Understanding Reactive Attachment Disorder

by Heather Forbes, LCSW

Perhaps you have been seeking a more scientifically based explanation of attachment and attachment-based treatment for funding or services, or just want to understand upon what foundation the love-model is based. The article below can serve as such a resource for you. Throughout the article, you will notice that all the information presented is backed by scientific sources. All of these sources are peer-reviewed articles published in research journals; journals where every article is scrupulously reviewed prior to being published. This increases the validity and reliability of the information presented. My hope is that it will be a valuable and helpful resource for you and your family to move forward in your healing journey or to simply understand more about the foundations of the love-model of parenting.

To fully understand the attachment disordered child, or the child diagnosed with reactive attachment disorder (RAD), a discussion of attachment theory is warranted. "Much of the research examining mother-child interactions in neglectful families has been conducted within the attachment theory model" (Hanson & Spratt, 2000). Attachment theory addresses and helps to comprehensively explain RAD.

The genesis of attachment theory is from the work of John Bowlby. Bowlby's writings, including the Attachment Trilogy, grew out of of psychoanalytic theory in order to emphasize "the role of the child-parent relationship in the development of the personality and psychopathology" (George, 1996). As seen by Bowlby, the basic nature of the child's tie to his or her mother is protection. Children are evolutionarily predisposed to form a close, trusting, dependent bond with their mother at the moment of life (Hardy, 2007). The fulfillment of their physiological needs requires close and frequent physical contact throughout infancy (Carlson, Sampson, & Sroufe, 2003).

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). 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. Thus, normal development occurs in a social context, which begins for a child in the mother-child relationship at birth. As the mother, or primary caregiver, cares for and engages with the child, attachment develops...attachment is developed within this process. It is not an innate individual trait (Carlson, et al., 2003).

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).

Thus, the attachment system is maintained by a system of reciprocal feedback between the mother and child, in which the child uses the mother as a secure base, thus using her as a regulator (Benedict, 1998). Stern emphasizes (as cited in Schwartz & Davis, 2006) that "in the development of a secure attachment, the infant is able to draw upon the mother for responsive, nurturing and reliable care for regulating distress." The infant's capabilities to self-regulate are insufficient, thus caregiver responsiveness is imperative (Carlson, et al., 2003).

Previously, attachment was viewed primarily as a relationship between parent and child in order to satisfy a child's need, such as hunger. A need's cycle was often used to describe the child's instinctive search to satisfy that need from his mother; the mother then responded to meet and satisfy the need. The final step in this cycle was when the child was satisfied, receptive to his mother's gratifying efforts, and returned to a state of homeostasis. Yet, it is now seen that attachment penetrates much deeper than the obvious benefits of having one's basic needs for food and protection satisfied. It is the relationship between the primary caretaker and the child that is of primary importance. This relationship ensures the optimal development of the child's emotional and physiological regulation (Haugaard & Hazan, 2004). Schore (as cited in Schwartz & Davis, 2006) posited when a child experiences the consistency of an attuned caregiver who assists the child in shifting his/her levels of arousal and emotional states, the child develops the ability to cope and respond appropriately to stress.

Schore's work in the past decade has essentially reframed basic attachment theory as a regulatory theory. "He described attachment as a primarily dyadic emotion-regulation system of interactions between child and parent that foster emotional regulation and create transactional patterns, which lead to a secure attachment" (Schwartz & Davis, 2006). Children who experience this secure attachment are then equipped to regulate their own affect and develop internal coping mechanisms for self-regulation. Conversely, children with early trauma-attachment experiences, histories of abuse and neglect, and breaks in primal relationships have been seen to be at a significant risk of behavioral difficulties (Kennedy & Kennedy, 2004, as cited in Schwartz & Davis, 2006). The result is a child whose regulatory system is underdeveloped, leaving him unequipped in a world where he is expected to behave appropriately and to be able to follow directions without the internal mechanisms to do so.

Many therapies for RAD have isolated the child in the treatment plan and placed the child at the center of clinical intervention (Barth et al., 2005). Most of these therapies do not routinely require the parents to take responsibility for their own reactions, stress, and feelings of rejection. These therapies and techniques disregard the concept that attachment happens in the context of a relationship and negate the necessity of the parent to be in a state of compassion, emotional openness, and warmth. Rather, these methods are confrontive, controlling, and unidirectional (Barth, et al., 2005).

Treatment methods, therefore, must reflect what has been sustained by scientific research. Attachment theory, with the reframing of regulatory theory through the work of Dr. Allan Schore, provides a solid foundation for the implementation of practice strategy in treating RAD and attachment disorders because it clearly delineates the source of these children's behaviors. Regulatory theory refers to a pattern of behavior within a relationship. It is not a theory of outcome, it is a theory of process. "Regulatory capabilities are at first dyadic, with the parent taking an important co-regulating role in scaffolding regulation" (Dozier, et al., 2006). A nurturing parent's role is to help the child develop his/her own regulatory capabilities. Through the safety of this relationship, the child generally comes to take over regulatory functions independently (Dozier, et al., 2006). Dysregulation occurs when relationships are disrupted or when parents and caregivers demonstrate inappropriate or stressful care. This dysregulation occurs within the body system, leaving the child in a stressful state at a neuro-biological level with a stress response system that puts them at risk for later problematic outcomes (Dozier, et al., 2006).

Attachment and regulation are not merely developmental tasks to achieve; it is this experience that builds a framework in which children relate to their external environment. In order to help children with underdeveloped regulatory systems, it is the parents' role to create an environment that fosters the child's regulatory capabilities. A predictable, controllable interpersonal environment will give the child the opportunity to develop his/her regulatory capabilities (Dozier, et al., 2006).

