Pratibha Reebye, MBBS, FRCPC, Terry Kope, MD, FRCPC

Attachment disorders

Several effective interventions for disturbed attachment relation- ships rely on a developmental rather than psychiatric classification approach.

ABSTRACT: Attachment disorders ttachment behaviors em- encounter a clearly disturbed attach- are serious disorders that have po- body what an does ment relationship. tentially deleterious effects on a to promote proximity to developing child. Identification of What is not an attachment A a caregiver and ensure attachment disorders is best done disorder? safety, security, and survival. Warm, by direct observation of the child in sensitive, and responsive parenting In identifying attachment disorders we the context of the child's relation- generally contributes to secure attach- look at what is happening to individ- ship with the primary caregivers by and ment. In order for an infant to be ual partners what is happening trained early childhood clinicians. attached, an attachment figure or ob- within their relationship. An attach- Diagnosis involves complex issues. ject must, of course, be available. The ment disorder is not defined solely in The point of entry for interventions attachment figure needs to have an terms of an infant’s behavioral distur- can be the infant, the mother or ongoing emotional investment in the bances. Day-to-day parenting errors are other caregiver, dyadic interactions, 1,2 child. In some situations caregivers commonplace anddo not contribute to triadic interactions, or group work. other than parental figures, often out an attachment or relationship disorder. Physicians can also help their pa- of necessity, act as temporary attach- A typical parent-infant relationship is tients by utilizing a variety of clinical ment figures; not all of these will not always optimal; repairing mis- resources. become attachment objects. Certain matches or interactive errors is an situations may preclude the develop- essential part of the ongoing negotia- 3 ment of relational stability and secure tion within the dyad. attachment. Children placed in emer- Secure attachment facilitates in- gency foster homes, children placed in fant mental health andcan mitigate the orphanages with multiple care- effects of other social-emotional risk givers, and children displaced by envi- factors, thus operating as a protective ronmental and other disasters are at factor. However, not all atypical risk. When attachment falls outside of attachment patterns (insecure, disorga- a normative range and into extremes, nized) described previously in this BC Med J mental health clinicians commonly theme issue ( 2007; use the term “.” 49[3]:117) give rise to an attachment Unfortunately, this term is sometimes disorder or future psychopathology. usedin an imprecise manner to refer to Dr Reebye is a clinical professor at the general relationship disturbances in University of British Columbia and clinical early infancy. Empirical data through head of the Infant Psychiatry Clinic at BC longitudinal and cross-sectional stud- Children’s Hospital. Dr Kope is a clinical ies is emerging but is fraught with assistant professor at the University of methodological constraints. Here we British Columbia and a psychiatric consul- will address the current clinical under- tant to the Alan Cashmore Centre, Vancou- standing of what an attachment disor- ver Community Mental Health Services. der represents andwhat to do when you

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Nor do social deprivations necessarily develop healthy attachment relation- ment disorder (reactive attachment dis- 6 give rise directly to an attachment dis- ships and are not always destined to order) in 1980, earlier versions of the International Statistical Classifica- order. However, research findings indi- experience disordered attachment. tion of Diseases9 Diagnostic cate that those in the social high-risk Attachment cannot be quantified and the and Statistical Manual of Mental Dis- sample who also have insecure attach- and every dyad has unique qualities. orders10 ICD-9 DSM-III ment often develop psychopathology Measurement of attachment security ( and ) 4 when followed to adolescence. Even is complex and includes variables that required an age of onset before 8 disorganizedattachment is best viewed are sometimes difficult to decipher on months, failure to thrive, and a perva- 7,8 as a vulnerability factor for adverse clinical observation alone. Tradition- sive lack of social responsivity. De- 5 social and emotional outcomes. ally, clinicians have depended upon spite revisions, newer versions of both Parents who plan to adopt may observable attachment behaviors in manuals continue to be less than ade- approach physicians with questions relation to a particular attachment fig- quate in that they do not describe the regarding attachment disorders. They ure, the caregiver’s accessibility and full range of observed difficulties. should be told that attachment securi- responsiveness to the child, and the Also, children with attachment diffi- ty has been related to the timing of the constancy of this relationship over culties may not show problems across placement and adoptive caregiving time, especially in situations where all relationships. A child may experi- quality. Research suggests that theDiagnostic infant is distressed. classification ence an attachment difficulty with the adoptedearly in the first year of life are primary caregiver but not with other 11 just as likely as non-adoptedinfants to For the formal diagnosis of an attach- adults or peers. Finally, attachment

