches is
essential in treating children with attachment problems. As attachment and treatment are on a
continuum, interventions should be flexible and specific to the needs, history and cognitiveemotional state of each member of the family, on the child’s inner working model and on parent’s
abilities and style. The primary goal of treatment with children and adults with attachment
problems is to enable them to form healthy attachment relationships with their current and future
families, and to resolve the dysfunctional feelings and behaviors developed in response to the
early attachment breaks. Discovering the child’s individual inner working model (beliefs about
self, others and environment) is important for therapeutic success.
Attachment therapy emphasizes trust, empathy, reciprocal behaviors, attunement,
communication, touch, physical and emotional closeness and humor and playfulness.
Responsible practitioners in any mental health discipline serving children with severe emotional
and behavior problems, including attachment and bonding therapists, do so with the utmost
attention to the psychological and physical well being and safety of the children and adults
involved.
Attachment therapy requires a family systems approach. The heart of this disorder is the child’s
relationship with their primary caregiver. Working with the family system is essential to the
success of the child’s treatment. It is insufficient to treat the child’s clinical issues as the
mechanism for forming an attachment with the primary caregiver. These issues did not cause the
attachment disorder, and therefore correcting them is not sufficient to correct the disorder.
Parents may have problems, which must be understood and addressed if they are to help their
child resolve attachment and other problems.
Thorough assessment, including the following as indicated: History of treatment, Psychological
history, Educational history, Medical history, Attachment and social history including
breaks/disruptions in attachment, Developmental history (including prenatal and birth), Family
functioning, Intellectual and cognitive skills and deficits, Differential diagnosis (this may include
any or several DSM or ICD diagnoses).
Parents and children are active members of the treatment team working to develop healthier
patterns of interacting and communicating. Both the child and the family must have a
developmentally appropriate understanding of the therapeutic processes and goals. The
practitioner should always approach a family and child with respect and without blame. They
should support, not undermine, the authority and values of the parents during therapy sessions,
providing them with relevant information about the treatment process and offering every
opportunity to ask questions. The family’s emotional response to the therapy needs to be
monitored, as well as the child’s. When exploring unresolved issues, treatment will take into
account past and present family dynamics. A central therapeutic activity is for the child and family
members to experience and then express their emotional responses to past and present
situations that are interfering with attachment. Parent-child interactions that are central to
establishing a healthy attachment (i.e. eye contact, physical contact, tone of voice, smiles, other
non-verbal communication and gestures) are central to the interactions of therapy.
The practitioner assists the parents in developing parenting strategies and philosophies, which
support the development of healthy attachments. The practitioner serves as a consultant to the
parents on issues and interventions, including but not limited to the following:
a. Supporting the parents’ authority and need to maintain control over the family environment,
while assisting the child to feel safe enough to relinquish his/her compulsive need to be in
control.
b. Increasing the child’s readiness to rely on the parent for safety, help, comforting, nurturing.
c. Encouraging a positive, supportive, family atmosphere.
d. Encouraging a high level of nurturance.
e. Encouraging structure and limits.
f. Increasing reciprocal, positive interactions between parent and child.
g. Helping the child make choices that are in his own best interest, and in the best interest of
his family, and to accept the consequences of those choices.
h. Helping parents become emotionally available for their child as healthy and safe
individuals. This may include examining their own issues, such as the marital relationship,
infertility, grief and loss, childhood trauma, etc.
i. Helping families and children develop reasonable expectations of success.
Attachment therapies based on ‘cognitive restructuring’ and ‘therapeutic holding’ appear to be having
some success with children who have failed to respond to other treatments employed by the child mental
health services. (Howe & Fearnley 1999)
Criticisms of Attachment Therapy
1) All forms of attachment therapy are equated with “rebirthing” or “holding” therapy and techniques
used are dangerous.
According to ATTACh:
Attachment Therapy denotes the focus of the therapeutic process rather than a specific intervention
technique. Attachment Therapy can encompass and integrate a variety of treatment interventions. It
is based on treatment theories drawn from an array of relevant therapeutic approaches including
behavioral, cognitive, and psychodynamic.
Although the term “holding therapy” has been used in the past, holding is currently recognized as a
technique which can be one part of a more comprehensive treatment for attachment issues during
which other supportive therapeutic techniques may be utilized. Essential components include eye
contact, appropriate touch, empathy, genuine expression of emotion, nurturance, reciprocity, safety
and acceptance. Holding as a therapeutic technique provides a multi-sensory experience that refines
attunement, facilitates emotional reciprocity and honesty, enhances empathy responses, allows the
child to experience emotional openness in a safe way, and reenacts the holding nurturing experience
of infancy; all of which provide a corrective cognitive-emotional experience. While a variety of holding
positions can be used, the physical safety of the client is the primary consideration.