It is also important to recognize that the behavioral system is only a communication or an indicator of the child's attachment system. Too often, professionals neglect this concept and work solely with the behaviors of a child, not assessing or addressing the child's emotional state or attachment state. Using fear-based techniques, which are based on power, control, and submission blatantly contradict what is known about attachment and the neurobiology of interpersonal behavior (Becker-Weidman, 2006). Within the attachment framework, it is understood that the behaviors are simply a manifestation of the strained attachment between the parent and child. Attachment theory directly identifies these troubling behaviors as symptomatic of insecure attachments.

With this understanding, it can be seen that “the building blocks of secure attachment are interactive moments in which the caregiver’s sensitively attuned behavior serves to help the child develop an internal sense of security” (AACAP, 2005). The parent is to serve as the external regulator of the child’s internal emotional state. The parent’s role is vital to the child’s healing. In a study by Dozier, Stovall, Albus, and Bates (2001), it was “found that the attachment classification of a foster mother has a profound effect on the attachment classification of the child” (as cited in Becker-Weidman, 2006). After three months of being in a foster placement, the child’s attachment classification became similar to that of the foster mother’s attachment classification. This finding reveals the significance and impact of healthy and healing relationships to the child’s ability to find connection in relationships.

Treatment requires maintaining “an affectively attuned relationship with the child, a deep acceptance of the child’s affect and experience, and greater emphasis on experience and process” (Becker-Weidman, 2006) rather than outcome. The treatment must work to redefine the child’s negative internal working models and to change the child’s “blueprint” of their caregivers. It is to be experientially oriented with the goal of securing the child’s base for comfort and regulation. Specifically, intervention needs to include three components in order to create a secure base for a child with RAD. First, is to learn to follow the child’s lead, or simply, to meet the child where he is. Second, is to help parents/caregivers provide more touch, cuddling, and hugging for their child as this has been associated with both behavioral and biobehavioral regulation (Dozier, et al., 2006). Third, is to help parents/caregivers to create an environment that is open to emotional expression and for parents to gain a deeper understanding of emotions. Research by Schultz, Izard, & Bear (as cited in Dozier, et al., 2006) has shown that emotional expression and emotional understanding have been linked to better behavioral regulation.

Congratulations! You made it all the way through to the end. Did you read that last line? That’s all you really need to know: “Emotional expression and emotional understanding have been linked to better behavioral regulation.” Giving your children emotional space, understanding, unconditional love, and acceptance is far more powerful than stressing yourself out about what consequences to implement. Stay focused on enriching your relationship with your child and the respect, the obedience, the self-motivation, and the self-control you’ve been longing for will have automatically surfaced!

Keep pressing on!
Heather Talbert Forbes

List of Resources for this article:

AACAP (2005). Practice parameter for the assessment and treatment of children and adolescents with reactive attachment disorder of infancy and early childhood. Journal of the American Academy of Child and Adolescent Psychiatry(44), 11, 1206-1219.

Barth, R.P.; Crea, T.M.; John, K.; Thoburn, J.; & Quinton, D. (2005). Beyond attachment theory and therapy: Towards sensitive and evidence-based interventions with foster and adoptive families in distress. Child and Family Social Work, 10, 257-268.

Becker-Weidman, A. (2006). Treatment for children with trauma-attachment disorders: Dyadic developmental psychotherapy. Child and Adolescent Social Work Journal, 23(2), 147-171.

Benedict, N.J. (1998). Reactive attachment disorder: A neuropsychological study. Dissertation Abstracts International, 59(7B), 2680. (UMI Libraries No. 717).

Bowlby, J. (1988). A secure base. London: Routledge.

Bowlby, J. (1982). Attachment. New York: Basic Books.

Carlson, E.A., Sampson, M.C., & Sroufe, L.A. (2003). Implications of attachment theory and research for developmental-behavioral pediatrics. Development and Behavioral Pediatrics, 24, 364-379.

Dozier, M.; Peloso, E.; Lindhiem, M.; Gordon, M.K.; Manni, M.; Sepulveda, S.; Ackerman, J.; Bernier, A.; & Levine, S. (2006). Developing evidence-based interventions for foster children: An example of a randomized clinical trial with infants and toddlers. Journal of Social Issues (62), 4, p. 767-785.

George, C. (1996). A representational perspective of child abuse and prevention: Internal working models of attachment and caregiving. Child Abuse and Neglect, 20(5), 411-424.

Hanson, R.F. & Spratt, E.G. (2000). Reactive attachment disorder: What we know about the disorder and implications for treatment. Child Maltreatment, 5(2).

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.

Haugaard, J.J., & Hazan, C. (2004). Recognizing and treating uncommon behavioral and emotional disorders in children and adolescents who have been severely maltreated: Reactive Attachment Disorder. Child Maltreatment, 9 (2), 154-160.

Schwartz, E. & Davis A.S. (2006). Reactive attachment disorder: Implications for school readiness and school functioning. Psychology in the Schools, 43(4), 471-479.

Heather Forbes

Heather Forbes, LCSW, is the co-founder of the Beyond Consequences Institute, LLC. Ms. Forbes has been training in the field of attachment and trauma with nationally recognized, first-generation attachment therapists since 1999. She has been active in the field of adoption with experience ranging from pre-adoption to post-adoption work, including domestic and international adoptions. Ms. Forbes is a published author and presents workshops both nationally and throughout the State of Florida. Much of her experience and insight on understanding trauma, disruptive behaviors, and adoption related issues has come from her direct mothering experience of her two adopted children. She has a passion for helping families to find the peace in their homes that they deserve. For more information, please visit http://www.beyondconsequences.com

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