Infants & Young Children

Vol. 32, No. 1, pp. 43–59

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Integrating Connection
A Mixed-Methods Exploration of
Sensory Processing and Attachment
Katherine M. Walbam, PhD, LICSW
Attachment is considered a fundamental aspect of social and emotional development in children.
Attachment is established, in part, through sensory processes, yet many children have unique
sensory needs. The present study explores the association between sensory processing disor-
der and attachment by examining primary caregivers’ perception of the attachment relationship
with their children with SPD. Following a mixed-methods design, 24 self-identified primary care-
givers completed 3 questionnaires: a demographic profile, a sensory processing profile, and an
attachment-related questionnaire. Of those 24, 12 also completed a semistructured interview. The
findings of this study suggest that a correlation exists between sensory processing and attachment
measurement scores and specifically with 3 subscales of sensory processing: tactile sensitivity,
auditory filtering, and responsiveness to stimuli. This correlation, however, appears to exist de-
spite the fact that none of the children met the full criteria for insecure attachment, according
to the attachment measure. Key words: attachment, child, parent–child relationship, primary
caregivers, sensory processing

S ECURE attachment between infants and

caregivers is regarded as a fundamental
component of healthy social and emotional
gazing with a caregiver promote healthy at-
tachment and impart important messages to
the child about self, relationships, and the
development (Fairchild, 2006; Gullone, Ol- world (Bowlby, 1958; Schore, 2001). These
lendick, & King, 2006; Morrison & Mishna, behaviors involve visual, auditory, and tactile
2006; Moutsiana et al., 2015). Attachment be- stimulation; sensory stimuli appear to be an
haviors such as sucking, clinging, following inherent part of the process of establishing at-
the caregiver with the eyes, and intense eye tachment (Perry, 2001). Furthermore, infant
“negotiation of reciprocity” in relationships
often derives from “tactile and auditory and
Author Affiliation: Simmons College, School of
visual inputs” by the caregiver (Brazelton &
Social Work, Boston, Massachusetts. Als, 1979, p. 365). Yet, between 5% and 16%
Some funding for this study was provided by the Sim- of school-aged children (as many as 11 mil-
mons College Student Research Fund. This research lion, based on census statistics) in the United
was conducted while at Simmons College, Boston, Mas- States experience sensory processing disor-
sachusetts, as a dissertation study. This work was com-
pleted under the guidance of my committee mem- der (SPD; Ahn, Miller, Milberger, & McIntosh,
bers: Johnnie Hamilton-Mason, PhD, Simmons College 2004; Ayres, 2005; Owen et al., 2013; U.S.
School of Social Work; Committee Chair, Annette Cor- Census Bureau, Population Division, 2016),
reia, OTR/L, Children’s Hospital Boston; Dana Gross-
man Leeman, PhD, Simmons College School of Social a neurobiological condition that affects the
Work; and Gerald Koocher, PhD, Provost and Senior way that they receive, process, and under-
Vice President for Academic Affairs, Quincy College. stand sensory messages (Ayres, 2005).
The author acknowledges no other conflicts of interest.
Both sensory processing and attachment
Correspondence: Katherine M. Walbam, PhD, LICSW,
Salem State University School of Social Work,
are prevalent in the literature of their fields
352 Lafayette St, Salem, MA 01970 (kwalbam@ (occupational therapy and the social sci-
salemstate.edu). ences, respectively), and there is evidence
DOI: 10.1097/IYC.0000000000000134 that other neurodevelopmental disorders,

43

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 44 INFANTS & YOUNG CHILDREN/JANUARY–MARCH 2019

such as autism spectrum disorders that treatment of problematic sensory reg-

(ASDs) and attention-deficit hyperactivity ulation with a sensory diet led to improved
disorder (ADHD), may be linked to attach- interactions between children with SPD and
ment in childhood (Chang et al., 2014; their caregivers. If treatment for SPD can
Cheung & Siu, 2009; Clarke, Ungerer, Cha- significantly improve attachment, then it may
houd, Johnson, & Stiefel, 2002; Finzi-Dottan, be that SPD is, itself, connected to attachment
Manor, & Tyano, 2006; Tomchek & Dunn, processes.
2007). These studies all examined a rela- Finally, Whitcomb, Carrasco, Neuman, and
tionship between a neurodevelopmental Kloos (2015) have directly joined the con-
disorder, like SPD, and attachment. Given cepts of attachment and sensory processing.
that attachment is related to other neurode- Using the Short Sensory Profile (SSP), which
velopmental disorders, it is logical to also was also used in the current study, and the
explore attachment and SPD. Attachment Q-Set, the authors observed 68
However, empirical research exploring a children between the ages of 3 and 6 years to
specific connection between attachment and determine whether there was a relationship
SPD is limited. A few factors may explain this between attachment and sensory processing
deficiency, including a traditional understand- and whether either of the two concepts might
ing of attachment insecurity as the result of predict the other. The authors examined the
mistreatment or inadequate care (American relationship between the two using correla-
Psychiatric Association, 2013), a lack of famil- tion and regression, finding a modest corre-
iarity with SPD by practitioners outside of oc- lation and a small, but significant, predictive
cupational therapy (Walbam, 2014), or some relationship (both attachment and sensory
uncertainty about SPD as a valid classification processing appeared to predict the other
of symptoms (Koziol, Budding, & Chidekel, on a small scale). From their findings, the
2011). authors suggest “a dynamism between the
Some studies, however, have suggested that two processes” (p. 7), which may impact the
treatment of sensory processing challenges child–caregiver relationship.
has a positive impact on attachment scores As children with SPD have difficulty
(Jorge, de Witt, & Franzsen, 2013; Purvis, receiving and processing sensory input, and
McKenzie, Cross, & Razuri, 2013). Jorge et al. as attachment behaviors appear to be sensory
(2013), for example, conducted a study on the in nature, greater understanding of an asso-
effectiveness of treatment of SPD symptoms ciation between sensory processing and at-
in infancy. The researchers examined the use tachment is essential. Such an understanding
of a sensory diet, which “refers to a planned has the potential to enhance the attachment
and scheduled activity programme which . . . relationship for millions of children and their
is designed by an occupational therapist to caregivers, which may yield better mental
meet the child’s specific and unique sensory health outcomes for the children in the long
needs” that “includes modifying daily rou- run. Through a mixed-methods approach
tines, changing the environment and using in- examining both current and retrospective ex-
dividualised sensory stimulation to normalise periences, this study has aimed to (1) examine
specific sensory responses” (Jorge et al., 2013, the recollections of early (infant and toddler
p. 29). Of note, one of the measures used, years) and current attachment experiences by
the Infant Toddler Symptom Checklist (De- caregivers of children with SPD (aged 3 years,
Gangi, Porges, Sickel, & Greenspan, 1993), 0 months to 11 years, 11 months) through
measures attachment. This study found that qualitative methods, (2) examine caregivers’
treatment of infants using a sensory diet perceptions of their child’s current attitudes
significantly improved parents’ reports of and behaviors pertaining to attachment
attachment behaviors, per the Infant Toddler through both qualitative and quantitative
Symptom Checklist. The authors observed measures, (3) compare caregivers’ responses

