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Introduction
o Family and play therapy can help family overcome difficulties in
which a child has Reactive Attachment Disorder (RAD)
o Strengthen attachments within family relationships
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Diagnostic and clinical definitions of RAD
o Diagnostic definition
• Markedly disturbed, developmentally inappropriate social relatedness
• Inhibited
• Disinhibited
• Must have received pathogenic care (abuse or neglect) or repeated
changes of primary caregiver (e.g., multiple foster care placements)
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Diagnostic and clinical definitions of RAD (cont.)
o Clinical definition (examples of symptoms)
• Aggressive or oppositional-defiant demeanor
• Social interactions that lack mutual enjoyment and spontaneity
• Increased attachment efforts by caregivers produce discomfort or
resistance
• Clingy
• Gorging food
• Indiscriminate friendliness or social withdrawal
o Behavior approaches to correct behaviors in attachment-disordered
children increase problematic behaviors
o Focusing on attachment improves problematic behaviors, not
focusing on problematic behaviors
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Treatment literature
o Attachment theory
• Attachment – “meeting the child’s basic needs for protection, safety,
and security in human relationships” (p. 246)
• Caregiver responds to needs when the child’s attachment system is
activated
• Parents’ attunement to attachment needs improves parent-child
relationships
• Parents have four styles of parenting their children’s attachment needs
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Love, affection, structure, discipline  secure attachment (B)
Inconsistency, unpredictability  anxious-resistant attachment (C)
Rejection  anxious-avoidant attachment (A)
Abuse, neglect  disorganized/disoriented attachment (D)
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Treatment literature (cont.)
o Treatment for RAD
• Play therapy
• Systemic interventions
o Coercive therapies
• Source of controversy with attachment therapy
• Holding Therapy and Rebirthing Therapy are examples of coercive
treatments for attachment disturbance
• Holding Therapy – forcing a “reconnection with [the child’s] primal needs” (p.
249)
• Rebirthing Therapy – forcing “attachment through the figurative replication of
the birthing process” (p. 250)
o Behavioral treatments
• Training parents to model appropriate behaviors
• Psychoeducation
• Childhood misbehavior
• Parenting skills
• Behaviorally based disciplinary systems (e.g., sticker charts)
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Treatment literature (cont.)
o Moderate models that show promise
• Family therapy
• Attachment-based family therapy (ABFT) – repairs relational ruptures and
rebuilds trustworthy relationships
• Critical to explore family dynamics and prevent maintenance and
exacerbation of problematic behaviors
• Play therapies and attachment-based parent-child relational models
• Child-centered play therapy and filial therapy
• Ecosystemic play therapy
• Theraplay
• Directive, fun, and safe
• Parents are taught to balance four dimensions of attachment-building
• Structure
• Engagement
• Nurture
• Challenge
• Parents are coached and then “bridged into the play”
• Household items used – cotton balls, straws, lotion, M+M’s, toilet paper
• Appropriate touch is used (e.g., patty cake, snack feeding)
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Treatment literature (cont.)
o Dyadic Developmental Psychotherapy (DDP)
• Focuses on reciprocal attunement in parent-child dyad
• Five crucial therapeutic stances (PLACE):
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Playful
Loving
Accepting
Curious
Empathic
• Psychoeducational programs such as Circle of Security
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Whole Family Theraplay: An integrative model for the
treatment of RAD
o Traditional Theraplay does not teach parents how to apply
attachment knowledge to siblings

Whole Family Theraplay (cont.)
o Whole Family Theraplay brings in the richness of sibling dynamics to
support attachment-enhancing processes
o Sessions are structured with activities (interventions) planned from
the four dimensions of attachment-building
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Structure
Engagement
Nurture
Challenge
o Theraplay can be supplemented by traditional family therapy to
process family concerns or couples therapy to process couples
concerns
o Homework assignments for the family can be given

