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The term “attachment” gets thrown around…a lot…There’s some negative history associated with attachment treatment in the past that I think grossly misrepresented attachment. We’re going to review attachment theory basic concepts. If you have had any training in attachment this specific post may not be informative but stay tuned, there will be more. To be able to effectively assess attachment you will need to READ, READ….and READ some more. Take some training with the specific population you are working with as well. I will have to write several different blogs to cover attachment concepts.

Attachment theory was developed by John Bowlby in the 60’s. Attachment theory has some further development with Mary Ainesworth and Mary Main. If you want more information on the development of Attachment theory I would suggest reading more in-depth materials.

When assessing attachment, clinicians need to be looking at infant development (regardless of the client’s age) with the stages of attachment AND the pattern of attachment. Both of these are important. Stages of attachment are based on a progressive development from birth until the age of 18 months. Typically birth – 3 months, there is no specific attachment to adults; from 6 weeks to around 7 months there is preference developing for a primary caregiver, and secondary as well. From 7-11 months, there is a stronger sense of attachment to a primary caregiver. Around 11 months and up, the infant is able to bond to other caregivers. This stage of development was developed by Schaffer and Emerson.

Patterns of attachment develop when an infant displays protesting behaviors; crying, fussing. Then how the caregiver responds creates a behavioral pattern for the infant to get their needs met. Based upon a predicted pattern of these protesting behaviors a strategy develops thus one is able to predict expected behaviors when attachment needs flare up or activate. As the child develops behaviors change but the patterns remain. What I mean by that is, an infant will have different behaviors than a 5 year old, or a 15 year old. However, the underlying need remains the same.

Secure attachment is what we all long for.  Being able to safely explore the world knowing, we have a secure base, whether that be our parent, grandparent, someone whom we are bonded. Someone who validates us, supports us, and allows us to have distance when we need it. We may have moments like this in our relationships but when our attachment needs become activated, our primary pattern emerges. Those of us with an insecure attachment will either experience anxious or avoidant behaviors. These two broad categories offer a description of what an individual experiences.  More specifically, these categories have other names in adulthood; anxious ambivalent and anxious preoccupied. The pattern we have in infancy is likely to be the pattern we have in adulthood. There is A LOT of research behind this; Sue Johnson and Daniel Siegel are some great resources on this topic.

I view attachment as a continuum rather than rigid categories. This is not something I have seen in literature but it something I am developing. But I need to explain. When working through attachment issues and attachment correction I have observed those with avoidant type behaviors will often experience these anxious behaviors when moving towards a secure attachment. Now does that mean their primary pattern has shifted from avoidant to anxious, probably not but it is possible. Research has not touched on this too much and I think we have a lot more to learn. There are limitations of attachment research so learning from clinicians experience is just as important.

The fourth categories of attachment is disorganized. Individuals in this area have experienced harm from those whom they were attached. this happens a lot in early infant and childhood trauma and neglect. These children vacillate between avoidant and anxious. This is because at their core, they do not know who to trust, what to do when this attachment system actives, and will have different behaviors. A lot of these children are misdiagnosed, or rather under-diagnosed.

Just like with everything else, there is severity. A child with severe attachment needs will likely get noticed and diagnosed before one with mild symptoms. A lot of times, these children will receive an ADHD or bipolar diagnosis. While they may meet criteria for that as well, it is important to assess the attachment layer so the underlying attachment injury can be resolved. This goes for those with disorganized attachment, and insecure. Severe attachment disorders are Reactive Attachment Disorder and Disinhibited Social Engagement Disorder. The DSM 5 states that these are rare disorders, however, with my experience, it is not as rare as suggested and simply because clinicians are not looking for it. These children may again, qualify for other disorders as well. RAD kids do not form attachment bonds and I think sometimes may present with disorganized patterns. DSED, in my opinion, is an anxious attachment on steroids. These children form attachment bonds with everyone. They show no fear of strangers.

My biggest concern is most of the clinical population, has attachment issues/injury, especially traumatized children but if this layer of need is not being addressed, this area may not resolve. Sometimes patterns resolve on their own. However, I stand firm in supporting that services can be preventative and proactive in resolving the patterns. I see no reason why a child that has experience attachment or trauma would not be in services regardless of the outward behaviors. There are many many things happening on the sub-conscience and neurobiological level that can be addressed. I think we should honor children with services. Furthermore, helping the caregivers navigate parenting difficulties, growing attachment, transitions and so forth.

Check out my blog on resolving the attachment and trauma issues to help with assessing trauma in the therapy room.


Schaffer HR, Emerson PE. 1964;29:1-77. doi:10.2307/1165727

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