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Lynne Murray Winnicott Research Unit, University of Reading with

The role of attachment and resiliency in the intergenerational transmission of depression: results from the Cambridge Longitudinal Study. Lynne Murray Winnicott Research Unit, University of Reading with Adriane Arteche, Peter Cooper, Sarah Halligan, Pasco Fearon and Matt Woolgar

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Lynne Murray Winnicott Research Unit, University of Reading with

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  1. The role of attachment and resiliency in the intergenerational transmission of depression: results from the Cambridge Longitudinal Study Lynne Murray Winnicott Research Unit, University of Reading with Adriane Arteche, Peter Cooper, Sarah Halligan, Pasco Fearon and Matt Woolgar Funding: MRC, UK; Tedworth Trust; Winnicott Trust

  2. Intergenerational transmission of depression • Consistent reports of offspring of parents with depression being at substantially increased risk for depression themselves: - e.g., Leib et al., 2002 Lewinsohn et al., 2005 Weissman et al., 2006 Timko et al., 2008 • However, little prospective longitudinal data concerning development of disorder through childhood.

  3. How might insecure attachment be involved in intergenerational transmission of psychopathology? Dear Nick, it was very helpful to meet last

  4. Bowlby’s theory of attachment • Concerns propensity to make close emotional bonds • Need for protection a prominent feature early in development • Security promotes independence

  5. Attachment quality • Secure: can rely on parent for support when distressed • Insecure avoidant: minimize expression of distress, avoid close contact • Insecure ambivalent: maximize expression of distress at separation, mixed with anger • Disorganised: no clear strategy, confused, irrelevant, freezing

  6. Parenting and attachment • Secure: available, responsive, sensitive • Insecure avoidant: rejection • Insecure ambivalent: inconsistent • Disorganised: frightening behaviour/ maltreatment

  7. Bowlby’s view of mental health implications • Avoidant • Deny needs • Attempt to live without others’ love and support • Sense of self as not worthy of love • Low expectations of others • Ambivalent • Pervasive anxiety, especially re. separation/abandonment • Limited exploration of world • Coping capacities not developed

  8. Characteristics of attachment • Repeated patterns of interaction become internalised as IWM’s • Self-perpetuating • Relatively flexible early on, but become more fixed over time • Early experience special, as provides ‘setting point’

  9. Evidence to date: Minnesota longitudinal study of mental health outcomes • Avoidant/disorganized – predicts more global pathology (Sroufe, 2005) • Ambivalent – predicts anxiety diagnoses (Warren, 1997) • Avoidant – predicts externalizing, early onset antisocial (Aquilar, 2000; Sroufe, 2005) • Disorganised – predicts dissociation (Carlson, 1998) other disorders (Liotti, 2004; 2008) • NB not strong effects, adversity adds

  10. Role of attachment insecurity in transmission of depression • Depressed mothers’ interactions: Generally insensitive – - Withdrawn, unresponsive - Intrusive, hostile

  11. Effects of depression on infant attachment Systematic associations shown between PND and insecure attachment Meta analyses- Martins and Gaffan, 2000 Atkinson et al., 2000 Plus Campbell et al., 2004 (NICHD sample)

  12. Bowlby’s view of mental health implications of attachment for ego resiliency • Avoidant • Deny needs • Attempt to live without others’ love and support • Sense of self as not worthy of love • Low expectations of others • Ambivalent • Pervasive anxiety, especially re. separation/abandonment • Limited exploration of world • Coping capacities not developed

  13. Ego resiliency Thus, the insecure child may:- lack capacity to cope with threat have rigid, or limited coping strategies be overwhelmed with sense of loss/anxiety have low self-worth (Erikson, 1985)

  14. Predicted pathway PND insecurity low ego resiliency depression

  15. Cambridge longitudinal study • Sample • Low risk mothers cohabiting/married • Infants healthy • Community sample screened at 6 weeks • 58 depressed, 42 controls recruited • Assessed so far to 16 years

  16. video clips of interactions

  17. Key child assessments beyond postnatal period • 18 months- attachment • 5 years- ego resiliency • 8 years- ego resiliency • 16 years- psychiatric outcome

  18. Other potentially important influences • Continuing quality of mother-child relationship • Chronicity of maternal depression • Marital conflict

  19. Occurrence of depression assessed 8-16 years • At each time point, a standardised interview (the K-SADS) was used, and administered by a researcher unaware of maternal diagnosis, to mother and child independently • At 8 years current state was assessed • At 13 and 16 years current and previous mental state to previous assessment was assessed • Diagnoses assigned by senior clinical team, according to best estimate, combining maternal and child report.