Introduction
o Application of attachment theory to clinical material
o Therapists need to increase understanding of underlying
relationships and changes within these relationships
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Rationale for the integrative approach
o Description of Nondirective Play Therapy (NDPT)
• Attachment theory and child-centered play therapy (CCPT) are
connected
• “Attachment theory provides a framework for further understanding
these features of relationships that play therapists aim to foster with
children” (p. 266)
o Description of attachment theory and extended attachment theory
• Goal-corrected careseeking (i.e., attachment system)
• Children seek care and protection when distressed
• Internal working model of the experience of relationships (IMERs) –
more than one template per relationship is possible
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Rationale for the integrative approach (cont.)
o Extended attachment theory (dynamics of attachment and interest
sharing model) – five interrelated behavioral systems
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Attachment or careseeking system
Parenting or caregiving system
Exploratory interest-sharing system with peers
Sexual/affectional system
Personal self-defense system
• Defensive exclusion (similar to repression, denial)
• Cognitive disconnection (similar to isolation of affect)
• Segregated systems (similar to dissociation)
o In extended attachment theory, caregiver responses are as
important, if not more important, than achieving caregiver proximity
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Rationale for the integrative approach (cont.)
o NDPT sessions – an optimal environment
• Aim of NDPT – provide emotional security with physical safety
• Therapist conveys emotional availability and dependability through
verbal and nonverbal messages
• Use of limits to provide emotional containment and self-regulation
• Use of congruence (i.e., self-disclosure) – designed to help RAD
children understand others’ thoughts and feelings at key moments and
to deepen the therapeutic encounter
• Both child and parents are included in the work to varying degrees
• Parents observe last 10 minutes of session
• Parents are actively involved for most of session
• Joint play therapy moving toward filial therapy
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Practical implementation of this integrative approach
o Assessments
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Diagnostic – inhibited or disinhibited RAD
Parent interview
Standardized quantitative measures (e.g., CBCL)
Home visit
Story stems (i.e., Attachment Story-Completion Task)
• Play narratives can be fun to complete
• Play narratives “demonstrate the child’s most basic scripts for human
relationships – their internal working model” (p. 273)
• Play narratives can be informative when little is known about child’s early history
(e.g., Douglas)
• Play narratives can indicate child's propensity for traumatic play
• Adult Attachment Interview/Attachment Style Interview
• Attachment patterns of therapist and parent are important when integrating
attachment theory and NDPT
• Filial therapy would be contraindicated for parents assessed as having high
defensiveness
• Family play observation – 20 minutes of free play
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Practical implementation of this integrative approach (cont.)
o Case formulation and chosen treatment approach
• Careseeking behaviors
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Indications of tiredness or discomfort
Uncertainty, mild fear, distress
Seeking interaction
Stating concerns
• Caregiving behaviors
• Verbal statements that incorporate empathy
• Mutually resonating affective states between therapist and patient
• Providing comfort or relieving discomfort
• Exploratory system/interest-sharing system
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Sharing of views, experiences, interests
Engaging in play behavior
Exploring playroom environment
Expressions of pleasure or joy
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Practical implementation of this integrative approach (cont.)
o Case formulation and chosen treatment approach (cont.)
• Defensive system
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Angry responses
Fearful behaviors
Withdrawn responses
Distressed behaviors
• Sexual system
• Sexualized behaviors
• Sexual talk
o Play therapist’s attachment pattern
• Therapist must reflect on own responses to child’s defensive system
within the interaction
• Therapist must pay particular attention to strong emotional reactions
(countertransference)
• Clinical supervision
• Personal assessment (e.g., AAI) and therapy

Practical implementation of this integrative approach (cont.)
o Applying extended attachment theory to working with caregivers and
other professionals
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Therapist responds to child’s careseeking system
Therapist responds to parents’ careseeking systems
In both cases, therapist must also work to deactivate defensive systems
Defensive behavior can appear in two forms
• Extremely dominant (controlling/punitive)
• Extremely compliant (caregiving/role-reversing)
• “Therapists need to look for opportunities for closeness that children
will allow and also promote this in carers’ [parents’] interactions with
children” (p. 278).
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Practical implementation of this integrative approach (cont.)
o Ending NDPT
• Five interrelated systems in harmony
• Relationships are supportive and collaborative, not dominant/
submissive
• Increase activation of careseeking system
• Reduce activation of defensive system
o Treatment plan
• Initial play therapy sessions (first four months)
• Provide emotional availability and predictability
• Interpret defenses while expressing concern about underlying needs (e.g.,
“you need to show me you’re brave, but I’m concerned”)

Practical implementation of this integrative approach (cont.)
o Treatment plan (cont.)
• Middle play therapy (5-15 months)
• Congruence (i.e., self-disclosure) practiced
• Introduction of calm five minutes at end of session
• Interpretation (e.g., “you like your body going fast because it makes you feel
safe and in charge of what happens next”)
• Defiance can be perceived as less avoidance and greater ability to show
feelings
• Later play therapy sessions (16-24 months)
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Generalize to other settings (e.g., home, school)
Less focus on competition
More focus on competence-building
Greater in-session relaxation of child and therapist
Introduction of parent into sessions
Readministration of Attachment Story-Completion Task