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

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

Although the four patterns of attachment are used to describe designated patterns of infant behavior in the Strange Situation experiment, they can also be used symbolically to understand John's behaviors as an older child. John exhibited conflicted behaviors towards others in accordance with the disorganizeddisoriented pattern. At times he would seek proximity to and interaction with adults, and at other times he would actively attempt to distance himself from them. His frequent attempts to secure peer approval were interspersed with socially unacceptable behaviors that peers found reprehensible. He did not seek comfort from adults and refused it when it was offered during periods of distress, but he expressed reproach when his perceived needs were not met. In terms of the RAD diagnosis, John's symptoms cannot easily be classified as primarily inhibited or disinhibited. Approximately 20% of the children in one sample of maltreated toddlers were found to have characteristics of both subtypes of RAD (Zeanah et al., 2004). John appeared to be inhibited in his ability to form close, emotionally connected relationships to others, but he appeared disinhibited in his immediate attempts to engage with anyone he encountered.

According to Schore's perspective (1994, 2002), John's experiences with his early caregiver would have prevented his right hemisphere from developing normally. Since his biological mother did not provide adequate regulation of John's internal affective states, John's brain would not have been able to maintain its neural connections effectively, and a state of internal collapse and dissociation would have resulted. Later correlates of these early crises would be an inconsistent sense of self and an inability to perceive and understand the emotional states of others. This provides another way to understand John's antisocial behaviors with his peers and his apparent indifference to approval or disappointment from adults. In psychodynamic terms, it would also help to illuminate the complexity of the staff's countertransferential reactions to John. Since John himself did not have the capacity to maintain internal affective consistency, his own rapidly shifting emotional states were reflected in the widely disparate feelings he evoked in others. In addition, the lack of stability in his selfhood could create a proverbial blank slate for the projection of staff's own anxieties and insecurities, which might help to explain the multiple contradictions in the team's suggestions for him.

Using attachment theory to determine John's treatment plan would have yielded a set of recommendations that would not fit easily into the existing treatment program. An attachment perspective would indicate that John's behaviors were the result of his desperate attempts to maintain a semblance of internal stability amid complex external stimuli. He would be viewed as a child who had developed coping strategies that were effective for him in an unstable, unpredictable environment. His internal working models for interpersonal relationships would have been defined by his experiences with caregivers who were not only neglectful of his needs but who also actively harmed him. Because these strategies and models were neurologically encoded during his early brain development, they would be expected to continue even when he was placed in a relatively safe and consistent living situation.