Attachment
Dr Anne Shortall
Learning outcomes
• Increase knowledge of attachment theory
• Describe healthy attachment patterns
• Describe disorders of attachment
• Diagnostic challenges
• Assessment of attachment
• Interventions
• Relevance for adult mental health
Why should adult psychiatrists care about
attachment?
• Understand underlying aetiological factors in adults who present with
mental health disorders, particularly personality disorders
• Understand how adults patients’ early attachment patterns could
explain aspects of how that patient presents and uses services
• Understand how patients with severe mental illness/ personality
disorders’ parenting affects the development of secure attachment in
their children and why that is important for the child.
• Points towards where preventative interventions could be used in
that group of patients.
•
Definitions of attachment
• An affectionate bond between two people that endures through time
and space and serves to join them emotionally
• The deep and enduring connection established between child and
caregiver in the first three years of life. It is a learned ability, the result
of on-going two-way interactions characterised by protection,
fulfilment of needs, limits, love and trust
• Attachment is the base from which children explore, and their early
attachment experiences form their concepts of self, others and the
world
• Through a positive two-way relationship children learn to regulate
their mood and responses, soothe themselves and relate to others
Definitions
• Immediate and long-term benefits to mental health result if an infant
or young child should experience a warm, intimate and continuous
relationship between child and mother (or permanent mother
substitute), in which both find satisfaction and enjoyment
Purpose of attachment behaviours
• It is through important attachment relationships that the child makes
sense of herself, her emotions, other people and relationships
• Early attachments affect the course of psychological and social
development and mental health. For children who have not formed
secure attachments during the prime ‘window of opportunity’ in the
first three years of life, their chances of developing healthy
attachment relationships in later life are diminished
• Through repeated patterns of caretaker response, the child
internalises a working model of his world and this guides his
behaviour. Important attachment relationships help the child make
sense of himself, his emotions, other people, and the social world
Purpose of attachment behaviours
• Attachment has survival value. It ensures physical survival and emotional
well-being. It is behaviour concerned with response to stress and safety of
the child
• It is not the only domain of parenting- there are others e.g. discipline, play,
etc.
• Evolution has ensured that when infants experience distress, discomfort,
anxiety or fear they seek closeness to an adult who provides protection,
care and comfort. Closeness is achieved through attachment behaviors. E.g
crying, signaling, holding up arms
• How adults respond to the child’s discomfort and distress will affect how
that child’s attachment style will develop, i.e. whether it will be healthy or
unhealthy. Therefore parental sensitivity is important.
Attachment behaviours
• Babies are primed to develop attachments to caregivers
• The existence of a relationship characterized by dependency is absolutely
central. A child cannot ’learn’ about how to attach in the absence of a
caregiver
• How adults respond to the child’s discomfort and distress will affect how
that child’s attachment will develop, i.e. whether it will be healthy or
unhealthy
• Internal working models established early in infancy are extremely robust
• Attachment behaviour competes with exploratory behaviour. The less a
child needs to engage in attachment behaviours, the more it will be free to
explore, interact with and learn from it’s environment
Attachment and exploratory systems
• Are complimentary subsystems
• Mutually inhibiting
• The attachment subsystem is triggered by an internal anxiety
thermometer
• Once triggered all exploration is inhibited until security is found
• The more the child can use their attachment figure as a ‘safe base’
the more time they can spend in ‘exploration mode’
• The exploratory system focuses attention outwards, motivating the
child to explore and learn about the world
Care giving styles
• Sensitivity----------------insensitive
• Acceptance-----------------Rejection
• Co operation__________interference
• Accessibility_____________Ignoring
Care giving styles-examples from observation
• Sensitive- parents meshes their responses to infant’s signals and
communication to form a cyclical turn taking and pattern of
interaction
• Insensitive-Parent intervenes in an arbitrary way, these intrusions
reflecting their own mood and wishes
• Acceptance-parent generally accepts the responsibility of child care,
demonstrating few examples of irritation with the child.
