Attachment Disorder and Developmental Disabilities: Understanding, Treatment, and the Positive Systems Approach

Introduction

Attachment disorder is a complex and often misunderstood condition that can significantly impact individuals with developmental disabilities. Early disruptions in caregiver relationships, trauma, or neglect can lead to attachment difficulties, which in turn affect emotional regulation, social skills, and behaviour. For individuals with developmental disabilities, these challenges can be even more pronounced due to cognitive limitations and communication barriers.

Research indicates that individuals with intellectual disabilities (ID) may be at a higher risk of experiencing attachment difficulties. A critical review found a higher prevalence of insecure and disorganized attachment classifications among people with ID. However, the validity and reliability of attachment measures in this population have not been firmly established, highlighting the need for standardized assessments and evaluation of attachment-based interventions. ​PubMed+1SAGE Journals+1SAGE Journals+1PubMed+1

In toddlers with autism and other developmental disorders, studies have shown an increased occurrence of disorganized attachment patterns. The severity of autism spectrum disorder has been associated with higher attachment insecurity, and lower developmental levels have been linked to disorganized attachment. These findings underscore the importance of addressing attachment issues early in children with developmental disorders. ​PubMed

Traditional therapies for attachment disorders, such as Attachment-Based Therapy, Cognitive-Behavioural Therapy (CBT), Play Therapy, and Parent-Child Interaction Therapy (PCIT), may require modifications for individuals with developmental disabilities, particularly those with limited verbal abilities. Adaptations can include the use of visual supports, nonverbal communication strategies, sensory-based interventions, behavioural reinforcement approaches, and caregiver training.​

The Positive Systems Approach (PSA) offers a structured and compassionate framework for addressing attachment-related challenges in individuals with developmental disabilities. PSA emphasizes systematic and consistent support, positive reinforcement over punishment, building emotional regulation skills, strengthening caregiver relationships, and implementing data-driven, individualized strategies.​

Implementing PSA in attachment-focused care involves creating a stable, predictable environment; using visual and behavioural cues; encouraging small, positive social interactions; focusing on caregiver training and support; and utilizing multi-sensory approaches. By integrating PSA principles into treatment, we can provide individuals with developmental disabilities the stability, support, and connection they need to thrive.​

This blog post explores the impact of attachment disorders in individuals with developmental disabilities, the different types of attachment disorders, traditional therapeutic approaches, and how these need to be modified for those with limited language skills. Additionally, we will examine how the Positive Systems Approach (PSA), as outlined in my book Managing Disruptive Behaviours with a Positive Systems Approach, provides an effective framework for addressing attachment-related challenges in this population.

Understanding Attachment Disorders

Attachment disorders stem from disruptions in early caregiving relationships. When a child does not form a secure bond with a primary caregiver, they may develop maladaptive ways of relating to others. This is particularly common in children who have experienced neglect, abuse, or frequent changes in caregivers (e.g., foster care placements).

The three primary forms of attachment disorders recognized in psychological research are:

1. Reactive Attachment Disorder (RAD) – Characterized by withdrawn, emotionally detached behaviour toward caregivers. Individuals with RAD often struggle to seek comfort when distressed and may appear unresponsive to social interactions.

2. Disinhibited Social Engagement Disorder (DSED) – Marked by indiscriminate friendliness and a lack of appropriate social boundaries. Individuals with DSED may approach strangers with little hesitation and struggle with appropriate attachment to caregivers.

3. Avoidant Attachment Disorder – While not always classified as a formal disorder in diagnostic manuals, avoidant attachment patterns can significantly impact individuals. Those with avoidant attachment often suppress emotions and resist seeking support, viewing dependence as unreliable or unnecessary. They may appear highly independent but struggle with deep, meaningful relationships. In individuals with developmental disabilities, this can manifest as social withdrawal, resistance to help, and difficulty forming trusting relationships with caregivers or peers.

Attachment Disorders in Individuals with Developmental Disabilities

Attachment disorders manifest uniquely in individuals with developmental disabilities due to their cognitive and communicative challenges. Some common presentations include:

• Difficulty in forming and maintaining relationships – Individuals may struggle with trust, showing affection, or interpreting social cues.

• Increased anxiety and behavioural challenges – Many individuals exhibit heightened levels of fear, anxiety, or aggression, often triggered by perceived abandonment or inconsistencies in care.

