Attachment Close observation Clinical applications John Richer CHOX

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

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

Video Temper tantrum

Describe What 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 Child Parent Angry avoidance Let go Approach, Attachment behaviour Pick up /Retrieval

Escape Go to Attachment driven approach Strength of motivation Tempers happen here Near Distance apart Avoidance Far

Fear, Frustration, Insecurity Child Parent Distance apart Avoidance Pull away Collapse on floor Pull head back Attachment behaviour Move towards Bury head in “Mummy” Let go Move hands away Do little Retrieval Hold Arm around Speak to Increasing Decreasing

Video Mum reduces her approach behaviour Mum reduces her retrieval behaviour /// Child increases his approach behaviour Child increases his attachment behaviour

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

Motivational conflict • • • [One wins out] Alternation Simultaneous Compromise Overintensity Displacement activities Aggression Re-directed aggression Regression e. g. dither e. g. approach +gaze avert e. g. side on e. g. OTT, too close e. g. stereotypies, tics e. g. to mother, sibs e. g. baby behaviour

Ongoing behaviour is blocked • Internally - motivational conflict • Externally - frustration

Reactions to frustration • Exploration • Overintensity • (impulsive , careless) • Switch attention – from task – from person • Displacement activities • (fidget, fiddle, stereotypies, tics) • (Re-directed) aggression • Regression • Attachment

Approach Overintensity OK Too soon To partial cues Too intensely Too briefly Fear/Frustration/Anxiety Avoidance Maintain focus Switch attention

Approach OTT OK 2 year old with mother meeting a stranger Fear/Frustration/Anxiety Avoidance “Relaxed” “Silly” “Shy”

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, 1970 s • 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 1990 s) – Disrupted strategy, child confused, stereotypies. – ? = severe Ambivalent / ? more stressed

Effect in increasing stress 0. 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. 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]

Attachment behaviour Approach C B Fear / insecurity A Avoidance 0 I II III

Firing rate of a nerve cell Firing rate Resting rate Input

Pavlovian conditioning Law of S e. g. Salivation tre ngt Response strength h Threshold of transmarginal inhibition Resting level Stimulus strength e. g. bell volume/duration Paradoxical response

Variable Security, Caregiving Style • Secure: Trust that mother will meet needs Caregiving - Sensitive • Insecure: Do not trust that mother will meet needs Caregiving - Insensitive (but children’s needs vary) – Ambivalent: – Avoidant: Caregiver is unreliable 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 Autonomous. Attachment Relationship with her child Secure Realistic, resolved Preoccupied. Ambivalent Angry/hurt feelings still present Dismissive. (BUT, or A) Avoidant Denies feelings Unresolved trauma Violence, abuse (BUT, or C) Disorganised

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 DRD 4 7 -repeat allele: lower dopamine receptor efficiency (Dopamine associated with reward /Go /appetitive behaviour) • Maternal loss + DRD 4 7 -repeat allele Disorganised • Maternal loss + DRD 4 shorter allele Not Disorganised Rutter et al (2006), Gervai et al (2005)

Variable impact of poor parenting Infant’s attachment (continuous score) Less secure More secure Differential susceptibility 0. 3 0. 2 Infant genotype ll 0. 0 ss/sl -0. 2 Serotonin transporter gene 5 -HTTLPR -0. 4 low medium high Maternal responsiveness Barry, Kochanska, Philibert, (2008)

Differential susceptibility (Belsky 1997, 2001) Less susceptible to experience (? resilient? ) More susceptible to experience (? vulnerable? ) “Good” Outcome “Poor” Low High Maternal sensitivity

Differential susceptibility (Belsky 1997, 2001) - Openness to experience “Good” Outcome “Poor” Low High Maternal sensitivity

Openness to experience Children Mothers Externalising behaviours DRD 4 -7 R allele Insensitive Sensitive Highest frequency Least frequency DRD 4 short allele no effect of maternal sensitivity Bakermans-Kranenburg and van IJzendoorn (2006)

(Achenbach) Behaviour problems at 54 months Differential susceptibility (Belsky 1997, 2001) “Few” 40 Low negativity High negativity (Infant temperament questionnaire at 1 & 6 months) “Many” 58 Low High Childcare quality Pluess and Belsky JCPP 2009

Nietzsche “What does not kill us makes us stronger”

Protective effects of security 2, 4, 6 months Cortisol levels, Security reactivity 2 years Fearfulness rating by M High Insecure Fearful High Secure Not fearful Security protects against later fearfulness Gunnar 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 feelings 2. Mother’s energetically played with babies “Mothers who were sensitive to what was in baby’s mind + shared what was in their own mind Had baby’s with the best minds”

Later effects Infants /toddlers 4 -5 years in preschool Secure histories warm, socially mature, popular with peers Ambivalent insecure low status La. Freniere 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

Plooij: Regressions and developmental stages System Principles Programmes Sequences Categories ? Relationships Events Transition markers: Configurations Regression, upset, irritability, comfort seeking. Sensations 0 5 8 12 17 Age in weeks 25 36 44 52 61 -2 72 -3

Regression Periods Parental stress and coping Depressed mothers avoidant babies Children of depressed mothers: Regression periods at: 12 and 17 weeks longer 25 weeks shorter (Woolmore and Richer)

Mean length of regression periods 0. 8 0. 7 mean length over 1 week 0. 6 0. 5 0. 4 Control Depressed 0. 3 0. 2 0. 1 0 3 (12/14 -15) 4 (16/17) regression period (control/depressed) 5 (24/25)

Attachment security types • Avoidant insecure • Ambivalent insecure • Secure

Avoidant children Experience: 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: Demanding, noisy, protesting, disruptive, emotional, aggressive (“You shall attend to me”) Babyish, helpless, injury/illness feigning, nurturance seeking (“Poor little me, look after me”) Focus on own emotions, and emotions of others towards self Negatives – Not liked, rejected

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 others Story Stem test (Bretherton et al, 1990) 1. 2. 3. 4. 5. Spilled Juice Hurt knee Monster in the bedroom Departure Reunion

Story stem Close observation Girl: (5 years) two siblings, 3 & 1, all in care Average 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)

<30 AD Rabbi Hillel the Elder Essence 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