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Integrating Connection

A Mixed-Methods Exploration of Sensory Processing and Attachment

Walbam, Katherine M., PhD, LICSW

doi: 10.1097/IYC.0000000000000134
Original Research/Study

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 disorder 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 caregivers 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 despite the fact that none of the children met the full criteria for insecure attachment, according to the attachment measure.

Simmons College, School of Social Work, Boston, Massachusetts.

Correspondence: Katherine M. Walbam, PhD, LICSW, Salem State University School of Social Work, 352 Lafayette St, Salem, MA 01970 (kwalbam@salemstate.edu).

Some funding for this study was provided by the Simmons College Student Research Fund. This research was conducted while at Simmons College, Boston, Massachusetts, as a dissertation study. This work was completed under the guidance of my committee members: Johnnie Hamilton-Mason, PhD, Simmons College School of Social Work; Committee Chair, Annette Correia, OTR/L, Children's Hospital Boston; Dana Grossman Leeman, PhD, Simmons College School of Social Work; and Gerald Koocher, PhD, Provost and Senior Vice President for Academic Affairs, Quincy College. The author acknowledges no other conflicts of interest.

SECURE attachment between infants and caregivers is regarded as a fundamental component of healthy social and emotional development (Fairchild, 2006 ; Gullone, Ollendick, & King, 2006 ; Morrison & Mishna, 2006 ; Moutsiana et al., 2015). Attachment behaviors such as sucking, clinging, following the caregiver with the eyes, and intense eye gazing with a caregiver promote healthy attachment and impart important messages to the child about self, relationships, and the world (Bowlby, 1958 ; Schore, 2001). These behaviors involve visual, auditory, and tactile stimulation; sensory stimuli appear to be an inherent part of the process of establishing attachment (Perry, 2001). Furthermore, infant “negotiation of reciprocity” in relationships often derives from “tactile and auditory and visual inputs” by the caregiver (Brazelton & Als, 1979, p. 365). Yet, between 5% and 16% of school-aged children (as many as 11 million, based on census statistics) in the United States experience sensory processing disorder (SPD; Ahn, Miller, Milberger, & McIntosh, 2004 ; Ayres, 2005 ; Owen et al., 2013 ; U.S. Census Bureau, Population Division, 2016), a neurobiological condition that affects the way that they receive, process, and understand sensory messages (Ayres, 2005).

Both sensory processing and attachment are prevalent in the literature of their fields (occupational therapy and the social sciences, respectively), and there is evidence that other neurodevelopmental disorders, such as autism spectrum disorders (ASDs) and attention-deficit hyperactivity disorder (ADHD), may be linked to attachment in childhood (Chang et al., 2014 ; Cheung & Siu, 2009 ; Clarke, Ungerer, Chahoud, Johnson, & Stiefel, 2002 ; Finzi-Dottan, Manor, & Tyano, 2006 ; Tomchek & Dunn, 2007). These studies all examined a relationship between a neurodevelopmental disorder, like SPD, and attachment. Given that attachment is related to other neurodevelopmental disorders, it is logical to also explore attachment and SPD.

However, empirical research exploring a specific connection between attachment and SPD is limited. A few factors may explain this deficiency, including a traditional understanding of attachment insecurity as the result of mistreatment or inadequate care (American Psychiatric Association, 2013), a lack of familiarity with SPD by practitioners outside of occupational therapy (Walbam, 2014), or some uncertainty about SPD as a valid classification of symptoms (Koziol, Budding, & Chidekel, 2011).

Some studies, however, have suggested that treatment of sensory processing challenges has a positive impact on attachment scores (Jorge, de Witt, & Franzsen, 2013 ; Purvis, McKenzie, Cross, & Razuri, 2013). Jorge et al. (2013), for example, conducted a study on the effectiveness of treatment of SPD symptoms in infancy. The researchers examined the use of a sensory diet, which “refers to a planned and scheduled activity programme which ... is designed by an occupational therapist to meet the child's specific and unique sensory needs” that “includes modifying daily routines, changing the environment and using individualised sensory stimulation to normalise specific sensory responses” (Jorge et al., 2013, p. 29). Of note, one of the measures used, the Infant Toddler Symptom Checklist (DeGangi, Porges, Sickel, & Greenspan, 1993), measures attachment. This study found that treatment of infants using a sensory diet significantly improved parents' reports of attachment behaviors, per the Infant Toddler Symptom Checklist. The authors observed that treatment of problematic sensory regulation with a sensory diet led to improved interactions between children with SPD and their caregivers. If treatment for SPD can significantly improve attachment, then it may be that SPD is, itself, connected to attachment processes.

Finally, Whitcomb, Carrasco, Neuman, and Kloos (2015) have directly joined the concepts of attachment and sensory processing. Using the Short Sensory Profile (SSP), which was also used in the current study, and the Attachment Q-Set, the authors observed 68 children between the ages of 3 and 6 years to determine whether there was a relationship between attachment and sensory processing and whether either of the two concepts might predict the other. The authors examined the relationship between the two using correlation and regression, finding a modest correlation and a small, but significant, predictive relationship (both attachment and sensory processing appeared to predict the other on a small scale). From their findings, the authors suggest “a dynamism between the two processes” (p. 7), which may impact the child–caregiver relationship.