Rebirthing is the name of an intervention that has been mistakenly identified with “holding therapy”.
Currently the term “rage reduction” refers to a therapeutic goal, not a specific technique.
As with any form of treatment, medical, mental health or pharmaceutical, consumers need to education
themselves about the treatment being recommended and ask questions of the service provider
concerning the provider’s education and skills and intervention/s methods.
2) Attachment therapists are criticized for using criteria beyond that provided by the DSM-IV-TR in
making a diagnosis of Reactive Attachment Disorder.
The diagnosis of Reactive Attachment Disorder of Infancy or Early Childhood first appeared in the
Diagnostic and Statistical Manual of Mental Disorders DSM-III (APA, 1980) and modifications were made
in the DSM-III-R (APA, 1987) and the DSM-IV (APA, 1994). The DSM criteria for Reactive Attachment
Disorder was criticized as having no published studies using or evaluating the criteria for reactive
attachment disorder and that the criteria was insufficient in describing children who have seriously
disturbed attachment relationships. Research on both the criteria and the constructs of RAD began in
1994 and consistently show DSM criteria as unreliable in diagnosising Reactive Attachment Disorder
(Richter 1994; Zeanah 1996; Sheperis et al 2003; Boris et al 2004).
“The reliability of alternative criteria was acceptable, but the reliability of DSM-IV criteria in diagnosing
attachment disorders was marginal”. (Neil W. Boris, M.D. et al 1998).
Observation and research has shown a strong correlation between pathological parent-child interactions
and insecure attachment with a range of serious behavioral disturbances in children beyond the
symptoms listed in the DSM criteria. (Aichhorn 1925: Levy 1937; Bowlby 1944, 1973; Bender 1947; Winnicott
1946, 1956; Tizard and Hodges, 1978; Fahlberg, 1991; James, 1994; Levy & Orlans 2004). These extreme
behavior problems have resulted in a growing consensus of how attachment disorder present in clinical
presentations.
The implications of the inability of children with RAD to form normal attachments are best demonstrated
through the many maladaptive behaviors associated with the disorder. Such behaviors include stealing,
lying, cruelty to animals and other people, avoidance of eye contact, indiscriminate affection with relative
strangers and a refusal to express affection with family members, destruction of property, gorging of food,
abnormal speech patterns, lack of remorse, impulsivity, inappropriate sexual behavior, role reversal, and
over activity (Aber et al 1989; Reber 1996; Kay Hall & Geher, 2003; O'Conner et al 2000).
3) Reactive Attachment Disorder is “uncommon” or “rare” and attachment therapists are accused of
over diagnosising Reactive Attachment Disorder.
•
Among children who have experienced abuse, neglect or both, 87% to 95% show an insecure
attachment. (Crittenden, P.M. 1988).
•
Approximately 2% of the population is adopted and between 50% and 80% of such children have
attachment disorder symptoms. (Carlson V et al 1989).
•
The researchers identified attachment disorders in nearly two thirds of children in foster care and
20% of those living in a homeless shelter. (Boris NW et al 2000).
•
Prevalence of RAD in the sample of maltreated toddlers in foster care was 38-40%. (Zeanah CH et
al 2004).
•
During 2003, 760,134 children were found to be victims of maltreatment by at least one parent
including approximately 124,662 children between the ages of birth to 3 years and 47,372
experienced a recurrence of maltreatment within 6 months. Approximately 198,740 children age
5 or younger were in the U.S. foster care system. (U.S. Dept. of Health and Human Services).
4) There is no “ empirical evidence” to support this form of treatment for children with Reactive
Attachment Disorder.
There is no empirical evidence to support any treatment model for children with Reactive Attachment
Disorder especially school age children and those with moderate to severe levels of this disorder.