Cases of attachment disorder seen at the Infant Psychiatry Clinic at BC Children’s Hospital Referral criteria The important parts of therapy rec- ommended for Mary included: Patients who are acceptedto the Infant Psychiatry Clinic range in age from • Working with the stepmother regard- birth to 5 years. ing her feelings of guilt and her con- Patients are assessedfor a the full range of concerns, including (but not cern about not being a good parent. limited to) attention deficit hyperactivity disorder (ADHD), anxiety disor- • Framing the child’s behavior as adap- ders, attachment disturbances, , behavior problems, developmental tive to the previously experienced delays, mood disturbances, and regulatory difficulties. neglectful environment. After patients are assessed, that require long-term intervention • Empowering the stepmother and are directed to resources in the community. father to act as secure bases and pro- vide a safe haven. Case 1 The empowerment of the parents “Mary,” a 16-month-old girl, was with a smile, and participate in inter- was the most important strategy. This brought to the clinic by her step- active games. This was in contrast to was achieved through parent-infant mother and natural father. This child Mary’s previous behavior, while in her psychotherapy. was previously caught in a bitter mother’s care, when she seemed with- Case 2 custody battle andwas removedfrom drawn and uninterested in adults. The her biological mother because of stepmother took Mary’s behavior as a “Roger,” a 21/2-year-old boy, was re- extreme neglect. She was subse- rebellion against her new parental fig- ferredto theADHD clinic. He was con- quently placed with her father. ures and sought psychiatric advice sidereda hyperactive, aggressive child, The stepmother did not have regarding what she should do. andwas seen as destructive andaggres- children of her own and had no pre- During assessment Mary’s indis- sive during play. vious parenting experience. She criminate social behavior continued His impulsive behaviors included became very alarmed by Mary’s de- with the examiners, with the resident leaving home in the middle of night mands on male andfemale strangers. trainees, and the patients waiting in and darting into heavy traffic. He had Mary would follow any stranger the reception area. been lost in the local supermarket on

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relational 16 disorders are disorders and Table 1. Types of attachment disorders. do not conform to nosological sys- • Infant has no preferred attachment figure tems that characterize the disorder as DSM- • Can be associated with the infant's emotional withdrawal or indiscriminate sociability and extend to all social interactions residing in the individual. The Disorder of IV-TR • Behaviors highly suggestive of emotional withdrawal: comfort seeking and describes reactive attachment nonattach- displays of affection are remarkably restricted; emotional blunting is observed disorder that can manifest as either ment • Behaviors highly suggestive of indiscriminate sociability: seek proximity or inhibited or disinhibited behavior. DC: 0-3R12 comfort from strangers, with an absence of usual social reticence with The is somewhat more unfamiliar adults useful when classifying attachment • There is a discriminated attachment figure, but the infant does not have disorders but also limited. The advan- secure base, which is created when the caregiver allows infant to explore Secure base tage of this system over that of the the world while being available to the infant if he or she feels insecure DSM-IV-TR distortion is the introduction of a • Behaviors highly suggestive of secure base distortion: self-endangerment, relationship measure on axis 2, with clinging, inhibition, vigilance, hypercompliance, role reversal no relationship disorder at one end and • Involves a response to abrupt separation from significant caregiver an abusive relationship disorder at the or sudden loss other end. In between these two poles, Disrupted • Phases of behavior highly suggestive of disrupted attachment: protest we find over-involved, under-involved, attachment (intense reaction, searching for caregiver), despair (sadness or withdrawal), anxious, angry/hostile, and mixed re- detachment (suppression of attachment behaviors with renewed interest in activities and social relationships) lationship disorders. There are prob-