As children with SPD have difficulty receiving and processing sensory input, and as attachment behaviors appear to be sensory in nature, greater understanding of an association between sensory processing and attachment is essential. Such an understanding has the potential to enhance the attachment relationship for millions of children and their caregivers, which may yield better mental health outcomes for the children in the long run. Through a mixed-methods approach examining both current and retrospective experiences, this study has aimed to (1) examine the recollections of early (infant and toddler years) and current attachment experiences by caregivers of children with SPD (aged 3 years, 0 months to 11 years, 11 months) through qualitative methods, (2) examine caregivers' perceptions of their child's current attitudes and behaviors pertaining to attachment through both qualitative and quantitative measures, (3) compare caregivers' responses to both qualitative and quantitative attachment measures, specifically to examine how caregivers describe attachment with a child with SPD, and (4) compare quantitative attachment measures to quantitative measures of sensory processing and describe a possible relationship between attachment and SPD. These aims were attained through application of the following research question: What are caregivers' perceptions of the attachment relationship with their children identified as having sensory processing disorder?

Attachment is a dynamic created between two people: the caregiver and the child. As one-half of the attachment relationship, caregivers are in a distinct position to shed light on the nature of attachment among children with SPD. Better understanding of an association between sensory processing and attachment may result in more responsive service provision by practitioners of numerous disciplines, as well as collaboration across fields.

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METHODS

This study explored the association between SPD and attachment through examination of primary caregivers' perceptions of the attachment relationship with their children identified with SPD. A concurrent mixed-methods design was selected, wherein qualitative and quantitative data were analyzed separately and then compared (Creswell & Plano Clark, 2007). As the study explored a relatively novel topic, this approach allowed for a more well-rounded exploration of a potential association between SPD and attachment through triangulation of the data. This design allowed for exploration of the phenomenon from more than one perspective (Angell & Townsend, 2011), examining both sides of the caregiver–child dyad, as described by the caregiver. Current child behaviors associated with poor attachment and poor sensory processing were examined using quantitative questionnaires, respectively, whereas caregivers' perceptions of early and current attachment experiences were explored though the qualitative interview.

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Instruments

Short Sensory Profile

The items on the SSP describe children's responses to sensory stimuli, and caregivers report the frequency of those behaviors. Items include responses to sensory stimuli, such as “responds negatively to unexpected or loud noises” and “reacts emotionally or aggressively to touch” (Dunn, 1999). The SSP groups items into three main categories, including “sensory processing,” “modulation,” and “behavioral and emotional responses” (Dunn, 2008). It has been used in a number of studies (Engel-Yeger, 2010 ; Tomchek & Dunn, 2007), and found effective at accurately categorizing children with and without disabilities. The SSP comprised those items from the full, 125-item Sensory Profile (Dunn, 1999) that showed the highest discriminative ability in identifying atypical sensory processing (Engel-Yeger, 2010) and was designed for research purposes (Dunn, 1999). All participants in the proposed study completed the SSP to ascertain a score for their child's current sensory processing.

The SSP asks caregivers to rate their child using a 5-point scale, and scoring results in both section raw scores, representing different aspects of sensory processing, and a total raw score, representing sensory processing abilities as a whole. Both section raw scores and total raw scores indicate Typical Performance (TP), Probable Difference (PD), or Definite Difference (DD). The TP classification is given for scores at or above 1 standard deviation below the mean and indicates typical sensory processing abilities of the child. These are scores of 190–155. The PD classification is given for scores at or above 2 standard deviations below the mean but lower than 1 standard deviation below the mean. This indicates questionable areas of sensory processing abilities, meaning either questionable functioning across the board or questionable functioning in several areas of sensory processing abilities. The PD scores are 154–142. The DD classification is given for scores that fall below the point of 2 standard deviations below the mean and indicates sensory processing problems. These are scores from 141 to 38.

The internal consistency of the SSP was calculated by subcategory. All scores indicated good or moderate internal consistency (Engel-Yeger, 2010). Internal validity scores ranged from 0.25 to 0.76, all of which were significant at p < .01 (Dunn, 1999), and indicated that the different sections of the SSP measure relatively unique concepts. Content validity confirmed that the SSP measures the full range of sensory processing behaviors (Dunn, 2008). Discriminant validity was reported at 95%; the SSP accurately identified children with and without sensory processing problems (Engel-Yeger, 2010). In addition, Dunn (1999) reports good construct validity. These are good indications that the SP is able to provide accurate assessment of sensory processing difficulties in the target population. The SSP was also chosen because of its relative ease of completion; the SSP contains 38 items versus 125 for the full SP. This selection made the study more feasible for busy caregivers to complete.

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Randolph Attachment Disorder Questionnaire

The Randolph Attachment Disorder Questionnaire (RADQ; Randolph, 2000) was selected to measure behaviors indicative of current attachment problems. The RADQ is a 30-item, 5-point scale designed to assess attachment in children up to 18 years of age. The primary caregiver is asked to complete the scale, and items include, “my child has trouble making eye contact when adults want him/her to,” and “my child “shakes off' pain when he/she is hurt, refusing to let anyone comfort him/her.”