• Rejection- Parent has feelings of anger and resentment that eclipse
their affection for the child, often finding the child irritating and
resorting to punitive control
Care giving styles-examples from observation
• Co operation-parent respects the child's autonomy and rarely exerts
direct control
• Interference- parent imposes their own wishes on the child with little
concern for the child’s mood or current preoccupations
• Accessibility-parent is familiar with their child's communication and
notices them at some distance. Easily distracted by the child
• Ignoring-parent is preoccupied with their own activities and thoughts
They often fail to notice child’s communication unless they become
very obvious through intensification
Theoretical basis
• 1)Attachment theory (Bowlby 1951,1969,1988)
• Research and practice have confirmed its position as a most powerful and influential account of social and
emotional development.
• Bowlby asserted:
• children are biologically prepared to contribute to attachment relationships,
• a secure emotional base facilitates the development of self-esteem, empathy and independence,
• attachment behaviours most obviously occur within the relationship between infants and parents
between 6 months and 3 years.
•
) Ainsworth et al (1978)
2
• Provided scientific support for Bowlby’s theory
• Used the Strange Situation procedure to research child-parent interactions.
• Identified three patterns of attachment: insecure-avoidant, insecure-ambivalent and secure.
Theoretical basis
• Main and Solomon ( 1986 and 1990)
• Used strange situation test to add further category- disorganized
• Main and Goldwyn ( 1990)
• Suggested that parents’ mental representations of their own childhood experiences
determine their sensitivity to their child’s attachment needs and influence the
quality of their parenting.
• Developed the Adult Attachment Interview to assess an adult’s attachment
experiences, the meaning to the adult of these experiences and their current internal
working model.
Strange situation test
• Developed to assess attachment relationships between caregiver and
child between 9 and 18 months
• Developed by Mary Ainsworth
• Child is observed playing for 20 minutes, during which time a
sequence of events occur involving the carer and a stranger entering
and leaving the room. The purpose is to raise the child’s stress and so
observe the activation of their attachment behaviour. The amount of
exploration- i.e. how much the child plays throughout is also
observed
Categories of attachment behaviour on SST
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Ainsworth developed the following categories of attachment:
Rates in non clinical populations
Secure ( type B) -55-60%
Insecure –avoidant- ( type A)-20%
Insecure- ambivalent /anxious ( type C)- 10%
• Disorganized – ( type D)- later added by Main and Solomon -up to 15%
• These proportion are remarkable similar across cultures- secure is usually
55%-60% although rates of other types can vary slightly
Behaviours in strange situation test
• Secure pattern.
• Child-uses care giver as a secure base to explore. May be distressed at
separation. On carer’s return, greets caregiver positively, then gets on with
exploring again
• Care giver-sensitive to child signals. Responsive to child needs. Prompt
response to distress
Avoidant pattern
Child explores with little reference to caregiver. May show little distress on
separation . Avoids or ignores caregiver on return
Carer-actively rejecting of attachment behaviour or insensitively intrusive.
Lack of tenderness. Supressed parental anger
Behaviours in strange situation test
• Ambivalent
• Child. Minimal exploration. Highly distressed by separation. Hard to settle on
reunion , with mixture of clinging and anger
• Caregiver. –minimal or inconsistent caregiving. Preoccupied responsiveness
• Disorganized
• Child . Lack of coherent pattern in exploratory or reunion behaviours. Can
appear fearful or confused in caregivers presence e.g. rocking, covering face,
sudden freezing
• Carer-frightening or unpredictable. Insensitive to child’s cues, Can send child
conflicting messages through body language.
Secure attachment
• Parent/Carer: available, protective, sensitive, responsive, accepting,
consistent and predictable, able and willing to repair breaks in
relationship.
• Internal working model: I am lovable, effective, of interest to others;
others are caring, protective, available, dependable.
