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Paul Gaffney, of the Association for Psychological Therapies, and Cheryl Liberati-Comiskey examine the role of attachment theory in understanding some of our most troubled children

As professionals who work with young people who present with suspected mental health difficulties, one of the key questions each time a child is referred is why the child is behaving in the way that they are (whether this be hyper-activity, self-harm, disordered eating or difficult behaviour). One of the difficulties for all of us who work with young people is the need to both try to help solve the problem behaviour and to find an agreed story or formulation with the family and with the young person and those who care for them, as to how the problem arose and how to prevent it happening again. In this context, attachment theory and knowledge of attachment disorder can be helpful in addressing some of these questions

Growing out of the work of John Bowlby and Mary Ainsworth, attachment theory has given us a very useful understanding of how children begin to see the world through their early experiences. Bowlby and Ainsworth noted how important the relationship between the child and parent is. More difficult early experiences seem more predictive of future problems. For example, a child who was largely ignored when in need as an infant may grow to see the world and other people as uncaring and even threatening, thus developing an anxious view on life. This could render the person much more vulnerable to developing mental health problems. However, children with more positive experiences of their early years, perhaps through more consistent attention and nurturance, seem to develop in a way that make them less prone to later mental health difficulties.

Attachment theory is mainly concerned with a child being in a state of distress and the subsequent response of the parent or caregiver. This state of distress could include an infant being hungry, tired, or even unwell, or the infant reacting to an environment that may be unsafe, frightening, threatening or confusing. It could even include the parent or caregiver being unavailable emotionally and/or physically to the child. Once the child becomes distressed, the attachment system is triggered in order to get a response from the parent or caregiver to provide them with comfort. Attachment behaviour is goal-oriented behaviour aimed at getting the child in proximity to the parent or caregiver in order to receive comfort from this distress state. Attachment behaviour can include an infant crying, a young child turning to a parent for a cuddle or even a teenager looking for a shoulder to cry on.

An important point to remember is that when this attachment behaviour achieves its goal of comfort, the attachment system seems to turn off and the child is left to explore the world around them. Not only does the child receive comfort, but the child is also left with feelings of safety and security; this consistent experience of being comforted helps the child in regulating their own emotions and shapes their expectations or predictions of how they will behave in distressing situations in the future.

There are two basic types of attachment: secure and insecure. In secure attachments, the child experiences the parent or caregiver as responsive, predictable in how and when they will respond and also consistent in giving the child comfort and reassurance (Dallos, 2006).  The parent or caregiver is also attuned to the child’s emotional and physical needs and can relate to what they believe the child is thinking or feeling. Because children with secure attachments are able to predict their parents' or caregivers’ behaviour, they are able to express their feelings and are free psychologically to explore their world.

In insecure attachments, from which attachment disorder is thought to develop, there are three different subcategories: avoidant, anxious/ambivalent and disorganised/disoriented. In the avoidant attachment style, the child experiences the parent as repeatedly and predictably unavailable and/or the child is rejected when they attempt to get close to the parent (Dallos, 2006). Therefore, the child may learn to distract themselves from their emotional or even physical needs for attachment and becomes involved in active inattention to threatening events and suppression of thoughts and/or memories that may trigger any distressing feelings (Dallos, 2006). The child may become more preoccupied with objects than people and/or may become more task oriented than emotion oriented.

In the anxious/ambivalent attachment style, the parent and/or caregiver may be unpredictable and inconsistent in responding to the child when in a distressed state. Therefore, the child’s attachment behaviour may be exaggerated in order to get some response from the parent.  This behaviour may look like anger, fear, crying, whining, clingy behaviours, dependant or helpless behaviours, and/or provocative behaviours. The parent or caregiver’s inconsistent response triggers the child to become hypervigilant in order to maximise the possibility of getting a response from the parent or caregiver. This hypervigilance leaves the child preoccupied with getting a response and decreases their exploration of the world, leaving them in a distressed state (Dallos, 2006). 

In the last sub-category, disorganised/disoriented attachment style, the parent and/or caregiver is experienced as frightening and/or frightened and this can activate two incompatible responses in the child: avoid and approach. Avoidance comes from experiencing danger, while the approach is the attachment behaviour from the child looking for proximity to the parent or caregiver to receive comfort and be relieved of the distress. When a parent or caregiver is frightened, the parent or caregiver may become consumed with their distress or anxiety or even past trauma histories. The child becomes frightened from the parent or caregiver’s fear and does not know whether to approach them for comfort and/or to avoid them (Byng-Hall, 2008). Therefore, the child is left with a disorganised or disorienting view of themselves and of the world. 

This attachment style may occur in families where physical, emotional, and/or sexual abuse has occurred, or in cases of severe neglect, substance abuse or misuse, domestic violence, and/or when the child has had several placements in foster families or care settings. In turn, some children may develop controlling and compulsive care-giving strategies as means of responding to their environment and dealing with other people.

These categories can help us better understand the experience of both the child and their family and can help us to decide which interventions may be most appropriate. The key idea when addressing attachment disorder in clinical work is not to simply use these theories to blame parents, but instead to use this understanding to help deal with present problems, create a more positive parent/child relationship and to work together to create a better future for the young person.

Further information and references
Byng-Hall, J. (2008)  Crucial roles of attachment in family therapy.  Journal of Family Therapy, 30: 129-146.

Dallos, R.(2006)  Attachment Narrative Therapy:  Integrating Narrative, Systemic and Attachment Therapies. Maidenhead and New York. Open University Press. 

If you are concerned about attachment disorder, consult your family doctor and seek a specialist referral.

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