The RADQ results in subscale scores and a total score. There are two score sheets for the RADQ, one intended to discriminate children with conduct disorder from children with attachment problems, and another intended to discriminate children with histories of severe maltreatment from children with attachment problems. As maltreatment was part of the exclusion criteria for this study, only the score sheet for conduct was used to examine behaviors associated with attachment problems in the study sample. This score sheet results in two subscale scores. One represents children who display problematic attachment and those who have behavioral problems but no history of maltreatment (the Mean Score for Conduct, or MSC). The other, the Discriminant Score for Conduct (DSC), consists of the 10 items that “best distinguished the [Attachment Disorder] and [Disruptive Behavior Disorders] subgroups” (Randolph, 2000, p. 13). The total of these results in a Subscale Score for Conduct (SSC). Finally, the total RADQ score is calculated. If the subscale score is above 33 and the total score is above 64, “the child probably has [Attachment Disorder]” (Randolph, 2000). If the child's scores are below these demarcation points, the child does not have attachment difficulties. If the scores are mixed (one above, one below), “the child probably has attachment problems that fall short of [Attachment Disorder], or may have Conduct Disorder with symptoms that mimic [Attachment Disorder]” (Randolph, 2000).

Test–retest reliability scores for the RADQ were 0.82 for children with attachment problems and 0.85 for a nonclinical group. Internal consistency ratings also indicated good reliability (Fairchild, 2006). The RADQ scores were shown to distinguish subjects with attachment problems from those with behavioral disorders (Sheperis et al., 2003) reported as criterion-related validity (Fairchild, 2006). These scores indicate that the RADQ can be a useful tool in identifying attachment-related behaviors and problems among children with SPD.

Some researchers have found that the RADQ's use, as prescribed, does not provide a complete enough picture for research purposes. The RADQ's use of subscales for Conduct Disorder was intended to differentiate between behaviors indicative of Conduct Disorder and those of attachment difficulties. Although appropriate for client assessment, the categorical outcome of the measure does not indicate where subjects' scores fell within the ranges of each category and is therefore less descriptive. However, the RADQ is the only quantitative measure of attachment available that meets the age requirements of the SSP (3-14 years). In the current study, the total score, subscores (MSC and DSC), and subscore total (SSC) were entered into the data set and analyzed. In addition, the use of these scores, despite Randolph's cautioning, is consistent with the work of other researchers who have used these scores to conduct their own statistical analysis within which attachment is a variable (Becker-Weidman, 2006 ; Purvis et al., 2013 ; Wimmer, Vonk, & Bordnick, 2009). Wimmer et al. (2009) note that, as is the case in the current study, the RADQ was used not “as a diagnostic tool, but as a measurement tool” (p. 355). To better understand the relationship between SPD and attachment, the current study utilized the total score and subscores to examine correlations between the variables.

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Interview with caregivers

A sample of the caregivers who completed the questionnaires also completed a qualitative interview. This lasted approximately 45–60 min and was designed to elicit caregiver perceptions (both current and retrospective) regarding attachment experiences between themselves and their children with SPD. Open-ended questions were designed to gather information regarding child–caregiver interactions and attachment behaviors, child's preference for/separation from the primary caregiver, child's use of caregiver as a secure base, and caregiver response and reactions to the attachment relationship. The creation of these categories was influenced by the works of Bowlby (1958 , 1982), as well as those of Ainsworth (1969) and her colleagues (Ainsworth & Bell, 1970), and Fraiberg (1975), who all conducted much research regarding attachment in infancy. Because children were not interviewed as well, all questions refer to the caregivers' perceptions of their attachment relationships and behaviors. Examples include, “how did your baby respond to your attempts to soothe him/her?” and “was there a difference between his/her reaction to you, and to others?” The interview questions were piloted and found to elicit responses that pertained to the attachment relationship as designed.

The interview questions were focused on infant and toddler years, as this is the age during which attachment and its behaviors seem to be central, developmentally (Mercer, 2006). Because attachment develops in early childhood, the interview used that timeframe as a springboard for discussion of attachment. It was expected that the interviews would elicit a variety of themes relevant to attachment and the attachment process in those early, infant, and toddler years. However, caregivers typically commented on the full spectrum of their child's development and the attachment features throughout, making the study all the more rich and all the more balanced with regard to the RADQ. In addition, the interviews evoked many other themes pertaining to the experience of caregivers in raising children with SPD.

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Participants

Subjects were caregivers of children, between 3 and 11 years of age, who had been identified by a licensed occupational therapist (OT) as having sensory processing difficulties. Participants were recruited through 21 occupational therapy practices in Connecticut, Maine, Massachusetts, New Hampshire, and Rhode Island, using purposive and snowball techniques. Exclusion criteria included exposure of the child to abuse, neglect, or trauma; child diagnosis of ASD or pervasive developmental disorder; and child diagnosis of ADHD.

Of the 24 participants, 21 were female, and also identified as the “mother” of a child with SPD. Three participants were male and also identified as the “father” of a child with SPD. Twenty-three subjects identified their racial identity as “White,” whereas one subject identified as “Hispanic/Latino.” The ages of the caregivers ranged from 33 to 64 years, with a mean age of 40.17 years (SD = 6.657). Caregivers were generally well educated; 33.3% held bachelor's degrees, 50% held master's degrees, and 8.3% were PhDs. The subjects also reported relatively high levels of household income; 45.8% reported earning more than $150,000 per year.

