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Attachment Disorder

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Attachment Disorder

Judith Kaye Lawrence
2004

Brief Abstract

Attachment disorder is an environmental disorder and is the result of the bonding process that occurs between a child and caregiver during the first couple years of the child’s life.  It is a name for problems people have in forming affectionate bonds with others.  It begins early in life when infants are dependant upon others for survival.  The first year of life is the year of needs.  “At the level of mind, attachment establishes an interpersonal relationship that helps the immature brain use the mature functions of the parent’s brain to organize its own processes.   The aid parents can give in reducing uncomfortable emotions, such as fear, anxiety, or sadness, enables children to be soothed and gives them a haven of safety when they are upset.  Studies of attachment have revealed that the patterning or organization of attachment relationships during infancy is associated with characteristic processes of emotional regulation, social relatedness, access to autobiographical memory, and the development of self-reflection and narrative.” (Siegel pg. 67)  The child’s primary needs are touch, eye contact, movement, smiles, and nourishment.  When the infant has a need, he or she expresses the need through crying.  Ideally, the caretaker is able to recognize and satisfy the need.  Through this interaction, which occurs hundreds of thousands of times in a year, the child learns that the world is a safe place and trust develops.  Attachment is reciprocal, the baby and caregiver create this deep, nurturing connection together!  It takes two to connect. It is imperative for optimal brain development and emotional health, and its effects are felt physiologically, emotionally, cognitively and socially.

When this initial attachment is lacking, children lack the ability to form and maintain loving, intimate relationships.  They grow up impaired with an impaired ability to trust that the world is a safe place and that others will take good care for them.  Unfortunately, their idea about safety prevents them from allowing others to care of them in a loving, nurturing manner.  They become extremely demanding and controlling in response to their fear.  (Evergreen Consultants) “Attachment relationships thus serve a vital function in providing the infant with protection from dangers of many kinds.  These relationships are crucial in organizing not only ongoing experience, but the neuronal growth of the developing brain.  Attachment relationships may serve to create the central foundation from which the mind develops.  Insecure attachment may serve as a significant risk factor in the development of psychopathology.” (Siegel p. 68)

Discussion of the mental, emotional, or behavioral affects

Attachment has been identified as playing a vital role in maintaining the bonds of trust, attaining full intellectual potential, acquiring a conscience, developing relationships with others, identity and self-esteem, learning to regulate feelings, language development, and brain structures and organization of the nervous system. (Smith, Lawrence B. “What is Attachment?”)

High Risk Signs in Infants:

1.    Does not use crying appropriately to get someone to address needs.
2.    Often does not settle when needs are met by mom (primary caregiver.)
3.    Overreacts or often startles to touch, sound and/or light.
4.    Listlessness with no medical reason (infant depression).
5.    Limited holding onto or reaching for caregiver.
6.    Poor sucking response.
7.    Does not smile back or respond with activity to smiles or baby talk.
8.    Development delays.
9.    Lack of tracking.
10.  Self abusive behavior (head-banging, self-biting, hair pulling.)
11.  Is resistant to cuddling (stiff).  (Thomas)

For the infant of zero to 6 months, poor attachment appears as social withdrawal and or frequent screaming, pulling, away from all touch, rejection comfort from others and repetitive motions which are unsuccessful attempts at self-soothing.

For the child 6-10 months the effects of weak attachment are: over-reliance on repetitive motions, such as rocking, for comfort: lack of stranger anxiety; and extreme precociousness that moves the infant towards a position of not needing anyone because she/he can handle it all.

Should the attachment problems exist from 10-18 months, separation anxiety may intensify to the point that the child won’t leave the parent.  There may be generalized
disinterest in exploring the world and limited checking in with the parent.  The child assembles a repertoire of aggressive behaviors as outlets for the frustration.

For the 15-24 month-old, attachment difficulties often mire the child in an inability to integrate dependence and independence.  A child frozen in this dilemma usually ends up choosing one extreme or the other and may become withdrawn or clingy.  Attachment difficulties at this age also sensitize a child to frustration and failure which results in strong anxiety, anger, and a coloring of the self with shame.  The outward sign is often heightened aggressive behavior.

Weak attachment from 24-36 months can interfere with achieving self and object constancy.  Poor object constancy makes it difficult for a child to relate emotionally 
because of the expectation of inevitable loss.  This will manifest as clingy behavior to prevent the loss or distancing behavior to avoid any pain.  Poor self constancy undermines a child’s confidence in his ability to cope with changing situations.  As a result she/he may become very vigilant to prevent becoming overwhelmed.  Additionally, there may be problems with transitions or sudden changes.

