Introduction

Attachment theory is a framework conceptualised by English psychiatrist John Bowlby, which aims to understand the dynamics of human relationships. Bowlby hypothesised that a person's quality of relationships and emotional development are majorly influenced by the way their primary caregivers tend to them during their key developmental years, particularly in childhood.¹ He suggests that there are four key styles of attachment, shaped by the interactions and patterns of behaviour that a parent displays towards a child. The attachment styles are known as secure, ambivalent, anxious, avoidant, and disorganised. Attachment styles can impact a person's perception of their interactions and relationships; they can help predict how a person may react to negative events in their relationships, their ability to emotionally regulate themselves, and may impact their overall well-being.²

Play therapy is a psychodynamic tool used to explore a child’s needs, feelings, and worldview when a child’s vocal ability is still developing. It is used as a modality of self-expression for children, which can help address attachment-related issues in a safe and nurturing manner to forge healthier relationship patterns and behaviours.³

The purpose of this outline is to explore how play therapy can address the needs of children with various attachment styles. This will include examining the different types of attachment styles and understanding how each style influences a child's behaviour and emotional responses. It will also detail how play therapy techniques can be tailored to meet the specific needs of children with different attachment patterns. The outline aims to provide a comprehensive framework for using play therapy to foster healthier relationships and improve emotional well-being in children, ultimately aiding therapists in effectively supporting their young clients through this therapeutic approach.

What are attachment issues? 

Attachment issues can lead to attachment disorders, which are psychiatric conditions that refer to an individual's internal difficulties in forming and maintaining relationships. Negative interactions or lack of reciprocation from caregivers can adversely affect a child's internal representation of themselves and others, resulting in attachment issues.⁴

There are two main types of attachment disorders: Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED).⁵

There are multiple signs to look out for when suspecting attachment issues in a child, such as:⁶ 

• Emotionally withdrawing from others
• Not smiling and/or showing a limited emotional range
• Not joining in on playtime 
• Poor impulse control 
• Refusing affection 
• No fear of strangers
• Anger outbursts or difficulty regulating mood
• Lack of eye contact 
• Oppositional behaviour 
• Self-destructive behaviour 
• Low self-esteem
• Bullying

Although the above symptoms often appear in early childhood, they can persist into adulthood.

Where do attachment issues come from? 

Attachment issues stem from the type of attachment children form with their primary caregivers, resulting in a framework for relationships with others that is maintained into adulthood. According to Bowlby, there are four different types of attachment: secure, anxious-ambivalent, anxious-avoidant, and disorganised.^2,3 These attachment styles provide the framework for interpersonal relationships and help us understand attachment issues, their origins, and how interventions are planned and targeted.¹

Secure attachment

Secure attachment forms when a child’s caregivers show consistency and respond to their needs in a sensitive and responsive manner. Caregivers who are emotionally available, involved, and attuned to the child’s needs and cues foster a sense of security and trust in the child.³ This leads to the child forming secure attachments and feeling safe and confident as they grow up. As a result, the child is encouraged to explore their environment, knowing that their caregivers will be available to provide support and comfort if needed. Children with secure attachment seek proximity to their caregivers but feel confident exploring on their own.⁵

Anxious-ambivalent attachment or preoccupied attachment

Anxious-ambivalent attachment can form when caregivers are inconsistent in their responsiveness to the child’s needs, whether physical or emotional. Caregivers may sometimes respond promptly and warmly to the child, while at other times, they may be unavailable or unresponsive. This inconsistency creates anxiety and uncertainty, as the child does not know how and if their needs will be met, leading to a desire for reassurance and proximity.⁷ 

Children with this attachment style will exhibit clingy or attention-seeking behaviour and experience significant distress when separated from their parents. They may seek closeness and comfort on their own but may resist their caregivers’ reassurance as they grow up. As adults, they often seek reassurance from their partners due to a fear of abandonment or rejection; they may also have low self-esteem.⁷

Anxious-avoidant attachment or dismissive

Anxious avoidant attachment develops when caregivers are consistently unresponsive or reject the child’s cues for comfort and support. In the long term, this discourages the child from expressing themselves and leads to the suppression of their attachment needs, causing them to rely only on themselves for emotional regulation.⁸

Children with anxious-avoidant attachment appear distant and avoid seeking comfort from caregivers even when in distress. They may suppress their emotional needs, which makes them seem self-reliant and hyper-independent. From a young age, children with this attachment style may be self-sufficient and independent; this pattern of behaviour continues into adulthood. They may appear cold, distant, or lacking emotion as they fear that expressing their emotions will be rejected by others and therefore futile.⁸

