Attachment Theory and Reactive Attachment Disorder: Theoretical Perspectives and Treatment Implications

Journal of Child and Adolescent Psychiatric Nursing, Feb 2007 by Hardy, Lyons T

Various attempts were made to help John change his behaviors. A special program of more immediate rewards was tried (he earned video game time three times daily for having no aggressive behavior during a specified time period), but John's aggressive behaviors did not decrease. John was engaged in a program of receiving additional one-on-one services with occupational therapy and recreational therapy. At one point when John's behaviors had escalated to a dangerous point, he was required to alternate half hours of time away from the group and time in the unit milieu. Staff attempted to keep John engaged in enjoyable activities during his milieu time, but he often expressed anger at the intrusion or refused to participate. John enjoyed helping adults with tasks and playing games with them, but he always preferred to interact with his peers if given the choice.

John's behaviors elicited a wide range of emotional reactions from staff. Working with him aroused coutertransferential feelings of anger, fear, love, sadness, irritation, affection, helplessness, joy, hope, and hatred. One staff member described her experiences with John as being the precipitant in a personal spiritual crisis. Some staff saw him as conniving, mean, and intentionally oppositional. Others viewed him as intelligent, anxious, and severely damaged. Even for the adults who had a more positive view of John, at times his behaviors were so difficult to accept that they responded in a nontherapeutic manner. The staff could agree that interacting with John was extremely frustrating at times. The multidisciplinary team differed in their perceptions of what would help John. The opinions included a more punitive approach, a less punitive approach, more immediate rewards, more or different medication, more one-on-one adult time, more time with peers, more restrictions, or fewer restrictions

Many believed that residential treatment had made John's behaviors worse and that he should be discharged as soon as possible. Some felt that he had gained enough comfort to begin to express his true reactions to his traumatic past and that discharging him at this point would be detrimental. After several particularly bad episodes, one of which involved John stabbing a peer in the hand with a pencil, the team decided that John could no longer be maintained safely on the residential unit, and he was transferred to the acute unit. He remained there for approximately 1 month until another placement could be secured. Most facilities were unwilling to accept him due to his history of aggressive and sexualized behaviors, and no appropriate adoptive or foster families could be identified. He was finally discharged to a group home.

If John's history and behavior are conceptualized according to an attachment theory perspective, several themes emerge. John's experiences as an infant and young child were most likely characterized by confusion and contradiction. His biological mother did not provide consistent satisfaction of his physical and emotional needs. Since all infants are primed to form attachment bonds, parental behavior dictates the quality of the attachment rather than the quantity (Main, 1996). Maltreated infants are more likely to form insecure attachments (Bacon & Richardson, 2001). Main connects infant maltreatment to the disorganized-disoriented pattern of attachment and describes that pattern as originating from a "collapse of behavioral strategy" on the part of the infant (p. 239). Since the infant seeks the attachment figure for comfort during periods of distress, the infant is unable to integrate its experience when the attachment figure is also causing the distress. The disorganized-disoriented pattern of attachment is characterized by conflicted behaviors such as a frozen trance-like expression or approaching the attachment figure and then turning away.