two occasions. Because his mother had after her mother was forced to leave. other responsibilities at home. been diagnosed with ADHD in her After 2 months at the day care, staff She had stoppedworking andasked school days, this diagnosis seemed foundthat Mia was at her worst during her husband to cook the meals and plausible. However, examination on the first hour after her mother left and do the shopping because Mia was three different occasions in three dif- when her mother came to pick her up. so demanding. The most important ferent situations found Roger to be a It was as if Mia acted as a younger clue was that the mother would not cooperative, intelligent childwith good child as soon as her mother arrived and let Mia get out of her hearing. play skills. The history confirmedthat lost her skills. Each of these three cases depicts his unruliness came out prominently In the clinic office interview, a an attachment disturbance. with his motherbut not with other similar situation prevailed. Mia was Mary shows indiscriminate so- caregivers. clingy with her mother, did not say cial behavior and no particular pref- A diagnosis of attachment disorder one word, and showed total lack of erence for an attachment figure. was made, much to the chagrin of interest in toys. Throughout the inter- Roger shows secure base dis- Roger’s mother. The important as- view, Mia sat on her mother’s lap mak- tortion. He exhibits impulsive pects of therapy were to support the ing face-to-face contact and staring, risk-taking behavior in response to mother in understanding and accepting not shifting from that position even a caregiver who is not able to pro- and this diagnosis and to help her become when she seemed calmer. vide emotional care to set lim- a powerful regulator of Roger’s At the clinic’s request, a commu- its and become a container for the impulses. nity health nurse made a home visit. child’s anxiety and disorganization. The nurse reported that Mia seemed Mia shows classic secure base Case 3 happy and chatty at home, and was an distortion in response to her moth- “Mia,” a 3-year-old girl, was referred unusually witty child. However, the er’s overprotective and anxious through her day care for persistent and nurse also thought that the mother was stance, which has not provided Mia excessive separation anxiety. No mat- smothering Mia by giving her so with opportunities to explore and ter what the day-care staff tried, they much attention. Apart from parenting, learn problem solving in an unfa- were not successful in soothing Mia the mother seemed to have given up miliar setting.

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lems, however, in that parental behav- stance, the later development of cues appropriately. The materials can iors are emphasizedto the exclusion of attachment relationships in a child be used on their own or with the sup- 13 the child’s attachment behaviors. with Down syndrome (between 12 port of a professional. 14 Clinical presentations that can re- and 24 months). Where a mother presents with semble attachment distrubances in- Examples of cases where these signs of depression, timely referral to clude an infant’s withdrawal due to principles have been followed and an appropriate community resource is depression or autism. Although the children have been diagnosed with an important. Maternal depression and significant social impairments associ- attachment disorder can be foundin the anxiety are known risk factors for the 14 ated with autism may resemble an box on page188, “Cases of attachment offspring’s development, particularly attachment disorder, autistic children disorder seen at the Infant Psychiatry in the social and emotional domains. are capable of forming attachment rela- Clinic at BC Children’s Hospital.” Physicians areencouragedto pay atten- 14 tionships with their caregivers. tion to the dyadic relationship in this 15 Preventive intervention Zeanah and Boris suggest revised situation and refer the dyad, and not criteria for attachment disorders. Ac- physicians and pediatricians only the mother, when necessary. In cording to their classification system are well positioned to begin the pro- the Lower Mainland, physicians can Table 1 ( ), there are three main types cess of alleviating the suffering aris- refer patients to the Infant Psychiatry of disorders: disorder of nonattach- ing from relational disturbance. Some Clinic at BC Children’s Hospital (604 ment, secure base distortion, and dis- interventions do not need a child ther- 875-2719) and the Alan Cashmore 16 rupted attachment. apist or a child psychiatrist. Watchful Centre (604 454-1676). Outside the Assessment monitoring of the parent-child rela- Lower Mainland, community health tionship can be very useful and can nurses and local child and youth men- In spite of having an improved under- help prevent relational disturbance in tal health centres are a good source of standing of attachment disorders, we some cases. information about community still have difficulties with classifica- One effective form of preventive resources. tion and validation of attachment dis- intervention involves home visiting Specific interventions order, and assessment can be challeng- by a professional (e.g., community ing. In reality, it is often difficult to health nurse) or paraprofessional. Interventions that rely on a develop- sort out whether early attachment dis- Home visiting prevents abusive par- mental rather than psychiatric classifi- turbances constitute a risk for disorder, enting in vulnerable families by pro- cation approach have proven useful. In or are in themselves a clinical problem viding a therapeutic holding environ- this approach, disturbed attachment 17 requiring treatment. ment. The physician may also need relationships are seen as initiating Assessment for an attachment dis- to advocate regarding psychosocial processes that compromise devel- order is best done by a clinician trained issues, such as financial assistance opment, whereas secure attachment in mental health problems in early and housing. In general, policies that increases resistance to stress and pro- 15 childhood. An assessment in the clin- promote economic security, enhance motes resilience. ical setting includes the following: the parent-child relationship (e.g., In attachment disorders the patient • Focusing on the child’s relationship through maternity and paternity leave), is neither the parent nor the infant with attachment figures, especially strengthen parenting skills, and reduce alone, but both together. Stern des- the caregiver’s ability to provide a the isolation of the nuclear family can cribes several “ports of entry” where 20 secure base and a safe haven for the indirectly and positively affect the par- intervention may occur. These may 18 21 22,23 infant. ent-child relationship. be through the infant or mother. • Directly observing relevant infant Another preventive strategy in- Intervention models may be based on 24-27 behaviors through structured ob- volves using psychoeducational mod- dyadic interactions, triadic interac- 28 servational paradigms that capture els to encourage parents to respond tions, or group work. attachment to a caregiver, especially promptly to their child’s distress. Sev- More detailed information about reunion experiences and various eral well-known approaches are avail- different intervention models is pro- Table 2 attachment-seeking behaviors, in- able. For example, the Keys to Care- vided in . 19 cluding controlling behaviors. giving program provides educational Child maltreatment • Taking the infant’s developmental material (videotapes, pamphlets) for and neglect level into consideration—for in- parents to learn how to read infants’ In situations involving child endan-