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 Integrating Connection 45

to both qualitative and quantitative attach- and current attachment experiences were
ment measures, specifically to examine how explored though the qualitative interview.
caregivers describe attachment with a child
with SPD, and (4) compare quantitative at- Instruments
tachment measures to quantitative measures
of sensory processing and describe a possible Short Sensory Profile
relationship between attachment and SPD. The items on the SSP describe children’s re-
These aims were attained through appli- sponses to sensory stimuli, and caregivers re-
cation of the following research question: port the frequency of those behaviors. Items
What are caregivers’ perceptions of the include responses to sensory stimuli, such
attachment relationship with their children as “responds negatively to unexpected or
identified as having sensory processing loud noises” and “reacts emotionally or ag-
disorder? gressively to touch” (Dunn, 1999). The SSP
Attachment is a dynamic created between groups items into three main categories, in-
two people: the caregiver and the child. As cluding “sensory processing,” “modulation,”
one-half of the attachment relationship, care- and “behavioral and emotional responses”
givers are in a distinct position to shed light on (Dunn, 2008). It has been used in a num-
the nature of attachment among children with ber of studies (Engel-Yeger, 2010; Tomchek
SPD. Better understanding of an association & Dunn, 2007), and found effective at accu-
between sensory processing and attachment rately categorizing children with and without
may result in more responsive service provi- disabilities. The SSP comprised those items
sion by practitioners of numerous disciplines, from the full, 125-item Sensory Profile (Dunn,
as well as collaboration across fields. 1999) that showed the highest discriminative
ability in identifying atypical sensory process-
ing (Engel-Yeger, 2010) and was designed for
METHODS research purposes (Dunn, 1999). All partici-
pants in the proposed study completed the
This study explored the association SSP to ascertain a score for their child’s cur-
between SPD and attachment through ex- rent sensory processing.
amination of primary caregivers’ perceptions The SSP asks caregivers to rate their child
of the attachment relationship with their using a 5-point scale, and scoring results in
children identified with SPD. A concurrent both section raw scores, representing differ-
mixed-methods design was selected, wherein ent aspects of sensory processing, and a total
qualitative and quantitative data were ana- raw score, representing sensory processing
lyzed separately and then compared (Creswell abilities as a whole. Both section raw scores
& Plano Clark, 2007). As the study explored a and total raw scores indicate Typical Perfor-
relatively novel topic, this approach allowed mance (TP), Probable Difference (PD), or Def-
for a more well-rounded exploration of inite Difference (DD). The TP classification is
a potential association between SPD and given for scores at or above 1 standard de-
attachment through triangulation of the data. viation below the mean and indicates typical
This design allowed for exploration of the sensory processing abilities of the child. These
phenomenon from more than one perspec- are scores of 190–155. The PD classification
tive (Angell & Townsend, 2011), examining is given for scores at or above 2 standard devi-
both sides of the caregiver–child dyad, as ations below the mean but lower than 1 stan-
described by the caregiver. Current child be- dard deviation below the mean. This indicates
haviors associated with poor attachment and questionable areas of sensory processing abili-
poor sensory processing were examined us- ties, meaning either questionable functioning
ing quantitative questionnaires, respectively, across the board or questionable functioning
whereas caregivers’ perceptions of early in several areas of sensory processing abilities.

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 46 INFANTS & YOUNG CHILDREN/JANUARY–MARCH 2019

