Attachment Flashcards
Four patterns of attachment
» Secure attachment
» Avoidant attachment
» Resistant/anxious attachment (ambivalent)
» Disorganized attachment
None is a disorder; some are risk factors
» This system (esp 1-3) was developed to describe the range of patterns of attachment in normal range families
» Disorganised was added later, in studies of abused children
How does Attachment influence later behaviour?
Attachment is a basic part of us
» Those first two years are critical to brain development
» Interactions with caregivers shape the brain
» Deprivation or serious disruption of attachment disrupts
central developmental processes
Working models of relationships
Affect regulation
Self-regulation and stress response
Recognition of self/other (theory of mind)
Attachment Style Development
» As the child is responded to, they develop not only a
set of expectations about the world and their caregivers, but also a way of responding to themselves and to their own needs
» Dan Siegel on attachment styles:
» http://www.psychalive.org/what-is-yourattachment-
style/
Parental attunement and development
If parent can’t/doesn’t mirror
» Difficulties acknowledging/identifying affect
» Internal working model of self and other is
confused/confusing
» Developing stress response/self-soothing
affected
More intense emotional responses
Less ability to cope with emotion
Still Face Paradigm - baby can’t cope without seeing mother’s expression. if 2 minutes is traumatic, imagine years of neglect.
What happens when something goes wrong?
» Parent with serious mental illness/substance abuse
» Extremely young/immature parenting
» Parents who received inadequate parenting themselves
» Unstable/changing caregivers
» Inadequate individual interaction
Attachment Experiences Dan Siegel
» Dr Dan Siegel has taken this work into the realm of neurobiology and into the more ‘everyday’ attachment difficulties
» Here he describes how attachment experiences literally ‘create’ present relational experiences based on a developmental template
» https://www.youtube.com/watch?v=HzI5vLBrX8A&index=13&list=PLDCtwyPSjhlNEz4xuzxt6Tdsnyt2vChiB
Psychotherapy and Attachment
» Therapy can be a new template for a secure relationship
» Your responses, empathy, and trustworthiness create new experiences and over time can alter the brain and allow for new possibilities of relating both in the therapy room and outside
» Central to this change is also the understanding of how the old attachment framework was formed: the nature of childhood experiences and their impact on the present
How could we study social deprivation?
» Neglected children
But it’s often confounded with abuse, poverty, etc.
» Adoption (esp international) after institutional care
Major social intervention
Clear contrast between environments
Studies of British children (Tizard et al) in “good” institutional care—good basic care and stimulation, but multiple caregivers, no ongoing ones – behavioural and relationship disturbances
Studies of children adopted from Romanian orphanages – Physical, cognitive, and social effects
» Institutional Care and Adoption example of social deprivation
» Babies reared without attention/stimulation don’t grow normally
» Institutionally reared children have lags in physical, cognitive and language development
Even in a “good” institution, mean of 5 minutes talking with child per day
» Children who are adopted “catch up” physically and cognitively (mostly)
But, age at adoption matters
Children raised in institutional care are at increased risk of ADHD symptoms are poorer at theory of mind tasks are poorer at reading facial cues and understanding emotions have more social problems
» Rutter et al study of Romanian orphans example of social deprivation
» The longer in Institutional Care, the lower the IQ
» The longer in IC, the small the head circumference
» The longer in IC, the greater the risk of RAD-like
behaviour
Even in the highest risk group, most did not have it
Disruptions/deprivation of attachment has
consequences
» Disruptive behaviour Disorders
» Emotional Disorders
» Learning Disorders
» Reactive Attachment Disorder
Reactive Attachment Disorder
» One of the least well-defined and studied disorders in
DSM
» Think of it as a work in progress
» There has been a little bit of progress (or at least change) with DSM5
» Lots of questionable information and treatment
» Don’t believe everything you read, especially on
the internet
Reactive Attachment Disorder DSM
Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before 5 years, with either
» Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hypervigilant, or highly ambivalent and
contradictory responses (e.g. the child may respond to caregivers with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness)
(Inhibited type)
OR…
» Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e.g., excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures)
(Disinhibited (or indiscriminate) type)
AND
» It is not due to developmental delay or PDD
» Pathogenic care as evidenced by at least one:
» Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection
» Persistent disregard of the child’s basic physical needs
» Repeated changes of primary caregiver that prevent formation of stable attachments (e.g., frequent changes in foster care)
DSM5 changes RAD
» RAD is in a section called “Trauma and Stressor-Related Disorders”
» What used to be called RAD (two types) is now two separate disorders:
» Reactive Attachment Disorder (the old inhibited type)
» Disinhibited Social Engagement Disorder (the old disinhibited type)
New RAD (old inhibited type)
A. Consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers, with both
- Child rarely or minimally seeks comfort when distressed