While some professionals and professional organizations have presented recommendations for the
assessment and treatment of Reactive Attachment Disorder, most of the content of these reports
focus more on presenting criticisms about attachment therapy and attachment therapists and
dismissing parents’ reports on effectiveness of attachment therapies than addressing Reactive
Attachment Disorder, assessment and treatment. The recommendations provided are very general
and based on treatment methods for other mental health disorders. Providing “empirical evidence” is
difficult due to expense, definition and criteria for “empirical evidence” and transferring what is done in
a research setting to a clinical setting. It is made even more difficult in the area of Reactive
Attachment Disorder as disputes abound over causes of the disorder, symptom criteria, valid
assessment tools, etc. However most mental health interventions being provided do not have
“empirical evidence” and most treatments currently accepted began with no “empirical evidence.
If the mental health community cannot agree if Reactive Attachment Disorder exist, criteria for
symptoms, what assessment should assess and even if it should receive much attention due to being
“rare” then it is no wonder that determining an “empirically supported” treatment for Reactive
Attachment Disorder has received little attention since it was recognized over 20 years ago. Children
with Reactive Attachment Disorder and their families cannot wait until these disputes and criticisms
are resolved.
•
Research has shown that attachment disorder is the basis for various conduct and personality
disorders including antisocial personality disorder, narcissistic personality disorder, borderline
personality disorder, and psychopathic personality disorder. Severely attachment disordered
individuals who do not receive treatment are at serious risk for psychopathy (Hare, 1995; LyonsRuth, K 1996; Greenberg, M.T. et al 1993; Schore 1994, Speltz et al 1999; Dozier M 1999; Finzi R al et
2000 & Zeanah CH et al 2003).
•
“Without treatment and new attachments, the chance for normal emotional development,
building trusting relationships, and experiencing and tolerating intimacy and closeness with other
human beings is very poor”. (Martin Maldonado-Durán, MD, Linda Helmig, PhD & Teresa Lartigue, PhD).
Reference:
Aber, J.L., Allen, J., Carlson, V., & Cicchetti, D. (1989). The effects of maltreatment on development during early
childhood: Recent studies and their theoretical, clinical and policy implications. In D. Cicchetti, & V. Carlson (Eds.),
Child Maltreatment: Theory and research on causes and consequences, (pp. 579-619). New York: Cambridge
University Press.
Aichhorn, A. (1925). Wayward Youth. New York: Viking Press, 1965.
Bender, M. (1947). Psychopathic behavior disorders in children. In Handbook of Correctional Psychology, ed. R.
Lindner & R. Seliger. New York: Philosophical Library, pp. 360–377.
Bowlby, J. (1944). Forty-four juvenile thieves: Their characters and home life. International Journal of Psychoanalysis
25:19–53
Bowlby, J. (1973). Attachment and Loss: Vol. 2. Separation, Anxiety, and Anger. New York: Basic Books.
Boris, N.W., Zeanah, C.H., Larrieu, J.A., Scheeringa, M.S., & Heller, S.S. (1998). Attachment disorders in infancy and
early childhood: a preliminary investigation of diagnostic criteria. American Journal of Psychiatry, 155, 295-297.
Boris NW, Wheeler EE, Heller SS, Zeanah CH. (2000). Attachment and developmental psychopathology. Psychiatry.
2000; 63:75-84.
Boris NW, Hinshaw-Fuselier SS, Smyke AT, Scheeringa MS, Heller SS & Zeanah CH. (2004) Comparing criteria for
attachment disorders: establishing reliability and validity in high-risk samples. J Am Acad Child Adolesc Psychiatry.
2004 May; 43(5): 568-77.
Carlson V, Cicchetti D, Barnett D, & Braunwald K (1989): Finding order in disorganization: Lessons from research on
maltreated infants’ attachments to their caregivers. In: Child Maltreatment: Theory and research on the causes and
consequences of child abuse and neglect.
Crittenden, P.M. (1988). Relationships at risk. In J. Belsky & T. Nezworski (Eds.), The clinical implications of
attachment, (pp. 136-174). Hillsdale, N.J.: Lawrence Erlbaum.
Dozier, M., Stovall, K.C., & Albus, K. (1999). Attachment and psychopathology in adulthood. In J. Cassidy & P.R.
Shaver (Eds.), Handbook of attachment theory and research (497-519). New York: Guilford.
Fahlberg, V. (1991). A Child’s Journey Through Placement. Indianapolis, IN: Perspectives Press.
Finzi, R., Cohen, O., Sapir, Y., Weizman, A. (2000) Attachment Styles in Maltreated children: A comparative Study.
Child Psychiatry & Human Development, 31, 113-128.
Greenberg, M. T., Speltz, M. L., & DeKlyen, M. (1993). The role of attachment in the early development of disruptive
behavior problems. Development and Psychopathology, 5, 191-213.