The PD scores are 154–142. The DD classifi- maltreatment from children with attachment
cation is given for scores that fall below the problems. As maltreatment was part of the ex-
point of 2 standard deviations below the mean clusion criteria for this study, only the score
and indicates sensory processing problems. sheet for conduct was used to examine be-
These are scores from 141 to 38. haviors associated with attachment problems
The internal consistency of the SSP was cal- in the study sample. This score sheet results
culated by subcategory. All scores indicated in two subscale scores. One represents chil-
good or moderate internal consistency (Engel- dren who display problematic attachment and
Yeger, 2010). Internal validity scores ranged those who have behavioral problems but no
from 0.25 to 0.76, all of which were signifi- history of maltreatment (the Mean Score for
cant at p < .01 (Dunn, 1999), and indicated Conduct, or MSC). The other, the Discrimi-
that the different sections of the SSP mea- nant Score for Conduct (DSC), consists of the
sure relatively unique concepts. Content va- 10 items that “best distinguished the [Attach-
lidity confirmed that the SSP measures the full ment Disorder] and [Disruptive Behavior Dis-
range of sensory processing behaviors (Dunn, orders] subgroups” (Randolph, 2000, p. 13).
2008). Discriminant validity was reported at The total of these results in a Subscale Score
95%; the SSP accurately identified children for Conduct (SSC). Finally, the total RADQ
with and without sensory processing prob- score is calculated. If the subscale score is
lems (Engel-Yeger, 2010). In addition, Dunn above 33 and the total score is above 64, “the
(1999) reports good construct validity. These child probably has [Attachment Disorder]”
are good indications that the SP is able to pro- (Randolph, 2000). If the child’s scores are be-
vide accurate assessment of sensory process- low these demarcation points, the child does
ing difficulties in the target population. The not have attachment difficulties. If the scores
SSP was also chosen because of its relative are mixed (one above, one below), “the child
ease of completion; the SSP contains 38 items probably has attachment problems that fall
versus 125 for the full SP. This selection made short of [Attachment Disorder], or may have
the study more feasible for busy caregivers to Conduct Disorder with symptoms that mimic
complete. [Attachment Disorder]” (Randolph, 2000).
Test–retest reliability scores for the RADQ
Randolph Attachment Disorder were 0.82 for children with attachment prob-
Questionnaire lems and 0.85 for a nonclinical group. Inter-
The Randolph Attachment Disorder Ques- nal consistency ratings also indicated good re-
tionnaire (RADQ; Randolph, 2000) was se- liability (Fairchild, 2006). The RADQ scores
lected to measure behaviors indicative of cur- were shown to distinguish subjects with at-
rent attachment problems. The RADQ is a tachment problems from those with behav-
30-item, 5-point scale designed to assess at- ioral disorders (Sheperis et al., 2003) reported
tachment in children up to 18 years of age. as criterion-related validity (Fairchild, 2006).
The primary caregiver is asked to complete These scores indicate that the RADQ can be
the scale, and items include, “my child has a useful tool in identifying attachment-related
trouble making eye contact when adults want behaviors and problems among children with
him/her to,” and “my child “shakes off’ pain SPD.
when he/she is hurt, refusing to let anyone Some researchers have found that the
comfort him/her.” RADQ’s use, as prescribed, does not pro-
The RADQ results in subscale scores and a vide a complete enough picture for re-
total score. There are two score sheets for the search purposes. The RADQ’s use of sub-
RADQ, one intended to discriminate children scales for Conduct Disorder was intended
with conduct disorder from children with at- to differentiate between behaviors indica-
tachment problems, and another intended to tive of Conduct Disorder and those of at-
discriminate children with histories of severe tachment difficulties. Although appropriate

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 Integrating Connection 47

for client assessment, the categorical outcome ceptions of their attachment relationships
of the measure does not indicate where sub- and behaviors. Examples include, “how did
jects’ scores fell within the ranges of each cat- your baby respond to your attempts to
egory and is therefore less descriptive. How- soothe him/her?” and “was there a differ-
ever, the RADQ is the only quantitative mea- ence between his/her reaction to you, and
sure of attachment available that meets the to others?” The interview questions were
age requirements of the SSP (3-14 years). In piloted and found to elicit responses that
the current study, the total score, subscores pertained to the attachment relationship as
(MSC and DSC), and subscore total (SSC) designed.
were entered into the data set and analyzed. The interview questions were focused on
In addition, the use of these scores, despite infant and toddler years, as this is the age
Randolph’s cautioning, is consistent with the during which attachment and its behaviors
work of other researchers who have used seem to be central, developmentally (Mer-
these scores to conduct their own statistical cer, 2006). Because attachment develops in
analysis within which attachment is a variable early childhood, the interview used that time-
(Becker-Weidman, 2006; Purvis et al., 2013; frame as a springboard for discussion of at-
Wimmer, Vonk, & Bordnick, 2009). Wimmer tachment. It was expected that the interviews
et al. (2009) note that, as is the case in the would elicit a variety of themes relevant to
current study, the RADQ was used not “as a attachment and the attachment process in
diagnostic tool, but as a measurement tool” those early, infant, and toddler years. How-
(p. 355). To better understand the relation- ever, caregivers typically commented on the
ship between SPD and attachment, the cur- full spectrum of their child’s development and
rent study utilized the total score and sub- the attachment features throughout, making
scores to examine correlations between the the study all the more rich and all the more bal-
variables. anced with regard to the RADQ. In addition,
the interviews evoked many other themes per-
Interview with caregivers taining to the experience of caregivers in rais-
A sample of the caregivers who completed ing children with SPD.
the questionnaires also completed a quali-
tative interview. This lasted approximately Participants
45–60 min and was designed to elicit care- Subjects were caregivers of children, be-
giver perceptions (both current and retro- tween 3 and 11 years of age, who had been
spective) regarding attachment experiences identified by a licensed occupational therapist
between themselves and their children with (OT) as having sensory processing difficul-
SPD. Open-ended questions were designed to ties. Participants were recruited through 21
gather information regarding child–caregiver occupational therapy practices in Connecti-
interactions and attachment behaviors, child’s cut, Maine, Massachusetts, New Hampshire,
preference for/separation from the primary and Rhode Island, using purposive and snow-
caregiver, child’s use of caregiver as a se- ball techniques. Exclusion criteria included
cure base, and caregiver response and re- exposure of the child to abuse, neglect, or
actions to the attachment relationship. The trauma; child diagnosis of ASD or pervasive de-
creation of these categories was influenced velopmental disorder; and child diagnosis of
by the works of Bowlby (1958, 1982), as ADHD.
well as those of Ainsworth (1969) and her Of the 24 participants, 21 were female,
colleagues (Ainsworth & Bell, 1970), and and also identified as the “mother” of a child
Fraiberg (1975), who all conducted much re- with SPD. Three participants were male and
search regarding attachment in infancy. Be- also identified as the “father” of a child with
cause children were not interviewed as well, SPD. Twenty-three subjects identified their
all questions refer to the caregivers’ per- racial identity as “White,” whereas one subject

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 48 INFANTS & YOUNG CHILDREN/JANUARY–MARCH 2019