Four children were female, 19 were male, and one questionnaire contained missing data for this variable. Twenty-one children were identified by their caregivers as “White,” whereas one child was identified as “Hispanic/Latino” and one was identified as “other.” All children had been identified by a licensed OT as having sensory processing difficulties and had received treatment by an OT. The mean age of the children at identification of SPD was 4.08 years (SD = 1.841; one score missing).

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Procedure

Once finished with the eligibility screening and informed consent processes, subjects completed the demographic questionnaire, RADQ, and SSP, which are all pen-and-paper measures. Qualitative interviews were scheduled once these forms were complete. The interview was an option provided to all participants but not a requirement of their enrollment in the study. Of the 24 subjects who participated in the quantitative arm of the study, 12 chose to also participate in the qualitative arm.

If interested, the caregiver and the researcher scheduled a convenient time and place to meet, or scheduled a phone interview. Caregivers were asked a few warm-up questions regarding their pregnancy and birth experience or, if not applicable, their knowledge of those events. They were slowly guided into questions relating to the relationship with their child in the first years of life. To focus in on attachment specifically, questions were aimed at eliciting attachment behaviors and infant/toddler responses to caregiver soothing strategies. Subjects were then asked about their own feelings about their attachment with their child. Finally, the subjects were asked to give their perspectives on what would be helpful as the caregiver of a child with SPD.

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RESULTS

Quantitative results: Relationship between sensory processing and attachment scores

The mean for the total raw score for the SSP was 130.29 (SD = 24.820), which falls in the DD range. However, total scores from the SSP ranged from 82 to 173; 16 children fell in the “DD” classification of the SSP, four children fell in the “PD” classification, and five children fell in the “TP” classification. Almost all of the children (95.8%) did not meet the criteria for attachment difficulties, based on their caregivers' responses to the RADQ. One child's score (4.2% of the sample) resulted in a mixed result, meaning that the child “probably has attachment problems that fall short of [Attachment Disorder], or may have a Conduct Disorder with symptoms that mimic [Attachment Disorder]” (Randolph, 2000).

The examination of SSP and RADQ scores using Spearman rank order correlation produced a negative correlation (r s = −0.527, p < .01), which was statistically significant (see Table 1). This test indicates that there is, in fact, a correlation between SSP total and RADQ total scores. Specifically, this outcome indicates that scores of less typical sensory processing appear to be associated with scores of less secure attachment. This correlation was evident, despite the fact that none of the children's scores fell into the range of problematic attachment, based on caregivers' ratings.

Table 1

Table 1

Because the correlation between SPD and attachment scores was statistically significant, correlations between the different subsections of the SSP were also examined. Each subsection represents a different aspect of sensory processing. Three of the 7 subsections were found to be correlated with the RADQ scores, all using a two-tailed test (see Table 2). Tactile sensitivity (TS) was significantly correlated with the total RADQ (RADQTOT) score (r s = −0.652, p < .01); increased TS (low TS score) is correlated with less secure attachment (increased RADQ total score). There was also a correlation between the underresponsive/seeks stimulation subscale and RADQTOT (r s = −0.459, p < .05), indicating that difficulty with modulation (either being under- or overresponsive to stimuli) may be linked with less secure attachment. Finally, auditory filtering (AF) was significantly correlated with the total RADQ (RADQTOT) score (r s = −0.577, p < .01). This indicates that hyper- or hyposensitivity to sound may be linked with less secure attachment.

Table 2

Table 2

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Qualitative results: Caregivers' description of the attachment relationship

The demographics of the interview subsample are similar to those of the complete study sample. One subject was male and identified as “father” of a child with SPD, whereas the other 11 were female and identified as “mother” of a child with SPD. All 12 identified as White. These caregivers were also well educated; one subject (8.3% of the subsample) reported some college, one held a bachelor's degrees, eight (66.7%) held master's degrees, and two (16.7%) had earned PhDs. The subjects also reported relatively high levels of household income; 41.7% reported earning more than $150,000 per year. Reflecting the caregivers' ratings of their children, the mean total raw score for the SSP was 113.58 (SD = 16.462). With regard to the RADQ, none of the children met the criteria indicating attachment difficulties.

Qualitative data were analyzed apart from the quantitative data, as this study followed a concurrent design. The qualitative arm of the study followed a phenomenological approach, as it gathered data from several individuals who have had the experience of being a primary caregiver for a child with SPD. Using this approach, themes were identified that described the shared experiences of the participants. Through open coding, significant statements were pulled out from the body of the interviews for further analysis and comparison with others. These statements were not initially labeled but identified for further assessment. The statements were then examined and grouped by similarity into themes (Creswell & Plano Clark, 2007). However, borrowing from grounded theory, constant comparative analysis (Padgett, 1998) was also employed as a coding strategy to ensure that coding was thorough and consistent. This was an appropriate strategy as the researcher recognized new themes in later interviews and needed to return to earlier interviews to code them in accordance with these new themes. Because of the focus of the study, the researcher coded and evaluated statements that pertained to the attachment relationship, thus creating two themes regarding attachment. Eleven other themes also arose from the data, including caregiver comparison of the child with SPD to a sibling, reactions to the child by others involved with the child, and caregiver feelings regarding SPD and associated behaviors. For the purpose of this study, only those relevant to the attachment relationship were examined in detail.

