attachment: close observation clinical applications john richer chox and dpag oxford

Attachment:Close observation

Clinical applications

John RicherCHOX and DPAG

Oxford

Temper tantrum

• 3 years old • Behaviour problems +• Mother not coping +• Attachment insecurity ++

Temper tantrum

Video

DescribeWhat is going on?What do the behaviours mean?What are the child’s feelings / motivations?What are the mother’s feelings / motivations?

Fear, Frustration, Insecurity

Angry avoidance

Approach,Attachment behaviour

Let go Pick up /Retrieval

Child

Parent

Strength of motivation

Distance apartNear Far

Attachment driven approach

Avoidance

Escape Go to

Tempers happen

here

Fear, Frustration, Insecurity

AvoidancePull awayCollapse on floorPull head back

Attachment behaviourMove towardsBury head in

“Mummy”

Let goMove hands awayDo little

RetrievalHoldArm aroundSpeak to

Child

Parent

Distance apart Increasing Decreasing

Mum reduces her approach behaviour Child increases his approach behaviour ///

Mum reduces her retrieval behaviour Child increases his attachment behaviour

Video

Mum increases her approach behaviour Child increases his avoidance behaviour ///

Mum increases her retrieval behaviour Child increases his avoidance behaviour

Video

Motivational conflict• [One wins out]• Alternation e.g. dither

• Simultaneous e.g. approach +gaze avert

• Compromise e.g. side on

• Overintensity e.g. OTT, too close

• Displacement activities e.g. stereotypies, tics

• Aggression• Re-directed aggression e.g. to mother, sibs

• Regression e.g. baby behaviour

Ongoing behaviour is blocked

• Internally - motivational conflict

• Externally - frustration

• Exploration• Overintensity

• (impulsive , careless)

• Switch attention– from task– from person

• Displacement activities • (fidget, fiddle, stereotypies, tics)

• (Re-directed) aggression• Regression• Attachment

Reactions to frustration

Fear/Frustration/Anxiety

Approach

Switch attention

Overintensity

OK

Maintain focus

Avoidance

Too soonTo partial cuesToo intenselyToo briefly

Fear/Frustration/Anxiety

Approach OTT

OK

“Relaxed”

Avoidance

“Silly” “Shy”

2 year old with mother meeting a stranger

Attachment Theory and Evolution

• All mammals born immature

• Need protection and care to survive

• Unprotected human children under 7 years rarely survive

• Survivors have genes which promote behaviour:– Parent(s) - give protection and caregiving

– Offspring - seek protection and caregiving

• Mechanism: Attachment motivation/behaviour:– Parent(s) - Retrieval

– Offspring - Attachment behaviour

• Very powerful motivation - survival depends on it

Attachment Behaviour

• Attachment behaviour - proximity seeking – (cry, call, move towards. etc)

• Precipitant: anything fear provoking – (strangers, novelty, illness/pain/discomfort, separation, dark, danger, etc.)

• Termination: proximity/fear reduction

Attachment Relationship

• Attachment relationship - between offspring and parent or other important caregivers

• Parent = secure base

• Offspring can explore/play/learn, trusting that parent will protect/care for

Attachment Relationship: Variable Security

• Mary Ainsworth, 1970s• Strange situation 18 months

• The attachment relationship varies in its security• Secure <-> insecure

Types of Security of Relationship• B Secure:

– Child plays well, comforted on reunion

• C Insecure Ambivalent: – Vigilant about mother, hovers near mother, not cuddle, separation anxiety

and protest ++, less comforted on reunion,

• A Insecure Avoidant: – Generally but covertly vigilant, no separation protest, ignores mother on

reunion, ?play is less varied.

• D Insecure Disorganised: (Mary Main 1990s)– Disrupted strategy, child confused, stereotypies.– ?= severe Ambivalent / ?more stressed

Effect in increasing stress0. Ordinary, age appropriate sociable playful behaviour, able to balance own needs and those of others.

I. Attention seeking with attachment figures, wanting cuddles, separation protest, demanding whinging behaviour, regressive and “silly” behaviour, not being very exploratory, etc.. The child focuses on their own needs to the exclusion of the needs to others. When more relaxed, or when improving and becoming more secure, avoidant children sometimes this behaviour which is the opposite to stage III.

II. Avoidance: over independence/appearance of self sufficiency, high achievement orientation, compliance, wanting to please, seeming to be in control and coping, wanting to be able to predict what will happen, liking routine, restricted playfulness, being organising, not focussing on own or other’s feelings, etc.. The child denies its own needs. It is often seen as happy and well adjusted because apparently coping with demands.

III. Behaviour characterised by hyperactivity, self harm, destructiveness, very short attention span, negativity, soiling, smearing, wetting, aggression, and/or unfocussed violence. It seems out of control or hysterical. Underlying fears and angers come out.