• As infant/young child: explores, experiments and learns through play;
begins to understand own and others’ mental states.
Secure attachment
• As older child: has sense of self-efficacy, self confidence and social
competence; able to draw on full range of cognitive and emotional
material to make sense of the social world; good understanding of own and
others’ feelings; appropriate trust in others and will approach for help; able
to resolve conflicts; has some skills for coping effectively with frustration
and stress.
• As adult: values relationships; independent and secure.
• As parent: consistent, responsive and predictable; able to promote secure
attachment in own
Insecure attachment-avoidant
• Carer: consistently unresponsive to child’s needs and attachment
behaviours; resentful and rejecting or intrusive and controlling.
• Internal working model: I’m unlovable, of little worth; others are not
available, are rejecting, hostile or interfering.
• As infant/young child: deactivates attachment behaviours, appears
detached; inhibits emotional expression; undemanding, self-sufficient;
casually ignores parent; shows little distress on separation from parent;
uncomfortable with closeness; exploratory behaviour outweighs
attachment behaviour.
Insecure attachment-avoidant
• As older child: self-reliant, independent; achievement orientated (greater
satisfaction obtained from exploration and activity than from relationships;
cognitive ability may be good, however integration of thought and feeling
is limited; distress is denied or not communicated; self-worth and selfconfidence is poor.
• As adult: avoids emotional intimacy; intellectualizes emotions; task
orientated; may appear cold and detached; views feelings as unreliable and
insignificant and relies more on intellect.
• As parent: child’s distress leads to anxiety; uncomfortable with caring role;
dismissive of child’s distress and likely to view it as attention-seeking.
Insecure attachment- ambivalent
• Carer: inconsistent (sometimes available and responsive, sometimes not);
unpredictable; insensitive and poor and interpreting child’s attachment
signals.
• Internal working model: I’m unlovable, of little worth and ineffective;
others are unreliable, unpredictable, inconsistent and insensitive.
• As infant/young child: amplifies attachment behaviours to ensure they are
noticed; high but angry dependency (fretful, whingy, clingy); show marked
distress on separation from carer but resist being soothed; attachment
behaviour outweighs exploratory behaviour.
Insecure attachment-ambivalent
• As older child: pre-occupied with the availability of others; crave attention
and approval, constantly strive to keep others engaged; escalate
confrontation to hold attention of others; poor concentration skills, easily
distracted; emotional states are obvious; sees things as all good or all bad.
• As adult: pre-occupied with relationships but generally unhappy in them;
jealous, possessive; ambivalent feelings not tolerated easily and dealt with
by splitting (things, inc. people, seen as all good or all bad); feelings acted
out, not thought through.
• As parent: uncertain and ambivalent; needs child to have closeness and to
feel accepted but insensitive to child; treats children as entirely wonderful
or entirely awful.
Disorganized attachment
• Career: frightening to child (dangerous carer behavior e.g. through physical
or sexual abuse or lack of self control due to substance misuse); frightened
(alarming carer behaviour e.g. deeply unresponsive); following frightening
behaviour, does not repair the relationship with the child.
• Internal working model: I’m am unworthy of care; I am powerful but bad.
• As infant/young child: Confused since wants to approach carer for care but
is frightened of them and so wants to avoid them; fearful and helpless;
distress and arousal remain high and unregulated; no behavioural strategy
brings care and comfort.
Disorganized attachment
• As older child: fearful; and inattentive; highly controlling; avoids intimacy;
relationships cause distress with little provocation; violent anger; often
overwhelmed by strong feelings of being out of control, unprotected and
abandoned and of being powerfully bad; cannot understand, distinguish or
control emotions in self or others; dislikes being touched or held; apathy
and despair co-exist with aggression and violence.
• As adult: disturbance and disorganisation remains high.
• As parent: very significant difficulty acknowledging and meeting needs of
own children; look to children to meet some of their own needs.