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Caregiver perception of the attachment relationship

The theme of “caregiver perception of the attachment relationship” was defined as caregivers' feelings, attitudes, and perspective regarding their attachment with their child with SPD. Here, caregivers described “connection,” “relationship,” and “attachment.” All caregivers described a positive perception of attachment with their child with SPD, using words, such as “secure,” “attached, “close, and “two-way,” to define the relationship. They also described a preference for the caregiver (and often the caregiver's partner) over others.

The caregivers used very powerful language to describe this feeling of connection and their confidence in its strength. Jack commented, “I am a very important person in [his] life,” and “that feeling of, you know, that [he's] attached to you. I didn't birth [him], but I might as well have.” Caitlyn noted, “I am sort of like her security blanket,” and “it was easy, I would say, to connect with her.” Betsy noted that her son was “always very Mommy-oriented,” and that they “are totally connected.” When asked what it was like to interact with her young son, Jessica commented, “Oh my gosh. Amazing. He was very snuggly.” Marnie also described how her son “lit up when I'd come in the room” and that she “felt a positivity from him and a nice connection. Yeah. I didn't have any real questions about how he felt about me.” Georgia noted that in her daughter's eyes, “I'm number one.” These are all very strong endorsements of the attachment relationship, as experienced by the caregivers.

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Attachment behaviors and indicators

The “attachment behaviors/indicators” theme resulted from caregiver descriptions of indicators of attachment as outlined by Bowlby (1958 , 1982), Ainsworth (1969 , 1979), and Schore (2001 , 2002). Analysis of this theme indicated that nine out of 12 subjects described very clear indicators of secure attachment with their child with SPD. They consistently described positive attachment behaviors. These included seeking/following behaviors, positive reunion behaviors, affect synchrony and attunement, seeking the caregiver when upset, and exploration/use of the caregiver as a secure base.

Although no subjects described a clearly problematic attachment, three subjects described both positive attachment indicators and some behaviors that could indicate an insecure attachment (see Table 3). Betsy (all names have been changed) noted that her son displayed proximity-seeking behaviors by “reaching for me, looking for me, crying until he got me” but also commented that “he had a breakdown every time I left, screaming hysterically.” She described similar responses to separation over the course of the interview. Her son's reaction could be viewed as intense distress at separation, which is one gauge of insecure attachment (Ainsworth, Blehar, Waters, & Wall, 2015); however, this behavior could also be the result of typical behavior during a developmental stage of separation anxiety. Another subject, Sarah, described a lack of interest in touch and difficulty with eye contact, which she noted had improved over time. She also described a lack of seeking or calling behaviors when her son was distressed, commenting that “he would curl up and implode,” and that “he wouldn't call out, that's it. He wouldn't. He would implode and then I would be discovering things” that had upset him, after the fact. She also described a lack of exploration, meaning that he did not seem curious about his environment and venturing out to investigate it. However, she also described positive reunion behaviors, such as smiling when she returned after a brief separation, and showing a preference for his mother and father, over others. Finally, Karen commented on difficulty with affect synchrony, as she repeatedly noted, “we couldn't really console him.” However, she does note that nursing was soothing for him and that he enjoyed exploring.

Table 3

Table 3

These three subjects display some signs of insecure attachment, as well as other, healthy indicators of attachment. Valid classification of the attachment styles of these dyads (the subjects and their children with SPD) would likely require observation and further interviews with both the caregivers and the children, which was outside the scope of this study. However, these cases may highlight some challenges inherent in the process of attachment with children with SPD.

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Challenges to secure attachment

Although caregivers described their attachment relationships with their children with SPD as positive, overall, they also described the stress associated with establishing and maintaining the connection with their child with SPD, thus creating the “challenges to secure attachment” theme. Caitlyn commented that “I wouldn't say there was any, sort of, break in attachment, but it was definitely stressful.” Betsy commented “we couldn't be closer, but it is ... it's tough when I'm the only one who can fix things,” and “that it's really stressful when I can't even leave the room, I can't put a kid down.” Noting how hard it was to soothe her baby, and that while she “felt connected to him, definitely,” Regina also stated that “it felt ... you know, it was frustrating that he cried so much at first. You know, it was hard ... those first few months were really, really rough.” She also commented that, “I don't know if it was hard to feel connected. I mean, it was exhausting.” Again she notes, “I feel like our relationship was good,” but that “I guess I felt connected to him, but just exhausted and frustrated and, um, it wasn't really what I expected.” Similarly, Karen, in response to being asked whether she felt connected to her young son, stated, “Um... Yeah. Yeah definitely. I mean, it wasn't ALL the time, but it was... [SPD] was definitely impacting his experience. Negatively,” and that while “he's always been easy for me to connect with ... there have been times when he gets very out of sync, he's impossible to connect with.”

Many caregivers commented on how these challenges to the attachment relationship affected the way they saw themselves and their role as caregivers. Marnie noted “in terms of my experience of [the attachment relationship], it was really difficult just because I was exhausted, I was just so wrung out.” She also commented that she

just found it very isolating so, you know, that impacted my feelings about motherhood, but my feelings about him were mostly positive. I think I found him really challenging, um, and really demanding. I never said that to anybody, um, I felt bad thinking it.

Christina also described how these moments impacted her view of herself, “like, ‘I'm a rotten, awful mother because he isn't ... here with me,’ or ‘we're not connecting really well,’” yet,

then we would go through periods where it was really good and it was like, “Ok, I'm doing it. It's working.” And I would think, I would say to myself, “you know, anybody else doing this would have a much harder time with it. I am really doing a pretty good job.” So I gave myself pep talks.