• Sensory and emotional regulation difficulties – Poor attachment can exacerbate sensory sensitivities and lead to difficulties in self-regulation.

• Oppositional and defiant behaviours – Some individuals may exhibit controlling or defiant behaviours as a means of managing perceived threats or instability.

• Communication barriers – Those with limited language skills may express distress through behaviours rather than words, making it harder to diagnose and treat attachment disorders effectively.

• Avoidant behaviours and emotional suppression – Individuals with avoidant attachment may appear disengaged, refuse assistance, or isolate themselves, making intervention challenging.

Traditional Therapies for Attachment Disorders

Traditional treatments for attachment disorders include:

• Attachment-Based Therapy – Focuses on building trust and healthy caregiver-child interactions through structured interventions.

• Cognitive-Behavioural Therapy (CBT) – Helps individuals recognize and modify maladaptive thought patterns related to attachment and trust.

• Play Therapy – Used to help children express emotions and experiences in a nonverbal, developmentally appropriate manner.

• Parent-Child Interaction Therapy (PCIT) – Guides caregivers in fostering positive interactions and reinforcing secure attachment behaviours.

While these therapies are effective for many, they often require modifications for individuals with developmental disabilities, particularly those with limited verbal abilities.

Adapting Therapy for Individuals with Limited Language Skills

For individuals with developmental disabilities, traditional talk-based therapies may not be effective due to communication challenges. Modifications can include:

• Visual Supports and Social Stories – Using pictures and stories to teach social rules and expectations in attachment-related interactions.

• Nonverbal Communication Strategies – Encouraging the use of gestures, facial expressions, and augmentative communication devices to express emotions.

• Sensory-Based Interventions – Incorporating sensory activities (e.g., weighted blankets, deep-pressure therapy) to help with emotional regulation.

• Behavioural Reinforcement Approaches – Using structured reinforcement to encourage attachment-friendly behaviours.

• Caregiver Training – Equipping caregivers with strategies to provide consistent, responsive interactions.

The Positive Systems Approach and Attachment Disorders

Positive Systems Approach (PSA), as outlined in Managing Disruptive Behaviours with a Positive Systems Approach, provides a structured and compassionate framework for addressing attachment-related challenges in individuals with developmental disabilities. PSA emphasizes:

1. Systematic and Consistent Support – Predictability is crucial for individuals with attachment disorders. PSA promotes structured environments that reduce anxiety and foster trust. This includes maintaining stable routines, minimizing abrupt changes, and ensuring caregivers provide steady and reassuring interactions.

2. Positive Reinforcement over Punishment – Traditional disciplinary methods, such as punitive consequences or forced compliance, can exacerbate attachment issues by reinforcing feelings of rejection or insecurity. PSA encourages reinforcing desired behaviours through positive feedback, rewards, and intrinsic motivation strategies. This helps individuals associate social interactions and attachments with positive experiences rather than fear or avoidance.

3. Building Emotional Regulation Skills – PSA integrates structured techniques for developing self-regulation skills, such as deep breathing exercises, movement-based activities, and sensory supports like fidget tools or weighted blankets. By strengthening self-regulation, individuals with attachment disorders can manage distress more effectively and reduce maladaptive behaviours linked to attachment anxiety.

4. Strengthening Caregiver Relationships – A core principle of PSA is enhancing the caregiver-client dynamic through attuned, responsive interactions. This includes training caregivers to recognize nonverbal distress signals, providing comforting touch or proximity when appropriate, and modeling secure relational behaviours. By ensuring caregivers act as stable, predictable figures, individuals with attachment disorders can build a stronger foundation for trust and connection.

5. Data-Driven and Individualized Strategies – PSA utilizes behaviour tracking and structured data collection to tailor interventions to the specific needs of each individual. By monitoring triggers, behavioural patterns, and successful interventions, caregivers and professionals can refine their approach to ensure maximum effectiveness in building attachment security.

Implementing PSA in Attachment-Focused Care

To integrate PSA into attachment disorder treatment for individuals with developmental disabilities:

• Create a Stable, Predictable Environment – Individuals with attachment challenges thrive in structured, consistent settings with clear expectations.

• Use Visual and Behavioural Cues – Providing visual schedules, reinforcement charts, and structured routines helps bridge communication gaps and increase predictability.

• Encourage Small, Positive Social Interactions – Rewarding incremental steps in social bonding, such as making eye contact, engaging in joint attention, or initiating communication, builds confidence and trust in relationships.

