Attachment

Question 1

Four patterns of attachment

Answer 1

» 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

Question 2

How does Attachment influence later behaviour?

Answer 2

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)

Question 3

Attachment Style Development

Answer 3

» 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/

Question 4

Parental attunement and development

Answer 4

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.

Question 5

What happens when something goes wrong?

Answer 5

» Parent with serious mental illness/substance abuse
» Extremely young/immature parenting
» Parents who received inadequate parenting themselves
» Unstable/changing caregivers
» Inadequate individual interaction

Question 6

Attachment Experiences Dan Siegel

Answer 6

» 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

Question 7

Psychotherapy and Attachment

Answer 7

» 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

Question 8

How could we study social deprivation?

Answer 8

» 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

Question 9

» Institutional Care and Adoption example of social deprivation

Answer 9

» 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

Question 10

» Rutter et al study of Romanian orphans example of social deprivation

Answer 10

» 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

Question 11

Disruptions/deprivation of attachment has

consequences

Answer 11

» Disruptive behaviour Disorders
» Emotional Disorders
» Learning Disorders
» Reactive Attachment Disorder

Question 12

Reactive Attachment Disorder

Answer 12

» 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

Question 13

Reactive Attachment Disorder DSM

Answer 13

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)

Question 14

DSM5 changes RAD

Answer 14

» 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)

Question 15

New RAD (old inhibited type)

Answer 15

A. Consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers, with both

1. Child rarely or minimally seeks comfort when distressed
2. Child rarely or minimally responds to comfort when distressed

B. Persistent social and emotional disturbance characterized by at least two of

1. Minimal social and emotional responsiveness to others
2. Limited positive affect
3. 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

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. Not Autism Spectrum Disorder
F. Evident before five years old
G. Developmental age of at least 9 months

Question 16

RAD features according to DSM5

Answer 16

» 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

Question 17

Disinhibited Social Engagement Disorder

Answer 17

A.Pattern of behaviour in which a child actively approaches and interacts with unfamiliar adults and exhibits at least two of:

1. Reduced or absent reticence in approaching and interacting with unfamiliar adults
2. Overly familiar verbal or physical behaviour (that is not consistent with culturally sanctioned and with age appropriate social boundaries)
3. Diminished or absent checking back with adult caregiver after venturing away, even in unfamiliar settings
4. 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

Question 18

How do attachment disorders relate to Attachment?

Answer 18

» 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?

Question 19

Proposed Disorders of Attachment

Zeanah

Answer 19

» 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

Question 20

What can be done?

Infant-Parent Psychotherapy

Answer 20

» 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

Question 21

What can be done?

Therapeutic Foster Care

Answer 21

» 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

Question 22

Supporting Foster Parents

Answer 22

» 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

Question 23

Persistence of Attachment Style

Answer 23

» 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