Overall, the caregivers described their experience of a healthy, secure attachment with their children with SPD, even despite the challenges and the additional attention they felt were necessary to meet their children's needs. Alexandra was able to reassure herself about her attachment with her daughter, observing that,

yes, she does really, really love me and that we had a good attachment, um, and the fact that she wasn't nursing after six months, or that I was working full-time was not ... that's not what attachment is made out of. But, um, it took me a while to feel, kind of, more secure in that as a mom.

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Merging qualitative and quantitative data

There are two specific points of comparison for the current study. First, the subjects' responses with regard to attachment security were examined. In the quantitative data, most subjects responded to the RADQ in such a way that their children did not meet the criteria for Attachment Disorder on that measure. Only one subject's scores produced a mixed result. This is fairly consistent with the qualitative data, in which nine out of 12 interview subjects described secure attachment behaviors, whereas the other three subjects described behaviors that could be associated with an insecure attachment but were not enough to label the attachment relationship as insecure, categorically. In addition, although these three subjects described attachment behaviors that could be viewed as indication of insecure attachment, they, along with the other nine interviewees, described their own perception of having a secure attachment with their children with SPD. Overall, caregivers seem to describe secure attachment behaviors across qualitative and quantitative measures, while also describing their own perception of secure attachment with their children with SPD in the qualitative interview.

The qualitative and quantitative data were explored further to examine trends within the sample. This led to the second aspect of comparison, the correlation of SPD and attachment scores. The RADQ total scores were negatively correlated with the SSP total scores, indicating that, although no children were described by their caregivers as meeting criteria for Attachment Disorder per the RADQ, lower scores on the SSP (greater difficulty with sensory processing) were associated with higher scores on the RADQ (more behaviors associated with insecure attachment). This also seems to be in line with the discussions of the caregivers in the interviews, which detailed both subjects' perception of attachment security and the challenges inherent in creating attachment with their children with SPD.

Although all caregivers felt that their attachment with their children with SPD was secure, caregivers also made comments about how “exhausting,” “isolating,” “complicated,” and “intense” it was to interact with their children and meet their sensory needs. They also noted feelings of being “inadequate” as a parent; Sarah described the “constant effort part, the feeling of being a salmon swimming uphill.” Similarly, Caitlyn commented on how the effort of “trying to figure out how to help” her daughter led her to being “totally burnt out.” Christina described thinking, “‘Oh my God, what do I do with this kid? It's beyond my ability to handle.’” Karen commented on the effort, in her son's early years, of trying to understand “without [my son] being able to tell us what's going on,” and that sometimes she “felt like I was failing. Where I felt like, ‘I'm not the Mom [my son] needs,’ or, ‘Obviously I'm not doing a good job because he has so many problems.’” Alexandra observed, “[My daughter] was a really difficult baby and I don't think I gave myself enough credit for that at the time.” As attachment is a dyadic relationship, the experience of caregivers, within that role, is an important aspect of attachment. How caregivers feel about their ability to provide nurturing, containment, and comfort to their infants impacts their view of themselves as caregivers and how they view the attachment relationship (Goodman & Glenwick, 2012).

The caregivers who were interviewed also spoke to the correlations between certain SSP subscale scores and RADQ scores; the caregivers discussed their children's TS, AF, and responsiveness to stimuli. They referenced each of these to varying degrees. Many caregivers discussed the ways that they adapted their touching of the child, providing hugs with more or less pressure, carrying their babies frequently, and letting their babies sleep on them to maintain physical contact. They also discussed their children's need for more or less stimulation; some caregivers talked about bouncing their babies, or wrapping their babies with varying degrees of tightness. Others discussed using deep pressure, rocking, and being in perpetual motion. Finally, one caregiver commented on his child's AF. Jack noted that his son “always made eye contact, but, um, he wasn't really attuned to hearing things.” He had his son's hearing tested because

when you spoke to him he didn't always respond. And that was pretty early on.... And as much as they can test a baby's hearing, they said that it was fairly normal. And that was it. But that continued, that non-reaction to noise... I don't remember exactly if he ever startled from sounds, you know. But we knew he could hear.

These caregivers do not necessarily comment on the correlation between these facets of sensory processing and the process of attachment, as they experienced it. However, their attention to, and their descriptions of, their children's functioning in these areas adds detail to the statistical picture. Their attention and memory of these areas imply that they had an impact on the caregivers, if not the attachment relationship, itself.

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DISCUSSION

This study aimed to examine the nature of the attachment relationship between children identified with SPD and their caregivers. Specifically, both a statistical correlation between current attachment behaviors and sensory processing, as delineated by the use of quantitative measures, and caregivers' own perceptions of the attachment relationship (past and present) with their child with SPD, as described in a qualitative interview, were examined. The aims of this study are imbedded in the broader goals of better understanding of, and therapeutic support for, families and children in this critical period of infant and family development.