[ - more frustration behaviour/ fear-driven motivational conflict behaviour]

Approach

Fear / insecurity

Attachment behaviour

Avoidance

B

C

A

III0 III

Firing rate

InputResting rate

Firing rate of a nerve cell

Response strengthe.g. Salivation

Stimulus strengthe.g. bell volume/durationResting level

Pavlovian conditioning

Paradoxical response

Threshold of transmarginal inhibition

Law

of S

treng

th

Variable Security, Caregiving Style• Secure: Trust that mother will meet needs

Caregiving - Sensitive

• Insecure: Do not trust that mother will meet needsCaregiving - Insensitive (but children’s

needs vary)

– Ambivalent: Caregiver is unreliable– Avoidant: Caregiver dismisses child’s feelings,

expects child to be independent

– [Disorganised: Caregiver is frightened or frightening]

Adult Attachment Interview

• Mary Main and Hesse

• AAI

• Account of own childhood, especially parent’s relationships to own family.

• Reveals the parent’s own

“Internal Working Model”

of attachment relationships

Mother’s Attachment Relationship with her mother and later AAI type

Secure Autonomous

Realistic, resolved

Ambivalent Preoccupied.

Angry/hurt feelings still present

Avoidant Dismissive.

Denies feelings

Mother’s AAI type and

Attachment Relationship

with her childAutonomous. Secure Realistic, resolved

Preoccupied. AmbivalentAngry/hurt feelings still present

(BUT, or A)

Dismissive. AvoidantDenies feelings

(BUT, or C)

Unresolved Disorganised Unresolved traumaViolence, abuse

But - associations are not strong

Intergenerational transmission of security type

• 78% of variance unaccounted for• 22% due mainly to Bs (secure / autonomous)

• i.e. security is transmitted but insecurity types are less associated

Temperament effects

Temperament (reactivity, fearfulness etc.)

General finding:Security – insecurity affected by

– maternal sensitivity, – not temperament

Type of insecurity may be affected by temperament

Gene – environment effects on attachment

• Adopted siblings, genetically unrelated• AAI as adults

• 61% concordance in security

• Environment is the main factor in attachment security status

Caspers et al (2007)

Genetic protective/vulnerability factors

DRD4 7-repeat allele: lower dopamine receptor efficiency(Dopamine associated with reward /Go /appetitive behaviour)

• Maternal loss + DRD4 7-repeat allele Disorganised

• Maternal loss + DRD4 shorter allele Not Disorganised

Rutter et al (2006), Gervai et al (2005)

Barry, Kochanska, Philibert, (2008)

Variable impact of poor parentingDifferential susceptibility

0.3

-0.2

0.0

-0.4

0.2

Infa

nt’s

attac

hmen

t (co

ntinu

ous

scor

e)Le

ss s

ecur

e Mor

e se

cure

low

Maternal responsiveness

medium high

ll

ss/sl

Infant genotype

Serotonin transporter gene 5-HTTLPR

Maternal sensitivity

Low High

“Good”

“Poor”

Outcome

Less susceptible to experience (?resilient?)More susceptible to experience (?vulnerable?)

Differential susceptibility (Belsky 1997, 2001)

Maternal sensitivity

Low High

“Good”

“Poor”

Outcome

Differential susceptibility (Belsky 1997, 2001)

- Openness to experience

Openness to experience

Children MothersExternalising behaviours

DRD4-7R allele Insensitive Highest frequencyDRD4-7R allele Sensitive Least frequency

DRD4 short allele no effect of maternal sensitivity

Bakermans-Kranenburg and van IJzendoorn (2006)

Childcare quality

Low High

“Few”

“Many”Beha

viou

r pro

blem

s at

54

mon

ths

(Ach

enba

ch)

Pluess and Belsky JCPP 2009

Differential susceptibility (Belsky 1997, 2001)

40

58

Low negativityHigh negativity

(Infant temperament questionnaire at 1 & 6 months)

Nietzsche

“What does not kill us makes us stronger”

Protective effects of security2,4,6 months 2 years

Cortisol levels, Security Fearfulness rating by Mreactivity

High Insecure Fearful

High Secure Not fearful

Security protects against later fearfulnessGunnar et al (1996)

Attachment and development

Effect of parenting:Sher: Infants and toddlers developmental follow up: maternal sensitivity and play .Greatest developmental progress:1. Mothers were sensitive to baby’s intentions and feelings2. Mother’s energetically played with babies

“Mothers who were sensitive to what was in baby’s mind + shared what was in their own mindHad baby’s with the best minds”

Later effects

Infants /toddlers 4-5 years in preschoolSecure histories warm,

socially mature,

popular with peers

Ambivalent insecure low status

LaFreniere and Sroufe (1985)

General security effects on development

• Security has effects on development • When insecure, a child must attend to:

– short term safety/attachment needs, – not learning for later success in the long term

• Wastes time, constrains learning

• General finding: insecurity, especially disorganised, has negative effects on development and social behaviour, but individual variation and context dependency

Constraints of insecurity on learning

Both: distracted from learning by insecurity

C Ambivalent:– Bullies, aggressive, blame others, – Dominating / obsequious – Focus more on own immediate benefit and status in group, – Focus less on truth, accuracy

A Avoidant:– Compulsively compliant, wanting to please– Compulsively caretaking, helpful– Uncreative, less initiative, over objective.– Achievement oriented / compulsive– Vulnerable to an accumulation of failure –depression, sudden collapse,

? ME/Chronic Fatigue Syndrome / anorexia– Can be seen as devious, deceitful or manipulative

Crucial ages in Attachment

• Probably several.

