Attachment: Close observation Clinical applications John Richer CHOX and DPAG Oxford.
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Transcript of 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