Overall, the caregivers who participated in this study described, in both qualitative and quantitative measures, a secure attachment with their children with SPD. The RADQ scores were all below the cutoff for Attachment Disorder, and caregivers described mostly healthy, secure attachment behaviors during interviews. Caregivers also described their perception of secure attachment, as expressed in the interviews. However, there does appear to be a negative correlation between SPD and RADQ scores, indicating that greater sensory processing difficulties may be linked with increased behaviors associated with insecure attachment. Caregivers reflected on some of these challenges in their interviews, noting that the process of attachment was not always straightforward; they often felt confused, stressed, or inadequate in their attempts to recognize and meet their children's sensory needs.

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Sensory components and their association with attachment

When considering the correlation between sensory processing and attachment, it is notable that three subscales of the SSP were correlated with attachment scores. These included TS, underresponsive/seeks stimulation, and AF. The first seems logical. Touch is a primary sense involved in attachment behaviors. Infants cling to their caregivers, are held by caregivers, and receive regulation through these interactions. Touch is the first sense to develop in the womb at as early as 8 weeks of gestation (Pediatrix Medical Group, 2011). Skin-to-skin contact is encouraged in early infancy to help infants regulate heart rate, respiratory rate, body temperature (Bohnhorst, Heyne, Peter, & Poets, 2001), sleep, and motor organization (Ferber & Makhoul, 2004); increase oxygen saturation in the blood; and stabilize milk production by the mother (Bier et al., 1996); all are essential basic regulatory needs, impacted by touch. Skin-to-skin contact after birth has also been associated with improved attachment (Moore, Anderson, & Bergman, 2007). Finally, Schore and Schore (2014) also note that “tactile-gestural cues of the body” are one way that attachment communication is expressed. Touch is central to the caregivers' ability to meet basic needs and provide regulation, which is, itself, a key factor in the development of attachment, and correlation between scores for touch and attachment, therefore, seems logical. Despite the importance of touch, however, children with SPD may not be receptive. Hypersensitive children may be overwhelmed by their caregivers' touch and may “turn off” in order to manage their overstimulation, whereas hyposensitive children may feel that their caregivers' gentle touches are not stimulating enough.

The second aspect of sensory processing that was correlated with attachment scores was the child's modulation or his or her responsiveness (under or over) to stimuli. This, too, seems logical and is supported in the literature (Whitcomb et al., 2015). Children who are not able to recognize sensory stimuli, or who are overwhelmed by them, may not perceive their caregivers' attempts to engage with them as regulating. Children who are underresponsive to sensory stimuli may not experience their caregivers as being stimulating or engaging enough, whereas those who are overresponsive to sensory stimuli may experience their caregivers as overwhelming or not able to soothe their taxed neural system. Sensory modulation, then, is another area of sensory processing that may interact with the attachment process.

Finally, a correlation was found between attachment and AF scores. Again, Schore and Schore (2014) agree that “auditory expressions of the emotional tone of the voice” (p. 183) are yet another mode of attachment communication. Babies begin to respond to sound at 16 weeks of gestation, and the rhythm and pitch of sounds can impact the baby's heart rate in utero. Once babies are born, sounds are no longer muted and can be intense for newborns, which can negatively affect sleep and slow a newborn's growth (Pediatrix Medical Group, 2011). This may be exponentially so for a child who is sensitive to sound. On the contrary, children who are underresponsive to sound may not experience their caregiver's attempts to soothe them through behaviors such as cooing, using a soft voice, or playing gentle music to help alleviate an infant's distress. These infants may need more, not less, auditory stimulation to be regulated.

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Limitations

Although the RADQ has been evaluated to have good reliability (Fairchild, 2006) and criterion-related validity (Sheperis et al., 2003), it should be noted that the measure has drawn criticism regarding response bias (Mercer, 2006), the potential that caregivers might under- or overestimate their children's behaviors (Walter & Petr, 2004), and the fact that the RADQ does not measure symptoms of the attachment-related diagnoses in the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition) DSM-V. Also of note is the fact that none of the children met the criteria for attachment problems, per the RADQ, yet there was a correlation between greater sensory processing difficulties and greater symptoms of attachment problems. This may mean that the RADQ is not an adequate measure of attachment, or that attachment difficulties may present differently among children with sensory processing challenges.

Despite these concerns, the RADQ is the only attachment-related screening tool available that reports data regarding reliability and validity (Cappelletty, Brown, & Shumate, 2005). In fact, “excellent content validity was found in comparison to the attachment symptom checklist endorsed by ATTACh, a national professional organization specializing in treatment of attachment disorders” (Wimmer et al., 2009). Furthermore, it appears to be the only quantitative parent report measure of attachment that aligns with the age specifications of the SSP, thus fitting the design of this study. Despite the concerns regarding the RADQ, Sheperis et al. (2003) recommend the use of the RADQ by mental health counselors because it was specifically designed to examine attachment, in comparison with other measures. To temper the inherent flaws, Randolph (2000), herself, recommends using the RADQ in conjunction with other measures (Sheperis et al., 2003) to produce a more balanced assessment of the caregiver–child attachment relationship. This study includes a qualitative interview to balance the quantitative measure and its limitations.

