As a theory of socioemotional development, attachment theory has implications and practical applications in social policy, decisions about the care and welfare of children and mental health.
Child Care Policies
Social policies concerning the care of children were the driving force in Bowlby’s development of attachment theory. The difficulty lies in applying attachment concepts to policy and practice. This is because the theory emphasises the importance of continuity and sensitivity in caregiving relationships rather than a behavioural approach on stimulation or reinforcement of child behaviours. In 2008 C.H. Zeanah and colleagues stated, “Supporting early child-parent relationships is an increasingly prominent goal of mental health practitioners, community based service providers and policy makers … Attachment theory and research have generated important findings concerning early child development and spurred the creation of programs to support early child-parent relationships”.
Historically, attachment theory had significant policy implications for hospitalised or institutionalised children, and those in poor quality daycare. Controversy remains over whether non-maternal care, particularly in group settings, has deleterious effects on social development. It is plain from research that poor quality care carries risks but that those who experience good quality alternative care cope well although it is difficult to provide good quality, individualised care in group settings.
Attachment theory has implications in residence and contact disputes and applications by foster parents to adopt foster children. In the past, particularly in North America, the main theoretical framework was psychoanalysis. Increasingly attachment theory has replaced it, thus focusing on the quality and continuity of caregiver relationships rather than economic well-being or automatic precedence of any one party, such as the biological mother. However, arguments tend to focus on whether children are “attached” or “bonded” to the disputing adults rather than the quality of attachments. Rutter noted that in the UK, since 1980, family courts have shifted considerably to recognize the complications of attachment relationships. Children tend to have security-providing relationships with both parents and often grandparents or other relatives. Judgements need to take this into account along with the impact of step-families. Attachment theory has been crucial in highlighting the importance of social relationships in dynamic rather than fixed terms.
Attachment theory can also inform decisions made in social work and court processes about foster care or other placements. Considering the child’s attachment needs can help determine the level of risk posed by placement options. Within adoption, the shift from “closed” to “open” adoptions and the importance of the search for biological parents would be expected on the basis of attachment theory. Many researchers in the field were strongly influenced by it.
Clinical Practice in Children
Although attachment theory has become a major scientific theory of socioemotional development with one of the broadest, deepest research lines in modern psychology, it has, until recently, been less used in clinical practice than theories with far less empirical support.
In the early months of life, babies will direct attachment behaviours towards anyone in the vicinity. As attachment develops, so does age-appropriate stranger wariness.
This may be partly due to lack of attention paid to clinical application by Bowlby himself and partly due to broader meanings of the word ‘attachment’ used amongst practitioners. It may also be partly due to the mistaken association of attachment theory with the pseudoscientific interventions misleadingly known as “attachment therapy”.
Prevention and Treatment
In 1988, Bowlby published a series of lectures indicating how attachment theory and research could be used in understanding and treating child and family disorders. His focus for bringing about change was the parents’ internal working models, parenting behaviours and the parents’ relationship with the therapeutic intervenor. Ongoing research has led to a number of individual treatments and prevention and intervention programmes. They range from individual therapy to public health programmes to interventions designed for foster carers. For infants and younger children, the focus is on increasing the responsiveness and sensitivity of the caregiver, or if that is not possible, placing the child with a different caregiver. An assessment of the attachment status or caregiving responses of the caregiver is invariably included, as attachment is a two-way process involving attachment behaviour and caregiver response. Some programmes are aimed at foster carers because the attachment behaviours of infants or children with attachment difficulties often do not elicit appropriate caregiver responses. Modern prevention and intervention programmes are mostly in the process of being evaluated.
Reactive Attachment Disorder and Attachment Disorder
One atypical attachment pattern is considered to be an actual disorder, known as reactive attachment disorder or RAD, which is a recognized psychiatric diagnosis (ICD-10 F94.1/2 and DSM-IV-TR 313.89). The essential feature of reactive attachment disorder is markedly disturbed and developmentally inappropriate social relatedness in most contexts that begins before age five years, associated with gross pathological care. There are two subtypes, one reflecting a disinhibited attachment pattern, the other an inhibited pattern. RAD is not a description of insecure attachment styles, however problematic those styles may be; instead, it denotes a lack of age-appropriate attachment behaviours that amounts to a clinical disorder. Although the term “reactive attachment disorder” is now popularly applied to perceived behavioural difficulties that fall outside the DSM or ICD criteria, particularly on the Web and in connection with the pseudo-scientific attachment therapy, “true” RAD is thought to be rare.
“Attachment disorder” is an ambiguous term, which may be used to refer to reactive attachment disorder or to the more problematical insecure attachment styles (although none of these are clinical disorders). It may also be used to refer to proposed new classification systems put forward by theorists in the field and is used within attachment therapy as a form of unvalidated diagnosis. One of the proposed new classifications, “secure base distortion” has been found to be associated with caregiver traumatization.
Clinical Practice in Adults and Families
As attachment theory offers a broad, far-reaching view of human functioning, it can enrich a therapist’s understanding of patients and the therapeutic relationship rather than dictate a particular form of treatment. Some forms of psychoanalysis-based therapy for adults—within relational psychoanalysis and other approaches—also incorporate attachment theory and patterns. In the first decade of the 21st century, key concepts of attachment were incorporated into existing models of behavioural couple therapy, multidimensional family therapy and couple and family therapy. Specifically attachment-centred interventions have been developed, such as attachment-based family therapy and emotionally focused therapy.
Attachment theory and research laid the foundation for the development of the understanding of “mentalization” or reflective functioning and its presence, absence or distortion in psychopathology. The dynamics of an individual’s attachment organization and their capacity for mentalization can play a crucial role in the capacity to be helped by treatment.