identified as “Hispanic/Latino.” The ages of tachment with their child. Finally, the subjects
the caregivers ranged from 33 to 64 years, were asked to give their perspectives on what
with a mean age of 40.17 years (SD = would be helpful as the caregiver of a child
6.657). Caregivers were generally well edu- with SPD.
cated; 33.3% held bachelor’s degrees, 50%
held master’s degrees, and 8.3% were PhDs. RESULTS
The subjects also reported relatively high lev-
els of household income; 45.8% reported earn- Quantitative results: Relationship
ing more than $150,000 per year. between sensory processing and
Four children were female, 19 were male, attachment scores
and one questionnaire contained missing data The mean for the total raw score for the
for this variable. Twenty-one children were SSP was 130.29 (SD = 24.820), which falls in
identified by their caregivers as “White,” the DD range. However, total scores from the
whereas one child was identified as “His- SSP ranged from 82 to 173; 16 children fell in
panic/Latino” and one was identified as the “DD” classification of the SSP, four chil-
“other.” All children had been identified by dren fell in the “PD” classification, and five
a licensed OT as having sensory processing children fell in the “TP” classification. Almost
difficulties and had received treatment by an all of the children (95.8%) did not meet the
OT. The mean age of the children at identi- criteria for attachment difficulties, based on
fication of SPD was 4.08 years (SD = 1.841; their caregivers’ responses to the RADQ. One
one score missing). child’s score (4.2% of the sample) resulted in
a mixed result, meaning that the child “prob-
Procedure ably has attachment problems that fall short
Once finished with the eligibility screen- of [Attachment Disorder], or may have a Con-
ing and informed consent processes, subjects duct Disorder with symptoms that mimic [At-
completed the demographic questionnaire, tachment Disorder]” (Randolph, 2000).
RADQ, and SSP, which are all pen-and-paper The examination of SSP and RADQ scores
measures. Qualitative interviews were sched- using Spearman rank order correlation pro-
uled once these forms were complete. The duced a negative correlation (rs = −0.527,
interview was an option provided to all par- p < .01), which was statistically significant
ticipants but not a requirement of their enroll- (see Table 1). This test indicates that there
ment in the study. Of the 24 subjects who par- is, in fact, a correlation between SSP total
ticipated in the quantitative arm of the study, and RADQ total scores. Specifically, this out-
12 chose to also participate in the qualitative come indicates that scores of less typical sen-
arm. sory processing appear to be associated with
If interested, the caregiver and the re- scores of less secure attachment. This corre-
searcher scheduled a convenient time and lation was evident, despite the fact that none
place to meet, or scheduled a phone inter- of the children’s scores fell into the range of
view. Caregivers were asked a few warm- problematic attachment, based on caregivers’
up questions regarding their pregnancy and ratings.
birth experience or, if not applicable, their Because the correlation between SPD and
knowledge of those events. They were slowly attachment scores was statistically signif-
guided into questions relating to the relation- icant, correlations between the different
ship with their child in the first years of life. subsections of the SSP were also examined.
To focus in on attachment specifically, ques- Each subsection represents a different aspect
tions were aimed at eliciting attachment be- of sensory processing. Three of the 7 sub-
haviors and infant/toddler responses to care- sections were found to be correlated with
giver soothing strategies. Subjects were then the RADQ scores, all using a two-tailed test
asked about their own feelings about their at- (see Table 2). Tactile sensitivity (TS) was

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 Integrating Connection 49

Table 1. Correlation of RADQ and SSP Total Scores

RADQ Total SSP Total

Spearman ρ RADQ total Correlation coefficient 1.000 − 0.527a

Significance (1-tailed) – 0.004
N 24 24
SSP total Correlation coefficient − 0.527a 1.000
Significance (one-tailed) 0.004 –
N 24 24

Note. RADQ = Randolph Attachment Disorder Questionnaire; SSP = Short Sensory Profile.
a Correlation is significant at the 0.01 level (one-tailed).

significantly correlated with the total RADQ study sample. One subject was male and iden-
(RADQTOT) score (rs = −0.652, p < .01); tified as “father” of a child with SPD, whereas
increased TS (low TS score) is correlated with the other 11 were female and identified as
less secure attachment (increased RADQ total “mother” of a child with SPD. All 12 identi-
score). There was also a correlation between fied as White. These caregivers were also well
the underresponsive/seeks stimulation sub- educated; one subject (8.3% of the subsam-
scale and RADQTOT (rs = −0.459, p < .05), ple) reported some college, one held a bache-
indicating that difficulty with modulation lor’s degrees, eight (66.7%) held master’s de-
(either being under- or overresponsive to grees, and two (16.7%) had earned PhDs. The
stimuli) may be linked with less secure at- subjects also reported relatively high levels
tachment. Finally, auditory filtering (AF) was of household income; 41.7% reported earning
significantly correlated with the total RADQ more than $150,000 per year. Reflecting the
(RADQTOT) score (rs = −0.577, p < .01). caregivers’ ratings of their children, the mean
This indicates that hyper- or hyposensitivity total raw score for the SSP was 113.58 (SD =
to sound may be linked with less secure 16.462). With regard to the RADQ, none of
attachment. the children met the criteria indicating attach-
ment difficulties.
Qualitative results: Caregivers’
Qualitative data were analyzed apart from
description of the attachment
the quantitative data, as this study followed
relationship
a concurrent design. The qualitative arm
The demographics of the interview sub- of the study followed a phenomenological
sample are similar to those of the complete approach, as it gathered data from several

Table 2. Correlations of RADQ Total Score With Three Short Sensory Profile Subscales

RADQ Total TS USS AF

Spearman ρ RADQ total Correlation coefficient 1.000 − 0.652a − 0.459b − 0.577a

Significance (two-tailed) – 0.001 0.024 0.003
N 24 24 24 24

Note. AF = auditory filtering; RADQ = Randolph Attachment Disorder Questionnaire; TS = tactile sensitivity; USS =
underresponsive/seeks stimulation.
a Correlation is significant at the .01 level (two-tailed).
b Correlation is significant at the .05 level (two-tailed).

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 50 INFANTS & YOUNG CHILDREN/JANUARY–MARCH 2019