Other information about attachment
• Attachment is person specific- child can have different attachment
patterns to different care givers.
• But during lifetime- these tend to become consolidated into one
dominant pattern
• We continue to develop attachment relationships during our lifetimeto partners, our own children
Neurological basis
• Brain develops in utero to a quarter adult size. Many brain cells
unconnected.
• Massive rate of development and growth over first 2 years. At 2 years,
brain is 85% adult size and has twice the number of connections and twice
the energy expenditure of the adult brain.
• Brain cell connections established according to experience. The activity of
brain cells alters the physical structure of the brain. ‘Those that fire, wire’.
Experience and environment are the chief architects of the brain.
Neurological basis
• More connections established than needed. Connections that are
seldom used or not well established are eventually pruned.
• Parents play a vital role in establishing the neural circuitry that
enables children to regulate their bodily functions and their
management of their emotions.
• Repeated neglect, adversity or abuse can result in underdevelopment
of some areas of the brain and in over-sensitivity of others. It can also
result in poor integration between brain areas.
Neurological basis
• The relevance to attachment is this:
• Attachment style is robust since neural circuitry established early in life does
not easily allow for the development of new skills of arousal reduction.
• A child’s style of bodily and emotional regulation (which is controlled by it’s
neural circuitry) typically elicits responses in other people which generally
serve to reinforce the internal working model. (A child who has acquired good
skills of self-soothing and impulse control will generally elicit positive
responses from others, particularly adults. A child in whom such skills are
lacking will often be seen as difficult and unrewarding and may elicit
disapproval, distancing and possibly rejection from adults).
What is disordered attachment?
• Approximately 60% of children develop secure attachment.
• Of the remainder many children will develop insecure patterns, i.e.
avoidant or ambivalent. These patterns, whilst exhibiting some behaviours
of concern, nevertheless represent an organised approach by the child to
elicit care and to feel safe. It is important to remember that these patterns
are not the same as disorders- they are v common in the general
population. They may be risk factor but do not necessary lead on to
mental health difficulties.
• The term disordered attachment is probably most appropriately used to
describe that proportion of children ( 5-7% of general population, 67% of
children in foster care) whose attachment is disorganised and who show
the greatest degree of disturbance. Here the child has been unable to
identify a reliable way of orgainising behaviour that elicits care from carers
and helps him to feel safe.
Features of disordered attachment
• Very common in looked after population
• Dysregulation in number of domains of functioning e.g.
• -Emotions-poor recognition of internal emotional states, labile mood,
anxiety, angry outbursts; or very detached emotionally.
• -Relationships- clinging; lack of discrimination; over friendly; or
withdrawal. Poor maintenance of relationships. Need to be in control.
Aggressive interactions. Ambivalence. Poor eye contact. Problems
regulating physical closeness
Features of disordered attachment
• -Behaviour- inattentive, impulsive, poor concentration
• - Cognitive- fail to learn from mistakes, poor cause and effect
thinking, poor sequencing and planning – executive functioning
problems
• -Physical- enuresis, encopresis, difficulty sleeping, problems
regulating food intake (too much or too little)
• Many other symptoms can be attributed to disorders of attachment
Disorganized attachment
• Infants with disorganized attachment on the strange situation test
are more likely to show high levels of aggression in middle childhood
• This is likely to be a long lasting trait
• Rates of disorganised attachment are much higher in children who
are looked after; or where there is a history of abuse/ traumapossibly as high as 90%
• There may be an overlap between the concept of disorganised
attachment and the diagnostic category of Reactive Attachment
Disorder. ( although some dispute that they are the same)
Psychiatric definitions of attachment disorder
• ICD 10- Reactive attachment disorder and disinhibited attachment
disorder of childhood
• DSM- Reactive attachment disorder- inhibited and disinhibited sub
types
• Initially described in institutionally reared children.
