Attachment: Close observation Clinical applications

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

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

3. Video Temper tantrum

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

5. Fear, Frustration, Insecurity Angry avoidance Approach, Attachment behaviour Child Parent Let go Pick up /Retrieval

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

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

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

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

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

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

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

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

14. 2 year old with mother meeting a stranger Approach OTT OK Fear/Frustration/Anxiety Avoidance “Silly” “Shy” “Relaxed”

15. 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

16. 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

17. 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

18. Attachment Relationship: Variable Security • Mary Ainsworth, 1970s • Strange situation 18 months • The attachment relationship varies in its security • Secure <-> insecure

19. 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

20. Effect in increasing stress 0. Ordinary, age appropriate sociable playful behaviour, able to balance own needs and those of others. • 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. • 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]

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

22. Firing rate of a nerve cell Firing rate Input Resting rate

23. Pavlovian conditioning Threshold of transmarginal inhibition Response strength e.g. Salivation Law of Strength Stimulus strength e.g. bell volume/duration Resting level Paradoxical response

24. 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: Caregiver is unreliable • Avoidant: Caregiver dismisses child’s feelings, expects child to be independent • [Disorganised: Caregiver is frightened or frightening]

25. 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

26. Mother’s Attachment Relationship with her motherand later AAI type SecureAutonomous Realistic, resolved AmbivalentPreoccupied. Angry/hurt feelings still present AvoidantDismissive. Denies feelings

27. Mother’s AAI type and Attachment Relationship with her child Autonomous. Secure Realistic, resolved Preoccupied.Ambivalent Angry/hurt feelings still present (BUT, or A) Dismissive. Avoidant Denies feelings (BUT, or C) UnresolvedDisorganised Unresolved trauma Violence, abuse

28. 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

29. Temperament effects Temperament (reactivity, fearfulness etc.) General finding: Security – insecurity affected by • maternal sensitivity, • not temperament Type of insecurity may be affected by temperament

30. 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)

31. Genetic protective/vulnerability factors DRD4 7-repeat allele: lower dopamine receptor efficiency (Dopamine associated with reward /Go /appetitive behaviour) • Maternal loss + DRD4 7-repeatallele Disorganised • Maternal loss + DRD4 shorterallele Not Disorganised Rutter et al (2006), Gervai et al (2005)

32. Variable impact of poor parenting Differential susceptibility Infant’s attachment (continuous score) Less secure More secure 0.3 0.2 Infant genotype 0.0 ll ss/sl -0.2 Serotonin transporter gene 5-HTTLPR -0.4 medium low high Maternal responsiveness Barry, Kochanska, Philibert, (2008)

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

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

35. Openness to experience Children Mothers Externalising behaviours DRD4-7R allele Insensitive Highest frequency DRD4-7R allele Sensitive Least frequency DRD4 short allele no effect of maternal sensitivity Bakermans-Kranenburg and van IJzendoorn (2006)

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

37. Nietzsche “What does not kill us makes us stronger”

38. Protective effects of security 2,4,6 months 2 years Cortisol levels, Security Fearfulness rating by M reactivity High Insecure Fearful High SecureNot fearful Security protects against later fearfulness Gunnar et al (1996)

39. 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”

40. Later effects Infants /toddlers 4-5 years in preschool Secure histories warm, socially mature, popular with peers Ambivalent insecure low status LaFreniere and Sroufe (1985)

41. General security effects on development • Security has effects on development • When insecure, a child must attend to: • short term safety/attachment needs, • notlearningfor 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

42. Constraints of insecurityon 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

43. 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

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

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

46. Mean length of regression periods 0.8 0.7 0.6 0.5 0.4 Control mean length over 1 week Depressed 0.3 0.2 0.1 0 3 (12/14-15) 3 (12/14-15) 4 (16/17) 4 (16/17) 5 (24/25) 5 (24/25) regression period (control/depressed)

47. Attachment security types • Avoidant insecure • Ambivalent insecure • Secure

48. 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 Focuson external world, achievement Negatives – depression, psychosomatic, sudden explosions of anger, distant relationships, ?uncreative.

49. Ambivalent children Experience: mother unreliable Strategy: keep mother close and attentive Tactics: Attention seeking by: Focuson 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”)

50. 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. Focuson integrating -one’s own needs with -a clear understanding of the social and non social world, undistorted by own needs Negatives– ?None