individuals who have had the experience of The caregivers used very powerful lan-
being a primary caregiver for a child with guage to describe this feeling of connection
SPD. Using this approach, themes were and their confidence in its strength. Jack com-
identified that described the shared expe- mented, “I am a very important person in
riences of the participants. Through open [his] life,” and “that feeling of, you know, that
coding, significant statements were pulled out [he’s] attached to you. I didn’t birth [him],
from the body of the interviews for further but I might as well have.” Caitlyn noted, “I
analysis and comparison with others. These am sort of like her security blanket,” and “it
statements were not initially labeled but iden- was easy, I would say, to connect with her.”
tified for further assessment. The statements Betsy noted that her son was “always very
were then examined and grouped by simi- Mommy-oriented,” and that they “are totally
larity into themes (Creswell & Plano Clark, connected.” When asked what it was like
2007). However, borrowing from grounded to interact with her young son, Jessica com-
theory, constant comparative analysis (Pad- mented, “Oh my gosh. Amazing. He was very
gett, 1998) was also employed as a coding snuggly.” Marnie also described how her son
strategy to ensure that coding was thorough “lit up when I’d come in the room” and that
and consistent. This was an appropriate strat- she “felt a positivity from him and a nice con-
egy as the researcher recognized new themes nection. Yeah. I didn’t have any real questions
in later interviews and needed to return to about how he felt about me.” Georgia noted
earlier interviews to code them in accordance that in her daughter’s eyes, “I’m number one.”
with these new themes. Because of the focus These are all very strong endorsements of the
of the study, the researcher coded and eval- attachment relationship, as experienced by
uated statements that pertained to the attach- the caregivers.
ment relationship, thus creating two themes
regarding attachment. Eleven other themes Attachment behaviors and indicators
also arose from the data, including caregiver The “attachment behaviors/indicators”
comparison of the child with SPD to a sibling, theme resulted from caregiver descriptions
reactions to the child by others involved with of indicators of attachment as outlined by
the child, and caregiver feelings regarding Bowlby (1958, 1982), Ainsworth (1969,
SPD and associated behaviors. For the pur- 1979), and Schore (2001, 2002). Analysis of
pose of this study, only those relevant to the this theme indicated that nine out of 12 sub-
attachment relationship were examined in jects described very clear indicators of secure
detail. attachment with their child with SPD. They
consistently described positive attachment
Caregiver perception of the attachment behaviors. These included seeking/following
relationship behaviors, positive reunion behaviors, affect
The theme of “caregiver perception of the synchrony and attunement, seeking the
attachment relationship” was defined as care- caregiver when upset, and exploration/use
givers’ feelings, attitudes, and perspective of the caregiver as a secure base.
regarding their attachment with their child Although no subjects described a clearly
with SPD. Here, caregivers described “con- problematic attachment, three subjects de-
nection,” “relationship,” and “attachment.” scribed both positive attachment indicators
All caregivers described a positive perception and some behaviors that could indicate an in-
of attachment with their child with SPD, us- secure attachment (see Table 3). Betsy (all
ing words, such as “secure,” “attached, “close, names have been changed) noted that her
and “two-way,” to define the relationship. son displayed proximity-seeking behaviors by
They also described a preference for the care- “reaching for me, looking for me, crying un-
giver (and often the caregiver’s partner) over til he got me” but also commented that “he
others. had a breakdown every time I left, screaming

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 Integrating Connection 51

Table 3. Examples of Attachment Indicators in the Qualitative Interviews

Attachment Behaviors Secure Response Possibly Insecure Response

Following behaviors Son “would just trail me. If I “He had a breakdown every time I
had to do anything, he left, screaming hysterically.”
would be right behind.”
Reunion behaviors “Hugs and loves and smiles” “He was really kind of angry. Visibly,
physically, almost in a bad mood.”
Affect synchrony/ “He had wonderful eye contact “Nothing seemed to comfort him.
attunement . . . and he responded to Um, no matter what we did, you
facial cues.” know, like we’d rock him, we’d
feed him, we’d this him, we’d that
him, you know. We’d play music,
everything and nothing seemed to,
like, calm him.”
Seeking caregiver when “He looked for me, and wait “Would more or less, kind of just cry
upset for me to come.” in his own area.”
Exploration/use of “He saw something he was “He wouldn’t explore new
secure base interested in, and he would experiences.”
just go.”

hysterically.” She described similar responses as she repeatedly noted, “we couldn’t really
to separation over the course of the interview. console him.” However, she does note that
Her son’s reaction could be viewed as intense nursing was soothing for him and that he en-
distress at separation, which is one gauge joyed exploring.
of insecure attachment (Ainsworth, Blehar, These three subjects display some signs of
Waters, & Wall, 2015); however, this behav- insecure attachment, as well as other, healthy
ior could also be the result of typical behavior indicators of attachment. Valid classification
during a developmental stage of separation of the attachment styles of these dyads (the
anxiety. Another subject, Sarah, described a subjects and their children with SPD) would
lack of interest in touch and difficulty with likely require observation and further inter-
eye contact, which she noted had improved views with both the caregivers and the chil-
over time. She also described a lack of seek- dren, which was outside the scope of this
ing or calling behaviors when her son was dis- study. However, these cases may highlight
tressed, commenting that “he would curl up some challenges inherent in the process of
and implode,” and that “he wouldn’t call out, attachment with children with SPD.
that’s it. He wouldn’t. He would implode and
then I would be discovering things” that had Challenges to secure attachment
upset him, after the fact. She also described a Although caregivers described their attach-
lack of exploration, meaning that he did not ment relationships with their children with
seem curious about his environment and ven- SPD as positive, overall, they also described
turing out to investigate it. However, she also the stress associated with establishing and
described positive reunion behaviors, such as maintaining the connection with their child
smiling when she returned after a brief separa- with SPD, thus creating the “challenges to se-
tion, and showing a preference for his mother cure attachment” theme. Caitlyn commented
and father, over others. Finally, Karen com- that “I wouldn’t say there was any, sort of,
mented on difficulty with affect synchrony, break in attachment, but it was definitely

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 52 INFANTS & YOUNG CHILDREN/JANUARY–MARCH 2019