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Table 2. Interventions for attachment disorders.

One approach that makes use of the infant’s behavior was developed by Brazelton.21 Otherwise, few therapies use infants as a sole focus. Infant-specific • Example of strategy: Clinician simply calls baby’s name and then asks parent to do the same (a baby knows a par- ent’s voice better than that of a clinician, confirming unique place for parents in relation to their infant).

Maternal representations of her own experiences of being parented are of interest to infant psychiatrists. Interventions that focus on the mother’s emotional and physical health have been described in the literature.22 Mother-specific • Example of strategy: Having a mother narrate her own experiences (coherence and consistency) to predict how she will fare with her baby.23

This approach identifies a new “patient” population, namely the relationship between caregiver and infant. Several validated approaches are used:

Interaction Guidance24 • Most commonly used mode of dyadic intervention. • Developed specifically to meet the needs of infants and their families strained by poverty, poor education, family mental illness, substance , inadequate housing, and other psychosocial stressors. • Aims at promoting and nurturing the caregiving relationship. • Focuses on observable interactions between the baby and the caregiver to gain understanding of caregiver and baby’s representational world. • May use videotape to allow for immediate feedback to the parent(s) or family regarding their own behavior and its effect on the infant’s behavior.

Modified Interaction Guidance25 Dyadic models • Aims at decreasing caregiving behaviors associated with disorganized attachment.

Watch, Wait and Wonder26 • Relies on a child-led interaction followed by discussion between therapist and parent reflecting on the infant/child’s inner world of feelings, thoughts, and desires. • Relatively brief treatment consisting of 12 to 14 sessions over 5 months.

Infant-parent psychotherapy, San Francisco model27 • Initially served a population composed of poor, ill-educated, homeless, sometimes mentally ill parents. • Explores links between parent’s early childhood experiences and their current practices and emotional dialogue with their babies. • Uses a combination of insight-oriented psychotherapy, unstructured developmental guidance, emotional support, and concrete assistance as well as crisis intervention as required. • Focuses on therapeutic relationship as an important component of change.

Based on research of the Lausanne University Centre for Family Studies on the development of three-person relation- ships between new parents and their first child.28 Triadic model • Example of strategy: “Trialogue play” is used to enable three-person families to share moments of pleasure and experience intersubjectivity (intentions, feelings, and meanings shared between family members).

“Bonding” groups at BC Children’s Hospital are a prototype of this approach. • Usually follows a psychoeducational approach in empowering parents. • Groups conducted with a specific goal of helping attachment bonding processes between insightful but demoral- ized mothers and their newborns. • Aims to create a warm, welcoming environment where each participating parent is taught bonding exercises using Group-based approach several modalities, including infant , to connect with a child. • Each parent is given a co-therapist to work with who helps as a co-parent would, thus providing a secure base for practising parenting skills. • Includes booster sessions and home visitation as part of ongoing monitoring designed to maintain success obtained during groups. This monitoring can be particularly important in cases of postpartum depression, where relapses are common and preventable.

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germent, attachment therapy takes a external component, that is, interac- lies, provided team building occurs so different form. Physicians are mandat- tions that can be observed, appears to that multiple therapies are synchro- edto report their concerns to the appro- be a necessary component of effective nized. Currently, thereis amajor thrust priate authorities, even though they intervention. to evaluate all the modalities and we may sometimes feel that they cannot When Bakermans-Kranenburg and hope to gain insight soon into what continue to be helpful to the child and colleagues completed a metaanalysis works best for whom. family if an adversarial relationship of 70 studies of sensitivity and attach- The psychoanalyst Michael Balint ensues. These situations usually occur ment interventions in early childhood referredto the doctor herself or himself 32 within multiproblem families and in families with and without multiple as a powerful “medication.” The power of relationships is undeniable, and makes the patient-doctor relation- ship an important ingredient in pro- moting healthy parent-child interac- tion.

Competing interests Day-to-day parenting errors are None declared.

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