• These are psychiatric categories and although they have some overlap
with the concepts described above, there are some difficulties in their
use.
Reactive attachment disorders-ICD 10
• Onset before the age of 5
• Persistent abnormalities in the pattern of children’s social
relationships- across different social relationships
• Emotional disturbance ; reactions to changes in environmental
circumstances.
• Can have fearfulness and hypervigilance, poor social interaction with
peers; aggression towards self and others
• Occurs probably as a result of severe parental neglect, or abuse
Disinhibited attachment disorder of
childhood-ICD 10
• Pattern of abnormal social functioning that arises in first 5 years of lifetends to persist despite changes in environmental circumstances.
Associated with severe early deprivation, absence of available caregiver
and frequent change of caregiver.
• Diffuse, non selective attachment focused behaviour; attention seeking and
indiscriminately friendly; poorly modulated peer relationships
• May have other emotional and behavioural disturbances
• This pattern of indiscriminate socially disinhibited behaviour- appears to
persist despite later developing secure attachment to care givers e.g.
Romanian orphan study. Therefore- may reflect processes other than
attachment.
Problems with definition
• Reactive attachment disorder-although clear types of behaviour exist,
there are some problems in categorising this as a disorder of attachment
• Includes cause as part of clinical definition
• ICD10 /DSM definitions do not include anything about attachment
behaviours in the clinical characteristics ( e.g. proximity seeking when
distressed, acceptance of comfort)
• Includes a lot of other behavioural descriptors e.g. challenging behaviour,
cruelty to animals
• It may be that the concept of RAD really reflects the broader consequences
of early abuse/ trauma/ neglect.
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Problems
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It is likely that RAD- includes symptoms such as
impaired affect regulation;
Heightened patterns of arousal; lack of reciprocity; lack of empathy
Deprivation based behaviour e g. food hoarding
Coercive controlling behaviour
These can be seen as a result of a lack of early attunement and emotional
regulation associated with neglect / abuse- probably modulated via
changes in neural and endocrine systems
• Is RAD- a disorder of social attuntement that follow on from early
disorganized attachment pattern?
Differential diagnosis
• Children with attachment disorders are dysregulated in many ways- emotional
dysregulation needs to distinguished from sustained depression, or Bipolar
disorder in older adolescents
• ASD- may be difficult to distinguish from disinhibited types of attachment
behaviour-distinguishing features can include:
• -specific communication deficits of ASD, e.g. echolalia, literal understanding,
unusual voice tone not usually seen in attachment disorder.
• -Play- in ASD tends to be related to intense interests, involve collecting/ordering;
have high cognitive content. Children with attachment disorders may lack play
skills but interests tend to be more usual.
• -Social relationships-Children with ASD may show one sided interaction, unaware
of other’s perspective. Children with attachment disorders- might lack social skills
but do not have unusual types of interaction; can be highly attuned to other’s
reactions.
Differential diagnosis
• Children with attachment disorders may have disregulated attention,
poor concentration and hyperactivity- so will fulfil criteria for ADHD
and may benefit from treatment for ADHD. But has to be seen as part
of a broader pattern of difficulties
Assessment in children
• Focused observations of child and carer. Strange situation test- mainly a research
tool. Adaptation have been developed for slightly older children
• Structured assessment may be used, e.g. Story Stems, MCAST-play based
methods designed to access attachment representations
• Structured interviews for older children (7 upwards ) and adolescents.- e.g.
adaptation of adult attachment interview.
• Most of the above are predominately used in research; clinical assessment tends
to rely on history taking and general observations
Assessment in adults
• Mainly structured interviews-self report questionnaires also exist
• Most widely used- Adult attachment interview AAI- ( George, Kaplan
and Main 1984)
• Semi structured interview- lot of research validity
• Aims to elicit adult representations of their attachment experiences.