  20. ** * Cambridge Longitudinal study: Depression in the children 8-13 years Depression begins to emerge at 11-yrs: higher rates of depressive disorder present in the PND group by 13-yrs

  21. Cambridge Longitudinal study: Depression in the children 13 to 16-years ** *** Rates of disorder continue to increase, particularly because of the emergence of depression in the PND group

  22. Cambridge Longitudinal PND study: 16 years life-time depression - full sample

  23. PND and 16 yr life-time depression, including child sex

  24. Developmental trajectory to depression The roles of infant attachment and ego resiliency, and the subsequent mother-child relationship

  25. Insecure infant attachment: Effects of PND

  26. Infant attachment: Relation to 16 years lifetime depression

  27. Ego resiliency at 5 and 8 years: Effects of PND and attachment, and relation to 16 yr life-time depression • The Snap card game (Murray et al., 2001) • Child at home with friend • Competitive card game • Rigged by experimenter to provide losing and winning deals (both children win at end!) • Rate child’s distress and anxiety in the face of the mild threat of loss

  28. video clips of card game

  29. Ego resiliency at 5 and at 8 years: Effects of PND

  30. Ego resiliency at 5 and at 8 years: Effects of attachment

  31. Ego resiliency at 5 and at 8 years: Relation to 16 yr life-time depression

  32. Maternal sensitivity and emotional support at 5 and 8 years • Maternal sensitivity at 5 years- assessed during ‘snack’ in research unit (warmth, appropriate responsiveness) (Murray et al., 1999) • Maternal emotional support at 8 years- assessed during child homework session (available, positively responsive) (Murray et al., 2006)

  33. Maternal insensitivity at 5 years: Effects of PND + PND effects: F(1, 84)=2.91, p<.10 sex effects: ns PND*sex: ns

  34. Maternal insensitivity at 5 years: Effects of attachment + attachment effects: F(1, 84)=2.90, p<.10 sex effects: ns attachment*sex: ns

  35. Maternal insensitivity at 5 years: Relation to adolescent depression *

  36. No effects of 8 yr emotional support

  37. Pathway so far: PND, attachment, 5 and 8 yr resiliency, and maternal insensitivity at 5 yrs ER ER 5yrs 8yrs p=.05 p=.006 p=.06 p=.06 p=.06 16y lifetime p<.001 p=.05 Infant PND depression Attach p=.004 p=.05 p=.09 5yrs insensitivity

  38. The role of chronic difficulties • Maternal depression • Assessed at each time point, with month-by-month recording of offsets and onsets of disorder to give chronicity • Marital conflict • Assessed at each time point by interview/questionnaire

  39. Chronicity of maternal depression Women in the PND group experienced further depression outside the postnatal period

  40. Marital conflict: Relation to PND ** ** **

  41. What about continuing maternal depression & marital conflict? Effects of these difficulties following each stage of child development chronicity mat. depression p<.01 marital conflict at 18m, 5, 8 & 13y p=.04 attachment Depression <16yrs 18m

  42. chronicity mat. depression (5y-onset) p<.05 marital conflict 5+8 +13 p=.06 MODEL 1 attach Depression <16yrs 18m low ego resilience 5y chronicity mat. depression (8y-onset) ns marital conflict at 8+ 13y ns attach low ego low ego MODEL 2 18m resilience 5y resilience 8y Depression <16yrs

  43. What about mother-child interactions? maternal insensitivity at 5yrs p<.10 maternal emotional support at 8yrs ns attachment Depression <16yrs 18m maternal insensitivity at 5yrs ns maternal emotional support at 8yrs ns MODEL 1 attachment Depression <16yrs 18m low ego resilience 5y

  44. Summary Main study finding: Child depression up to 16 yrs is predicted by PND, insecure attachment, and poor resiliency, especially at 8 yrs.

  45. Supplementary findings: a) the role of subsequent maternal interactions • Once infant attachment is taken into account, the contribution of maternal insensitivity at 5 yrs is only marginal. That of 8yr maternal support is not significant. • Once infant attachment and 5yr resiliency are taken into account, the mother’s insensitivity at 5 yrs does not contribute further to risk of depression (and 8yr support remains non-significant)

  46. Supplementary findings: b) the role of further maternal depression and conflict • Once infant attachment is taken into account, there is still an additional effect of continuing maternal depression and marital conflict • Once attachment and 5yr resiliency are taken into account, the effect of continuing maternal depression is still significant, but the role of subsequent marital conflict is reduced • Once attachment and both 5 and 8yr resiliency are taken into account, neither further maternal depression, nor marital conflict add to the risk of child depression

  47. Overall conclusion • PND and its effects on child development through the first 8 years predict the occurrence of child depression up to 16 years. • Negative experience subsequent to the first 8 years does not add further to the child’s risk of depressive disorder

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