If attachment problems linger through the preschool years and into the elementary years, they are at risk of intensifying.  Children with this disorder have a generalized distrust of others, particularly authority figures, who are seen as exploitive.  They see 
themselves as defective victims of life and accept no responsibility for anything, and internally they feel responsible for everything bad that happens.  There is little satisfaction in mastery, and learning is seen as relevant only if it has survival value.   Social skills are quite limited. (Smith, Lawrence B. “Bonding”)

Other symptoms of unattached children includes the following:  superficially charming, abnormal eye contact, extreme self-control problems, manipulative, controlling, destructive to self and others, cruelty to animals, hoarding and hiding food or toys, inability to connect cause with effect, lack of conscience, preoccupied with fire, blood and gore, poor peer relationships, stiffens when touched, persistent nonsense questions incessant chatter, crazy, chronic, obvious lying, refusal to show affection to parents, leaning lags and disorders. (Smith, Linda Ann) Attachment has been identified as playing a vital role in all of the following: maintaining the bonds of trust, attaining full intellectual potential, acquiring a conscience, developing relationships with others, identity and self-esteem, learning to regulate feelings, language development, and brain structures and organizations of the nervous system. (Smith, Lawrence B. “What is attachment?”)

Unattached children are difficult to recognize. They deceive their elders with superficial charm while they scrutinize the environment. 

Discussion of Etiology

A baby’s attachment to his/her mother includes a physical and emotional dependence upon her.  As she touches her baby and makes eye contact she may develop strong, powerful need to be with her baby, to keep him close to her.  Fathers develop similar attachments.  As they share positive emotions, they develop deep and lasting attachments to one another.  Although the attachment with parents tends to be the most crucial to the child’s well-being, a child also will form secondary attachments to grandparents or other substitute caregivers.  These additional attachment figures can play a very important role in a child’s emotional development.

Any of the following conditions occurring to a baby during the first 36 months of life puts a child at risk: Unwanted pregnancy, re-birth exposure to trauma, drugs, or alcohol, abuse (physical, emotional, sexual) neglect (not answering the baby’s cries for help), separation from primary caregivers (i.e. illness or death of mother or severe illness, or hospitalization of the baby, or adoption, on-going pain such as colic, hernia, or many ear infections, changing day cares or using providers who don’t do bonding, moms with chronic depression o illness), several moves or placements (foster care, failed adoptions), caring for baby on a busy schedule or other self-centered parenting and an extreme temperamental misfit between parent and child. (Thomas)

The relationship between a parent and infant is intensely close both physically and emotionally.  When our children are infants they are completely dependent on us for their very survival. 

Bonding and attachment are both cornerstones of human development, essential to a child’s stable functioning as she/he grows.

Bonding and attachment are terms that are often used interchangeably.  However, the stages of infancy and toddler hood are more accurately portrayed by distinguishing bonding from attachment.

Bonding is the basic link of trust between infant and caregiver, usually the mother.  It develops from repeated completions, particularly during the first six months of the following cycle: infant need-crying-rage reactions-parental action to meet need-satisfaction-relaxation.  Successful bonding results in an infant acquiring a basic trust in others as responsive, in the world as a benign place, and in self as able to communicate needs.  Attachment grows from a good foundation in bonding.  While bonding is about trust, attachment is about affection.  Attachment can be defined as a person specific relationship that is dominated by affectionate interchanges.

The quality of an infant’s initial attachment is enormously important for it influences all subsequent development. (Smith, Lawrence B.  What is Attachment?)

Discussion of causative agent/factor

A child’s attachment behavior is activated in times of “pain, fatigue, and anything frightening, and also by the mother being or appearing to be inaccessible.” (Bowlby, 1988 p.3)  This idea led Bowlby to propose that in order for a child to grow in a secure manner, the child and the mother must participate in a reciprocal relationship, with the primary function being that of protection.

Bowlby theorized that within this mother-child relationship, control systems are in place.  He explained that the “simplest form of a control system is a regulator, the purpose of which is to maintain some condition constant.”  A simple metaphoric example Bowlby gave is that of a thermostat.  A thermostat is designed “to switch on heat when temperature falls below the set level and switch it off when temperature rises above that level.” (Bowlby, 1982 p.42)

Thus, the attachment system is maintained by a system of reciprocal feedback between mother and child, in which the child uses the mother as a secure base, thus using her as a regulator. (Benedict)

Attachment is not something mothers do to their children, but rather something that is created together between mother and child.  All aspects of the child’s development, neurological, physical, emotional, behavioral, cognitive, and social are fundamentally affected by the quality of this unique relationship.” (Hughes 1997 p.11-12)

