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. Temper tantrum Video

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 Let goPick up /Retrieval Child Parent

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

7. Fear, Frustration, Insecurity 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 Child Parent Distance apart IncreasingDecreasing

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

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

10. 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

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

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

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

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

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. 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]

21. Approach Fear / insecurity Attachment behaviour Avoidance B C A III0III

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

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

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 mother and later AAI type Secure Autonomous Realistic, resolved Ambivalent Preoccupied. 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) Unresolved Disorganised 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-repeat allele Disorganised Maternal loss + DRD4 shorter allele Not Disorganised Rutter et al (2006), Gervai et al (2005)

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

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

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

35. Openness to experience ChildrenMothersExternalising behaviours DRD4-7R alleleInsensitiveHighest frequency DRD4-7R alleleSensitiveLeast frequency DRD4 short alleleno effect of maternal sensitivity Bakermans-Kranenburg and van IJzendoorn (2006)

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

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

38. Protective effects of security 2,4,6 months2 years Cortisol levels, SecurityFearfulness rating by M reactivity HighInsecureFearful 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 /toddlers4-5 years in preschool Secure historieswarm, socially mature, popular with peers Ambivalent insecurelow 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, – 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

42. 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

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. 5812172536445261-272-3 ? Principles Configurations Transitions Events Relationships Categories Sequences Programmes Plooij: Regressions and developmental stages Regression, upset, irritability, comfort seeking. Transition markers: 0 Age in weeks System Sensations

45. 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)

46. 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 length over 1 week 3 (12/14-15)4 (16/17)5 (24/25) regression period (control/depressed) Mean length of regression periods 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 Focus on external world, achievement Negatives – depression, psychosomatic, sudden explosions of anger, distant relationships, ?uncreative.

49. Ambivalent children mother unreliable Experience: mother unreliable keep mother close and attentive Strategy: keep mother close and attentive Attention seeking by: Tactics: Attention seeking by: on own emotions, and emotions of others towards self Focus on own emotions, and emotions of others towards self Not liked, rejected 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. Focus on integrating -one’s own needs with -a clear understanding of the social and non social world, undistorted by own needs Negatives – ?None

51. 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.

52. Dr Patricia Crittenden Dispense with Disorganised category Disorganised = highly insecure Developmental approach More avoidant: more distorted affect More ambivalent: more distorted cognition Useful clinically

58. Disorganised? Crittenden: Increasing severity of insecurity + developmental effects Fonagy: Disorganised subsumed in Ambivalent category

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

60. 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.

61. Video

62. 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)

63. <30AD 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

64. johnricher@oxhs.co.uk john.richer@nhs.net john.richer@dpag.ox.ac.uk