stressful.” Betsy commented “we couldn’t be much harder time with it. I am really doing a pretty
closer, but it is . . . it’s tough when I’m the good job.” So I gave myself pep talks.
only one who can fix things,” and “that it’s Overall, the caregivers described their ex-
really stressful when I can’t even leave the perience of a healthy, secure attachment with
room, I can’t put a kid down.” Noting how their children with SPD, even despite the chal-
hard it was to soothe her baby, and that lenges and the additional attention they felt
while she “felt connected to him, definitely,” were necessary to meet their children’s needs.
Regina also stated that “it felt . . . you know, Alexandra was able to reassure herself about
it was frustrating that he cried so much at her attachment with her daughter, observing
first. You know, it was hard . . . those first that,
few months were really, really rough.” She
also commented that, “I don’t know if it was yes, she does really, really love me and that we
hard to feel connected. I mean, it was ex- had a good attachment, um, and the fact that she
hausting.” Again she notes, “I feel like our wasn’t nursing after six months, or that I was work-
ing full-time was not . . . that’s not what attach-
relationship was good,” but that “I guess I
ment is made out of. But, um, it took me a while to
felt connected to him, but just exhausted and
feel, kind of, more secure in that as a mom.
frustrated and, um, it wasn’t really what I ex-
pected.” Similarly, Karen, in response to be-
ing asked whether she felt connected to her Merging qualitative and quantitative data
young son, stated, “Um . . . Yeah. Yeah def- There are two specific points of compari-
initely. I mean, it wasn’t ALL the time, but son for the current study. First, the subjects’
it was . . . [SPD] was definitely impacting his responses with regard to attachment security
experience. Negatively,” and that while “he’s were examined. In the quantitative data,
always been easy for me to connect with . . . most subjects responded to the RADQ in
there have been times when he gets very out such a way that their children did not meet
of sync, he’s impossible to connect with.” the criteria for Attachment Disorder on that
Many caregivers commented on how these measure. Only one subject’s scores produced
challenges to the attachment relationship af- a mixed result. This is fairly consistent
fected the way they saw themselves and their with the qualitative data, in which nine out
role as caregivers. Marnie noted “in terms of of 12 interview subjects described secure
my experience of [the attachment relation- attachment behaviors, whereas the other
ship], it was really difficult just because I was three subjects described behaviors that could
exhausted, I was just so wrung out.” She also be associated with an insecure attachment
commented that she but were not enough to label the attachment
relationship as insecure, categorically. In addi-
just found it very isolating so, you know, that
tion, although these three subjects described
impacted my feelings about motherhood, but my
feelings about him were mostly positive. I think attachment behaviors that could be viewed as
I found him really challenging, um, and really de- indication of insecure attachment, they, along
manding. I never said that to anybody, um, I felt with the other nine interviewees, described
bad thinking it. their own perception of having a secure
attachment with their children with SPD.
Christina also described how these mo- Overall, caregivers seem to describe secure
ments impacted her view of herself, “like, ‘I’m attachment behaviors across qualitative and
a rotten, awful mother because he isn’t . . . quantitative measures, while also describing
here with me,’ or ‘we’re not connecting re- their own perception of secure attachment
ally well,’” yet, with their children with SPD in the qualitative
then we would go through periods where it was interview.
really good and it was like, “Ok, I’m doing it. It’s The qualitative and quantitative data were
working.” And I would think, I would say to myself, explored further to examine trends within
“you know, anybody else doing this would have a the sample. This led to the second aspect of

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 Integrating Connection 53

comparison, the correlation of SPD and at- The caregivers who were interviewed also
tachment scores. The RADQ total scores spoke to the correlations between certain SSP
were negatively correlated with the SSP to- subscale scores and RADQ scores; the care-
tal scores, indicating that, although no chil- givers discussed their children’s TS, AF, and
dren were described by their caregivers as responsiveness to stimuli. They referenced
meeting criteria for Attachment Disorder per each of these to varying degrees. Many care-
the RADQ, lower scores on the SSP (greater givers discussed the ways that they adapted
difficulty with sensory processing) were as- their touching of the child, providing hugs
sociated with higher scores on the RADQ with more or less pressure, carrying their ba-
(more behaviors associated with insecure at- bies frequently, and letting their babies sleep
tachment). This also seems to be in line with on them to maintain physical contact. They
the discussions of the caregivers in the in- also discussed their children’s need for more
terviews, which detailed both subjects’ per- or less stimulation; some caregivers talked
ception of attachment security and the chal- about bouncing their babies, or wrapping
lenges inherent in creating attachment with their babies with varying degrees of tightness.
their children with SPD. Others discussed using deep pressure, rock-
Although all caregivers felt that their attach- ing, and being in perpetual motion. Finally,
ment with their children with SPD was secure, one caregiver commented on his child’s AF.
caregivers also made comments about how Jack noted that his son “always made eye con-
“exhausting,” “isolating,” “complicated,” and tact, but, um, he wasn’t really attuned to hear-
“intense” it was to interact with their children ing things.” He had his son’s hearing tested
and meet their sensory needs. They also noted because
feelings of being “inadequate” as a parent;
when you spoke to him he didn’t always re-
Sarah described the “constant effort part, the
spond. And that was pretty early on . . . . And as
feeling of being a salmon swimming uphill.” much as they can test a baby’s hearing, they said
Similarly, Caitlyn commented on how the ef- that it was fairly normal. And that was it. But that
fort of “trying to figure out how to help” her continued, that non-reaction to noise . . . I don’t
daughter led her to being “totally burnt out.” remember exactly if he ever startled from sounds,
Christina described thinking, “ ‘Oh my God, you know. But we knew he could hear.
what do I do with this kid? It’s beyond my abil-
These caregivers do not necessarily com-
ity to handle.’” Karen commented on the ef-
fort, in her son’s early years, of trying to under- ment on the correlation between these facets
stand “without [my son] being able to tell us of sensory processing and the process of at-
tachment, as they experienced it. However,
what’s going on,” and that sometimes she “felt
like I was failing. Where I felt like, ‘I’m not their attention to, and their descriptions of,
the Mom [my son] needs,’ or, ‘Obviously I’m their children’s functioning in these areas
adds detail to the statistical picture. Their at-
not doing a good job because he has so many
problems.’” Alexandra observed, “[My daugh- tention and memory of these areas imply that
they had an impact on the caregivers, if not
ter] was a really difficult baby and I don’t
the attachment relationship, itself.
think I gave myself enough credit for that at
the time.” As attachment is a dyadic relation-
ship, the experience of caregivers, within that DISCUSSION
role, is an important aspect of attachment.
How caregivers feel about their ability to pro- This study aimed to examine the nature
vide nurturing, containment, and comfort to of the attachment relationship between chil-
their infants impacts their view of themselves dren identified with SPD and their care-
as caregivers and how they view the attach- givers. Specifically, both a statistical correla-
ment relationship (Goodman & Glenwick, tion between current attachment behaviors
2012). and sensory processing, as delineated by the