Discussion of possible mechanisms of action of this causative agent

Children who have been mistreated or abused may become insecure and, as a result, may not view the world as a safe place.  These children can be disruptive as a way of attempting to regulate care giving patterns.  While their strategies are ineffective, disrupted behavior such as whining, noncompliance, and other negative forms of attention seeking behaviors may serve to regulate the parent’s proximity and monitoring of the child.  The childe does this because previous care was problematic and the child is insecure. (State p.1)

The largest organ of the body is the skin.  When people are stroked and massaged they are flooded with feelings of good will.  Children who are touched and caressed in non-sexual ways are soothed and comforted by the presence of their parents.  They become responsive to their parents.  They become responsive to their parent’s directives and wishes. (Hage p.1)

Infant that was raised without loving touch and security have abnormally high levels of stress hormones, which can impair the growth and development of their brain and bodies.  The neurobiological consequences of emotional neglect can leave children behaviorally disordered, depressed, apathy, slow to learn, and prone to chronic illness.  Teenage boys, for example, who have experienced attachment difficulties early in life, are three times more likely to commit violent crimes.  Disruption of attachment during the crucial first three years can lead to what has been called “affectionless psychopathic”, the inability to form meaningful emotional relationships, coupled with chronic anger, poor impulse control, and a lack of remorse. (Attachment Treatment and Training Institute p.1-2)

Assessment Techniques

There are therapeutic methods that can be used to help people reprogram their 
deepest core beliefs as well as techniques for helping people manage their emotions.  They must resolve trauma, and be taught emotion management skills, inner child therapy and taught to heal the inner wounds of the past. (Wesselman, Debra p. XVI)

There are no laboratory tests that can establish attachment disorder. The clinician can use a questionnaire/checklist to see if the child meets the profile, and is able to conduct a psychological evaluation to determine level of behavioral functioning, cognitive style, and intelligence.

There is a range of Attachment problems resulting in varying degrees of emotional disturbances in the child.  Some of these children may have concurrent diagnoses such as Oppositional Defiant Disorder, Conduct Disorder, and Attention Deficient Hyperactivity Disorder, Mood Disorders such as Depression or Bipolar Disorder and Posttraumatic Stress Disorder.  It is important to rule out any other possible disorders or medical problems. 

When therapy is conducted several modalities can be used: individual, parent, family and group therapy; however family therapy is the most effective modality.

Treatment and Therapy

Long-term goals:

1.    Establishment and maintenance of a bond with primary care-givers.
2.    Resolution of all barriers to forming healthy connections with others.
3.    Capable of forming warm physical and emotional bonds with parents.
4.    Has a desire for and initiates connections with others.
5.    Keeps appropriated distance from strangers.
6.    Tolerates reasonable absence from presence of parent or primary caregiver
        without panic.

I believe that family therapy is the most effective modality because the parents or care-givers are the greatest allies in helping a Attachment Disorder child.  Teaching and educating parents how to bond with their children becomes a major part of family based attachment therapy. The therapy needs to be confrontational because these children tend not to discuss or share present problems or past trauma.  Having the parents present helps the therapist confront past issues. Holding therapy is highly effective and provides the ultimate corrective emotional experience.  It repairs a child’s disturbed development more fully than any other therapy.

Any treatment done with these children must account for the child’s unique personality and needs, and the specific emotional climate between child and care-taker.  This type of therapy aims at getting the child to relinquish control, which has been his/hers vehicle for surviving in the world.  The idea of holding is to stimulate good mothering and allow the child a chance to experience missed bonding.

Short-term Objectives

1.    Parents and child will be able to openly express thoughts and feelings.
Therapeutic Intervention (TI) Conduct an interview to obtain information in order to build a relationship and conduct each session in a consistent manner so that the client can build a trust.
2.    The parents need to be educated about Attachment Disorder to help them to understand why their child thinks, feels, and acts the way he does.  Understanding their child will also increase feelings of compassion for him.
3.    Teach the parent consequential parenting skills.  These skills will help them to regain control of their child as well as create a bond with him.
4.    Ask the parents to make a verbal commitment to take an active role in client’s treatment and in developing skills to work with client and his/hers issues.

Elicit from parents a firm commitment to be an active part of client’s treatment by participating in sessions and being co-therapist in the home.

Train and empower the parents as “co-therapists” (e.g. being parent, showing unconditional positive regard, setting limits firmly but without hostility, verbalizing love and expectations clearly, seeking understand messages of pain and fear beneath the acting out behavior) in the process of developing the clients capacity to form healthy bonds/connections.