A small sample size, due largely to recruitment difficulties, is another limitation, as the sample size limited the statistical analysis that was possible. In addition, the sample from this study was largely White, highly educated, and upper/upper-middle class. These findings then are based on those caregivers who were able to obtain services for their children, oftentimes paying out of pocket for services that were not covered by insurance. One can assert that these findings are both economically and racially skewed and are not representative of the experiences of poor or racially diverse caregivers and their children with SPD. In addition, the retrospective nature of the qualitative interview means that caregivers' perceptions and recollections may have been influenced by both their child's current functioning (eg, having more positive memories because their child is functioning well now, or vice versa) and the amount of time since they were immersed in the infant/toddler years. It is also possible that caregivers' completion of the any one of the measures may have impacted their responses on another. For example, bringing to light sensory processing may have made caregiver think about and respond differently to the attachment measure. Similarly, having completed the quantitative measures prior to the interview may have influenced the way the caregivers recalled their experiences when their children were young, as described in the interview. The small sample size also made it possible for one researcher to complete the work. Although the researcher did receive feedback from others in the mental health and occupational therapy fields at each phase of the study and from the subjects themselves after the themes were identified, the independent nature of the analysis could certainly allow for bias. Finally, it may be that children with sensory processing difficulties relate and develop attachment with their caregivers differently than do typically developing peers. As a result, typical attachment measures may not provide an accurate reflection of the true nature of their attachment relationship.

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Implications

In light of this study's findings, problems establishing a secure attachment may be more complicated than previously thought. More research is needed to better understand the relationship between sensory processing and attachment. Although this study explored a potential relationship between the two, there is a possibility that sensory processing difficulties of young children may impede the ability of infants to be regulated by a caregiver. Even caregivers who work very hard to meet the perceived needs of their children may feel the confusion, intensity, and stress reported by the caregivers in this study. Either because they are unable to understand their children's needs for more or less stimulation or because infants with sensory processing challenges have difficulty processing their caregivers' attempts to soothe and regulate them, caregivers of children with SPD may be at a disadvantage from the start. Sensory processing challenges may represent a barrier to successful navigation of needs and connection between caregiver and child at the crucial period of attachment's development.

The association of these concepts raises questions about how current policies and practices address SPD and attachment, both separately and together. For one, current diagnostic criteria for problematic attachment include the assumption that children have experienced “insufficient care” (American Psychiatric Association, 2013). Should future studies corroborate and further explain the connection between SPD and attachment, our current diagnostic tenets will need to reflect that knowledge. For example, an additional explanation for “insufficient care,” beyond neglect or instability of the relationship (American Psychiatric Association, 2013), might include sensory processing challenges. This criterion would reflect the neurobiological implications of SPD and attachment as a problem more so in the caregiver's ability to understand the true needs of the child, rather than a problem in providing care. In addition, language such as “insufficient,” “neglect,” and “deprivation” (American Psychiatric Association, 2013, p. 265) would need to be changed, as even diligent caregivers may have a child whose sensory systems make the provision of attuned care more challenging.

The way that services are provided and reimbursed for children with SPD and attachment problems may also need revision. Services for SPD are typically provided by OTs. As 20% of OTs in the United States work with children (Jongbloed & Wendland, 2002), access to services should not be a problem. Yet, access is largely tied to means of payment (Jongbloed & Wendland, 2002); many children with SPD are either deemed ineligible for OT services or cannot afford them. These deficits in access create the risk of unidentified and untreated SPD impacting a child's ability to bond with a caregiver. This exposes children with SPD to a host of physical, emotional, and behavioral consequences that are complex, chronic, and costly.

Finally, the collaboration of mental health providers with OTs would also result in better understanding of neurobiological processes, attachment, and the behavioral outcomes that may result from both. Champagne, Koomar, and Olson (2010) suggest that OTs can provide assistance and train clinicians in the use of sensory strategies within mental health treatment, including in sensory modalities that address regulation, and consult with clinicians regarding “sensory integration-informed psychotherapy approaches” (p. CE-5). The consistent use of strategies grounded in the same philosophy and understanding of child and family dynamics by multiple providers would enhance treatment, and the experience of it, for families of children with SPD. Mental health providers can also help caregivers understand that infants have a variety of regulatory needs, including variations in sensory processing, and can help caregivers better read these cues from the infant. These interventions, particularly at the earliest stages in a child's life, have the potential to have lifelong impact.

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CONCLUSION

If children with SPD have difficulty being regulated by caregivers, even attuned caregivers, behaviors associated with problematic attachment, if not problems within the attachment relationship, itself, may result. Caregivers may work very hard to meet their infant's needs but may not fully comprehend their child's sensory disposition. In addition, a child with SPD may not be able to receive the regulation being offered because it is not in alignment with that child's unique sensory processing capacities. The caregivers who participated in this study mirrored this concept in their comments regarding the challenges in their relationship with their child with SPD as a result of those sensory processing difficulties. Examples of these included comments about the time, energy, and patience required to understand and meet their child's needs, while also respecting their child's sensory needs.

Despite the obstacles, caregivers did, overall, describe secure attachments with their children with SPD. This outcome may seem in contrast to the statistical correlation of scores indicating greater sensory processing problems with scores indicating increased behaviors associated with problematic attachment. In reality, these two concurrent findings highlight the complex nature of attachment with children with SPD and caregivers' powerful attunement to their children. These complementary outcomes suggest that further examination of sensory processing and attachment is necessary. To the extent that SPD and attachment are correlated, many children with SPD, and their relationships with caregivers, may be negatively impacted. As insecure attachment is linked with many concerning outcomes, the association between SPD and attachment provides a significant opportunity to support healthy caregiver–child attachment.

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Keywords:

attachment; child; parent–child relationship; primary caregivers; sensory processing

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