• Focus on Caregiver Training and Support – Caregivers play a pivotal role in attachment repair. (see Cautionary Note below). Providing them with PSA-based training improves consistency, emotional responsiveness, and the ability to meet attachment needs effectively.

• Utilize Multi-Sensory Approaches – PSA recognizes the importance of incorporating movement, tactile, and auditory cues to help individuals regulate emotions and engage socially.

Cautionary Note:

When discussing attachment disorder, we must be careful not to frame the young person as the driver of a clinical problem that is purely transactional. For instance, while it is true that children with attachment disorder often exhibit oppositional behaviours, difficulties with emotion regulation, and communication challenges, these issues are not simply a byproduct of disrupted attachment. Many of these difficulties stem from underlying neurodevelopmental differences that predate any attachment disruptions but are then compounded by relational adversity.

A crucial reality is that many children with developmental disorders have parents who also experience developmental challenges, often co-occurring with other vulnerabilities. These caregivers may struggle to meet their child's complex emotional and developmental needs, not due to a lack of love or effort, but because of their own limitations. This mismatch in needs and capacity can lead to cycles of distress, ultimately contributing to traumatic separations or placement in group homes.

It is essential to avoid oversimplifying the issue by attributing it solely to caregiver deficiencies. Instead, we must examine how difficulties emerge transactionally between the child and their caregiving environment. The same child with an intellectual disability (ID), for example, may present with vastly different clinical challenges depending on whether they are raised in a stable, well-resourced, and resilient environment versus one marked by trauma and instability. This underscores the need to move beyond a one-dimensional view of attachment disorder and instead consider the broader systemic factors at play.

Part of this systemic approach involves critically examining challenges within parenting and caregiving systems. Some international models, such as those used in Australia, recognize this complexity by intervening at the level of the parent-child dyad rather than focusing solely on either the child or the caregiver. In these approaches, rather than breaking the bond through removal, parents with intellectual disabilities receive direct, hands-on support from care staff, who model effective parenting strategies while ensuring the child’s needs are met. This kind of intervention acknowledges that attachment is not just about the child's behaviour or the caregiver's capacity in isolation, but about the dynamic between them and the supports available to sustain that relationship.

​Several Australian models exemplify interventions that address the parent-child dyad, focusing on both the child and the caregiver:​

1. Parent-Child Interaction Therapy (PCIT): Implemented in Australia, PCIT is an individualized program for preschool children displaying disruptive behaviours and their parents. Rooted in social learning, attachment, and behavioural theories, it aims to strengthen the parent-child bond and enhance prosocial behaviour. ​Communities and Justice

2. Single Session Family Consultation (SSFC): This brief family-inclusive practice model has been introduced in Australian youth mental health services to engage families in the treatment process. SSFC has been found acceptable to clients and their families, and its implementation led to increased practitioner confidence in providing family interventions. ​Wiley Online Library+1Australian Institute of Family Studies+1

3. Kids+ Parent Infant Program (PIP): This community model supports early developmental follow-up by fostering partnerships between parents and therapy teams. The program emphasizes active listening to parental concerns, building upon parental strengths, and respecting family values, aiming to enhance parental competence and infant development. ​Frontiers

These models highlight Australia's commitment to integrated approaches that support both children with developmental challenges and their caregivers, recognizing the importance of the parent-child relationship in therapeutic interventions.​

By shifting the focus from blame or deficiency to a transactional and systemic perspective, we can develop more effective interventions that acknowledge both the child's neurodevelopmental profile and the realities of the caregiving system—ultimately fostering stronger, healthier attachment relationships

Conclusion

Attachment disorders can have profound effects on individuals with developmental disabilities, making it essential to adapt interventions to their unique needs. While traditional therapies provide a foundation, modifications are often necessary for those with limited language skills. The Positive Systems Approach aligns well with these needs, emphasizing structured support, positive reinforcement, and enhanced caregiver relationships to foster trust and security.

By integrating PSA principles into attachment disorder treatment, we can provide individuals with developmental disabilities the stability, support, and connection they need to thrive. For a deeper understanding of how PSA can be applied, I encourage you to explore our book, Managing Disruptive Behaviours with a Positive Systems Approach, where these concepts are discussed in greater detail.

For more insights, resources, and professional guidance, visit drbobcarey.com.