5.    Have parents acknowledge their frustrations regarding living with a detached child and state their commitment to keep trying.
Parents demonstrate firm boundaries on client’s anger expression.
Have family engage in social/recreational activities together.
Meet with parents conjointly on regular bases to allow them to vent their concerns and frustrations in dealing day in and day out with client.  Also, provide parents with specific suggestions to handle difficult situations when they feel stuck.
6.    Verbalize memories of the past that have shaped current identity and emotional reactions.
Assign parents to help client create a “life book” that chronicles the client’s life to this point in order to give a visual perspective and knowledge of his/her history and identity. 
7.    Parents need to acknowledge client’s history and affirm him/her as an individual.
Educate parents on the importance of affirming the client’s entire identity (i.e., self, bio-parents, adoptive parents), and show them specific ways to reaffirm with client.
8.    Parents increase the frequency of expressing affection verbally and physically toward client.
Encourage parents to provide large, genuine, daily doses of positive verbal reinforcement and physical affection.  Monitor and encourage parents to continue this behavior and to identify positive attachment signs when they appear.
Assign family the homework exercise of 10 minutes of physical touching or holding for nurturing twice daily for two weeks: snuggling with parent while watching T.V., feet or shoulder message, being held in a rocking chair, or physical recreation games.)  The parents need to process the experience with therapist at the end of two weeks.
9.    Parents will need to use respite care to protect them from burnout.
Assist parents in developing a list of potential respite care providers.
Encourage and monitor parent’s use of respite care on a scheduled basis to avoid burnout and to keep their energy level high, as well as to build trust with client through the natural process of leaving and returning.
10.    Complete a psychotropic medication evaluation and comply with all recommendations.  Identify and treat any other disorder that sometimes co-exists with Attachment Disorder.
Arrange if needed for client to have a psychiatric evaluation for medication.
These children are almost always intensely angry children.  If therapy is effective it will constructively address the child’s anger.  One goal of the therapy is to address the child’s troubling emotions versus being only a cognitive or behavioral approach.  The main goal of therapy is not to reduce his anger or to change his behaviors.  The ultimate goal is to attach or bond the child to the parents or care-givers.  A good relationship between the child and therapist is not important, what is important is that the child and the caregiver have a good relationship. (Buenning p.2)  The anger will dissipate once the relationship is nurtured.

The treatment stages are variable and can endure for months to years.  The therapy sessions should be conducted regularly providing at least 90 minute sessions.  The sessions will involve both parents and children, and are geared to improve the child’s emotional functioning and to iron out problems between the child and parent or caregiver.

The child will also play with toys and do exercises that help him/her to build sensory and motor skills, which are often severely impaired in children who live fearfully and hyper vigilantly.  I would also use stories, singing nursery rhymes, and play dough.

I want to provide hope to the entire family and remind them that positive change is possible, no matter how difficult the situation.  The parents need to adjust without lowering their expectations. The child needs to be challenged to work hard on his life while maintaining respect for him as a person.

References

1.    Attachment Disorder, What is an Attachment Disorder? P. 1-6, (2004) 
       www.state.nj.us.

2.    Benedict, N. J. Reactive Attachment Disorder: a neuropsychological study. 
       Dissertation abstracts International, 59 (7B), 3680(1988) 

3.    Bowlby’s, John Attachment Trilogy (1988) p. 3 New York: Basic Books

4.    Bowlby’s, John A Secure Base, (1982) p. 42 London: Roultedge

5.    Buenning, Walter D. Ph.D., Bonding and Attachment, p. 1-3, (2004) 
       http.//attachment.adoption.com

6.    Evergreen Consultants, What is Attachment Disorder, p.1-3 (2000-2001), 
       http://attachmenttherapy.com.

7.    Evergreen Psycholtherapy Center, Attachment Institute and Training Institute, 
       What Is Attachment Disorder, www.attachmentsexperts.com., p. 1-2 (2004)

8.    Hage, Debora, MSW, Foundations of Attachment p.1-2 (2000)
       www.deborahhage.com.

9.    Hughes, D.A. Facilitating Development Attachment:  The Road to Emotional
       Recovery and Behavioral Change in Foster and Adopted Children. (1997)
       Northvale, NJ: Aronson

10. Siegel, Daniel, J., The Developing Mind, Guiliford Press (1999) p. 67-68, 85-86

11. Smith, Lawrence B., Bonding and Attachment, When it Goes Awry, p. 1-4, (2004)
       http.//attachment.adoption.com 

12. Smith, Lawrence B., L.C.S.W.-C., L.I.C.S.W., What Is Attachment? P. 1-3
       http://attachment.adoption.com., lbsmith@annapolis.net.

13. Smith, Linda Ann, Attachment Disorder: part III Enemy Within p. 1-3
       http://attachment.adoption.com.

14. Thomas, Nancy, Taming The Tiger, While It’s Still A Kitten p. 1-2 (2004)
       http://www.attachment.adoption.com.

15. Wesselman, Debra, “Whole Parent,” p. 3-4 (1998) Insight Books.