Fearful avoidant or disorganized attachment

Disorganised attachment occurs in more complex contexts, usually when there is abuse, neglect, or unpredictable behaviour from the caregiver. Caregivers may exhibit frightening, inconsistent, or unpredictable behaviours, leading the child to feel anxious or confused in their presence. This style of attachment forms when the caregiver, a source of safety, becomes a source of fear.⁹

Children with disorganised attachment seek comfort and safety but often have no strategy due to the lack of consistency. This attachment style has been linked to Reactive Attachment Disorder, which is a delay or disturbance in the development of age-appropriate social behaviours before the age of five. It can occur when a child’s primary caregiver frequently changes or when their emotional or physical needs are not met.⁹

In adulthood, as they may still view attachment figures as unpredictable, they expect others to reject, hurt, or disappoint them, leading to self-sabotaging relationships. Research also displays a link between disorganised attachment styles with more aggressive behaviour, substance abuse, abusive behaviour towards partners or children, and mental health issues, particularly Borderline Personality Disorder.¹⁰

The different types of attachment styles highlight that attachment issues have different origins, are not uniform, and vary in their essence. They stem from different parenting styles or circumstances, forming ‘attachment trauma’ – trauma that occurs in the context of relationships and damages the ability to develop secure attachments.¹¹ Poor attachment shows in the child's ability to self-soothe, collaborate, be assertive, and display self-control. Identifying the child’s attachment style provides a framework for the play therapist to understand the child’s behaviour and what they might be experiencing internally.¹²

What is play therapy? 

Theories of human development, attachment, and psychology recognise play therapy as a natural and essential activity through which children can process emotions, develop social and problem-solving skills, and make sense of the world around them. Play therapy is a form of psychotherapy in which the therapist uses play as the primary form of communication; an expression to help the child explore their feelings, thoughts, and experiences in a safe and empathetic environment.¹²

Non-directive play therapy focuses on creating a safe environment in which the child feels free to lead play in the presence of the therapist. The aim is to create a non-judgmental environment, fostering a space in which the child can experience and explore their emotions and perspective of events.^12,13

There are different types of play therapy, with Theraplay being the most common one. Theraplay is a model based on healthy child-parent interaction in a play modality. Theraplay uses techniques such as drawing, storytelling, painting, sculpting, building, and roleplaying with the child. Initially, sessions are led by the therapist playing with the child and will slowly include caregivers to partake in play. Theraplay is a form of family therapy that helps strengthen the bond and trust between the child and the caregivers through interactive activities.^12,16

Filial Therapy was developed in the 1950s and has been extensively used and researched as an intervention for attachment issues. This intervention has a particular focus on insecure attachment types and targets attachment trauma. Similar to Theraplay, it includes family members in its process.¹²

Play therapy has been shown to increase emotional attachment between caregivers and children, as play therapy involving caregivers helps them develop an understanding of the child’s psychology.¹⁷ Meanwhile, children develop a sense of permanence in relationships, experience less separation anxiety, score higher in confidence, and improve their self-concept.^14,17 In different reviews of studies, all therapy styles mentioned above have been shown to be effective in attachment disorders such as RAD, as they are effective in building secure attachments and creating therapeutic relationships.^15,17

Summary 

Attachment theory, developed by John Bowlby, explains how early interactions with primary caregivers shape a person's ability to form relationships and regulate emotions. Bowlby identified four attachment styles: secure, ambivalent, anxious, avoidant, and disorganized. These styles affect how individuals perceive and react to relationships and emotional challenges.

Play therapy is a psychodynamic approach used to address attachment issues in children. It provides a safe and expressive outlet for children to explore their feelings and needs, helping them to develop healthier relationship patterns. This article has explored how play therapy can be tailored to address different attachment styles in children.

Attachment issues, or disorders, arise from negative caregiver interactions and can manifest as emotional withdrawal, poor impulse control, refusal of affection, and other behavioural problems. They can persist into adulthood and are primarily categorised into Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED).

Play therapy, recognised as a natural activity for emotional and social development, uses play to help children process their experiences. Types of play therapy include non-directive play therapy, Theraplay, and Filial Therapy. All these approaches involve creating a safe environment for self-expression and involving caregivers in the therapeutic process.

Play therapy has been shown to be effective in increasing emotional attachment, reducing separation anxiety, and improving self-concept in children. It provides a comprehensive framework for therapists to support children with attachment issues, fostering healthier relationships and emotional well-being.