• Romanian orphans: adverse effects of gross neglect and malnutrition rarely persist if “rescued” before 6 months

Rutter et al (2007)

• Avoidant insecurity develops after 26 weeks.• (After “relationships between two events” can be understood)

Woolmore and Richer

5 8 12 17 25 36 44 52 61-2 72-3

?

Principles

ConfigurationsTransitions

EventsRelationships

Categories

SequencesProgrammes

Plooij: Regressions and developmental stages

Regression, upset, irritability, comfort seeking.

Transition markers:

0

Age in weeks

System

Sensations

Regression Periods Parental stress and coping

Depressed mothers avoidant babies

Children of depressed mothers:

Regression periods at: 12 and 17 weeks25 weeks

longer shorter

(Woolmore and Richer)

3 (12/14-15) 4 (16/17) 5 (24/25)0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

mean

len

gth

over

1 w

eek

3 (12/14-15) 4 (16/17) 5 (24/25)

regression period (control/depressed)

Mean length of regression periods

Control

Depressed

Attachment security types

• Avoidant insecure• Ambivalent insecure• Secure

Avoidant childrenExperience: mother rarely attends to negative feelings

Strategy: keep mother close by denying own feelings

Tactics: Be independent, don’t show feelings, be compliant, caretaking, role reversal, be in control, predict what will happen, be vigilant

Focus on external world, achievement

Negatives – depression, psychosomatic, sudden explosions of anger, distant relationships, ?uncreative.

Ambivalent children

Experience: mother unreliable

Strategy: keep mother close and attentive

Tactics: Attention seeking by:

Focus on own emotions, and emotions of others towards self

Negatives – Not liked, rejected

Demanding, noisy, protesting, disruptive, emotional, aggressive (“You shall attend to me”)

Babyish, helpless, injury/illness feigning, nurturance seeking (“Poor little me, look after me”)

Secure children

Experience: mother is reliable and sensitive

Strategy: can focus on world trusting mother will protect / come and help if necessary

Tactics: Exploration, play etc. undistracted by need to attend to one’s own security.

Focus on integrating -one’s own needs

with -a clear understanding of the social and non social world,

undistorted by own needs

Negatives – ?None

Disorganised children

Experience: mother is frightening or frightened

Strategy: short term, focus on immediate survival

Tactics: various, indiscriminate approaches, over independence, (much motivational conflict behaviour)

Focus: on immediate survival

Negatives – High chance of later severe psychosocial problems and underachievement.

• Dr Patricia Crittenden

• Dispense with Disorganised category Disorganised = highly insecure

• Developmental approach• More avoidant: more distorted affect• More ambivalent: more distorted cognition

• Useful clinically

Disorganised?

Crittenden: • Increasing severity of insecurity + developmental effects

Fonagy: • Disorganised subsumed in Ambivalent category

Assessment methods

(Strange situation)Many othersStory Stem test (Bretherton et al,1990)

1. Spilled Juice2. Hurt knee3. Monster in the bedroom4. Departure5. Reunion

Story stem

Close observation

Girl: (5 years) two siblings, 3 & 1, all in careAverage IQ, articulation difficulties.

Mother: Young single, unsupported, several partners, strangers in house ++, drugs, mother’s handling grossly insensitive, loud, minimal insight.

Child: Careless, impulsive, accident prone, frenetic caring for siblings, demanding, attention seeking, clingy, controlling and defiant towards mother. Disorganised attachment.

Sudden shifts of behaviour. “Leakage” of fear and anger.

Video

Implications:Principles of handling

C Ambivalent:– Warm undivided attention– Very firm boundaries

A Avoidant:– Joint activity focus– Clear structures and expectations– Forewarn of changes – With improvement goes through a period of more difficult behaviour,

attention seeking, over assertive, (cf C)

<30AD Rabbi Hillel the ElderEssence of his religion

1. If you don’t look after yourself nobody else will– Don’t be avoidantly insecure

2. If you only look after yourself, what is the point?– Don’t be ambivalently insecure

3. If not now, when?– Carpe diem

johnricher@oxhs.co.uk

john.richer@nhs.net

john.richer@dpag.ox.ac.uk