- Child rarely or minimally responds to comfort when distressed
B. Persistent social and emotional disturbance characterized by at least two of
- Minimal social and emotional responsiveness to others
- Limited positive affect
- Episodes of unexplained irritability, sadness, or fearfulness that are evident even during nonthreatening interactions with adult caregivers
C. The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of
- Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
- Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., multiple foster homes)
- Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions)
D. The care in criterion C is presumed to be responsible for the disturbed behaviour in Criterion A
E. Not Autism Spectrum Disorder
F. Evident before five years old
G. Developmental age of at least 9 months
RAD features according to DSM5
» Often co-occurs with developmental delays, because
of neglect; also depressive symptoms
» Prevalence unknown, rare in clinics
» Even among severely neglected children, possibly less than 10%
» Risk factors—serious social neglect…don’t know what
else
» Prognosis depends on quality of caregiving
» Differential diagnoses (watch for) ASD, ID, Depression
Disinhibited Social Engagement Disorder
A.Pattern of behaviour in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of:
- Reduced or absent reticence in approaching and interacting with unfamiliar adults
- Overly familiar verbal or physical behaviour (that is not consistent with culturally sanctioned and with age appropriate social boundaries)
- Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings
- Willingness to go off with an unfamiliar adult with minimal or no hesitation
B. The behaviours in Criterion A are not limited to impulsivity but include socially disinhibited behaviour
C.The child has experienced a pattern of extremes of insufficient care as evidenced by at least one of
1. Social neglect or deprivation in the form of persistent lack of having basic emotional needs for comfort, stimulation, and affection met by caregiving adults.
2. Repeated changes of primary caregivers that limit opportunities to form stable attachments (e.g., multiple foster homes)
3. Rearing in unusual settings that severely limit opportunities to form selective attachments (e.g., institutions)
D.The care in criterion C is presumed to be responsible for the disturbed behaviour in Criterion A
E. Developmental age of at least 9 months
» The child may or may not show other signs of severe neglect or disordered attachment
» Prevalence unknown, rare in clinics, maybe 20% of those at risk by virtue of criterion C
» If neglect begins after 2 years old, not likely to result in DSED
» Moderately stable over time, but different behaviours
» In early childhood, verbal and social intrusiveness, attention-seeking
» In middle childhood, verbal and physical overfamiliarity and inauthentic expression of emotions, esp with adults
» In adolescence, peer relationships are affected; indiscriminate behaviour and conflicts
» Not described in adults
» Little research on comorbidity or much else
» Differential diagnosis: watch for ADHD
How do attachment disorders relate to Attachment?
» A lack of attachment?
» Maybe, but some seem to form attachments
» A strategy for survival?
» Minnis et al article
» Intersubjectivity is so crucial you settle for what you can get
If it is missing, you seek it anywhere
If it is discordant/painful, you withdraw
» The most extreme of a set of possible attachment
disorders?
Proposed Disorders of Attachment
Zeanah
» Non-attachment (RAD) - No clearly preferred attachment figure
» Secure Base Distortions - Disturbed relationship with attachment figure Self-endangering Clinging/inhibition Vigilance/hypercompliance Role reversal
» Disrupted Attachment - Sudden loss of attachment figure
What can be done?
Infant-Parent Psychotherapy
» Usually provided to very high-risk parents
- History of serious mental illness
- Poverty, lack of support, abuse history
» In-home sessions with infant present
» Psychoeducational and psychotherapeutic
» Intensive and extensive—so, not cheap
- Cheaper than foster care?
» Some brief (e.g. 8 sessions)versions have been tested
- Efficacy studies show impact on parent-infant interactions, infant symptoms/child behaviours, cortisol, and (sometimes) attachment security
What can be done?
Therapeutic Foster Care
» Bucharest Early Intervention Project
» Randomly assigned abandoned children to foster
care (FC) or institution (IC)
» FC consists of
Parent hired as employee
Parent(s) supported by social worker
Not paid per child
» Children in FC have higher cognitive functioning than those in IC
» Still following and looking at other outcomes
Supporting Foster Parents
» Mary Dozier work on training foster parents
» Attachment and Bio-behavioural Catch-up (ABC) goals
Provide environment where foster child can feel nurtured even if they push the foster parent away
Help caregiver work through personal issues/responses
Provide a more controllable interpersonal environment to allow children to self-regulate stress responses
» ABC intervention and outcomes
10 joint foster-parent child sessions
Children showed fewer avoidant behaviours
Cortisol production similar to those not in foster care
Persistence of Attachment Style
» While attachment is related to early life trauma, there is significant evidence that our style of relating persists into adulthood in our close relationships
» Current couple work based on an attachment framework, such as EFT, focuses on deconstructing and de-escalating attachment-trigger patterns in order to facilitate the development of more secure partnerships and parenting
» Intake consists of establish the dyadic pattern and individual style inventory http://personalitytesting. info/tests/ECR.php