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 54 INFANTS & YOUNG CHILDREN/JANUARY–MARCH 2019

use of quantitative measures, and caregivers’ tor organization (Ferber & Makhoul, 2004);
own perceptions of the attachment relation- increase oxygen saturation in the blood; and
ship (past and present) with their child with stabilize milk production by the mother (Bier
SPD, as described in a qualitative interview, et al., 1996); all are essential basic regulatory
were examined. The aims of this study are needs, impacted by touch. Skin-to-skin con-
imbedded in the broader goals of better un- tact after birth has also been associated with
derstanding of, and therapeutic support for, improved attachment (Moore, Anderson, &
families and children in this critical period of Bergman, 2007). Finally, Schore and Schore
infant and family development. (2014) also note that “tactile-gestural cues of
Overall, the caregivers who participated the body” are one way that attachment com-
in this study described, in both qualitative munication is expressed. Touch is central to
and quantitative measures, a secure attach- the caregivers’ ability to meet basic needs and
ment with their children with SPD. The RADQ provide regulation, which is, itself, a key fac-
scores were all below the cutoff for At- tor in the development of attachment, and
tachment Disorder, and caregivers described correlation between scores for touch and at-
mostly healthy, secure attachment behaviors tachment, therefore, seems logical. Despite
during interviews. Caregivers also described the importance of touch, however, children
their perception of secure attachment, as ex- with SPD may not be receptive. Hypersensi-
pressed in the interviews. However, there tive children may be overwhelmed by their
does appear to be a negative correlation be- caregivers’ touch and may “turn off” in or-
tween SPD and RADQ scores, indicating that der to manage their overstimulation, whereas
greater sensory processing difficulties may hyposensitive children may feel that their
be linked with increased behaviors associ- caregivers’ gentle touches are not stimulating
ated with insecure attachment. Caregivers re- enough.
flected on some of these challenges in their The second aspect of sensory processing
interviews, noting that the process of attach- that was correlated with attachment scores
ment was not always straightforward; they of- was the child’s modulation or his or her re-
ten felt confused, stressed, or inadequate in sponsiveness (under or over) to stimuli. This,
their attempts to recognize and meet their too, seems logical and is supported in the
children’s sensory needs. literature (Whitcomb et al., 2015). Children
who are not able to recognize sensory stimuli,
Sensory components and their or who are overwhelmed by them, may not
association with attachment perceive their caregivers’ attempts to engage
When considering the correlation between with them as regulating. Children who are
sensory processing and attachment, it is no- underresponsive to sensory stimuli may not
table that three subscales of the SSP were experience their caregivers as being stimulat-
correlated with attachment scores. These ing or engaging enough, whereas those who
included TS, underresponsive/seeks stimula- are overresponsive to sensory stimuli may ex-
tion, and AF. The first seems logical. Touch is perience their caregivers as overwhelming or
a primary sense involved in attachment behav- not able to soothe their taxed neural system.
iors. Infants cling to their caregivers, are held Sensory modulation, then, is another area of
by caregivers, and receive regulation through sensory processing that may interact with the
these interactions. Touch is the first sense to attachment process.
develop in the womb at as early as 8 weeks Finally, a correlation was found between at-
of gestation (Pediatrix Medical Group, 2011). tachment and AF scores. Again, Schore and
Skin-to-skin contact is encouraged in early in- Schore (2014) agree that “auditory expres-
fancy to help infants regulate heart rate, res- sions of the emotional tone of the voice”
piratory rate, body temperature (Bohnhorst, (p. 183) are yet another mode of attachment
Heyne, Peter, & Poets, 2001), sleep, and mo- communication. Babies begin to respond

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 Integrating Connection 55

to sound at 16 weeks of gestation, and the only quantitative parent report measure of at-
rhythm and pitch of sounds can impact the tachment that aligns with the age specifica-
baby’s heart rate in utero. Once babies are tions of the SSP, thus fitting the design of
born, sounds are no longer muted and can this study. Despite the concerns regarding the
be intense for newborns, which can neg- RADQ, Sheperis et al. (2003) recommend the
atively affect sleep and slow a newborn’s use of the RADQ by mental health counselors
growth (Pediatrix Medical Group, 2011). This because it was specifically designed to ex-
may be exponentially so for a child who is sen- amine attachment, in comparison with other
sitive to sound. On the contrary, children who measures. To temper the inherent flaws, Ran-
are underresponsive to sound may not experi- dolph (2000), herself, recommends using the
ence their caregiver’s attempts to soothe them RADQ in conjunction with other measures
through behaviors such as cooing, using a soft (Sheperis et al., 2003) to produce a more bal-
voice, or playing gentle music to help alle- anced assessment of the caregiver–child at-
viate an infant’s distress. These infants may tachment relationship. This study includes a
need more, not less, auditory stimulation to be qualitative interview to balance the quantita-
regulated. tive measure and its limitations.
A small sample size, due largely to recruit-
Limitations ment difficulties, is another limitation, as the
Although the RADQ has been evaluated sample size limited the statistical analysis that
to have good reliability (Fairchild, 2006) was possible. In addition, the sample from
and criterion-related validity (Sheperis et al., this study was largely White, highly educated,
2003), it should be noted that the measure has and upper/upper-middle class. These findings
drawn criticism regarding response bias (Mer- then are based on those caregivers who were
cer, 2006), the potential that caregivers might able to obtain services for their children, of-
under- or overestimate their children’s behav- tentimes paying out of pocket for services that
iors (Walter & Petr, 2004), and the fact that were not covered by insurance. One can as-
the RADQ does not measure symptoms of the sert that these findings are both economically
attachment-related diagnoses in the Diagnos- and racially skewed and are not representa-
tic and Statistical Manual of Mental Disor- tive of the experiences of poor or racially di-
ders (Fifth Edition) DSM-V . Also of note is the verse caregivers and their children with SPD.
fact that none of the children met the criteria In addition, the retrospective nature of the
for attachment problems, per the RADQ, yet qualitative interview means that caregivers’
there was a correlation between greater sen- perceptions and recollections may have been
sory processing difficulties and greater symp- influenced by both their child’s current func-
toms of attachment problems. This may mean tioning (eg, having more positive memories
that the RADQ is not an adequate measure because their child is functioning well now, or
of attachment, or that attachment difficulties vice versa) and the amount of time since they
may present differently among children with were immersed in the infant/toddler years. It
sensory processing challenges. is also possible that caregivers’ completion of
Despite these concerns, the RADQ is the the any one of the measures may have im-
only attachment-related screening tool avail- pacted their responses on another. For exam-
able that reports data regarding reliability ple, bringing to light sensory processing may
and validity (Cappelletty, Brown, & Shumate, have made caregiver think about and respond
2005). In fact, “excellent content validity was differently to the attachment measure. Simi-
found in comparison to the attachment symp- larly, having completed the quantitative mea-
tom checklist endorsed by ATTACh, a national sures prior to the interview may have influ-
professional organization specializing in treat- enced the way the caregivers recalled their ex-
ment of attachment disorders” (Wimmer et periences when their children were young, as
al., 2009). Furthermore, it appears to be the described in the interview. The small sample

