During infancy, a profound emotional connection is established between a baby and their caregiver. This attachment can exhibit varying degrees of quality and significantly influences a child's developmental journey. Additionally, the attachment experience formed during early stages shapes how individuals approach and build adult relationships as they mature. In instances where the quality is unfavorable, it may result in the development of attachment issues.
Attachment Theory explains how these bonds with caregivers develop and how different styles of attachment are formed. Healthy attachments lay the foundation for resilience, positive interactions, and stable relationships in adulthood, which are most likely to develop when primary caregivers respond sensitively to a child's needs and provide reliable and consistent care.
For various reasons, when children receive inconsistent caregiving, they may not develop healthy bonds. This can adversely affect emotional relationships and mental health conditions in both childhood and adulthood. There is no quick, complete fix for disturbances of attachment. However, with proper 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 selective attachment bond, where a strong sense of trust is formed between the child and the primary or familiar caregiver, leading to better relationship and mental health outcomes over the longer-term.
- Insecure attachment: The selective attachment bond between caregiver and child 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- Reactive Attachment Disorder (RAD) is characterized by emotionally withdrawn behavior.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) or Disinhibited Attachment Disorder, is characterized by over-familiar social behavior. Normal social boundaries are overstepped without regard for safety.
While there are no formal diagnostic guidelines for attachment disorders in adults, the effects of the attachment bond formed in childhood can be seen in adulthood. For example, adults may continue to have difficulty with romantic relationships or experience codependency. Or they may struggle with symptoms of emotional disorders like anxiety, depression or other mental health challenges. It's equally important for adults and children to receive help.
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 emotional or social neglect
- They experience trauma or physical abuse
- They experience abrupt separation from the caregiver
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.
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 and underdeveloped social skills
- Emotional neglect or limited experience of positive emotions
- Difficulty with physical or emotional closeness or boundaries
- Mood changes
- Poor emotional regulation with intense reactions to changes in routine or attempts to control
- Engaging in high-risk behaviors such as substance abuse
- Behavioral difficulties or unpredictable behavior; outbursts or other emotional issues
- 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.
Attachment in Adults
There are 4 styles experienced by people with attachment issues of all ages. These types of mental and physical health challenges are usually rooted in childhood issues that influence development and social interactions as a person matures. They are outlined as:
- Secure: is a healthy and positive early childhood bond formed between an infant and their caregiver. It involves trust, safety, and emotional regulation, allowing individuals to explore the world confidently. Those with secure attachment have a positive view of themselves and others, cultivate strong social skills, establish healthy boundaries, and are more likely to have stable, fulfilling, and intimate relationships throughout their lives.
- Anxious- Preoccupied: An anxious attachment style is characterized by high levels of anxiety and a low tendency to avoid intimacy in relationships. Individuals with this style often seek reassurance and may have difficulty trusting others. They tend to harbor fears of abandonment or being unloved, leading to a constant need for validation and attention from their partners.
- Dismissive-Avoidant: The dismissive-avoidant attachment style is characterized by low levels of anxiety and a high tendency to avoid intimacy in relationships. Individuals with this style may appear emotionally distant and have difficulty expressing their feelings or seeking support from others. They often value independence and may struggle with committing to close relationships due to a fear of vulnerability and dependence on others.
- Fearful-Avoidant (Disorganized): The fearful-avoidant attachment style is characterized by prominent levels of anxiety and avoidance in relationships. Individuals with this style desire emotional closeness but also have deep fear of rejection and abandonment, leading to conflicting emotions and difficulty in forming and keeping intimate relationships. They may have experienced abuse during childhood and inconsistent caregiving, contributing to their ambivalent approach to relationships in adulthood.
Attachment in children
There are 4 styles experienced by children with disorders of attachment that differ slightly from adults. These styles are highly influenced by inadequate care and impact social development. They are:
- Secure attachment in children is a healthy and positive bond formed with their primary caregiver. It is characterized by trust, comfort, and the ability to seek support when needed, leading to confident exploration and emotional regulation. These children tend to hit developmental milestones without delay and form a strong basis for future relationships.
- Anxious-ambivalent attachment in children is characterized by elevated levels of anxiety and a strong dependency on the caregiver. These children may display clingy behavior, seek excessive reassurance, and have difficulty calming down after being upset. They may feel uncertain about the availability of their caregiver's support, leading to inconsistent feelings of security in the relationship.
- Avoidant-insecure attachment in children tends to avoid or distance themselves from their caregivers. These children may appear emotionally distant, avoid physical touch, have difficulty expressing emotions, and show little distress when separated from their caregivers. They may have learned to suppress their needs due to past experiences of irresponsiveness from their caregiver, leading to a sense of self-reliance and a reluctance to seek comfort or support from others.
- Disoriented or Fearful-Avoidant Attachment (or Disorganized-insecure) in children is characterized by inconsistent and unpredictable behavior in response to their caregiver. These children may display contradictory emotions, such as showing deep fear or freezing during interactions with caregivers. Disorganized attachment style often arises from experiences of abuse, neglect, or other childhood trauma, leading to a lack of clear coping strategies and difficulty in forming a coherent emotional attachment.
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:
- Attachment Therapy: Talking therapies in individual or family therapy contexts can help develop secure attachment styles, 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 upbringing may have caused unhealthy attachment styles that they experience today and improve any interpersonal relationship dynamics and work through fear of rejection.
- Education: The primary caretaker (or replacement caregiver) of a child with attachment issues may benefit from learning positive behavior management and communication strategies or attending classes to improve poor parenting skills. A therapist can provide this and help facilitate a nurturing healthy bond 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: Adults 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.
Assessment for attachment difficulty and Therapy
There is a range of therapeutic approaches available that can help people experiencing issues with attachment security, effective treatment plans may include:
- 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
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 distinct attachment disorders. Therapists for young people or children with attachment problems 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. Therapists in the care of children may use different modalities. Adults seeking therapy could look for a psychodynamic therapist, or those specializing in attachment in 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 bond issues who can have difficulty with close relationships and may need a safe space for recovery.
Your primary care doctor may be a reliable source for a secondary care specialist or therapist. 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
- Minnis, H., et al., (2003). Prevalence of reactive attachment disorder in a deprived population
- Lehmann, S., et al., (2013). Mental disorders in foster children: a study of prevalence, comorbidity and risk factors
- Bowlby, Richard. Attachment Theory: How to help young children acquire a secure attachment (PDF).
- Elizabeth E. Ellis & Abdolreza Saadabadi, Reactive Attachment Disorder
- Medscape, Attachment Disorders