• Interview codes content and coherence of discourse
• Categories are autonomous; dismissing; preoccupied; unresolved
AAI categories
• Autonomous-value attachment relationships, describe them in a
balanced way. Discourse is coherent and internally consistent
• Dismissing-have memory lapses. Minimize negative experiences, deny
impact on relationships. Positive descriptions may be contradicted.
• Preoccupied. Have continuing preoccupation with own parents
Incoherent discourse. Have angry or ambivalent reprentations of the
past
• Unresolved- evidence of trauma or unresolved loss or abuse
• Research has shown link between parents AAI categories- and later
attachment of their infants on strange situation test
Therapeutic interventions for children
• A range of approaches have been developed.
• None are, or attempt to be, a substitute for good quality care at
home. They can only be an extra.
• All professional attachment interventions emphasize the central
importance of carers and largely describe therapeutic work with, and
through parents, long-term substitute carers or adoptive families.
Principles of care giving for children with
disrupted attachments (Looked after children)
• Information giving
• Co regulation of emotions
• Limit setting, discipline with empathy
• Claiming behaviours
• Help child build narrative about their experiences
• Carer coping and self care
Carer characteristics (looked after children)
• Need for realistic expectations, flexibility in approach, persistence,
stamina, and accepting long term nature of problems in some cases.
• Maintaining calm reflective stance
• Avoiding being drawn into negative cycle
• Maintaining positivity
• Managing extreme behaviours
Therapeutic interventions
• Therapeutic interventions aim to increase parental sensitivity to
child's cues (behavioral interventions)
• Combined in some cases with psychotherapeutic work with parents
to work with their mental representations of their own childhood.
• Number of video based feedback programs exist for parents and
young babies e.g. infant parent programmes; watch, wait, wonder.
• All other CAMHS interventions may be appropriate for managing the
associated emotional and behavioral presentations
Preventative interventions
• Have been used in high risk groups with parents and babies
• Or for adoptive parents and children
• Tend to focus on behavioural change in parents- to increase parental
sensitivity to infants’ cues
• Many use video feedback techniques e.g. VIPP video feedback to
promote positive parenting
Therapeutic interventions
• Parenting Education-understanding about effects of early disrupted
attachment on current behavior
• Adapted Webster Stratton groups ( parenting groups)
• Attachment groups for carers
• Parent-Child Game
• Video interaction guidance
• Relationship Play Therapy-theraplay, filial play therapy
• Dyadic Developmental Psychotherapy ( Dan Hughes)
Evidence for interventions
• Not a lot of clear evidence about therapeutic interventions.
• Some evidence to suggest that behavioural based interventions can
increase parental sensitivity especially with young children
• But harder to address parents' own attachment representations
• In older children, a range of CAMHS interventions may be useful for
addressing problem areas such as increased arousal, social problem
solving, coping with frustration, closer family relationships- but studies do
not generally show a change in attachment status of the child
• Studies favour- short term interventions with clear focus.
Prognosis
• In general, insecure attachment patterns are best thought of as risk/
vulnerability factors for later problems, including mental health disordersrather than predictive factors.
• Little evidence about links between infant attachment patterns and later
adult psychopathology.
• Some studies have shown that those adults with preoccupied/ ambivalent
attachment-have higher rates of mood disorder, anxiety and borderline
personality disorder
• Disorganized attachments in young children- are associated with later high
levels of aggression in middle childhood/adolescence, and possibly predict
a higher level of mental health difficulties in later life. Studies have shown
link with more hostility in later adult relationships
Prognosis
• Difficult to know if continuity of problems is due to continuity of
environment.
• Psychiatric in patients- shown to have higher rates of disorganized
attachment than controls
• Extreme disturbances of attachment are like be associated with history of
abuse and /or trauma as children as well
• We do know that attachment patterns in parents- closely mirror those of
their infants
• Therefore consequences are broader than mental health difficulties but
can affect quality of adult relationships, parenting, employment,
criminality, drug use, etc.