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 56 INFANTS & YOUNG CHILDREN/JANUARY–MARCH 2019

size also made it possible for one researcher to Psychiatric Association, 2013). Should future
complete the work. Although the researcher studies corroborate and further explain the
did receive feedback from others in the men- connection between SPD and attachment, our
tal health and occupational therapy fields at current diagnostic tenets will need to reflect
each phase of the study and from the sub- that knowledge. For example, an additional
jects themselves after the themes were iden- explanation for “insufficient care,” beyond
tified, the independent nature of the analysis neglect or instability of the relationship
could certainly allow for bias. Finally, it may (American Psychiatric Association, 2013),
be that children with sensory processing dif- might include sensory processing challenges.
ficulties relate and develop attachment with This criterion would reflect the neurobiolog-
their caregivers differently than do typically ical implications of SPD and attachment as a
developing peers. As a result, typical attach- problem more so in the caregiver’s ability to
ment measures may not provide an accurate understand the true needs of the child, rather
reflection of the true nature of their attach- than a problem in providing care. In addition,
ment relationship. language such as “insufficient,” “neglect,”
and “deprivation” (American Psychiatric
Implications Association, 2013, p. 265) would need to
In light of this study’s findings, problems es- be changed, as even diligent caregivers may
tablishing a secure attachment may be more have a child whose sensory systems make the
complicated than previously thought. More provision of attuned care more challenging.
research is needed to better understand the The way that services are provided and re-
relationship between sensory processing and imbursed for children with SPD and attach-
attachment. Although this study explored a ment problems may also need revision. Ser-
potential relationship between the two, there vices for SPD are typically provided by OTs.
is a possibility that sensory processing dif- As 20% of OTs in the United States work with
ficulties of young children may impede the children (Jongbloed & Wendland, 2002), ac-
ability of infants to be regulated by a care- cess to services should not be a problem. Yet,
giver. Even caregivers who work very hard access is largely tied to means of payment
to meet the perceived needs of their children (Jongbloed & Wendland, 2002); many chil-
may feel the confusion, intensity, and stress dren with SPD are either deemed ineligible
reported by the caregivers in this study. Ei- for OT services or cannot afford them. These
ther because they are unable to understand deficits in access create the risk of uniden-
their children’s needs for more or less stimu- tified and untreated SPD impacting a child’s
lation or because infants with sensory process- ability to bond with a caregiver. This exposes
ing challenges have difficulty processing their children with SPD to a host of physical, emo-
caregivers’ attempts to soothe and regulate tional, and behavioral consequences that are
them, caregivers of children with SPD may complex, chronic, and costly.
be at a disadvantage from the start. Sensory Finally, the collaboration of mental health
processing challenges may represent a barrier providers with OTs would also result in better
to successful navigation of needs and connec- understanding of neurobiological processes,
tion between caregiver and child at the crucial attachment, and the behavioral outcomes that
period of attachment’s development. may result from both. Champagne, Koomar,
The association of these concepts raises and Olson (2010) suggest that OTs can pro-
questions about how current policies and vide assistance and train clinicians in the use
practices address SPD and attachment, both of sensory strategies within mental health
separately and together. For one, current di- treatment, including in sensory modalities
agnostic criteria for problematic attachment that address regulation, and consult with clini-
include the assumption that children have cians regarding “sensory integration-informed
experienced “insufficient care” (American psychotherapy approaches” (p. CE-5). The

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 Integrating Connection 57

consistent use of strategies grounded in the comments regarding the challenges in their
same philosophy and understanding of child relationship with their child with SPD as a
and family dynamics by multiple providers result of those sensory processing difficulties.
would enhance treatment, and the experi- Examples of these included comments about
ence of it, for families of children with SPD. the time, energy, and patience required to
Mental health providers can also help care- understand and meet their child’s needs,
givers understand that infants have a variety while also respecting their child’s sensory
of regulatory needs, including variations in needs.
sensory processing, and can help caregivers Despite the obstacles, caregivers did, over-
better read these cues from the infant. all, describe secure attachments with their
These interventions, particularly at the earli- children with SPD. This outcome may seem in
est stages in a child’s life, have the potential contrast to the statistical correlation of scores
to have lifelong impact. indicating greater sensory processing prob-
lems with scores indicating increased behav-
CONCLUSION iors associated with problematic attachment.
In reality, these two concurrent findings high-
If children with SPD have difficulty being light the complex nature of attachment with
regulated by caregivers, even attuned care- children with SPD and caregivers’ powerful
givers, behaviors associated with problematic attunement to their children. These comple-
attachment, if not problems within the mentary outcomes suggest that further ex-
attachment relationship, itself, may result. amination of sensory processing and attach-
Caregivers may work very hard to meet ment is necessary. To the extent that SPD
their infant’s needs but may not fully com- and attachment are correlated, many children
prehend their child’s sensory disposition. with SPD, and their relationships with care-
In addition, a child with SPD may not be givers, may be negatively impacted. As in-
able to receive the regulation being offered secure attachment is linked with many con-
because it is not in alignment with that cerning outcomes, the association between
child’s unique sensory processing capac- SPD and attachment provides a significant op-
ities. The caregivers who participated in portunity to support healthy caregiver–child
this study mirrored this concept in their attachment.

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