Attachment, a Neurodevelopmental Perspective

1. Attachment, a Neurodevelopmental Perspective • Dr Bruce Chenoweth • Consultant Psychiatrist • Senior Staff Specialist, D.A.S. Division. of Women and Children’s Health, St. George Hospital • Conjoint Senior Lecturer, School of Psychiatry, U.N.S.W.

2. Psychiatry—Then and Now!

3. Brain Stuff and Attachment • Walking upright needed bigger prefrontal cortex • Sophisticated ability then possible to focus, plan, control actions, reflect and anticipate, and manage social relations. • Babies needed to be born prematurely and nurtured outside the womb

4. Neurobiology of secure attachments • When a baby is born-------! • Brain development before age of 1 yr is much more extensive than realized • Brain development is much more vulnerable than previously suspected • Neural genesis and apoptosis • Empathic attunement directly influences the maturation of regulatory mechanisms • Stress = asynchrony which is reflected permanently and architecturally

5. Dyadic interaction and brain development • From outset, reciprocal stimulation occurs • Mother is an external CNS regulator of emotion and hence development of the infant PFC • Facial expressions, gaze, touch, body movements and vocalizations generate a symbiotic state • Conversely, lack of +ve interaction causes withdrawal and failure to develop affect self-regulation and to co-regulate social interactions.

6. Physiology of regulation • New neural pathways permit subtle sensory discrimination • Enhanced signaling systems enables the child to construct patterns and take on meaning • This leads to less stress-induced autonomic arousal [which can damage irreparably the formation of sophisticated regulatory pathways] • The full expression of emotional dysregulation may not be apparent until teenage years

7. Not just unhappy kids! • Maternal absence in the first year of life is negatively linked to physiological regulation • Symbiotic “Mind-reading” is only achieved through countless hours of contact. Not innate. • Neural deficits are apparent in children not exposed to good and consistent empathic attunement. • Stress levels are measurable

8. Neural Structures 1 • Brain overview

9. Neural Structures 2 • Old brain

10. Biochemistry of attachment failure • Chronic stress--<corticotrophin releasing factor and loss of diurnal variation in cortisol level. • High concentration of cortisol receptors in parts of brain responsible for arousal and ability to learn • Rapid increase, adrenalin, nor adrenalin, dopamine • Hyper metabolism in some parts of brain • High thyroid activity-active in brain differentiation and regulation

11. Biochemistry of Good Empathic Attunement • Low stress, low cortisol and low proinflammatory cytokines • High oxytocin leading to down-regulation of primitive fight or flight responses • Hippocampal generation and regeneration after stress. • Improved cortical activity improving executive functioning and affect regulation

12. Attachment Switch—ON!

13. Oxytocin and Fight/Flight Response

14. Impact of Disruption of Bonding on Infant R. Brain Development • Time of most rapid R. brain growth spurt • Neuronal overproduction vs. apoptosis • Semi-permanent arrest of development • Stressful growth inhibitors: excito-toxicity pruning of R. brain cortical circuits • Regulatory failure of emotional homeostasis and attachment • Up-regulation of primitive survival pathways • Vestigial switch-gear, readily triggers emotional dysregulation

15. Before After Yiddisher Mommas!

16. Critical role of the Caregiver in the first three months • Continuity of interaction crucial • Caregiver imparts ability to self-sooth • Baby differentiates global states-calmness. Distress and pleasure • Physical sensation and the emotional are bound together-motor responses move from reflexive to volitional mediated by affect.

17. Two to five months • Withwarm nurturing, investment in and from caregivers increases—differentiation from other adults • Gaze, listening and movement become synchronized • Patterns discerned in caregivers voices • Discrimination occurs between joy, indifference and annoyance • Emotional significance of facial expression and vocalization

18. Infant Development • Baby at 3 months

19. Four to ten months • Purposeful 2-way interaction • Constant carers need to read and respond to emotional signals and challenge to reciprocate • Signaling through facial gestures, gestures, vocalization—broad range of emotions and sensations • By eight months, integrated sequencing of responses and adoption of social patterns

20. Infant Development • Baby at 6 months

21. Infant Development • Baby at 9 months

22. Nine to eighteen months • Continuous flow of to-and fro communication • Complex interactions • Language acquisition

23. Science into Action • Immediate contact following birth • Biological parents preferred over extended family or other care givers • Empathic attunement with baby the critical factor • This requires extended time together with baby • The younger the baby, the more essential is continuity of empathic attunement • Transitions between environments can be stressful for young babies

24. Special Needs Children • Attachments difficult • Reciprocity limited • Dysmorphia • Additional demands • Relationship stress • Maternal guilt/depression • Challenging behaviour

25. Autistic Children • Difficulty with communication, socialization, lack of awareness of others, inability to play, or to copy, and will not seek comfort. • Marked abnormal nonverbal communication • Lack of imaginal world • Abnormal speech, no reciprocal responses • Restricted and stereotyped interests • Extreme distress on transitions

26. Family Court Issues • “Marriage on Rocks” common • Changes very difficult • Consistency essential, transitions difficult • Independent Legal Advisors sometimes don’t understand • Need to work outside established shared-care precedents

27. Take-home message • The brain is plastic—whatever you put in changes the architecture • There are critical times in the developmental trajectory for the establishment of stable patterns which are enduring • The first 18 months are critical times for the genesis of emotional and cognitive regulation • Empathic attunement is critical for this to happen