Greenspan, S.1. (1997). The growth of the mind and the endangered origins of intelligence. Reading, MA: Perseus
Books.
Howe, David; Fearnley, Sheila. (1999) Adoption & Fostering Journal, Volume 23, Number 2, Summer 1999, pp. 1930(12) Disorders of attachment and attachment therapy
Hare, R. D. (1995). Psychopaths: New trends in Research. The Harvard Mental Health Letter. Boston, MA: Harvard
University.
James, B. (1994). Handbook for Treatment of Attachment-Trauma Problems in Children. New York: Lexington.
Kay Hall, S. E., & Geher, G. (2003). Behavioral and personality characteristics or children with reactive attachment
disorder. Journal of Psychology: Interdisciplinary and Applied, 137, 145-16
Ledoux, J. (1996). The Emotional Brain: The Mysterious Underpinnings of Emotional Life. New York: Simon &
Schuster.
Levy, D.(1937). Primary affect hunger. American Journal of Psychiatry 94:643–652.
Levy, Terry; Orlans, Michael (2004) Attachment disorder, antisocial personality, and violence. Annals of the American
Psychotherapy Association
Lyons-Ruth, K. (1996) Attachment relationships among children with aggressive behavior problems: the role of
disorganized attachment patterns. J Consult Clin Psychol 1996; 64(1): 64-73
Maldonado-Duran, Martin MD, Helmig, Linda PhD & Lartigue, Teresa PhD (2005). Child Abuse & Neglect: Reactive
Attachment Disorder. E-medicine.
Moss, E., St-Laurent, D., & Parent, S. (1999) Disorganized attachment and developmental risk at school age. Pp 160186 in: Solomon, J. & George, C. (Eds) (1999) Attachment Disorganization.
O'Connor TG, Rutter M (2000) Attachment disorder behavior following early severe deprivation: extension and
longitudinal follow-up. Journal of the American Academy of Child & Adolescent Psychiatry. 39(6): 703-712
Perry, B.D. (1997). Incubated in terror: Neurodevelopmental factors in the “cycle of violence.” In Children in a Violent
Society, ed. J. Osofsky. New York: Guilford Press, pp. 124–149.
Reber, K. (1996). Children at risk for reactive attachment disorder: Assessment diagnosis and treatment. Progress:
Family Systems Research and Therapy, 5, 83-98.
Schore, A. N. (1994). Affect Regulation and the Origin of the Self: The Neurobiology of Emotional Development.
Hillsdale, NJ: Erlbaum.
Schore, A. N. (2001). The effects of early relational trauma on right brain development, affect regulation, and infant
mental health. Infant Mental Health Journal 22:201–269.
Shaw, D. S., Owens, E. B., Vondra, J. I., Keenan, K., & Winslow, E. B. (1996) Early risk factors and pathways in the
development of early disruptive behavior problems. Development and Psychopathology, 8. 679-699
Sheperis, C. J., Doggett, R. A., & Hoda, N. E. (2003). The development of an assessment protocol for reactive
attachment disorder. Journal of Mental Health Counseling, 25, 291-310.
Siegel, D. (1999). The Developing Mind: Toward a Neurobiology of the Interpersonal Experience. New York: Guilford
Press.
Siegel, D. (2001). Toward an interpersonal neurobiology of the developing mind: Attachment relationships,
“mindsight,” and neural integration. Infant Mental Health Journal 22:67–94.
Speltz, ML, DeKlyen, M, Greenberg MT. (1999). Attachment in boys with early onset conduct problems. Dev
Psychopathol 11(2): 269-85
Tizard, B. and Hodges, J. (1978). The effect of early institutional rearing on the development of 8 year old children.
Journal of Child Psychology and Psychiatry, 19, 2, 99 – 118.
Winnicott, D. (1946). Some psychological aspects of juvenile delinquency. In Deprivation and Delinquency, ed. C.
Winnicott, R. Shepherd, & M. Davis. London: Tavistock Publications, 1984, pp.113–119.
Winnicott, D. (1956). The antisocial tendency. In Deprivation and Delinquency, ed. C. Winnicott, R. Shepherd, & M.
Davis. London: Tavistock Publications, 1984, pp. 120–131.
Zeanah, C. H., Scheeringa, M., Boris, N. W., Heller, S. S., Smyke, A. T., & Trapani, J. (2004). Reactive attachment
disorder in maltreated toddlers. Child Abuse & Neglect, 28, 877-888.