Attachment issues

Attachment is the deep emotional bond formed between a child and their caregiver. The quality of this attachment is critical for the emotional and social development of children. In addition, it has an enduring effect on the nature of future relationships and wellbeing.

Attachment theory explains how this bond develops and how different styles of attachment are formed. A secure style of attachment leads to the best outcomes for people. Secure attachment lays the foundations for resilience and stable, positive relationships in adulthood. It is most likely to develop when caregivers respond sensitively to the child’s needs and provide reliable and consistent care.

For various reasons, when children do not receive sufficient care, they may not develop a secure attachment style. This can adversely affect relationships and mental health in both childhood and adulthood. There is no quick, complete fix for attachment issues. However, with appropriate support and a skillful therapist, it is possible to develop positive, healthy relationships.

Types of attachment issues

There are two broad types of attachment:

• Secure attachment: This is the ideal form of attachment, where a trusting and secure bond is formed between the child and caregiver, leading to better outcomes over the longer-term.
• Insecure attachment: The trusting and secure bond between child and caregiver has not been established; the child does not trust that their needs will be met.

The Diagnostic and Statistical Manual for Mental Disorders (DSM 5) recognizes two types of attachment disorders. These are diagnosed during childhood, where a child has experienced extremes of insufficient care.

• Reactive Attachment Disorder (RAD) is characterized by emotionally withdrawn behavior.
• Disinhibited Social Engagement Disorder (DSED) is characterized by over-familiar social behavior. Normal social boundaries are overstepped without regard for safety.

While there are no formal diagnoses for attachment issues in adults, the effects of the attachment style formed in childhood can be seen in adulthood. For example, adults may continue to have difficulty with close relationships or experience codependency. Or, they may struggle with symptoms of anxiety, depression or other mental health challenges. It’s equally important for adults and children to receive help.

Causes of attachment issues

A number of different situations can lead to an increased likelihood of developing an attachment issue. Children are at increased risk if:

• Their caregiver responds inconsistently or is unreliable in their care
• The child has multiple or changing primary caregivers or insensitive caregivers
• The child experiences neglect
• They experience trauma
• They experience separation from the caregiver

Prevalence of attachment issues

There currently isn’t enough data available to determine the prevalence of RAD and DSED in the general population. One UK study found that 1.4% of deprived children met diagnostic criteria for RAD. (1) In a Norweigan study, researchers diagnosed RAD in 19.4% of foster children, revealing a relatively high prevalence. (2)

Some sources estimate that around 35% of American middle-class children have an insecure attachment style, although it does not necessarily follow that they are experiencing one of the diagnosable conditions described above.

Symptoms of attachment issues

If you or a child experience some of the following symptoms, seek an evaluation from a qualified mental health professional for attachment issues:

• Difficulty forming emotional bonds to others
• Limited experience of positive emotions
• Difficulty with physical or emotional closeness or boundaries
• Anxiety
• Mood changes
• Intense reactions to changes in routine or attempts to control
• Engaging in high-risk behaviors such as substance abuse
• Behavioral difficulties or unpredictable behavior
• Relationship problems

Some of these symptoms are similar to those of other mental health diagnoses, such as Autism Spectrum Disorder or Depression. Therefore, if you experience some of these symptoms, it’s important to see a qualified mental health professional for an accurate diagnosis.

Treatments options for attachment issues

There are a number of treatment options to help support children and adults with attachment issues, but therapy is an important component. Effective treatment usually involves a combination of the following:

• Therapy: Talking therapies in individual or family contexts can help improve attachment, address mental health or behavioral challenges, and help children and adults heal from trauma. Therapists can help children  make sense of their feelings and provide them with coping strategies. They can also help adults understand how past experiences and upbringings may have caused attachment issues they experience today, and improve any unhealthy relationship dynamics.
• Education: The caregiver (or replacement caregiver) of a child with attachment issues may benefit from learning positive behavior management and communication strategies or attending parenting skills classes. A therapist can provide this and help facilitate a nurturing relationship between the child and caregiver.
• Helplines: If you need immediate support, call 1-800-273-8255, or go to the National Suicide Prevention Lifeline website. If you think a child is in danger or at risk, contact the Childhelp National Child Abuse Hotline at 1-800-422-4453.
• Self-care: People with attachment issues sometimes haven’t had the opportunity to learn good self-care habits. It’s important to get an appropriate amount of sleep, eat nutritious foods, exercise regularly and learn helpful self-talk and self-soothing skills.
• Online resources: Explore self-guided psychological and educational resources online. The Child Welfare Information Gateway, for example, has some helpful resources for parenting children who have experienced abuse or neglect.
• Check-up: See your physician to explore or rule out any physical factors contributing to symptoms. If other issues are present, such as depression, some people may benefit from medication as well as psychological therapy.

Therapy for attachment issues

There is a range of therapeutic approaches available that can help people experiencing attachment issues, including:

• Cognitive Behavioral Therapy (CBT) helps change unhelpful thoughts and behaviors, and create better balanced perspectives. In particular, Trauma-Focused CBT can help children and adults heal from traumatic experiences.
• Psychodynamic Therapy is better suited to adults, and explores how past relationships with parents or caregivers may influence current relationships, patterns of thought, emotion, and behavior. Accelerated Experiential Dynamic Psychotherapy is a particular approach that draws on attachment theory.
• Emotionally Focused Couples Therapy helps couples experiencing relationship difficulties to develop the trusting and secure bond that is considered to be of utmost importance in attachment theory.
• Family Systems Therapy helps all family members to understand and learn to better support each other.
• Art Therapy or other creative arts therapies are helpful for people who have difficulty expressing their thoughts and emotions. You don’t need to be creative or good at art to benefit from it.
• Sand tray therapy can be particularly helpful for enabling children to express themselves nonverbally and learn skills for interacting appropriately with others.
• Mindfulness Practices helps to become more aware of thoughts and emotions without automatically reacting to them.

It’s important to consider different therapy types and how they resonate with you before choosing. If you’re unsure, your prospective therapist is a great person to seek advice from.

What to look for in a therapist for attachment issues

The best-fitting therapist depends on individual factors, symptoms, your location and finances. Other factors to consider include:

• Specialized therapists: It’s important to work with a therapist who specializes in the treatment of attachment issues. Therapists for young people often identify themselves as “child and adolescent therapists,” or will have “adolescents” or “teenagers” indicated as a clientele type on their website or online profile. Adults seeking therapy could look for a psychodynamic therapist, or those specializing in attachment theory, relationship problems, family issues, or trauma-focused therapy.
• Qualifications: With so many different provider types available, it can be difficult to decide which type of mental health professional to see. The most important thing is to look for a currently licensed mental health professional. That said, if you think medication might be needed, you’ll want to make sure you see a psychiatrist. This particular type of mental health professional is able to prescribe.
• Relationship: The trusting relationship with a therapist is called the therapeutic alliance, and it’s the number one indicator of treatment efficacy. This is particularly important for people with attachment issues who can have difficulty with close relationships.

The best way to judge how you might feel about a therapist is to ask for a preliminary phone call. This also enables you to ask about their experience and what therapy with them will be like. Try to speak to a few different therapists before deciding on a provider.

Sources and references

1. Minnis, H., et al., (2003). Prevalence of reactive attachment disorder in a deprived population
2. Lehmann, S., et al., (2013). Mental disorders in foster children: a study of prevalence, comorbidity and risk factors
3. Bowlby, Richard. Attachment Theory: How to help young children acquire a secure attachment (PDF).
4. Elizabeth E. Ellis & Abdolreza Saadabadi, Reactive Attachment Disorder
5. Medscape, Attachment Disorders